RUNNING HEAD: QUALITY IMPROVEMENT 1

Quality Improvement Project

Kelsey Reid

Bon Secours Memorial College of Nursing

Professional Role Development: Servant Leadership

Pryor NUR4144

10/24/18

I pledge
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QI project

The Coronary Care Unit (CCU) is an intensive care unit that is focused on the heart. They

receive patients who suffered from a myocardial infarction, unstable angina, arrhythmias,

electrolyte imbalances such as sodium or potassium issues, transcatheter aortic valve

replacements, and some other heart issues. At Bon Secours St. Mary’s hospital, the CCU is an

eight-bed unit with a 1:2 patient ratio. All of these patients are hooked up to continuous cardiac

monitoring, heart rate, blood pressure, and oxygen saturation monitors. They’re monitored all the

time and shown at the nurse’s station to alert them if a rhythm has changed or the patient’s vitals

are abnormal. As well as being on continuous monitoring, a lot of these patients have many IV’s,

central and PICC lines, drains, some are intubated or have tracheostomies, as well as Foleys.

These patients are very sick and at a high risk of infection due to all the lines and attachments

they have in their bodies. One of the many quality improvement projects going on in this unit is

trying to eliminate the use of Foleys. In some cases, a Foley catheter is the only option for some

of these patients but not all of them. It puts them at increased risks of infection due to the Foley

pushing and accumulating bacteria into the bladder or urethra thus creating a urinary tract

infection.

The goal of this project is to eliminate some of the unneeded lines these patients have.

They try to pull Foley catheters and central lines as soon as possible to help reduce the risk of

further infection. A lot of these patients are on bed rest due to their illness, so they’re at risk for

lung infections, pressure ulcers and many others associated with hospitals. By reducing the

entryway for infections to invade the host, infections acquired in the hospital will decrease

allowing the patients to be able to recover quickly and get back to their normal life.
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There are many risk factors for catheter-acquired urinary tract infections such as

prolonged catheterization, use of systemic antibiotics, other active infections, diabetes mellitus

and elevated creatinine (Parida, S. & Mishra, S. (2013). All of these are very prevalent in the

Coronary Care Unit making these patients at a very high risk. Malnutrition also plays a factor

which is relevant because a lot of these patients aren’t allowed to eat due to having tests done or

being intubated. Their main source of nutrition is usually TPN or tube feedings.

The outcome of this project is to help reduce infections within this population of people

specifically catheter-acquired urinary tract infections. By using different resources, pulling foleys

out in a timely matter and using proper hygiene; they hope to reduce these risks. To evaluate this

outcome, they’re going to implement these interventions into practice and compare the number

of urinary tract infections with the number of infections occurring last year. This will tell them if

some of the interventions worked and what needs to be integrated into practice.

Heart Domain

As a nurse manager facing this issue, it’s important to stop and reflect on one’s own

opinion of the issue. To be able to do this, people need to understand when the proper use of a

foley catheter is appropriate. According to the U.S. Department of Health and Human Services,

Foley catheters are only supposed to be used for output monitoring in unstable patients, voiding

management and some surgical procedures. They are not supposed to be used for incontinent

issues (Nicolle, L. (2008). As nurses, it’s important to remember the outcomes of the things we

do to our patients. It can be very time consuming, aggravating, and draining to constantly have to

change your incontinent patient but the easy option of using a foley is an unsafe option for that

patient. Foley catheters are responsible for 40% of the infections acquired by hospitals (Nicolle,

L. (2008). A significant goal for nurses is to establish trust with their patients as well as the
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patient’s family members. They need to know that when they come to the hospital, they’re

getting the best care possible. They’re already going through enough stress and trying to heal

from their injury; they don’t need to worry about acquiring another infection from the hospital.

To help fix the issue with Foley catheters, it’s a good idea for the nurse to be transparent and

look at the different perspectives from the nurses, patient and doctor’s standpoint. This way you

can see issues from each party and be effective in finding a way to benefit every side. If more

people are pleased and happy, then the outcome will be better and you’re more likely to get

positive results. As a leader, it is important to be humble and open to different ideas or thoughts

from your coworkers. This shows that you’re vulnerable and confident in your approach and

ability to lead. Eventually, this will bring trust and empower your unit to work together as a team

to provide the best care possible. Also, by showing your wisdom, experience, and knowledge to

others, it will impact other units to do the same thing. In the end, it will allow you to help more

people and be an example to others.

Head Domain

Bon Secours mission statement is to give good help to those in need. If someone comes

into the hospital who is already sick and gets a hospital-acquired urinary tract infection, is that

good help? As a healthcare team, it's important to understand the benefits and risks for the

equipment we use. People need to realize the outcomes of their actions and think through if a

urinary catheter is actually important or needed in each client’s different situation. Every patient

is different and should be treated as so. Bacteria accumulate in the urine bag and slowly travels

up the tube that is inserted into the bladder creating an infection (Nicolle, L. (2008). Urinary tract

infections can be very minor, but if left untreated could lead to sepsis.

Hands Domain
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A way this can be changed is through performance planning. As a nurse manager, they

can provide direction and clear communication about what needs to be done. They can set goals

so that the employees know exactly what is expected of them. Weekly meetings can be held so

that everyone can voice their opinion on how to fix and prevent patients from acquiring a urinary

tract infection from a foley catheter. A nurse manager can observe performances from the nurses

on the unit to see if there is something that needs to be changed. By doing day-to-day coaching,

the nurse manager can praise those who do a good job but also demonstrate and coach others

how to be better. It’s important to get everyone’s opinion and ideas on how to implement a

change so everyone is included. You can combine ideas to make something happen to make our

health care better for our patients.

Habits Domain

Hospital-acquired infections are a huge safety issue within hospitals that need to be

addressed. One of the jobs of a nurse manager is to help prevent issues from recurring. I believe

that as a respectable leader it is important to be in solitude for a short period of time and pray

about what you are being called to do. Get your own thoughts together and figure out a plan

before you go before others. The first step to help prevent urinary tract infections acquired by

urinary catheters would be education. As a nurse manager, I would instruct the employees to do

an annual training on when the proper use of a catheter should be used, how long it should be in

place, the proper way to insert it, and other options that are available. Strick hospital-wide

guidelines need to be in place on how long a foley catheter needs to be in place. If a patient

needs a foley, the nurse can fill out a form or document in the chart of why they need it, when it

was placed, and have an order the day it needs to be removed. Also, foley bags need to be

emptied regularly so bacteria don’t start to form. Foleys should be used as a last option. If the
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patient is able to safely get up and use the bedside commode, then they should be allowed to do

that and use a plastic hat to measure the urine if needed. Also, new equipment has come out

called a purwick and condom catheter. The purwick is for females and is hooked up to the wall

suction. It is great for incontinent patients so the urine doesn’t sit directly on the skin causing

skin breakdown leading to more issues and risks of infection. You can also keep track of how

much they’re urinating by the suction canister. The condom catheter is for males and is less

invasive then foleys. All of these things should be implemented before the use of a urinary

catheter. If the only option you have is to use a urinary catheter, then you need to use sterile

technique when inserting it and use proper hygiene techniques. Education for the patient is

important too so they don’t constantly touch or pull at the tube. Making sure that the urinary

catheter is cleaned properly with each shift is an important way to help prevent further infections.

Model the Way

As a leader, it's important to understand your own beliefs and values. Values shape the

way you act and make decisions. If you stand strongly by your beliefs instead of bending when

faced with resistance, then you’re a good, strong, dependable leader. If you aren’t consistent with

your values, you will not be a consistent leader. Beliefs and values help you to envision your

main goal and stick to it. It is also important to ensure that your organization reflects your own

values. For example, if you work for Bon Secours, then you should have respect, integrity,

stewardship, and grace. As a leader, you need to show the people the right way to do something.

You’re constantly being watched by others. As a nurse manager on CCU, I would instruct and

demonstrate how to properly insert a foley. I would assist the nurses a few times to watch and

observe them placing one. By doing this, I am seeing first hand if someone is doing it right or if

they need more training. Sometimes nurses do things so many times, they go for the quickest
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way to save time. They’re very busy and forget the right technique to do something. This would

also allow me to assess if the unit would need more training. I would praise the employees who

accomplished the goal and educate and guide those who were less successful. My new goal for

those would be to help ensure they were prepared and successful the next time.

Inspire a Shared Vision

A good leader needs to be ensured that everyone can see his/her vision. A common goal

is to make tomorrow a better day for yourself, your coworkers and your patients. It's important to

keep your employees or coworkers motivated. Controlling them will only make them stop once

the goal is reached rather than maintaining it. The vision here is for the use of Foley catheters to

decrease, therefore, decreasing infections. Expanding on this issue, if people didn’t use catheters

as much and actually had to get up to use the restroom, this could have many positive effects. It

would allow the patients to get up and get stronger, decrease the chances of acquiring atelectasis

or pneumonia, and helping them feel better if they aren’t always laying in bed. At the end of the

day, this allows patients to get well and out of the hospital faster (Parida, S. & Mishra, S. (2013).

Challenge the Process

Leaders must be alert and aware of the constantly changing elements in the healthcare

field. New equipment and evidence-based practices are constantly emerging with brilliant new

ideas. This is how the use of condom catheters and purwicks came about in hospitals. You will

never get anything done if you’re laid back and lazy. You need to be energized and search for

new ideas and ways to make your hospital or unit better. A good way to do this is to have

monthly meetings with our staff to go over the issues you face on a regular basis. This allows the

nurse manager to understand and see an issue they might not have seen before. Also, this allows
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the nurses to voice their opinion and be included in the decisions made. Maybe there is another

reason why nurses think its easier to place a foley catheter in rather than using a brief or

frequently changing their patients. A possible issue could be that skin breakdown and pressure

ulcers are a bigger threat than a urinary tract infection. This would bring up a good point and

give the nurse manager another issue to solve. By working as a team, you can make a huge

impact on your patients. It is also important to learn from your mistakes as well as your other

coworkers. Instead of blaming each other if something didn’t work properly, you should get

together and brainstorm a way to be better. Most people aren’t successful the first go around, but

they learn from that. Personal growth makes everyone stronger.

Enable others to Act

Trusting leaders nurture openness, involvement, and satisfaction amongst those they are

leading. If you don’t have a good framework and trust those around you, you won’t be

successful. It's also important to remember as a leader not to look down on your employees. If

they have a suggestion, then you need to listen fully and see if it could work or if a part of it

could work. When you work together you get a greater positive outcome. The coronary care unit

is a small unit that functions purely on the staff’s ability to function together as a team. They

have many responsibilities such as responding to codes in the hospital, helping out other units

with I.V. draws and interpreting rhythm strips, as well as taking care of their own patients. A

nurse manager cannot micromanage their employees because it breaks trust. By listening to the

other nurses’ concerns or questions about changing the way we use foleys within the hospital, it

allows their voice to be heard as well as encourage them to give feedback with their opinions.

When they feel included, they’re more likely to stay motivated and find a healthier solution.

Encourage the Heart

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Recognizing people who are doing a good job and staying on track is a good way to

motivate others to do to the same. You need to be creative and find a way to show appreciation

to your coworkers. A way to do this would be to have a unit competition to see if you would

reach a set goal of removing a set number of foleys out within a certain amount of time. Setting a

goal makes it easier to reach rather than just telling someone to do it. You could bring in treats,

deserts or buy lunch for the staff if the goal is reached. People like to be appreciated and know

their hard work is being seen.

Professional Practice Implications

Some interventions that would help reduce the risk of infections due to urinary catheters

are to reduce the number of inappropriate times when a urinary catheter is used, infection control

and timely catheter removal (Parker, V., Giles, M., Graham, L., Et all. (2017). Studies have

shown that bathing every day with chlorhexidine wipes have decreased the number of infections

in the intensive care setting (Frost, S., Alogso, M., Metcalfe, L. Et Al. (2016). It's important to

implement this into your care with patients and give them proper baths every day.

By the 30th day of catheterization, the risk of infection goes up to 100%. Closed drainage,

depended drainage including the proper positioning of the drainage tubing and collection bag and

protection of the drainage port can also help to reduce infection rates (Parida, S. & Mishra, S.

(2013). To prevent infections, other techniques such as briefs, condom catheters, and purwicks

should be tried first. If these options do not work or aren’t eligible for a patient, strict sterile

techniques must be in place. Educating the nurses on the proper way to set them up would be

beneficial. The collection system should always be in place below the level of the bladder but

should never touch the floor (Parida, S. & Mishra, S. (2013). Having the bag attached to the side

of the bed and clipping the tubes to the bottom sheet on the bed should help everything to stay in
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place the correct way. A simple thing both patients and nurses can do to help eliminate the risk

of infections is proper hand hygiene before and after touching the catheter. Some interventions

that are currently in place are bundles for catheter infection preventions, education, outcome

surveillance, process surveillance, feedback for catheter infection rates and performance of

infection control practices (Parida, S. & Mishra, S. (2013).

Outcomes evaluation

According to the CDC, urinary tract infections are the most common type of healthcare-

associated infection. About 75% of these urinary tract infections are caused by a prolonged use

of urinary catheters (Centers for Disease Control and Prevention, (2015). Studies have shown

that interventions combining best practice guidelines with staff engagement, education, and

monitoring have been shown to be more effective in bringing about change within a healthcare

facility (Centers for Disease Control and Prevention, (2015). An estimated cost of each catheter-

acquired urinary tract infection ranges from $1,200 to $4,700 (Parker, V., Giles, M., Graham, L.,

Et all. (2017). By making changes and implementing different strategies or tools to use besides a

urinary catheter, we can make a difference with our patients such as reducing the risk of further

infections, getting them out of the hospitals quicker, as well as, saving the hospital money by not

having to pay for unnecessary costs. A simple task such as limiting the use or time frame of

catheters can make a huge difference in our healthcare system. By being aware of the issues we

face every day, having the ability and knowledge to be able to speak freely about them and

implementing different factors into our everyday care; we will be able to make a difference not

only in our patient's lives but in how our health care system works overall.
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References:
Centers for Disease Control and Prevention, (2015), catheter-associated urinary tract infection.
Retrieved from https://www.cdc.gov/hai/ca_uti/uti.html
Frost, S., Alogso, M., Metcalfe, L. Et Al. (2016) Chlorhexidine bathing and healthcare-
associated infections among adult intensive care patients: a systematic review and meta-
analysis. Critical care doi: 10.1186/s13054-016-1553-5
Nicolle, L. (2008) Health Care-Acquired Urinary Tract Infection: The Problem and Solution.
U.S. Department of Health and Human Services. Retrieved from
https://psnet.ahrq.gov/perspectives/perspective/68
Parida, S. & Mishra, S. (2013) Urinary tract infections in the critical care unit: A brief review.
Indian Journal of Critical Care Medicine. doi: 10.4103/0972-5229.123451
Parker, V., Giles, M., Graham, L., Et all. (2017), Avoiding inappropriate urinary catheter use and
catheter-associated urinary tract infection: a pre-post control intervention study, BMC
Health Service Research doi: 10.1186/s12913-017-2268-2