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Locate an evidence-based article published in a peer-reviewed journal. You can use one of the articles on your Evidence Summary Table. Use the evidence hierarchy attached to determine the level of evidence in the article. Refer to your text and other resources to assist in identifying the specific design of your selected article. Think of this discussion assignment as a practice paper with a title (name of assignment), introduction, APA formatted headings, and references. This post must reflect proper sentence structure, spelling, punctuation, and basic rules of grammar. ANSWER THESE QUESTIONS??? Introduction (do not use the word Introduction as a heading): What sparked your interest in this topic? End with the following thesis statement: This post provides a discussion of the level of evidence and research design from the selected article, Title. Research design (level 1 heading): What is the research design of the article? State your rationale for determining the research design and identify the resources that you used to support your determination. Level of evidence (level 1 heading): Based on the evidence hierarchy table in the module resources, what level of evidence is reflected in the article? Provide a brief explanation of your rationale and identify the additional resources that you used to assist in determining the level of evidence. References (level 1 heading; hanging indent not necessary for discussion boards): the article, the text, and any other resources used. Attach a copy of the article to the post. ARTICLE Reduction of Catheter-Associated Urinary Tract Infections Through the Use of an Evidence-Based Nursing Algorithm and the Implementation of Shift Nursing Rounds: A Quality Improvement Project Thomas, Kamishia L.Author Information Complete Reference Abstract Catheter-associated urinary tract infections (CAUTIs) are the most common hospital-acquired infections. The purpose of this quality improvement (QI) project was to successfully implement a nurse-led evidence-based practice change designed to reduce CAUTIs in a cardiac intensive care and step-down unit. The QI project was implemented using a convenience sample of patients admitted to the cardiac intensive care and step-down unit. Evaluation data were collected 3 months pre-implementation and 9 months postimplementation. We used Wick’s Check-Plan-Do-Check-Act model of continuous QI to guide the project. A statistically significant change in the number of CAUTIs (P = .009) and CAUTI occurrences (P = .005) was observed following the intervention. The number of indwelling catheter days and indwelling catheter utilization did not significantly differ following implementation of the intervention. Nurse compliance with the intervention was computed for each month; the average compliance rate was 91%. Findings from this project indicate that a nurse-led evidence-based practice project exerted a positive influence on CAUTI occurrences. Introduction Hospital-acquired infections are associated with increased length of stay, financial burdens, and a negative impact on health-related quality of life.1 Catheter-associated urinary tract infections (CAUTIs) are the most common hospital-acquired infections; 40% of all hospital-acquired infections are attributed to CAUTIs.2 A CAUTI is defined by the Centers for Disease Control and Prevention3 as a urinary tract infection that is acquired when an indwelling urinary catheter has been in place for greater than 2 calendar days on the date of the event; occurrence rates are calculated as: number of CAUTIs/(number of indwelling urinary catheter days) × 1000. Indwelling urinary catheter days are expressed as the total number of patients with an indwelling urinary catheter at the same time once in a 24-hour period. Indwelling urinary catheter utilization is expressed as the number of patient days/number of indwelling urinary catheter days.4A cardiac intensive care and step-down unit at a 536-bed teaching hospital in the southeastern United States experienced an increase in the rates of CAUTI. Although the healthcare system as a whole had a CAUTI rate of 2.19 per 1000 catheter days for the fiscal year of 2012, the 28-bed cardiac intensive care and step-down unit had a CAUTI rate of 3.79 per 1000 catheter days, with a surge in the last quarter to a CAUTI rate of 10.53 per 1000 catheter days. The final quarter CAUTI rate was significantly more than the 90th percentile of the National Healthcare Safety Network benchmark.4These findings prompted development of an evidence-based quality improvement (QI) project designed to reduce CAUTI rate on the cardiac intensive care and step-down unit. The QI project had 2 aims: (1) to improve patient outcomes through the reduction of CAUTIs, CAUTI rates, indwelling urinary catheter utilization rates, and indwelling urinary catheter days, and (2) to assess utilization and compliance with indwelling catheter nursing rounds completed 3 times daily (10 am, 4 pm, and 10 pm), and a nurse-driven catheter removal algorithm.Project Design A pre/postdesign guided data collection and analysis. The project setting was a 536-bed teaching hospital that is part of a larger not-for-profit healthcare organization encompassing 5 hospitals, 2 medical centers, and 3 urgent care centers located in southeastern United States. The facility is a Level II Trauma Center with 4 adult intensive care units (medical, surgical, neuroscience, and cardiac). The cardiac intensive care and step-down unit is a 28-bed unit with 14 designated intensive care unit beds and 14 designated step-down unit beds. The cardiac intensive care and step-down unit mainly cares for patients with myocardial infarctions after percutaneous interventions. The unit also provides care for patients with heart failure and cardiogenic shock, respiratory failure requiring ventilator support, septicemia, and cardiac arrhythmias.The QI project incorporated all patients admitted to the cardiac intensive care and step-down unit who required indwelling urinary catheters; patients with long-term indwelling urethral or suprapubic catheters did not participate. We also solicited participation of the unit’s 36 RNs. This heterogeneous group ranged in age (21 to 65 years), in academic preparation (diploma, associate degree, and bachelor of science) and clinical experience (<1 to >40 years). Project procedures were reviewed by and exempted from individual consent requirements by the institutional review boards at Duke University and the implementation site. Intervention The intervention was a nurse-driven protocol (Figure 1). The Wick Check-Plan-Do-Check-Act (CPDCA) model of continuous QI guided the project.5 According to the CPDCA model, successful implementation relies on identifying a problem, developing a plan to rectify the problem, implementing the plan on a small scale, monitoring results, and sharing the results. It is then necessary to determine if the intervention resulted in the desired outcome and determine how this experience will influence policy and/or procedure changes at the organizational level.5 Using the CPDCA model’s sequence of actions, the unit’s and healthcare system’s existing problem was identified through meetings and interviews with the unit director, chief nursing officer, critical care clinical nurse specialist, and unit nursing staff who confirmed that the existing nurse-driven algorithm for indwelling catheter removal was not being adequately implemented in daily practice. FIGURE 1 Protocol. Implementation Process The implementation process comprised 5 steps. We completed a 3-month evaluation of CAUTI occurrences, indwelling urinary catheter utilization rates, and indwelling urinary catheter days prior to implementation of the intervention. We held a skills fair to educate nursing staff about insertion technique, proper care, and appropriate indications. Nurses were also educated about the existing evidence-based nursing-algorithm promoting assessment of indwelling urinary catheters and removal of nonindicated indwelling urinary catheters without a physician order.We developed a nursing round sheet for catheter tracking; rounding times were determined through feedback from end users and the unit director. The rounding sheet included 7 columns: the first column documented the room number. The remaining columns queried presence of an indwelling urinary catheter; proper labeling of urinary catheter system including time, date, and place of insertion; appropriate management and care of the indwelling urinary catheter system; indication for its ongoing use; and discontinuation of the catheter based on the protocol during nursing rounds. Nursing rounds were held 3 times daily at 10 am, 4 pm, and 10 pm.Following these steps, we conducted a 9-month postimplementation evaluation of CAUTI occurrences, indwelling urinary catheter utilization rates, and indwelling urinary catheter days. Compliance with indwelling catheter nursing rounds and the nurse-driven catheter removal algorithm was measured through a fidelity outcome operationally defined by the equation: total number of indwelling nursing rounds performed/total number of days in the project period × 3. Clinical outcomes data were collected 3 months before and 9 months after implementation by the health system’s infection prevention analyst. Fidelity (compliance) outcome data were collected during the 9-month intervention phase. Statistical analyses were completed using Statistical Package for the Social Sciences, version 20 (SPSS, Chicago, IL). Because data were not normally distributed, the Mann-Whitney U test was used to compare data pre- and postimplementation. The alpha value was set at .05.Meaningful Feedback and Strategies to Ensure Sustainability Meaningful feedback was shared with staff using several mechanisms. We used a bulletin board that was visible to staff, patients, and visitors to present data, summarizing the number of CAUTIs and indwelling urinary catheter days. Data were also shared at monthly staff meetings, giving staff an opportunity to provide feedback. After successful implementation, results were also shared with the healthcare system’s CAUTI Task Force; this enabled them to decide if the program could be successfully implemented at the organizational level.I believe that the use of the CPDCA model was essential to the project’s success and that aligning the intervention with goals of the unit and the healthcare system was critical to its sustainability. At the unit level, sustainability was attributable to 2 main factors: (1) the observable improvement in CAUTI patient outcomes and (2) the shift to continued use of nursing rounds for assessing indwelling urinary catheters indications. At the organizational level, monitoring the results of this QI project and sharing the outcomes and barriers of this project with the existing healthcare system’s CAUTI Task Force enabled the healthcare system to incorporate this evidence-based practice into healthcare system policies. Outcomes Clinical outcomes used for the QI project, the number of CAUTIs, the number of indwelling catheter days, CAUTI occurrences, and catheter utilization are summarized in Figures 2 and 3 and Table 1. Fewer CAUTIs occurred following implementation (P = .009), as was the CAUTI rates (P = .005). The number of indwelling catheter days and catheter utilization rates did not significantly differ following project implementation. Nurse compliance with the 3 times daily indwelling catheter rounds was also measured; the mean compliance rate was 91%. FIGURE 2 Number of catheter-associated urinary tract infections. FIGURE 3 Catheter-associated urinary tract infection rate. TABLE 1. Analysis of Clinical Outcomesa Discussion The QI project described in this article reduced CAUTI occurrences during a 9-month postimplementation evaluation period. Following project implementation, the unit’s CAUTI rate was found to be less than the 10th percentile of the National Healthcare Safety Network benchmark.4 Nevertheless, only 2 of the 4 clinical outcomes (CAUTI rates and total number of CAUTI occurrences) reached statistical significance when compared to preimplementation data. In contrast, indwelling catheter days and catheter utilization rates did not achieve statistically significant differences before and after implementation of the QI project.Huang and colleagues6 implemented a similar QI project. Their aim was to evaluate the efficacy of nurse-generated daily reminders to physicians to remove unnecessary urinary catheters 5 days after insertion. The project comprised a 12-month observation phase, followed by a 12-month intervention phase, resulting in a significant reduction in the rate of CAUTIs (P = .009) and a decrease in the duration of urinary catheterization (P < .001).6Topal and coworkers2 compared physician notification through computerized order entry system to a nurse-driven protocol for indwelling catheter removal. The nurse-driven protocol allowed nurses to remove urinary catheters that were no longer indicated without a specific order. The study included all patients consecutively admitted to 4 general medical units; CAUTI rates were evaluated at baseline and at 1 and 2 years following implementation of the protocols. They found an 81% reduction in indwelling urinary catheter use, 79% reduction in indwelling catheter days, and a 73% reduction in CAUTI occurrences.2Elpern and colleagues7 reported outcomes of a QI project designed to limit the use of indwelling urinary catheters via daily evaluations of the appropriateness of catheter use, and recommendations for catheter removal when appropriate indications were not present. The project included patients consecutively admitted to a 21-bed medical intensive care unit that provided intermediate and critical care to adults. Catheter-associated urinary tract infection rates and indwelling catheter utilization were measured 11 months pre- and 6 months postimplementation. Catheter days were reduced from a mean of 311.7 to 238.6 days per month, and the duration of urinary catheterization was reduced from 7.0 ± 1.1 to 4.6 ± 0.7 days.7Our findings are similar to these reports. However, these authors reported significant reductions in not only CAUTI rates but also indwelling urinary catheter days. Despite this difference, the findings from our QI project indicate that a nurse-led evidence-based practice can have a positive influence on CAUTI occurrences. The success of this QI project may primarily be attributable to a shift in the nursing care culture. The fidelity outcome showed a 91% compliance rate with the 3 times daily indwelling catheter rounds during the 9-month implementation phase.Challenges were experienced when implementing this QI project. The nursing algorithm that allowed nurses to remove nonindicated indwelling urinary catheters promptly was introduced a year prior to the implementation of this project. Investigation of the high CAUTI rates revealed that nurses were unaware of the protocol and were not comfortable with removing catheters without a physician order. The involvement and support of the stakeholders, which included the unit director and chief nursing officer, allowed the nurses to embrace the protocol. Education at the skills fair was also a key component in overcoming these barriers to a practice change. In addition, I believe that education about the need for prompt catheter removal and support from senior leadership also empowered nurses to follow the protocol.Conclusion The use of the CPDCA framework allowed for the successful implementation of a nurse-led evidence-based practice change targeted at the reduction of CAUTIs on a cardiac intensive care and step-down unit. The success of this QI project was predicated on the shift in nursing care culture.KEY POINTS ACKNOWLEDGEMENT The author thanks Dr Jane Blood-Siegfried, Capstone Committee Chairperson; Dr Margaret Bowers, Capstone Committee Member; Dr Theresa Brodrick, Capstone Committee Member; and Teri Wyatt, Unit Director, for the support and guidance. The author is also appreciative of the statistical support and data analysis from Dr Julie Thompson and Melissa Morgan.

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