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Centers for Medicare and Medicaid Services (CMS) Essay

Procedure Until recently it was not uncommon for patients admitted to an acute care facility to have an indwelling catheter anchored for unnecessary reasons. Patients that came in thru the emergency department typically were sent to the units with unnecessary indwelling catheters in place and it was not unusual for a surgery patient to have an indwelling catheter anchored before or during a procedure. Once a patient was admitted and was transported to the units nursing would also anchor indwelling catheters for multiple unnecessary reasons.

These Catheters could be anchored for many unnecessary days and in some cases until discharge. In 2008 the Centers for Medicare and Medicaid Services (CMS) initiated a policy change to no longer reimburse hospitals for additional cost that were incurred due to catheter associated urinary tract infections or in another term CAUT’Is (Palmer, 2013). The CMS recognized that CAUTI’s are the most common type of hospital acquired infection. The CMS also determined that when evidence based practices are initiated and followed they can be highly preventable, leading to a change in practice.

Current Practice

Up until 2012 there were no policies pertaining to the anchoring or removal of indwelling catheters in the facility I work for. Nursing would complete their assessment of the patients and per their discretion they would determine if an indwelling catheter by their standards is appropriate. An indwelling catheter could be deemed appropriate according to nursing for multiple reasons including; urinary incontinence, retention, convenience, pressure ulcers, strict output recordings and in some cases per patient request. The nurse was required to obtain an order from the physician in order to anchor a catheter and most cases the physician would comply. After the nurse anchored a catheter it would most likely stay anchored until discharge or until and order was given by the physician to discontinue it. These procedures lead to the unnecessary length of times catheters were kept in place and the need for change.

Rational and Explanation

Even though in 2008 Medicare and Medicaid changed their reimbursement policies it wasn’t unit 2012 when the Joint Commission added guidelines for the prevention of CAUTI’s and the facility I work for initiated change. Prior to the Joint Commission’s new guidelines management relied on nursing to make the proper decisions for their patients and supported nursing when they deemed it necessary to anchor a catheter. In 2012 when the guidelines were initiated management chose to follow them when evidence based research supported CAUTI’s were preventable when the appropriate protocols were followed. Hospital management initiated evidence based practices that were supported by CMS and the Joint Commission that would assist nursing on when anchoring a catheter was necessary.

The team responsible for these changes included the clinical manager in charge of all medical surgical units, each medical surgical unit manager where these changes were to take place and the medical surgical educator. This team reviewed evidence based research and practices on how to improve CAUTI’s and thru this research came up with a plan to implement nurse driven protocols that would be beneficial to our facility. These protocols instructed nursing, thru protocols on the patient’s EMR to guide nursing when anchoring a catheter would be appropriated and it also gave nursing the ability to remove a catheter when it was deemed unnecessary. After the protocols were initiated management began to notice a decrease in the use of catheters and a decrease in CAUTI’s resulting in cost effectiveness and higher patient satisfaction scores for the hospital.

References
Bernard, Michael S, Hunter, Kathleen F, Moore, Katherine N. (2012). A Review of Strategies to

Decrease the Duration of Indwelling Urethral Catheters and Potentially Reduce the Incidence
of Catheter-Associated Urinary Tract Infections. Urologic Nursing, 32 (1): 29-37.

Carter, Nina M, Reitmeier, Laura, Goodloe, Lauren R. (2014). An Evidence-Based Approach To the Prevention of Catheter-Associated Urinary Tract Infection. Urologic Nursing, 34 (5):

238-45.
Hooton, T., Bradley, S., Cardenas, D., Colgan, R., Geerlings, S., Rice, J., Nicolle, L. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary track infection in adults: 2009 international clinical practice guidelinges from the infectious diseases society of America. Clinical Infectious Diseases, 50(March): 625-663. Knoll, Bettina M.; Wright, Deborah; Ellingson, LeAnn; Kraemer, Linda; Patire, Ronald; Kuskowski, Michael A.; Johnson, James R. (2011). Reduction of Inappropriate Urinary

Catheter Use at a Veterans Affairs Hospital Through a Multifaceted Quality Improvement Project. Clinical Infectious Diseases. Vol. 52 Issue 11, 1283-1290. DOI: 10.1093/cid/cir188.

Mori, C. (2014). A-Voiding Catastrophe: Implementing a Nurse-Driven Protocol. MedSurg Nursing. 23 (1), 15-28.

Clinical Implications

An implemented change that would reduce the rates of CAUTI’s in acute health care facilities would be evidence based nurse lead protocols. The protocols would not only benefit the hospitals but they would also contribute to patient satisfaction scores. Approximately 80% of all nosocomial infections are contributed to CAUTI’s and are the most common form of nosocomial infections (Knoll, 2011). Some of the symptoms that contribute to the patients discomfort include hematuria, flank pain, fever and in some cases altered mental status. After a patient develops a CAUTI the patient receives the recommended treatment of antibiotic therapy.

Antibiotic therapy could last up to 7 days which could result in an increase of stay (Hooton et al., 2010). Evidence supports that when nurse led or informatics led interventions are implemented CAUTI’s were decreased (Bernard, 2012). The interventions that assist in the prevention of CAUTI’s are protocol bundles that include insertion policies, removal policies, maintenance policies and competency training (Carter, 2014). If the proper prevention measures are implemented patient satisfaction scores would improve, infection rates would improve leading to a decrease infection rate and shortening patient’s length of stay.

Recommended Changes

If the prevention protocols that are listed above were implemented changes would occur that would lead to multiple benefits for both the acute care facilities and the patients. Extended hospital days due to CAUTI’s has added to approximately 90,000 days per year and due to Medicaid and Medicare no longer paying the associated cost for CAUTI’s the hospitals out of pocket expenses are estimated at approximately 424 million dollars per year (Mori, 2014). The changes that are discussed and supported in this research paper would have a positive impact on decreasing this data. If the protocols are implemented not only would they benefit the patient’s but they would also benefit the hospitals. Patients would have a decrease risk in acquiring nosocomial infections and hospitals would have the opportunity to use the millions they are losing to benefit the patients. The hospitals could apply the money they are losing for research and/or other areas to improve overall satisfaction, increasing hospital census.

Stakeholders

The stakeholders in implementing this change at the facility I work for would be the unit managers and the nurse educators in the units where these changes would take place. For the unit managers the increased costs that are acquired due to CAUTI’s would have a direct impact on them along with the patient’s overall satisfaction scores. The evidence based research that would be implemented would be presented to the unit managers and the nurse educators. The unit mangers would be the ones to determine if and when the new protocols would take effect. The nurse educators would be the ones educating staff on the new protocols and would be a vital part of evaluating the protocols along with suggesting and implementing changes if necessary. Change would happen in stages with the first stage being the unfreezing stage.

This stage occurs when stakeholders receive the information on a change along with supporting evidence to why the change would be beneficial. The second step would be the moving stage. This is the stage when goals and dates are set to when the change is to take place. The refreezing stage is the last stage. The refreezing stage is when the change is implemented and becomes hospital protocol. The end stage is when the nursing staff would need the most support until the change becomes the hospitals new standard (Cherry & Jacob, 2010). The steps listed will assist getting everyone on board with the change and complying with it.

Barriers

Anytime when new protocols or procedures are implemented barriers may occur. Not everyone is open to change and many may have a hard time adjusting. Many nurses have been following the same policies and procedures for many years and may be noncompliant due to habit. Another barrier may be the patients, “frequent fliers” or patients that frequent the hospital regularly have become accustomed to old protocols and may not be receptive to change. The frequent fliers are used to coming in and requesting catheters so they don’t have to get up to the bathroom or if they have incontinency issues. Management and the educators will have to work diligently with nursing to initiate change and nursing may have a difficult time adjusting to the change along with educating patients and enforcing the protocols.

Strategies

Strategies to overcome the barriers of change would include using Lewin’s Change Theory. This theory suggests that change should be initiated slowly and making the necessary changes with only the staff that would be involved (Cherry & Jacob, 2010). Management and the nursing educator should provide staff with the evidence based research as to why the change is being made so nursing can understand why the change is necessary. By following these strategies nursing may be more compliant with the change and can be better advocates for the patients.

Application of Findings

CDC guidelines recommend catheters to be inserted for necessary reasons which include urinary retention, strict intake and output, certain surgical procedures, healing for pressure ulcers in incontinent patients and in palliative care patients (Gray, 2010). As research has provided indwelling catheters should be placed only when deemed necessary and removed when they are unnecessary. The facility I work for along with quality control and the nursing educator put together CAUTI prevention strategies using evidence based research practices.

Protocols were initiated in the patient’s electronic medical record (EMR) that would assist nursing in making the right decision whether to cath or not and when it would be appropriate to remove an indwelling catheter. The charge nurses monitor the number of catheters each unit has and researches if they are deemed appropriate to keep anchored. All of these measures have decreased the occurrences of CAUTI’s in the facility I work for. Continued monitoring by quality control is still needed to insure assessments are completed properly and to monitor if the measure the protocols are working.

References

Bernard, Michael S, Hunter, Kathleen F, Moore, Katherine N. (2012). A Review of Strategies to

Decrease the Duration of Indwelling Urethral Catheters and Potentially Reduce the Incidence
of Catheter-Associated Urinary Tract Infections. Urologic Nursing, 32 (1): 29-37.

Carter, Nina M, Reitmeier, Laura, Goodloe, Lauren R. (2014). An Evidence-Based Approach To the Prevention of Catheter-Associated Urinary Tract Infection. Urologic Nursing, 34 (5):

238-45.
Cherry, B., & Jacob, S. (2010). Contemporary Nursing: Issues, Trends, and Management. (5th ed.) St. Louis, MO: Mosby Elsevier.
Gray, M. (2010). Reducing catheter associated urinary tract infection in the critical care unit. AACN Advanced Critical Care, 20(3), 247-257.
Hooton, T., Bradley, S., Cardenas, D., Colgan, R., Geerlings, S., Rice, J., Nicolle, L. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary track infection in adults: 2009 international clinical practice guidelinges from the infectious diseases society of America. Clinical Infectious Diseases, 50(March): 625-663. Knoll, Bettina M.; Wright, Deborah; Ellingson, LeAnn; Kraemer, Linda; Patire, Ronald; Kuskowski, Michael A.; Johnson, James R.
(2011). Reduction of Inappropriate Urinary

Catheter Use at a Veterans Affairs Hospital Through a Multifaceted Quality Improvement Project. Clinical Infectious Diseases. Vol. 52 Issue 11, 1283-1290. DOI: 10.1093/cid/cir188.

Mori, C. (2014). A-Voiding Catastrophe: Implementing a Nurse-Driven Protocol. MedSurg Nursing. 23 (1), 15-28.


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