NUR 4102 Module 5 Quality Improvement Paper: PDSA Cycles and a Unit CAUTI Project Example

Is the Catheter Still Needed? Running PDSA Cycles to Reduce CAUTI

Student Name

Bachelor of Science in Nursing, Thomas Edison State University

NUR-4102: Leadership and Management in Nursing: Scholars Track

Mentor Name

Month Day, Year

Is the Catheter Still Needed? Running PDSA Cycles to Reduce CAUTI

The Problem

Last quarter our unit recorded four catheter-associated urinary tract infections, twice the number in the quarter before. When the infection prevention nurse and I reviewed the cases, a pattern appeared: catheters often remained long after their original purpose had ended, usually because no one stopped to ask whether they could come out. Several had been inserted in the emergency department for convenience, with no documented reason. The infection prevention nurse asked our unit to lead an improvement project.

The Model for Improvement

Langley et al. (2009) set out an approach to improvement built on three questions: what the team hopes to achieve, how anyone will know whether a change helped and which changes are likely to lead to improvement. Answering those questions produces an aim, a set of measures and ideas for change. Ideas are then tried through Plan-Do-Study-Act cycles. Each cycle tries a change on a small scale, starts with a prediction, compares what happened with that prediction and ends with a choice to keep, revise or drop the idea before it spreads. Plotting measures over time, often on run charts, lets a team tell real improvement apart from ordinary variation.

How PDSA Is Often Misused

Taylor et al. (2014) reviewed 73 published reports that described using PDSA cycles in health care and checked each against the method's defining features. Few met them. Fewer than one in five reported cycles that built on one another, and small-scale testing, stated predictions and regular measurement over time were all uncommon. The authors concluded that many projects called PDSA skip the learning steps that give the method its value, which may help explain why published results are so mixed.

A National Program

Saint et al. (2016) described a prevention program that enrolled 926 hospital units in 603 hospitals across 32 states. It paired technical steps, such as criteria for when a catheter is appropriate, a daily check of whether each catheter is still needed and protocols that let nurses remove catheters without waiting for an order, with work on safety culture and teamwork. Across all units, infection rates fell modestly. In units outside intensive care, both catheter use and infection rates dropped significantly, while intensive care units showed no meaningful change.

Our Aim and Measures

Aim: within six months, cut catheter days on our unit by 30 percent and reach three straight months with no catheter-associated infections. Outcome measures: infections per 1,000 catheter days, along with catheter days for every 1,000 patient days. Process measure: the share of catheters with a documented reason in the chart. Balancing measure: catheters that had to be reinserted after removal, which would show whether we were removing them too soon.

PDSA Cycle 1

Plan: at the morning huddle, the day charge nurse asks about each catheter on the unit, using a printed list of accepted indications. Prediction: at least two catheters a week will come out earlier than they would have. Do: tried for one week on day shift. Study: four catheters came out earlier, but night shift did not know about the change, and one patient admitted overnight kept a catheter with no indication until morning. Act: extend the question to night shift and add a catheter line to the handoff sheet.

PDSA Cycle 2

Plan: with the medical staff's approval, introduce a protocol under which nurses may remove a catheter without a separate order once none of the listed indications applies. Prediction: catheter days on the test pods will fall by a further 15 percent. Do: tried on two hallway pods for two weeks. Study: catheter days fell by about 18 percent, but one patient developed retention and needed a catheter again. Act: add a bladder scan before any reinsertion and spread the protocol to the whole unit.

PDSA Cycle 3

Plan: work with the emergency department so that catheters are placed only when an indication is recorded. Prediction: fewer patients will arrive on our floor with catheters and no documented reason. Do: one month. Study: arrivals with undocumented catheters dropped from about one in three to fewer than one in ten. Act: the emergency department adopted the indication checklist as standard.

Keeping Staff Engaged

Projects like this can fade once the first enthusiasm passes. We posted the run chart in the break room each week, named nurses who had removed catheters early at huddles and asked two staff nurses to serve as champions who answered questions on each shift. The champions also collected the daily catheter count, so the data came from the floor rather than from an office.

Working With the Emergency Department

The third cycle depended on people outside our unit. I met with the emergency department's charge nurses, shared our infection data and asked what led them to place catheters. They described pressure to track output in crowded hallways and patients who could not reach a bathroom quickly. Together we agreed on alternatives, such as external catheters and bedside commodes, for patients without a true indication.

Results

Run charts showed catheter days falling from about 210 to 140 per 1,000 patient days over five months, a drop of one third, with no infections in the last three months and two reinsertions in total.

Limits

Infection counts on a single unit are small and can rise or fall by chance. Saint and colleagues found the strongest effects outside intensive care, which fits our medical-surgical setting but may not apply elsewhere. The unit is invented.

Conclusion

Langley and colleagues gave the project its aim, measures and small tests of change, Taylor and colleagues warned against the shortcuts that weaken PDSA and Saint and colleagues showed that daily review and nurse-led removal work on units like ours. Three linked cycles, tracked on run charts and shared with staff and the emergency department, cut catheter use by a third and brought infections to zero.

References

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Saint, S., Greene, M. T., Krein, S. L., Rogers, M. A. M., Ratz, D., Fowler, K. E., Edson, B. S., Watson, S. R., Meyer-Lucas, B., Masuga, M., Faulkner, K., Gould, C. V., Battles, J., & Fakih, M. G. (2016). A program to prevent catheter-associated urinary tract infection in acute care. New England Journal of Medicine, 374(22), 2111-2119. https://doi.org/10.1056/NEJMoa1504906

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862