NUR 300 Module 6 Short Paper example

Catheter-Associated Urinary Tract Infection as a Nursing-Sensitive Quality Indicator on a Medical Unit

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Southern New Hampshire University

NUR 300: Scholarly Inquiry

Module Six Short Paper

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[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Catheter-Associated Urinary Tract Infection as a Nursing-Sensitive Quality Indicator on a Medical Unit

Hospitals report dozens of quality measures, but only some of them tell us about nursing. A nursing-sensitive quality indicator is a measure that reflects the structure, process or outcome of nursing care, so that a change in how nursing care is staffed or delivered would be expected to change the measure. The National Database of Nursing Quality Indicators was created to collect such measures at the unit level and to let hospitals compare units of the same type, because a hospital-wide average can hide the performance of a single floor (Montalvo, 2007). This paper examines one indicator, catheter-associated urinary tract infection, on the 30 beds of a composite adult medical floor. It argues that the infection rate alone is a weak guide to nursing quality, and that the unit learns far more by tracking the nursing processes that come before it.

Structure, Process and Outcome

Donabedian (1988) proposed that the quality of care can be judged through three linked kinds of evidence. Structure refers to the setting and resources in which care happens, such as staffing levels, supplies and policies. Process refers to what is actually done for patients. Outcome refers to the effect of care on the patient's health. The model assumes that good structure makes good process more likely, and that good process makes good outcomes more likely.

Applied to catheter-associated urinary tract infection, the three layers become concrete. Structural measures include whether the unit has a nurse-driven protocol that allows nurses to remove a catheter without a new order when criteria are met, whether bladder scanners are available on every shift, and whether staffing allows time for catheter care. Process measures include the proportion of catheters with a documented indication, the proportion removed within 24 hours of the indication ending, and adherence to maintenance practices such as keeping the drainage bag below the bladder and the system closed. The outcome measure is the infection rate itself, usually expressed as infections per 1,000 catheter-days. National prevention guidance addresses each layer, calling for catheters to be inserted only for appropriate indications, inserted with aseptic technique, kept as a closed system, and taken out the moment the indication ends (Gould et al., 2010).

What One Year of Unit Data Shows

The table below reports composite data for the medical unit over two consecutive six-month periods. In the second period, the unit introduced a daily catheter review during morning huddle, led by the charge nurse.

Table 1

Catheter Use and Infection on a Composite Medical Unit, Two Six-Month Periods

Note. Device utilization ratio is catheter-days divided by patient-days. Figures are composite values written for this paper.

Reading the Numbers

At first glance, the infection rate fell from 3.4 to 2.6 per 1,000 catheter-days, which looks like progress. The count of infections, however, fell from four to two, and numbers that small can change by chance from one period to the next. A manager who relied on the rate alone might either celebrate too early or, in a period with one extra infection, abandon a practice that was working.

The process and exposure measures tell a more reliable story. Catheter-days fell by about a third while patient-days stayed nearly the same, so the device utilization ratio dropped from 0.23 to 0.15. The share of catheters with a documented indication rose from 73 percent to 94 percent. Both changes are driven directly by nursing decisions, and both reduce the opportunity for infection whether or not the infection count moves in a given six months. This matches the wider evidence. An integrative review found that reminders and stop orders prompting catheter removal reduced infection rates by roughly half across the studies that tested them (Meddings et al., 2014), while a multistate effort across hundreds of hospital units, pairing catheter practices with work on teamwork and unit culture, lowered infection rates outside intensive care, where catheter use declined as well (Saint et al., 2016).

What Nurses Control

Several of the actions behind these numbers belong to nursing practice. Nurses often identify the need for a catheter, insert it, maintain it and are best placed to notice when it is no longer needed. On units with a nurse-driven removal protocol, the nurse can act on that judgment without waiting for a provider to round. Nurses also teach patients and families not to disconnect the drainage system, position the bag correctly during transport, and use a bladder scanner rather than a straight catheter to check retention. When staffing is short, these are among the tasks most easily delayed, which is one reason the indicator is considered sensitive to nursing care.

Structure matters to these actions as much as individual skill. The daily huddle review on this unit works only because the charge nurse has a protected five minutes and a printed list of every patient with a catheter, and because the protocol allows removal without a new order. When the unit was short two nurses on several night shifts in October, the huddle was skipped on four mornings, and catheter-days for that week rose. A single week proves little, but it shows how a structural measure, staffing, can undo a process measure that the unit had worked to improve. Reporting the three layers together helps nurse leaders explain that connection to administrators who see only the infection rate on a hospital scorecard.

Not every infection reflects a nursing failure. Some patients have catheters for appropriate reasons over long periods, and some infections occur despite correct practice. That limit is another reason to track process measures: they allow the unit to separate infections that followed missed care from those that did not.

Conclusion

Catheter-associated urinary tract infection is a useful nursing-sensitive indicator because nurses influence nearly every step that leads to it. The infection rate alone, however, is too small and too variable on a single unit to guide practice from month to month. Tracking catheter-days, the device utilization ratio and documented indications alongside the rate gives the unit a clearer picture of nursing quality and a faster way to see whether a change is working. For this unit, the next step is to add the proportion of catheters removed within 24 hours of the indication ending, which would measure the nursing action most directly tied to the result.

References

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & Healthcare Infection Control Practices Advisory Committee. (2010). Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control & Hospital Epidemiology, 31(4), 319-326. https://doi.org/10.1086/651091

Meddings, J., Rogers, M. A. M., Krein, S. L., Fakih, M. G., Olmsted, R. N., & Saint, S. (2014). Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: An integrative review. BMJ Quality & Safety, 23(4), 277-289. https://doi.org/10.1136/bmjqs-2012-001774

Montalvo, I. (2007). The National Database of Nursing Quality Indicators (NDNQI). OJIN: The Online Journal of Issues in Nursing, 12(3), Manuscript 2. https://doi.org/10.3912/OJIN.Vol12No03Man02

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