Catheter-Associated Urinary Tract Infections

The United States Ministry of Health estimates that the federal and state governments spend billions of dollars and tens of thousands of lives are lost annually due to nosocomial infections. Modern technology has transformed the field of medicine by coming up with sophisticated types of equipment which have numerous merits when managing various chronic infections. Modern healthcare invasive devices like ventilators, IV drips, catheters, and procedures such as surgery and transplants have helped in the management of medical conditions that were not possible before their inception ( Magers, 2013) . However, they are linked to healthcare-associated infections (HAIs) which are important causes of morbidity and mortality in the U.S. HAIs is a safety concern for health care providers, the patients, and the government. Centers for Disease Control and Prevention (CDC) through the National Center for Health Statistics estimates that HAIs are the main cause of the increase in health care costs because one out of every 25 hospitalized patients is affected by nosocomial infections.

Hospital-acquired infections can be transmitted in any health facility ranging from acute care hospitals, ambulatory surgical centers, outpatient care, dialysis facilities, or even long-term care facilities such as rehabilitation centers and nursing homes (Sievert et al., 2013). Due to the high incidence of HAIs, the U.S. Department of Health and Human Services (HHS) established a Healthcare-Associated Infections objective for Healthy People 2020 to assist in preventing HAIs (Saint et al., 2016). Various stakeholders such as CDC and public health partners are trying to increase patient safety by ensuring infections that patients get while receiving medical treatment in a healthcare facility are eradicated. Some of the high-priority infections that they target to reduce are methicillin-resistant Staphylococcus aureus (MRSA), Catheter-associated urinary tract infections, central line-associated bloodstream infection (CLABSI), surgical and bloodstream infections, pneumonia, and Clostridium difficile (Sievert et al., 2013) . 

The roadmap to eliminating preventable HAIs involves eradicating all the risk factors which have been grouped into three categories. They include organizational factors, patient factors, and medical procedures and antibiotic use (Saint et al., 2016). Also, the behaviors of medical practitioners when handling patients can also lead to HAIs. Although significant progress towards preventing some of these infection types have been successful, there is much more work to be done. But recent studies have shown that there will be a 70% reduction in catheter-associated infections and CLABSI if the existing prevention practices are implemented. Some of the general best practices expected of health care providers in America include careful insertion and removal of invasive medical devices, careful use of antibiotics, and decolonization of patients to reduce transmission of MRSA in health facilities (Saint et al., 2016). Through proper education of medical practitioners, adoption of such practices can be an easy process. 

Urinary tract infection is among the common hospital-acquired infections in adult patients. It is estimated that at some point while in the hospital, 12-16% of adult in-patients use a urinary catheter. And 70 to 80% of UTIs are due indwelling urethral catheters. Even though the chances of acquiring infection from using a single catheter is very low, frequent using increases the daily risk of acquisition of bacteria from 2% to 6-8% when a catheter fixed in a person’s body remains in one position for a sustained period of time (Whittington et al., 2017). Apart from infections caused by improper use of catheters, there are other negative outcomes brought by catheters and they include urethral strictures, urethral inflammation, mobility impairment, genitourinary, and mechanical trauma. Some survey studies have shown that catheter-associated urinary tract infection (CAUTI) leads to increased length of stay in hospital hence increases the cost of medication. However, mortality is usually secondary to another clinical variable. For instance, when asymptomatic CAUTI is not treated properly, it may lead to antimicrobial resistance. However, in acute care hospitals, Clostridium difficile might develop. 

Some of the identified risk factors for the development of CAUTI include the duration of catheterization due to unnecessary catheter insertion and prolonged placement of indwelling catheters especially in an in situ position. Improper insertion and wrong size catheters also increase chances of developing UTIs (Whittington et al., 2017). Other minor factors such as female sex, having an open drainage, and older age should also be monitored. 

Significance of the Population Health Issue 

Description of the Population and Stakeholders 

Preventive interventions discussed in this paper target hospitalized elderly patients. This target population frequently receive urinary catheters and due to their low immunity are at a higher risk of getting CAUTI (Parry, Grant & Sestovic, 2013). Another reason for targeting the older patients is because around 45% of these patients are inserted urinary catheters without a clear indication for placement. Also, some elderly patients in long-term care facilities stay with indwelling catheters in one place for a longer time than the provided ( Magers, 2013). That is why CAUTI among the elderly is one of the most common types of health associated infections. Stakeholders with a vested interest in changing the situation of CAUTI in the United States include the Federal Government through Department of Health and Human Services, Centers for Disease Control and Prevention, Office of Disease Prevention and Health Promotion (ODPHP) (Parry, Grant & Sestovic, 2013). Other stakeholders include patients, caregivers, clinicians, other healthcare institutions, and research institutions. 

Description and Significance of the Issue 

The paper focuses on catheter-associated urinary tract infections as one of the common healthcare-acquired infections that are burdening the health care system in the United States. There is need to reduce the incidence and prevalence of CAUTI among hospitalized patients in acute care facilities and intensive care units especially the older patients who commonly use the catheters and other invasive medical devices for chronic conditions like kidney failure, diabetes, arthritis, high blood pressure, etc. Elderly patients are commonly affected than younger patients (Parry, Grant & Sestovic, 2013). Apart from human factors like immunity, older patients in a hospital setting suffer from conditions that require the use of catheters more than younger patients. It is estimated that 12-16% of adult inpatients use catheters. In younger patients, it is less than 4%. For that reason, older patients are affected more by CAUTI than younger ones. 

The most important risk factor for someone to develop CAUTI is prolonged use of urinary catheter hence the condition is not dependent on race. People from lower socio-economic status are affected more than those from high socio-economic status. However, CAUTI is not directly related to the social and economic factors but is due to the fact that poor people seek medication from public hospitals where CAUTI is rampant due to negligence from healthcare givers ( Magers, 2013). The female gender is more affected than the male gender. CAUTI is among the common causes of death in hospital-acquired infections. However, some clinicians argue that mortality due to CAUTI is usually due to another clinical variable especially due to improper treatment of asymptomatic catheter-acquired UTI. 

Identified Healthy People 2020 Objectives and Objectives of the Study 

Some of the identified objectives for the Healthy People 2020 is to reduce central line-associated bloodstream infections by 75%. Another objective is to reduce invasive healthcare-associated methicillin-resistant Staphylococcus aureus infections from 27.08 infections per 100,000 patients to 6.56 infections per 100,000 patients (Whittington et al., 2017). Also, another identified objective dealing with CAUTI is to achieve a sustainable decrease in CAUTI and catheter use through implementation of evidence-based culture improvement strategy through the help of CDC. Since most infections can be transmitted from one patient to another, decongesting the current population of patients by 50% is another identified objective being undertaken by HHS for Healthy People 2020 (Whittington et al., 2017). 

There is limited data that provide guidelines for preventive practices for CAUTI in the United States hospitals despite the national goal to reduce the burden by 2020. Also, little is known whether the outlined preventive strategies are being followed in healthcare facilities in the U.S. Therefore, the general objective of this program is to reduce CAUTI rate in all the participating health facilities upon completion of the 18-months initiative ( Magers, 2013). The specific objectives include fostering a culture of safe use of catheters by outlining guidelines for proper catheter use, catheter insertion, catheter care, and educational programs for both patients and caregivers. 

Level of Prevention, Genetic, and Environmental Risk Factors Associated with CAUTI 

Impact of Lifestyle on Prevention 

Primary prevention is the use of general and specific measures in a population to promote health and prevent the development of disease in those people who are predisposed to developing a certain condition. It is the first level of health care used by medical practitioners to prevent the occurrence of a disease and in the process promote health (Whittington et al., 2017). For example, using indwelling catheters only when medically necessary, use of external or condom-style catheters if appropriate in men, and maintaining hand hygiene by observing all standard precautions. 

Secondary prevention refers to the measures employed to stop the progress of the disease through early detection and treatment (Whittington et al., 2017). It is the second level of health care used to prevent the development of adverse sequelae by identifying a disease early enough so that it can be easily and readily treated. For example, use of antimicrobial or antiseptic-impregnated catheters and asymptomatic treatment of CAUTI upon being identified. 

Tertiary prevention can be defined as the process of stopping further disease-related deterioration in a patient so that a patient can resume maximum usefulness with minimum risk of recurrence of the condition ( Magers, 2013). For example, consideration of alternatives to indwelling catheters, maintaining unobstructed urine flow, and leaving catheters in place for the shortest time possible or only as long as needed. 

Genetic Impact 

Genetics play a role in increasing the chances of someone getting CAUTI. For example, mortality is higher in catheterized female patients than male patients. Also, older patients are affected more than younger patients due to immunological factors controlled by genetics (Whittington et al., 2017). However, in the prevention of CAUTI, genetics does not play any known role so far. Researchers are underway to exploit knowledge of genetics pertaining risk factors in designing methods and strategies for preventing UTIs acquired through the use of indwelling catheters. 

Environmental Impact 

Catheters are foreign objects and once inserted into the body, they provide a conducive medium where bacteria can grow. Some resistant gram-negative bacteria like Clostridium difficile, are among the common causes of UTIs in patients with indwelling catheters. Other environmental factors such as pollution of the environment with physical and chemical contaminants (Magill et al., 2014). Therefore, prevention strategies for reducing the incidence of CAUTI should aim at eradicating environmental factors that increase the risk of contaminating catheters before and after insertion. Such contaminants can be avoided by maintaining high standards of hygiene of the room, hands of the caregiver, the patient, and the catheters. Previous studies have indicated that the source of microorganisms that cause UTIs may be endogenous or exogenous (Magill et al., 2014). Possible endogenous sources can be due to vaginal or rectal colonization while exogenous sources are due to contaminated hands of caregivers during insertion or a contaminated catheter especially the collecting system and the insertion tube. 

Proposed Evidence-Based Prevention Program for CAUTI 

The study aimed at developing and implementing a strategic preventive strategy that will work as an easier reminder for healthcare providers and patients to mitigate the high incidence of CAUTI among elderly patients in health facilities (Magill et al., 2014). Before embarking on the prevention program, a comprehensive literature review was conducted. It served as a robust source of information which assured that the proposed implementation program was grounded in an evidence-based approach. The name of the proposed population health program is “Step by Step, Evidence-Based CAUTI Prevention Collaborative Resource Manual.” (Davis et al., 2014) 

Description of the Identified Strategy 

The study will be held at the Mississippi Hospital for Restorative Care, a health facility that provides long-term acute care for adult patients. Catheter-associated urinary tract infection is among the leading causes of avoidable hospital-acquired infections that cause morbidity and mortality among American citizens (Davis et al., 2014). Therefore, the article focuses on improving the quality of medication aimed at reducing the duration of catheterization in adult patients. During literature review, I will request a team of multidisciplinary healthcare providers at the facility to help me in the study and finding out the main cause of CAUTI among the ones outlined in the literature. I chose Mississippi Hospital for Restorative Care because, the facility practices all the CDC strategies for CAUTI prevention, yet the rates of infection are still very high (Davis et al., 2014). Therefore, the program is formulated in five steps to be conducted over a period of 18 months. 

Step 1: Search for the Best Evidence. From the previously collected information, the study will focus on the first three months collecting and synthesizing information. From the database available at the facility, I will perform a systematic literature search using keywords such as urinary catheterization, urinary tract infection, catheter-related/associated, UTI prevention and control strategies, etc. Also, periodicals and journals from the facility will yield more information that will help in subsequent studies (Johnson et al., 2014). 

Step 2: Critically Appraising the Collected Information. This is an important step because it helps in determining whether the gathered information is valid, reliable and relevant to the population health issue and the chosen population. It can take one month or less. Therefore, the collected data will be checked if it was correctly recorded, its relevance, and the period it was recorded. It can be performed by creating an evaluation table and check for some similarities and differences in the information especially for patients with a similar health condition (Davis et al., 2014). The information will, therefore, help in determining the reasons why some patients were continued or stopped from using indwelling catheters. 

Step 3: Integrating the Evidence. The information obtained after the second step will be combined with the clinical expertise of the medical practitioners and patient preferences and values. Therefore, for the next 2 months, I will invite a multidisciplinary team of various stakeholders ranging from medical practitioners (nurses, physicians, pharmacists, and laboratory technologists), willing patients, and any interested individuals (Davis et al., 2014). The exercise will provide valuable support to the project and promote supportive environment when the practical part of the study starts. 

The questions to be asked should aim at finding out if each healthcare personnel perform his or her specific role and responsibility when required and whether they are consistent with the CDC strategy that they are supposed to follow (Johnson et al., 2014). Also, to determine how the schedule of nurses is working which helps to find out whether night or day shift nurses are the ones supposed to change catheters and if there are any instances of confusion. Information obtained is crucial for knowing the chain of command and flow of information, catheter-days for particular patients for the study and the CAUTI rates. 

The next step will involve creating a brochure that outlines the protocol to follow when carrying out the study. Since the study will be based in the wards, 25 nurses, 3 physicians, and 15 support staff will be picked to participate in the study (Davis et al., 2014). They will be taken through the training session that will be provided as a soft copy in slideshows and hard-copy prints. Then they will be given a certain ward to work in and attend to elderly patients who require catheters for the next nine months. During the period, they will work under supervision to ensure that they change catheters according to the time provided by the manufacturers (Davis et al., 2014). Also, other hygiene and measures of preventing CAUTI provided by CDC should be followed during the time of exchanging the catheters. Pre-intervention and post-intervention strategies of using alternatives such as condom-type catheters in male and non-obstructive drainage will also provide data for comparison. 

Step 4: Evaluation of the outcomes. Once the study is complete, the data collected from the ward under study will be compared with records from other wards. Evaluation is a comparison of the available data from the established databases like CDC, the hospital records, and the data collected from the chosen study. The expected outcome is that the reduction in the number of catheter-days reduces the risk of CAUTI (Davis et al., 2014). In order to prove that the findings of the study are true, the results will be calculated using a device-utilization ratio. After which the variables will be discussed with the hospital council. The morbidity and mortality rates recorded during the period of the study will also be compared to with the previous data recorded by the hospital. The process will take approximately one month. 

Step 5: Dissemination of the Evidence-Based Information. Once the information has been proven to be effective and successful in curbing the rates of CAUTI, then with the help of the facility, the information can be provided for other health institutions for approval and implementation (Johnson et al., 2014). However, before the strategy is approved for implementation, the results will be sent to the nursing quality and research council for analysis and dissemination with other results from established evidence-based best practices (Davis et al., 2014). The process can take approximately two months. When the results obtained from the study ward are consistent with other well-conducted studies and systematic reviews, then it is evident that the chosen strategy can be implemented to handle the population issue of increased rate of catheter-associated UTIs. 

EBP Data to Support the Strategy 

CDC with the help of Institute of Health Investigation came up with CAUTI toolkit which comprised of core strategies and supplemental strategies for preventing catheter-associated urinary tract infections (Johnson et al., 2014). The collaborative study indicated that unnecessary insertion of catheters and prolonged catheterization were among the leading causes of CAUTI. With the implementation of the toolkit, there was a drastic change in all the trial hospitals. However, implementation of the project was faced with a lot of criticism where it was argued that the convenience of a urethral catheter outweighed the importance of its removal. Also, a 200 8 guide provided by the Association for Professionals in Infection Control and Epidemiology (APIC) geared towards antibiotic stewardship efforts found out that improper insertion of indwelling catheters was causing CAUTI among inpatients (Johnson et al., 2014). Also, the incidence was high in patients who had the catheter in situ for more than 48 hours. 

Potential Barriers to Adopting Strategy 

Managing data from multiple sources is difficult and therefore, analysis and comparison may be difficult. The nurses and physicians may be reluctant to accept the change which negatively affects the adoption or even trial studies of the strategy (Liedl, 2015). Also, the leadership may have other priorities at the time you are planning to implement the strategy. Therefore, they may not accept adopting the strategy because this program involves changing some major components of the usual routine. 

How to Address Cultural Diversity using Leininger Theory 

Leininger theory states that different cultures have different caring behaviors, beliefs, and values. Therefore, a strategy developed to be implemented in the whole nation is supposed to cover different cultures with respect to nursing and health-illness caring beliefs, practices, and values (Johnson et al., 2014). It is only after such considerations that a plan can be accepted by all the stakeholders supposed to contribute to its success. In life, people tend to support plans that are developed according to their cultural values. 

Health Literacy Considerations for Participants 

The success of the program depends on the literacy and willingness of the participants. The participants are supposed to understand the consequences of using urinary catheters. Understanding of the basic health information and services about catheters especially among the patients (Liedl, 2015). The ability of medical practitioners to make health care decisions is also another consideration when determining the literacy of the participants. Another consideration is the accessibility of relevant information to medical practitioners to enable them to make informed decisions. 

Modifications to Published Strategies to Fit Elderly Population 

The published strategies failed to prove the fact that the results they obtained during the survey were as a result of the achievements of the study and not a declining trend of census during that time. Therefore, the modification that they could have applied is using a device-utilization ratio so that they compare the trend from one health facility to another. If there is a consistent decrease in mortality rate and risk of CAUTI from one facility to another, then it is evident that the applied strategy is effective in curbing the issue of CAUTI (Liedl, 2015). 

Agencies to Partner with when Implementing this Strategy 

There are numerous health institutions and interested agencies that are willing to invest or venture into public concern health issues (Liedl, 2015). Most probable agencies that I can partner with to actualize my strategy include Centers for Disease Control and Prevention (CDC), Division of Healthcare Quality Promotion (DHQP), Lippincott Nursing Center, and other health and research institutions that have shown interest or conducted research studies in dealing with nosocomial infections. 

Evaluation of the Strategy 

How the Chosen Strategy meets the 9 Aims for Quality Improvement 

The chosen strategy that aims at reducing the incidence and rate of catheter-associated urinary tract infections meets the nine aims for improvement of quality in public health as a framework to identify quality measures (Lo et al., 2014). First, the chosen strategy is population-centered because it focuses a collection of individuals who have one characteristic (elderly people using catheters). The strategy is equitable because it covers all sorts of people irrespective of their gender, race, and disease condition. It is proactive because it is trying to come up with new measures that can be used to eradicate a population health issue. It is evident that reducing the frequency of using catheters decreases the risk of contracting CAUTIs, therefore, the program is risk-reducing (Lo et al., 2014). The issue of catheter-associated urinary tract infections is a health concern that the study is trying to reduce its rate of occurrence thus the study is health promoting. 

In order for the chosen strategy to succeed, it was designed to avoid the shortcomings that hindered the previous studies from succeeding and therefore, it is vigilant. The study is straightforward because it involves participants some of which do not have medical knowledge hence it is transparent (Lo et al., 2014). From the expected results, it is evident that the project has strived to avoid the previous mistakes and therefore it is anticipated to be effective in eliminating the issue of CAUTI and giving efficient results. 

Formative and Process Evaluation of the Chosen Strategy 

Since this is a proposed project that is yet to be actualized, formative and process evaluation is typically the best method of evaluating the program (Liedl, 2015). It assesses the strategy during developmental stages to provide adequate information that helps in revising and modifying the project to improve it. Since this study is based on improving on previous literature, formative evaluation helps in providing feedback that is used to modify the procedure to be tested. It acts as a diagnostic tool whereby it provides qualitative information from other established sources that will be used to improve on the original strategy. 

Increase in catheter-associated urinary tract infections and prolonged catheter-days are indicators that nurses can mitigate through the use of available evidence-based best practices. By using catheters only for appropriate indicators, minimizing catheter use and duration of use in all patients, proper choice, and handling of catheters by medical practitioners, the government can save a lot of money that is channeled into handling nosocomial infections. Also, by use of alternatives to indwelling catheters such as intermittent catheterization or external catheters, the prolonged stay of patients in hospitals and increased mortality rates due to CAUTI can be controlled. Most of the nosocomial infections are preventable, therefore, all the stakeholders involved should work together and ensure that the vision of Healthy People 2020 is achieved. The only way to attain high-quality and longer lives free from preventable nosocomial diseases and premature death is by eliminating hospital-acquired infections. Therefore, through the creation of a social and physical environment that promotes good health for all, is the key to achieving the goal of Healthy People 2020. 

References 

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Johnson, N. B., Hayes, L. D., Brown, K., Hoo, E. C., & Ethier, K. A. (2014). CDC National Health Report: leading causes of morbidity and mortality and associated behavioral risk and protective factors— the United States, 2005–2013. Retrieved from https://stacks.cdc.gov/view/cdc/25809 

Liedl, B. (2015). Catheter-associated urinary tract infections. Der Urologe. Ausg. A , 54 (9), 1301-8. Retrieved from http://europepmc.org/abstract/med/26275988 

Lo, E., Nicolle, L. E., Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., & Yokoe, D. S. (2014). Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology , 35 (5), 464-479. Retrieved from https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/strategies-to-prevent-catheterassociated-urinary-tract-infections-in-acute-care-hospitals-2014-update/D958834AE54E6AE841B335DA4201A462 

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Magill, S. S., Edwards, J. R., Bamberg, W., Beldavs, Z. G., Dumyati, G., Kainer, M. A., ... & Ray, S. M. (2014). Multistate point-prevalence survey of healthcare-associated infections. New England Journal of Medicine , 370 (13), 1198-1208. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa1306801 

Parry, M. F., Grant, B., & Sestovic, M. (2013). Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal. American journal of infection control , 41 (12), 1178-1181. Retrieved from http://www.ajicjournal.org/article/S0196-6553(13)00662-7/abstract 

Saint, S., Greene, M. T., Krein, S. L., Rogers, M. A., Ratz, D., Fowler, K. E., & Faulkner, K. (2016). A program to prevent catheter-associated urinary tract infection in acute care. New England Journal of Medicine , 374 (22), 2111-2119. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa1504906 

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Whittington, M. D., Bradley, C. J., Atherly, A. J., Campbell, J. D., & Lindrooth, R. C. (2017). Value of public health funding in preventing hospital bloodstream infections in the United States. American journal of public health , 107 (11), 1764-1769. Retrieved from http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.303987