Catheter-Associated Urinary Tract infection is ranked as one of the most commonly acquired condition in hospitals, and the trend is on the rise. According to the National Healthcare Safety Network (NHSN), approximately three-quarter of hospital-acquired UTIs are related with a urinary catheter. Fifteen to twenty-five percent of clients under hospital care obtain urinary catheters. Prolonged urinary catheter remains the most critical risk factor related to the development of CAUTI (CDC, 2021). Since implementing a new policy, the unit’s CAUTI has not decreased, and consequent financial repercussions cannot continue. Despite a consensus on the guidelines to be followed for diagnosis, treatment, and prevention of CAUTI, there lacks a single, evidence-based approach to reduce these infections. The most common interventions remain the placement of catheters and encouraging early removal. The current policy ensures that all urethral catheter insertions are completed under sterile technique. Two RNs should be present during the insertion. Other procedural guidelines are provided.
Though preventable, CAUTI continues to plague hospitals across the nation. In 2017, CDC estimated approximately 13,000 mortalities annually interrelated to catheter-associated urinary tract infections. The cost associated with CAUTI has been a financial burden on the healthcare system. The burden has been exacerbated by the limiting of hospital reimbursements by Centers for Medicare and Medicaid Services since 2008 (Kramm, 2018). CAUTI is also associated with an increased length of hospital stay.
The current policy gives registered nurses the responsibility to ensure that all urethral catheter insertion is done under sterile technique. Two RNs are supposed to be present during the insertion. One completes the insertion while the other observes to ensure the process is done under sterile technique. The last part of the policy covers documentation. Despite the policy being effected, the hospital’s CAUTI rates have not changed over the previous two years.
The hospital’s current policy of using an aseptic technique promotes sterility, thus minimizing the risk of catheter-associated urinary infections. Sterility during the CAUTI procedure reduces the possibility of bacteria entering the bladder during insertion, thus reducing the development of infection. Nurses should therefore perform appropriate hand hygiene before and after catheter insertion. The use of the appropriate sterile solution for cleaning ensures adequate hand hygiene. Employing a sterile technique promotes reasonable aseptic procedures and evidence-based best practices.
Requiring two registered nurses to be present for the procedure promotes integrity within the profession, enables them to learn from each other, and improves their skills. Having two nurses carry out the process decreases the risk of error and directly enhances patient safety.
The sterile procedure, aseptic technique, and catheter insertion is lean and not updated accordingly. New regulatory guidelines have been introduced in the recent past to keep up with research recommendations. Current CDC guidelines are more comprehensive and take account of a myriad aspects of catheter insertion (CDC, 2021). Such guidelines include the appropriate time to use catheters, how to insert catheters, patients not to use catheters on, and guidelines on the use of internal and external catheters. The policy fails to consider safety reminders and the need for a new catheter kit not to be contaminated. The failure to implement new guidelines leads to more CAUTI cases. The costs related to higher CAUTI rates will continue to be a financial burden on the hospital if changes to the policy are not initiated. A new policy will lower CAUTI rates and ease the financial burden on the hospital.
The two-nurse rule, however positive, might be counter-productive to the hospital in some cases. A second registered nurse may not be available for the procedure in emergency cases. The policy does not indicate what should be done in such circumstances. This scenario puts the hospital, nurses, and patients at risk. Requiring a second nurse for catheter insertion might put other patients behind care resulting in nurses doing extra hours on their shifts. It costs extra money on labor, which the hospital is trying to save. The policy fails to mention the steps to determine if catheter insertion is even needed. It does not also include the training and education of nurses on catheter care and appropriateness. There are no follow-up maintenance and precaution, which are crucial because CAUTI is still at risk with this procedure. Since CAUTIs are not covered by Medicare or the patient, nurses must appreciate the severity of the infections to the patient and the cost to the hospital to ensure they can carry out the procedure safely without the presence of another registered nurse.
The weaknesses analyzed call for the growth and improvement of the hospital’s policy on CAUTI. It should be expanded and provide more resources to address how nurses should carry out insertion and follow-up maintenance to curb continued infection risk. The policy should also be up to date with the current regulatory guidelines. Current guidelines are more specific and have more directives covering adherence monitoring, prevention practices, and incidence rates (Krammer, 2018). The policy should also cover other urination methods and the need for the procedure. Decreasing catheter insertions ultimately can serve as a financial opportunity for the hospital. Decreased CAUTI rates will also lower the financial burden and the legal risks involved with new infections. Amending or expanding the two nurse rule regarding emergency situations will lower ethical, quality, and safety concerns.
CAUTIs threaten a patient’s life in regard to mortality and morbidity. They also expose the hospital to financial and legal threats (Krammer, 2018). When CAUTI cases go up, the hospital covers the financial cost of CAUTI cases. Patients who contract CAUTI may sue the hospital if the deem the hospital responsible for negligence. Most nurses prefer catheters for their convenience, thus increasing the risk for patients. Catheter insertion also poses safety and ethical risks. Nurses may be caught in an ethical dilemma if they have to leave their patient to attend another during catheter insertion. In emergency situations, having two nurses attend a catheter insertion patient may not be possible due to shortage of staff. Pulling another registered nurse from other duties could leave other patients unattended, increasing the risk for error and diminish safety and quality standards.
Recommendations for Change
As indicated earlier in the opportunities section, the hospital’s policy on CAUTI should be expanded and provided with more resources to address catheter insertion and follow-up maintenance issues to curb continued infection risk. The policy should also be up to date with the current regulatory guidelines, which are more specific and have more directives covering adherence monitoring, prevention practices, and incidence rates. The policy should also cover other urination methods and the need for the procedure to decrease catheter insertions ultimately.
The policy should indicate that catheter insertion should only be carried out when medically necessary. The procedure should also be carried out only under physician orders. This provides an easier way to monitor the intake and output of patients. The process should also include the protocol for daily patient evaluation and continual infection prevention. The provision of feedback and auditing compliance should be added to the policy. References and standardized skills manuals for nurses in the policy should be updated to meet the current specifications. The policy should recommend an aseptic insertion technique. Emphasis on hand hygiene is vital. WHO and CDC provide guidelines for hand hygiene. RNs inserting catheters should have received proper competency-based training on sterility techniques. CDC HICPAC guidelines recommend that staff involved in catheter insertion and follow-up maintenance receive training and education (Letica-Kriegel et al., 2019). The hospital should provide routine audits to confirm that the sterility technique is being followed properly. Outside the police, the hospital should cultivate a culture committed to evidence-based practice and ways to improve catheter insertion. The formation of catheter teams and champions can also help support the insertion process, follow evidence-based guidelines, and keep best practices.
CDC. (2021). Catheter-associated urinary tract infections. Centers for Disease Control and Prevention. Web.
Kramm, Wallace. (2018). Catheter-associated urinary tract infection reduction: A quality Improvement Project. University of San Francisco. Pp 1-62. Web.
Letica-Kriegel, A., et al. (2019). Identifying the risk factors for catheter-associated urinary tract infections: a large cross-sectional study of six hospitals. BMJ Open, 9(2), e022137. Web.