Posted: March 23rd, 2023
Quality healthcare is a core aspect of every medical institution. Today, government agencies and other value organizations, including the Centers for Medicare and Medicaid Services, emphasize the need for healthcare professionals to engage in evidence-based projects, which are aimed at improving patient outcomes, while reducing healthcare costs. Although these tasks are mainly directed to physicians, advanced practice nurses (APN) can also play a vital role in developing and implementing quality improvement initiatives. However, this can only be achieved by overcoming perceptional barriers, which hinder nurses’ contribution to healthcare reforms (Williams & Simmons, 2012). Although healthcare providers play a significant role in the entire continuum of care, one of the critical areas in which nurses’ input may highly matter is the post-surgical unit, in an attempt to reduce the rate of Catheter-Associated Urinary Tract Infections (CAUTI).
The number of patients receiving surgical care has increased significantly. A study conducted by Donna and his colleagues revealed that approximately 10,000 inpatients administered in large acute care hospitals every year are surgical patients (Donna et al., 2016). The numbers are even higher when calculated on a national scale. For instance, Rose, Chang, Weiser, Kassebaum, and Bickler (2014) noted that for every 34.8 million hospital admissions reported in 2010, 10 million surgical procedures were performed. Hence, this growth has also been experienced in present times, and similar trends are anticipated in the future.
Increase in surgical processes in many organizations is one of the practices that onsets urinary tract infections. Notably, the inappropriate use of catheter among post-surgical patients is associated with 70%-80% increase in UTI (Thakker et al., 2018). Over the years, several medical facilities have reported multiple cases of CAUTI as compared to other types of nosocomial infections, including Candida albicans and Legionnaires’ disease. For instance, CAUTI “accounts for approximately one-third of all healthcare-associated infections” (Greene et al., 2014, p. 99). Letica-Kriegel et al. (2019) add that approximately 93,000 cases of CAUTI were reported in the United States acute care unit in 2011. This data is a source of healthcare concern, especially taking into account recent trends in medical surgeries.
The adverse effects of CAUTI can be viewed in two perspectives, from a patient’s and medical facility’s lens. Regarding the former, the infection is attributed to several health complications. Some of the most severe conditions associated with inappropriate use of catheter among patients include pyelonephritis, bacteremia, and meningitis (Davis et al., 2014). Patients also experience minor effects, such as distress, discomfort, pain, and frequent hindrances in the performance of their routine activities (Thakker et al., 2018). The infection is attributed to multiple deaths recorded in the United States. For instance, Davis et al. (2014) indicate that 13,000 deaths in the country are a result of CAUTI. Besides, CAUTI increases healthcare expenses among patients and third-party payers, such as private insurers and government-sponsored initiatives. Up to $450 million is spent on costs associated with catheter-related urinary tract infections among adults and children (Davis et al., 2014). Such expenditures are linked to prolonged hospital stays and frequent readmission.
On the hand, the facility incurs substantial costs associated with the increased use of antibiotics to treat CAUTI. Although the Centers for Disease Control and Prevention (CDS) discourages routine use of antibiotics for the infection, some hospitals still utilize the treatment among post-surgical patients (Pereira, Nguyen & Stevermer, 2014). Such centers may experience considerable financial losses, especially in instances where government incentives fail to cover costs associated with adverse reaction to antibiotics-related allergies. These and other previously mentioned effects of the condition necessitate the need for nurses to develop viable solutions to reduce CAUTI in post-surgical patients.
One of the approaches that healthcare organization can reduce incidences of CAUTI in post-surgical patients is through the appropriate use of catheter. Research reveals that up to 55.7% of urinary tubes are inappropriately inserted among patients (Meddings et al., 2014). In response to these findings, Thakker et al. (20180 assert that caregivers should “avoid unnecessary placement of indwelling urinary catheters” (1). Nurses, who are mostly in charge of catheter insertion, should use the tubes exclusively under the guidance of medical policies. For instance, catheterization is recommended in scenarios of surgery, urinary retention, and health conditions that require continuous measurement of urinary output (Hu, Shih, Hsu, Chen & Chang, 2018). Patients who undergo surgery may require the urinary tube to empty their tracts during anesthesia. Besides, post-surgical clients with high urinary retention may need the catheter to drain urine regularly. Advanced practice nurses should conduct a thorough assessment to determine whether catheter placement is necessary to reduce CAUTI.
Appropriate use of a catheter in the organization can reduce medical costs associated with treatment of CAUTI. For instance, a clinical study conducted by Umscheid and his colleagues revealed that CAUTI treatment costs averaged between $1200 and $4700 (Parker et al., 2017). Further research also showed that medical expenses were twice higher among CAUTI patients as compared to post-surgical individuals undiagnosed with the infection (Parker et al., 2017). Prior evidence-based practices indicate that appropriate use of catheters can facilitate reduction in healthcare expenditure.
Quality improvement programs aimed at minimizing catheter use can also facilitate a decline in incidences of UTI and other adverse health complications. For example, a clinical trial piloted in the division of Orthopedic Surgery at Toronto Western Hospital revealed a 1.1% reduction in UTI cases after a 19.8% decrease in the use of an indwelling catheter (Thakker et al., 2018). From this data, it is evident that the proposed practice may help reduce CAUTI in post-surgical patients and minimize the costs required to treat recurrent infections. In addition, the solution may facilitate effective utilization of medical resources, such as bed spaces and labor, required to manage hospital readmissions.
A SWOT analysis will be used to assess the organization’s strength, weaknesses, opportunities, and threats related to the planned project. Details of this analysis are provided in table 1 below in the appendix section.
The first step in implementing the proposed solution is seeking input from nurses in the post-surgical unit. Barnhorst, Martinez, and Geshengorn (2018) acknowledge this population as the largest in the healthcare workforce and whose attitude and practices impact changes in a healthcare facility. During the first stage of the quality improvement program, nurses will be tasked with collecting information on rates of CAUTI in the organization. This activity is expected to last for one month. Some of the resources that nurses may utilize to complete this task include patients’ medical reports and data gathered during their routine visits in the unit. The above step will be crucial in identifying the prevalence of CAUTI and convincing the medical practitioners on the need to indulge in the suggested quality improvement initiative.
After identifying the issue and gaining stakeholders buy-in, from advanced practice nurses and other nurse managers, the initiative will proceed to the initiation stage. The first step in this level will be educating the involved personnel on appropriate catheter use. Guidelines from the Centers for Disease Control and Prevention will be utilized during training. For instance, nurses will be enlightened about appropriate medical indications for catheter use, which include acute urinary retention, the need to measure accurate urinary output, surgery requirements, as a tool for the provision of comfort among patients undergoing end-of-life care, and during prolonged immobilization (Meddings et al., 2014). The involved human resource will also be educated on instances when catheterization should be avoided. Nurse training will be essential in equipping the staff with knowledge and skills required to indulge in the quality improvement program. The exercise will last for three weeks before the actual implementation of the practice in the selected department.
In addition to investing in employees’ training, there will be a need to buy materials required to facilitate the initiative. Additional computers will be purchased to enable the recording of data gathered among post-surgical patients with CAUTI. Use of electronic data entry will aid the collection of accurate and timely information (Barnhorst et al., 2018). Resources needed to purchase the equipment will be generated through organizational funding. The process will require approval from the management and finance department.
The proposed metric in the post-surgical unit is catheter-related urinary tract infections. Structure, process, and outcome quality measures will be used to evaluate patient outcomes. The appraisal shall comprise of two major components, patient-centered approaches and financial costs. In the first section, the assessment will focus on the extent to which the quality improvement program reduces healthcare costs. Secondly, the impact of the practice on patient outcomes will also be weighed.
Although structural measures will be evaluated during the program, they may not be of much significance in the identified organization because a large portion of the personnel involved in the initiative includes advanced practice nurses. However, this will be a procedural activity aimed at measuring indirect quality care in the facility. Some of the structural metrics that will be assessed include educational achievements and the level of training among the staff (Barnhorst et al., 2018). For the proposed initiative, high levels of training will be associated with improved quality care. On the other hand, nurses with minimal training on the practice will be attributed to low-quality care.
Process measures will also be used to evaluate the proposed practice. This category of quality metrics assesses the direct quality of services by describing the actual care offered to patients (Barnhorst et al., 2018). For instance, the suggested initiative is aimed at reducing the rate of CAUTI among post-surgical patients. The specific intervention involves appropriate utilization of catheterization in the identified unit. In the proposed program, reduced cases of CAUTI will be an indication of high-quality care delivered to patients. However, the recommended solution may require frequent monitoring and review over the project’s life to determine its suitability in improving patient outcomes. As Barnhorst et al. (2018) assert, the value of medical practice changes over time as a result of dynamic clinical research. Similarly, appropriate use of catheter may not be an ideal solution in the organization over the proposed one year of intervention.
Outcome measures will be significant in evaluating the recommended solution. Under this category of metrics, quality of care will be illustrated by patients’ health state following the implementation of the program (Barnhorst, 2018). Some of the aspects that will indicate an improvement in the outlined healthcare condition include reduced hospital stays, lower rates of clinical readmission, and lower health complications after insertion of the catheter. In addition, healthcare outcomes in the post-surgical unit will be compared to data gathered from other departments to facilitate the interpretation of clinical results in the entire organization. For instance, reduced rates of CAUTI-related hospital readmissions in the selected unit as compared to other departments will be an indication of quality improvement.
Return on Invest (ROI)
The planned project will follow the payback model to determine its value in the institution. The selection of this model is based on industry trends, which indicate a high use of payback budgeting in the healthcare sector (Waxman, 2014). The expected ROI will be determined by dividing the financial gains from the commencement of the project by the total amount of money invested in the initiative. For instance, the planned quality improvement program is expected to save the organization approximately $1200 annually. This amount equals to the total expenses that healthcare facilities incur as a result of CAUTI. The organization will also invest in two additional computers, which sell at an average price of $300 each. It will also finance training programs and purchase urine cultures, which will cost approximately $1,742 and $480, respectively as illustrated in table 2 in the appendix. Therefore, the projected ROI will be 3.54% (100/2,822*100). The results are a clear indication of relatively higher gains as compared to costs associated with the quality improvement project. The plan will break even at the point where total costs and profits remain at per.
The organization is expected to invest in different activities during the project’s life. An outline of the program budget is presented in table 2 in the appendix section.
Nurses’ input is highly essential in reducing the rate of CAUTI in post-surgical patients. One of the aspects that the organization may achieve this milestone is through appropriate catheter use. Hence, to successfully utilize the proposed plan, it will be necessary to invest in training programs and additional materials, such as computers. Some of the metrics that will be used to evaluate the quality improvement program include structural, process, and outcome measures. Facilities that implement the proposed solution will boost their quality of care by reducing CAUTI-related medical readmission, prolonged hospital stays, and healthcare costs.
Table 1: Market Analysis
· Availability of highly skilled advanced practice nurses.
· Highly competent management.
· High levels of interaction and collaboration in the organization.
· Self-driven employees.
· Inconsistent cash flow.
· Small operational scale.
· Clinical research is expanding in the organization, creating more opportunities to handle healthcare issues.
· Our competitors appear to be less indulged in evidence-based practices.
· The proposed solution may lose value over time due to dynamic changes in clinical research.
Table 2: Financials
|Expenses required||Cost||Quantity||Total Cost|
|Computer purchase (direct cost)||$300||2||$600|
|Educating Staff (direct cost)||$23.38 per day||21 days||$490.98|
|Training residents and family on catheter care, and appropriate use of chlorhexidine solutions for cleaning perineal area (direct cost)||$1,252 for 21 days||21 days||$1,252|
|Purchasing Urine Cultures||$80||6 patients in the surgical unit||$480|
The estimated cost of educating staff is based on prior studies, which engaged nurses in evidence-based practices. For instance, nurse enrollees recruited for a clinical trial were paid $25.38 per subject (Blewer et al., 2016). Similar charges will be used for the proposed project, which involves advanced practice nurses.
The cost of training residents and family on catheter care and appropriate use of chlorhexidine solutions for cleaning perineal area is estimated at $1,252. This cost is based on information gathered from clinical providers in the surgical unit, who conducted similar training programs in the institution.
Six urine cultures will also be acquired for use in the project. The estimated cost of one urine culture is $80 (The Initiative of the ABIM Foundation, n.d). A total of $480 will be spent on the purchase. The overall cost of the project will be $2,822.98.
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