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Analyzing Needs Assessment and Quality Improvement PlanResearch Paper

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¶ … Quality Improvement Plan

Needs' Assessment and Quality Improvement Plan

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This paper discusses the process of drafting a quality improvement plan at a community level medical facility, a plan that is aimed at reducing days under urinary catheter and also reducing the rates of infections associated with the said catheters.

CAUTI (Catheter-associated urinary tract infection) is the most prevalent HAI (hospital acquired infections), responsible for up to 34% of all hospital acquired infections. Over half a million cases of CAUTI are reported every year in the U.S., leading to higher rates of mortality and morbidity and overuse of hospital resources. The condition is of a special concern especially among older patients, based on the revelations of inappropriate use of IUCs (Indwelling urinary catheters) among this vulnerable population. In spite of being the most common HAI, catheter-associated urinary tract infection has never been a focus of HAI control programs (Fink, et.al, 2012). A countrywide survey of infections among professionals involved in the control of hospital infections reported poor implementation of catheter-associated urinary tract infection prevention measures meant to reduce the number of catheter days such as the early removals of catheters and avoidance of indwelling urinary catheters. These reports are of concern, especially when considering different studies that recommend several evidence-based prevention practices, for instance, those suggested by the CDC (centers for disease control) in its 2010 evidence-based guidelines, towards significantly reducing the number of catheter-associated urinary tract infections. The 2010 CDC document makes over sixty recommendations specific to CAUTI. However, it must be said that the majority of these recommendations are backed with very little evidence.

The Guidelines released in 2009 by IDSA (Infectious Diseases Society of America) defines catheter-associated urinary tract infections (CAUTI) as the infections contracted by patients currently fitted with catheters in their urinary tracts or had been fitted with catheters in their urinary tracts within the last forty-eight hours. Also, according to the IDSA Guideline, the term urinary tract infection (UTI) by itself refers to a significant concentration of bacteria in a patient with signs or symptoms ascribable to the urinary tract and no other source. UTIs (Urinary Tract Infections) are the most prevalent hospital acquired infections accounting for almost forty percent of all adult nosocomial infections. It is also important to note that an overwhelming majority of UTIs (eighty percent) are caused by IUCs (Leithhauser, 2004).

According to Gorman, between 15 and 25% of all hospitalized patients are fitted with short-term indwelling catheters. The day-to-day risk of contracting CAUTI is three to seven percent in an acute care environment. The IUCs are often placed for the wrong reasons and patients are often unaware of the presence of the medical equipments. As a result, the IUCs stay in the tract for lengthy durations. However, there is a significant variation of the reported rates of urinary tract infections among patients fitted with IUCs (Gorman).

Data from the CDC, through the NHSN (National Healthcare Safety Network) revealed that acute care settings reported rates of between 3 and 7.5 infections per a thousand catheter days. Another government agency, the CMS (Centers for Medicare and Medicaid Services), listed hospital-associated UTIs among the eight conditions for which health facilities will not be receiving any additional funds (Gorman). The CMS guidelines also noted complications and risks associated with catheter-associated urinary tract infections as gram-negative bacteremia, chronic or acute pyelonephritis, epididymitis, prostatitis, periurethral abscess, and cystitis, which can cause death in up to 60% of the cases. The agency also lists catheter associated urinary tract infections as the second most prevalent cause of nosocomial blood infection.

Definition of the problem

The stakeholders involved include the physicians, nurses, the hospital and the patient. As stated above the CMS has listed CAUTIs among the eight conditions for which health facilities will not be receiving any additional money (Gorman). The CMS guidelines also state that complications and risks associated with catheter-associated urinary tract infections as gram-negative bacteremia, chronic or acute pyelonephritis, epididymitis, prostatitis, periurethral abscess, and cystitis, which can cause death in up to 60% of the cases. A complication resulting from a catheter-associated urinary tract infection can increase the hospital stay of a patient by up to 0.4 days if it doesn't show any symptoms and 48 hours if it is symptomatic (Leithauser, 2004). Even though a lot of progress has been achieved in the prevention of catheter-associated urinary tract infections, there is still some way to go in addressing some of the unresolved issues surrounding the condition (Gorman). Efforts have to be focused on developing the best practices in IUC use and prevention of the condition. Research should also be done to investigate and document: which of the cases absolutely require the use of a catheter; after what time span should reassessments be done to check if a patient still needs to use an IUC; what alternative methods are available; and the best practices concerning catheter use. Attention should also be focused on the need to continuously reassess the healthcare gaps and also the retraining of staff when necessary. All these issues will be addressed in this plan.

Currently, there are two guidelines in place for catheter use. There is one by the CDC and another one by IDSA. The CDC one published in 2009 highlights several recommendations for the prevention of CAUTIs. First of all, the guideline recommends the utilization of catheters only for appropriate cases. The CDC guidelines also recommends that the frequency of use and the duration of use of catheters should be kept at a minimum among all patients, particularly among patients from vulnerable communities such as the elderly, women and individuals with impaired immunity. Even though, the CDC guidelines recommend that catheters should be maintained in place for as long as it is necessary, the CDC suggests that the indwelling catheters fitted in individuals undergoing operations ought to be removed as soon as possible after the surgery is completed (Brusch, 2015). The utilizations of IUCs for treatment of incontinence ought to be avoided. One of the other important recommendations by the 2009 CDC guidelines is that nurses and physicians should avoid routinely utilizing systemic anti-microbials to prevent CAUTIs in patients in need of either long of even short-term catheterization. This is because the routine use of systemic anti-microbials has been shown to lead to more resistant bacterial strains. The Guidelines released in 2009 by IDSA (Infectious Diseases Society of America) for CAUTIs recommend that the indwelling catheters should only be used with the patient's authorization in cases where there is an imperative need and when other alternatives used in the treatment of incontinence have been deemed ineffective. Long-term use of catheters may increase the satisfaction of patient but will also cause a rise in mechanical complications. Long-term use of catheters is not recommended in cases where the patient suffers from morbid obesity, bleeding disorders and has previously has abdominal irradiation or surgery. Use of catheters intermittently is an alternative, however, most individuals become bacteriuric in a few short weeks; the occurrence of bacteriuria is one to three percent per catheter insertion (Brusch, 2015).

Systemic use of antimicrobials has been reported to reduce the risk of contracting urinary tract infections in patients fitted with catheters. The most benefit was reported in individuals who have been catheterized for three to fourteen days. However, in many cases patients are often already taking antibiotics for other conditions (Brusch, 2015). The repeated use of so many antimicrobials may lead to the creation of resistant bacteria. This is why IDSA recommends against the repeated use of anti-microbials on patients who are already taking other antibiotics/antiseptics.

In the last few years a tremendous amount of progress has been achieved in the reduction of intravascular device infections. The need to reduce such infections was perhaps chiefly informed by the economic concerns i.e. it has been estimated that catheter-linked blood infections may bring about over twenty-five thousand dollars in additional hospital charges. One of the other main reasons that have resulted in such a tremendous amount of progress being made is that, the pathogenesis of device-associated infections is open to interventions at several points. The preventive approaches that have been made to reduce bloodstream infections are separated into three categories based on the degree of supporting evidence. There is: what might work; what probably works and what works. The approaches classified under what works are those that incorporate the basic principles of infection prevention. These approaches are also the ones that offer the best preventive measures against intravascular infections (Brusch, 2015). An example would be antimicrobial impregnated catheters. These catheters have proven efficacy in infection control when used in the right patient populations. The approaches classified under 'what probably works' are those that have shown some efficacy but require further trials. Examples of such approaches would include techniques used in the prevention of thrombus infections and also the use of antimicrobial catheter flushes. Lastly, the approaches classified under 'what work' are novel ideas that have been tested in trials such as new catheter securement devices, active… [END OF PREVIEW]

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