Imagine you have been asked to prepare and deliver an analysis of an existing QI initiative at your workplace. The QI initiative you choose to analyze should be related to a specific diseas

Quality Improvement Initiative Evaluation 1

Quality Improvement Initiative Evaluation

Jonathan Fisher

School of Nursing and Health Sciences, Capella University

MSN-FP6016: Quality Improvement of Interprofessional Care

February 2021

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Quality Improvement Initiative Evaluation 2

Quality Improvement Initiative Evaluation

The purpose of this paper is to provide an analysis of a quality improvement initiative at

my workplace. I will provide an overview of our current initiative and examine our metrics related

to the initiative to evaluate its successes and shortcomings. I will include an overview of how

interprofessional teams impact the both the initiative and the related condition. Finally, I will

provide recommendations for how the initiative could be improved or expanded with the goal of

continuing to improve the quality of care that our organization is providing to our patients.

Analysis of Current Quality Improvement Initiative

The current Quality Improvement initiative I will be examining is the catheter-associated

urinary tract infection prevention bundle. Our institution’s current bundle has been in use for more

than five years and is largely unchanged. There has been increased focus and re-education on

specific aspects of the bundle at different times along with minor changes aimed at decreasing the

incidence of false positive results for urine cultures. Our CAUTI prevention bundle includes a

nurse-driven protocol for insertion and removal, emphasis on sterile insertion, proper maintenance

and cleaning, and early removal. When we have had an increased incidence of catheter-associated

urinary tract infections the primary re-education has focused on decreasing device days unless the

incident review discovered other problems such as inadequate foley care, inappropriate flushing of

the catheter, or other missteps in the maintenance bundle.

Success of Current Initiative

The current catheter-associated urinary tract infection prevention bundle that is in use has

been credited with a large part of our success as an organization in meeting or exceeding our

benchmark goals. Our current hospital-wide incidence over the past year is 1.14 per 1,000 catheter

days. In addition, our intensive care units across the hospital have also made significant

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Quality Improvement Initiative Evaluation 3

improvements over the last several years and despite the higher risk profile in our patient

population, the combined incidence in the intensive care units is 1.2 per 1,000 catheter days which

is only marginally higher than the average incidence across all units in the hospital.

While the organization has made significant progress using the current initiatives, it seems

to be difficult to maintain continuous improvement beyond this level. The primary focus at this

point seems to be to watch for areas or units that have significantly higher rates than the hospital

average in order to provide targeted education to the staff in those areas. When a particular unit or

provider group has a higher than average or higher than expected incidence the primary cause is

often determined to be an increase in device days. This leads to the primary intervention being to

simply reeducate on the appropriated indications for a catheter and a re-emphasis on early

removal. While there is evidence that a nurse-driven protocol can and should significantly reduce

device days (Schiessler, 2019), there also needs to be adequate measure in place to decrease the

risk of an infection in those patients who truly need a catheter, especially if that catheter is needed

for an extended period of time.

A further example of how we may be nearing the end of the capabilities of a catheter-

associated urinary tract infection prevention bundle is the fact that in recent months the focus

within the infection control department of the organization has shifted slightly towards ensuring

more accurate measurement. In other words, we have decreased our incidence of catheter-

associated urinary tract infections to the point where one or two false positives will not only mean

potentially unneeded treatment for that individual patient, it could also significantly skew our

metrics. In addition, given the size of the hospital, it is not unusual for an individual unit to go an

entire calendar year with only one or even no catheter-associated urinary tract infections. While

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Quality Improvement Initiative Evaluation 4

this is obviously a testament to the progress that has been made, it can make it hard to relay the

importance of continuous improvement to the front-line staff.

Interprofessional Perspectives

As with any hospital acquired condition, interprofessional cooperation is also a significant

factor in reducing catheter-associated urinary tract infections incidence. The primary

interprofessional interactions related to foleys is between nursing staff and physicians. While

CAUTIs are primarily viewed as nursing sensitive quality indicators, the entirety of the healthcare

team and the organization need to take responsibility for decreasing them. The Joint Commission

(2017) alludes to this need for a broader view of patient safety in their list of National Patient

Safety Goals as they name both preventing infections and improving staff communication as

important aspects for the organization as a whole to embrace as ongoing goals. In addition,

Shojania (2020) makes the case that a narrow focus on individual metrics has only a limited

potential for improvement in that particular metric. Rather than focusing solely on individual

interventions we also must focus on teamwork, cultural change, and communication and include

these aspects in our overall approach to patient safety.

One example of this need for interprofessional collaboration is in patients in our Neuro-

Intensive Care Unit. These patients frequently have a foley place at the recommendation or

request of the neurosurgery team. While there are definitely times when a foley is indicated, the

neurosurgery team frequently insists on the foley primarily for accurate monitoring of intake and

output when that is far from the only option. In discussion with members of the neurosurgery

team, it becomes obvious that they are focusing only on their specialty and not really looking at

the patient as a whole. In addition, they are frequently a consulting service and not the patient’s

primary care team so they may not receive any notification if the patient does develop a catheter-

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Quality Improvement Initiative Evaluation 5

associated urinary tract infection in the future. When a patient who is under their care has a foley

placed they are also very likely to have the foley in place for much longer than is necessary. This

is partly due to the fact that they typically bypass the nurse-driven aspect of the foley protocol and

want to decide as physicians whether the patient is ready to have the foley removed.

Additional Recommendations

While we have made steady improvements over the last several years, I think there are still

a number of areas where we as an organization can make a big difference in catheter-associated

urinary tract infections prevention. One recommendation is to put more emphasis on tracking

device days for foleys rather than focusing primarily on times when the foley causes a urinary

tract infection. This would allow units that have a very low overall number of infections to have a

measurable goal to work towards. In addition, all units and all physician service groups

throughout the organization should be included in receiving information about recent infections

and what parts of the prevention bundle may have been missed. If one of the intensive care units

receives the information that there was a recent catheter associated urinary tract infection and the

chart review showed that the foley should have been removed days earlier than it was they are

more likely to pay more attention in the future than if they are only told that one of the other units

in the hospital had an adverse event but they still have not had any.

An additional recommendation is to increase the accountability of all interprofessional

team members for catheter-associated urinary tract infections prevention. If neurosurgery thinks

that a patient, they are consulted on meets the criteria for a foley, there should be a discussion both

with the nursing team and with the primary physician service rather than a unilateral decision. The

organization as a whole needs to continue to work towards a culture where every catheter-

associated urinary tract infection is treated as a serious event that should have been prevented. In

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Quality Improvement Initiative Evaluation 6

addition, it needs to become the norm within the organization that foleys are used only when

absolutely necessary and they are taken out as quickly as possible. One simple way to decrease the

time to removal would be to simply make foleys a standard part of interdisciplinary rounds. While

the entire team is a part of rounds, the information is primarily presented by the physician team

and as such when devices are addressed the primary focus is on devices in which the physician

team must be involved in the removal of. Endotracheal tubes and whether the patient is ready to

have it removed is always a part of the discussion, but the foley and whether it can be removed

can easily be missed.

Conclusion

In conclusion, our organization has a wide-ranging bundle related to prevention of

catheter-associated urinary tract infections. The bundle addresses prevention of unnecessary foley

placements, sterile technique during insertion, multiple aspects of daily care during the

maintenance phase, and an emphasis on early removal of the device. This bundle has been shown

to be effective in many institutions and has led to a significant decrease in incidence of catheter-

associated urinary tract infections within our organization. Though we are consistently at or close

to our benchmark goals, we continue to look for ways to improve the care we are providing to our

patients. The primary recommendations that I provide are focused more on building the teamwork

and the culture necessary to both decrease our device days and decrease our incidence of catheter-

associated urinary tract infections.

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Quality Improvement Initiative Evaluation 7

References

Montalvo, I. (2007).The national database of nursing quality indicators. Online Journal of Issues in Nursing, 12(3), 1–11.

Schiessler, M., Darwin, L., Phipps, A., & Hegemann, L. (2019). Don't Have a Doubt, Get the Catheter Out. Pediatric Quality & Safety., 4(4). https://doi.org/10.1097/pq9.0000000000000183

Shojania, K. G. (2020). Beyond CLABSI and CAUTI: Broadening our vision of patient safety. BMJ Quality & Safety, 29(5), 361. doi:http://dx.doi.org.library.capella.edu/10.1136/bmjqs-2019- 010498

The Joint Commission. (2017). National patient safety goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx

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