NUR 682 Module 3 Milestone One Example

Milestone One: Problem Statement and PICOT Question for a Nurse-Driven Catheter Removal Project

[Student Name]

Southern New Hampshire University

NUR 682: Generalist Nursing Capstone

Module Three Milestone One

[Instructor Name]

[Date]

Milestone One: Problem Statement and PICOT Question for a Nurse-Driven Catheter Removal Project

A capstone problem statement has one job: to convince a reader that a specific, measurable problem exists in a specific place, that it matters and that a change within nursing's reach could reduce it. This milestone makes that case for catheter infections on the general medical floor of Harbor Point Medical Center, a composite community hospital with 30 beds on that floor. It presents the unit's data, explains the consequences for patients and the organization, compares the unit with what a large national effort achieved, defines which catheters are justified and finishes with a PICOT question and the project's aims.

The Problem on the Unit

In the last twelve months, the unit recorded about 8,580 patient days and roughly 2,060 catheter days. Infection prevention staff confirmed seven infections meeting the national surveillance definition, a rate of 3.4 per 1,000 catheter days. The unit's device use ratio, catheter days divided by patient days, was 0.24, compared with 0.16 across the hospital's other medical units. In other words, the unit both uses more catheters and sees more infections per day of use.

A point-in-time review on one weekday morning found 26 patients with catheters. Nine had no reason documented in the record for the catheter to remain, and in four of those the admitting note listed incontinence or monitoring output in a patient who could void and be weighed. The median time from admission to removal was four days. Staff described waiting for a physician order as the main delay: nurses often recognized that a catheter was no longer needed on the night shift but could not remove it until morning rounds, and sometimes not then.

The unit's patients are mostly older adults admitted for heart failure, pneumonia, falls and complications of diabetes. Many have limited mobility, which makes catheters convenient and also makes their infections more consequential.

Table 1. Unit Baseline, Previous Twelve Months

Note. Values are illustrative for the composite unit and rounded.

Why the Problem Matters

For patients, a catheter infection can mean fever, delirium, a longer stay, another course of antibiotics and, in a minority, spread of infection into the bloodstream. Even without infection, catheters restrict movement, cause discomfort and can lead to trauma of the urethra. For older adults on a medical unit, each day tethered to a drainage bag is also a day of reduced mobility.

For the organization, Hollenbeak and Schilling (2018) reviewed U.S. studies of the added cost these infections bring. The cost per infection was lower than for bloodstream or surgical site infections, yet because catheter infections are so common, their combined cost is large, and the authors noted wide variation across studies depending on setting and methods. Medicare no longer pays hospitals extra for catheter infections acquired during a stay, so the cost falls on the hospital. Rates are also publicly reported, which makes them a reputational concern.

For nursing, the problem is a matter of professional practice. Catheter care and the recognition that a catheter is no longer needed are nursing responsibilities, and the unit's delays reflect a system that gives nurses the knowledge but not the authority to act.

What Improvement Looks Like Elsewhere

Saint et al. (2016) evaluated a national program in more than 600 U.S. hospitals that combined technical steps, such as daily review of catheter need and prompt removal, with attention to teamwork and unit culture. In units outside intensive care, catheter use declined and infection rates fell by roughly a third, whereas intensive care units showed no significant change. The results suggest that medical units like this one are where such programs have worked best, and a reduction of about a third is a realistic benchmark for the project rather than an aspirational one.

The program's structure also informs the capstone. The technical part centered on questioning each catheter's need every day, which the unit currently does inconsistently, and the adaptive part addressed the habits and relationships that decide whether a new practice survives.

Defining a Justified Catheter

The project uses the guideline from Gould et al. (2010) to decide whether a catheter is appropriate. Acceptable reasons include acute retention or blockage, exact output monitoring in critical illness, particular surgical procedures, open wounds in the sacral or perineal region of incontinent patients, prolonged immobilization and comfort care at the end of life. Incontinence alone, obtaining a specimen from a patient who can void and continued use after surgery without a current reason are not acceptable. Every catheter on the unit will be judged against this list during the project, and a catheter without a current guideline reason becomes a candidate for removal under the protocol.

PICOT Question

Among adults with an indwelling urinary catheter on the general medical floor (P), would a protocol letting nurses remove catheters after a structured daily review (I), set against the current wait for a physician order (C), reduce catheter days per 1,000 patient days and catheter infections per 1,000 catheter days (O) over twelve weeks (T)?

The question is written so that each element can be measured. The population is defined by unit and device, the intervention by a protocol and a checklist, the comparison by current practice and the outcomes by rates the hospital already reports.

Project Aims

The project has three aims. First, within twelve weeks of starting the protocol, at least 90% of catheters on the unit will have a guideline indication documented at the daily review. Second, catheter days per 1,000 patient days will fall by at least 20% from baseline. Third, the infection rate will trend downward toward the benchmark suggested by the national program, while reinsertions within 48 hours of removal will not rise. The first aim is a process measure, the second an intermediate outcome and the third the outcome of interest with a balancing measure, a structure that follows the framework chosen for the capstone.

Conclusion

The unit has a measurable problem with a clear likely cause: catheters stay in after they stop being useful since taking them out requires an order that often comes a day or more after the need has passed. Evidence from a national program suggests that improvement of about a third is achievable on units like this one. The PICOT question and aims set up the literature review in the next milestone, which will weigh the evidence for nurse-driven removal against other strategies.

References

Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., & Pegues, D. A. (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

Hollenbeak, C. S., & Schilling, A. L. (2018). The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review. American Journal of Infection Control, 46(7), 751-757. https://doi.org/10.1016/j.ajic.2018.01.015

Saint, S., Greene, M. T., Krein, S. L., Rogers, M. A., 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