Abstract
Because of their negative outcomes, catheter-associated urinary tract infections (CAUTIs) are a significant and rather widespread problem in long-term care. One of the potential interventions is daily bathing with 2% chlorhexidine gluconate washcloths. This intervention was used in a 100-bed long-term care facility unit with the intent of reducing CAUTI incidence in it. The quality improvement effort had a pre-test post-test design and involved 26 nurses and nursing assistants; only four older residents were able to remain in the project until its completion. The nurses were trained to apply the intervention, which resulted in statistically significant increases in their CAUTI prevention knowledge.
These changes were measured with a tailored tool and demonstrated by utilizing the Wilcoxon signed ranks test. The residents were bathed with the washcloths every day for two weeks, and their health and CAUTI status remained unchanged (based on their urinalysis data). The quality improvement project offers some evidence related to CAUTI prevention, including training and 2% chlorhexidine gluconate washcloths. The main limitations are that the samples were small and that the project took two weeks.
Introduction
Problem Description
A 100-bed unit, which is a part of a long-term care facility (nursing home) in the eastern part of the US, has been reporting a high prevalence of catheter-associated urinary tract infections (CAUTIs). The facility determined the problem by comparing the unit’s data to that of its other two units. The nursing home has established the goal of reducing its CAUTI rates because of the negative impact the issue can have on the residents of the facility. As a result, an intervention aimed at CAUTI prevention was developed.
Available Knowledge
The concern of the nursing home is supported by some relevant research. Thus, CAUTIs are confirmed to be a very significant problem that is also rather widespread (Centers for Disease Control and Prevention, 2017; Mitchell et al., 2019). The condition can affect the quality of life of residents with catheters and inflict significant harm, leading to negative outcomes, including death (Abbas & Sastry, 2016).
Also, the problem tends to prolong hospital stays and is rather costly (Mitchell et al., 2019; Swan et al., 2016). Since CAUTIs are a type of hospital-acquired infections, this issue is also directly associated with the quality of care provided by the facility, and a large percentage of CAUTI incidents may be classified as preventable (Schreiber, Sax, Wolfensberger, Clack, & Kuster, 2018). Such facts justify the task of preventing CAUTIs through improved practices.
In connection to that, it should be mentioned that nurses, including those working in nursing homes, might experience difficulties in preventing CAUTI. This problem can be associated with training, which several recent studies have found to be lacking (Jain, Thakur, Dogra, Mishra, & Loomba, 2015; Trautner et al., 2017). From this perspective, it may be necessary to equip the nurses of the project’s site with CAUTI prevention knowledge.
Long-term care can be considered a risk factor for CAUTIs. Indeed, CAUTIs are very frequently diagnosed in this setting, and older residents in nursing homes who need catheters are relatively likely to develop the condition (Abbas & Sastry, 2016; Jump et al., 2018). However, in the case of the described unit, the fact that it is performing worse than the other two units is a sufficient reason for looking into quality improvement options. To summarize, the literature implies that the described problem needs to be addressed.
Rationale
In order to ensure the evidence-based nature of the solution, it is necessary to consider the literature that reviews CAUTIs. The rationale for the use of chlorhexidine is that it is a very effective antimicrobial agent (Mitchell et al., 2019). Its application results in the removal of pathogens, which, in turn, prevents infections, including CAUTIs (Noto & Wheeler, 2015; Swan et al., 2016). Chlorhexidine is also a relatively cost-effective solution (Mitchell et al., 2019). In general, the mechanism of chlorhexidine’s ability to address the CAUTI problem is well-documented.
The question of the specific interventions that employ chlorhexidine’s properties is more significant and contentious. The claim that bathing with 2% chlorhexidine gluconate washcloths is effective in reducing infections is supported by reliable evidence, including randomized controlled trials (RCTs) and meta-analyses (Amirov & Candon, 2015; Huang, Chen, Wang, & He, 2016; Swan et al., 2016).
Some conflicting data were also provided for intensive care (Noto et al., 2015), but a recent meta-analysis by Huang et al. (2016) supports the effectiveness of chlorhexidine bathing after the review of 15 works, including RCTs and quasi-experiments. The recent data on the use of chlorhexidine bathing in long-term care are rather limited, but they are still present (Amirov & Candon, 2015). In summary, 2% chlorhexidine gluconate washcloths are a promising solution for CAUTI prevention, although more investigation of this intervention in long-term care could be helpful. As for the CAUTI training, training opportunities can improve the situation in case it is a concern in a particular facility (Jain et al., 2015). Therefore, the literature contains guidelines regarding the interventions that can be implemented to resolve the practice problem.
Specific Aims
The primary aim of the project was to assist the unit in bringing its CAUTI rates down through the introduction of an intervention evidenced to reduce CAUTI incidence. In addition, it was established that the appropriate application of the washcloths might need a brief training, which is why the secondary aim was to equip the nurses of the project’s site with the knowledge required to use the chosen intervention.
From this perspective, the project aimed to empower the nursing staff to reduce the CAUTI incidence in the unit. As for this report, its aim is to provide some information about the quality improvement effort, which was led by a nurse. This information can be of interest to specialists who are engaged in CAUTI prevention and quality improvement, especially in long-term care settings. Hopefully, the report can contribute some data related to CAUTI prevention in nursing homes (long-term care) and nurse-led quality improvements. The manuscript was prepared with the help of the SQUIRE (2015) framework.
Methods
Context
The project took place in a nursing home unit (100 beds). The unit has been reporting rather high CAUTI incidence, which was determined by the nursing home while comparing the performance of its three units. While it was not known at the time of the project’s planning, some of the nursing staff members also demonstrated gaps in CAUTI prevention knowledge. That information was discovered when the project had been already set in motion.
Intervention
The intervention that was proposed to deal with the problem of CAUTIs was daily bathing with disposable washcloths impregnated with 2% chlorhexidine gluconate. This CAUTI prevention solution was applied to a sample of four residents. Initially, five residents were successfully recruited, but one of them had to be transferred. The recruitment criteria included the residents’ age (between 65 and 90), CAUTI status (no CAUTIs), and urinary catheter use (an indwelling or suprapubic Foley catheter).
The process of the intervention’s introduction was guided by Lewin’s (1947) model, especially as related to the unfreezing stage. Based on the findings of the literature review and concerns of the unfreezing process, it was determined that training was required to ensure the appropriate implementation of the intervention and adherence to it.
All the nursing staff who could be involved in resident care attended a training session dedicated to CAUTI prevention and washcloths application. During the session, the relevant information was provided in the form of a lecture (20 minutes), hands-on demonstration (10 minutes), and instructional materials (handouts that remained with the staff for future reference). In addition, the staff members were provided with a checklist aimed at directing the procedure of caring for the residents. A total of 26 nurses and nursing assistants received the training.
Study of the Intervention
Both aspects of the intervention were measured to check their effectiveness. The CAUTI status of the residents was determined through dipstick urinalysis; they were also monitored for CAUTI symptoms. The training section was measured with the help of a tool that was developed to test the participants’ CAUTI knowledge. To be more specific, the tool tested the knowledge of the information covered by the training. The training, as well as the additional materials, including the checklists, was meant to reduce the possibility of nurses failing to apply the intervention correctly, which was supposed to minimize validity threats. In addition, the relative homogeneity of the samples was used to the same effect. The drawbacks of this approach will be discussed in the limitations section.
Measures
The interventions of the project were tested through a pre-test post-test design; the data were collected before the introduction of the interventions and after the event. The CAUTI knowledge tool produced a score, which corresponded to the number of correct answers. The tool was self-developed, although it used relevant literature for guidance (Jain et al., 2017). As a result, its reliability was not tested, although its face validity was determined due to its ability to check the understanding of the information contained in the training session.
Dipstick urinalysis determined the presence of leukocytes and nitrite in the residents’ urine, which is one of the methods of testing bacteriuria that is also fairly reliable (Shimoni, Hermush, Glick, & Froom, 2018). As an approach to controlling external variables, the continued monitoring of the application of the washcloths was ensured; the nurses’ checklists were employed to that end. The data were collected for all the participants, with the exception of the disenrolled fifth resident. The accuracy of the data was ensured through manual rechecking.
Analysis
The approaches to data analysis were aligned with the specifics of the data. For the scores, which demonstrated abnormal distribution, Wilcoxon signed ranks test was utilized to check the statistical significance in the score changes to account for the possibility of random variation. With resident data, the specifics of the dataset, as well as its small size, meant that the application of statistical analysis would not be helpful. Consequently, these data were summarized to demonstrate the lack of changes over time. Minitab was the software that was chosen for statistical tests.
Ethical Considerations
The project’s plan and procedures had obtained the approval of the institutional review board before it was implemented. All the participants, including the staff and residents, received full information about the project and its risks. The consent of all the participants was obtained; for residents, the consent of their legal guardians was also solicited when required because of their age and medical condition.
Results
The following procedures were carried out as a part of this project. After the recruitment, nurses and nursing assistants were engaged in a 30-minute training session. Their CAUTI performance data were gathered immediately before and immediately after the session with the help of the project’s tool. After that, the staff members were provided with the checklists, and they returned to their duties while taking into account the requirement to employ the washcloths when bathing the four enrolled residents.
Regarding the residents, the baseline data were collected before bathing was introduced into their routine, after which the procedure was carried out daily for two weeks. At the end of the two-week period, the second instance of data collection took place. No changes were made to the intervention or its procedures throughout the project; the nurses carried it out by following the checklists to the letter.
Regarding the challenges encountered throughout the project, no unintended consequences were detected over the course of the two weeks, and no instances of missing data were noted. However, the recruitment procedures were met with some difficulties. First, one of the participants who had already been enrolled had to be transferred, which limited the sample that had already been rather small. Moreover, the pre-test urinalyses demonstrated the presence of leukocytes in the residents’ samples (and nitrite in two cases).
Initially, the project was expected to enroll only those who had negative dipstick results, but no such residents were found at the beginning of the project. Consequently, it was decided to enroll the residents with positive dipstick results but no CAUTI symptoms and carefully monitor their state to check if chlorhexidine bathing could assist with preventing the development of CAUTI symptoms and negative changes dipstick urinalysis results.
The data collected for the staff members (see Table 1 in Appendix A) demonstrates that the majority of them were rather experienced. This information also helps to characterize the sample better so that the findings are applied to the correct population, which is female nursing assistants and nurses from long-term care settings with diverse experience and of different ages. Their CAUTI prevention scores, as shown in Figures 1 and 2 (Appendices B and C), changed after the training, and the change appears to be statistically significant with p=0.004. Regarding the residents, Table 2 (Appendix D) shows that there were absolutely no changes in their urinalyses; the same can be said about their symptoms.
Thus, the project’s findings suggest that the improvements in the CAUTI knowledge of long-term care nursing staff may be attributable to the training intervention, and the use of the chlorhexidine bathing intervention with residents, who had had leukocytes in their urine, did not result in any changes in their state.
Discussion
Summary
The project had intended to assist the unit’s nurses in reducing CAUTI incidence in their facility. In accordance with the aim, an evidence-based intervention was applied to the maximum number of eligible residents who were receiving treatment at the time, and the nursing staff underwent training pertinent to the use of this intervention and CAUTI prevention in general. The CAUTI knowledge of the staff appears to have been successfully increased; this change can be viewed as attributable to the training intervention based on the Wilcoxon signed ranks test (p=0.004). No new CAUTI incidents were recorded for the enrolled residents, but they had had leukocytes in their urine, even though they had exhibited no CAUTI symptoms.
The strengths of the project include the fact that it has been testing chlorhexidine in long-term care settings. There are not many recent articles that cover this specific application of this CAUTI solution (Abbas & Sastry, 2016), which, according to research data, is effective, for example, in intensive care units (Huang et al., 2016). Furthermore, the fact that the project has managed to achieve its goal, especially in equipping the nursing staff with better means of combating CAUTIs (in this case, knowledge), can be considered a strength. However, it is important to pay attention to all the relevant limitations while discussing the project’s findings.
Limitations
Several important limitations need to be listed before the findings are interpreted. First, the project did not last very long; the bathing was carried out for only two weeks, which was mostly associated with the project’s constraints and the costs of the intervention. In addition, no long-term effects of the training were checked for the same reason. Furthermore, the samples, including that of the staff and residents, were rather homogenous.
The attempts to relate the findings to other populations would not be appropriate. It is especially important because recruited residents had leukocytes in their urine before the beginning of the project, which is also a limitation explained by the shortage of eligible residents. Finally, the CAUTI score tool was self-developed; it was not tested for reliability because of time constraints, but it was explicitly aligned with the training program. Thus, the limitations are predominantly related to the shortages in the project’s resources.
Interpretation
The relationship between variables is relatively well-established for the training portion of the project. Indeed, the results of the statistical test suggest that the differences in the CAUTI scores are unlikely to be explained by accidental fluctuations. The limitations of the sample are important since the training session was only tested with a particular population; in addition, the absence of follow-ups is significant since the project only references immediate results. Still, the findings can be interpreted to indicate that the training has been effective and helped the nursing staff to achieve the desired results.
However, it is difficult to make similar conclusions based on the residents’ data, especially because of the limitations. Indeed, while no changes in urinalyses were found, which can be taken to imply that they did not develop new CAUTIs, the number of residents is too small for conclusive statements.
Therefore, the project did not provide sufficient evidence for the use of the intervention within the settings of a nursing home. However, it did not produce any evidence that would contradict the assertion that bathing with chlorhexidine washcloths is a reasonable solution to CAUTIs (Amirov & Candon, 2015; Huang et al., 2016; Swan et al., 2016). It can also be noted that the findings of the CAUTI knowledge test do not contradict the reviewed literature (Jain et al., 2015). As a result, the observed findings were not too different from the ones that had been anticipated.
A few notes on the project’s value should also be provided. The findings helped to identify a problem; specifically, the project’s site could benefit from CAUTI prevention training. The project also impacted the participants; the staff received the training that some of its members needed, and the residents were offered improved-quality care for two weeks. However, this project is not enough to keep this practice; more research will be required for that. The primary recommendations for future efforts would be to have greater duration, recruit residents without leukocytes in their urine, and attempt to secure greater samples.
Conclusions
The described quality improvement project has achieved its aim because it has successfully provided the nursing staff of the site with CAUTI prevention tools. It also identified a practical issue in the form of gaps in the nurses’ knowledge. The project’s contribution to the study of washcloths is modest, which is why the introduction of the intervention might not be sustainable yet since more data are needed. However, future projects should proceed to test it for longer periods of time and with more residents. In addition, the training program can be spread to other contexts and evaluated in them. Thus, the value of the project for practice and research is in its contribution to CAUTI prevention studies, as well as the promotion of more effective CAUTI prevention in a specific nursing home.
Funding
No funding was provided for the project, and there are no conflicts of interest.
References
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Appendix A
Table 1. Staff Demographics.
Appendix B
Appendix C
Appendix D
Table 2. Resident Data.