NUR 682 Module 9 Final Project Example

Nurse-Led Removal of Urinary Catheters to Reduce Catheter-Associated Infections on a Medical Floor: A Capstone Project

[Student Name]

Southern New Hampshire University

NUR 682: Generalist Nursing Capstone

Module Nine Final Project

[Instructor Name]

[Date]

Nurse-Led Removal of Urinary Catheters to Reduce Catheter-Associated Infections on a Medical Floor: A Capstone Project

Abstract

Catheter-associated urinary tract infections are among the most common and most preventable harms in hospitals. On a 30-bed medical floor at a composite community hospital, a year of surveillance showed 3.4 infections per thousand catheter days, and a point audit found that roughly a third of catheters had no documented reason to remain. This capstone proposes a protocol that allows registered nurses to remove a catheter once a structured check each day turns up no guideline reason for it, followed by bladder scanning to prevent needless reinsertion. Evidence from reviews and a national program supports the approach. Implementation proceeds through four small tests of change, and evaluation uses run charts of infections, catheter days, process measures and reinsertions, together with measures of adoption and sustainability.

Introduction and Problem

An indwelling urinary catheter is often placed for a good reason and kept for no reason at all. Every additional day raises the risk of infection, and on a busy medical floor catheters can remain for days after they stop being useful simply because no one is prompted to question them. Harbor Point Medical Center's adult medical floor, a composite unit used throughout this project, treats mostly older adults with heart failure, pneumonia, falls and diabetic complications. In the most recent year it logged seven confirmed catheter infections across roughly 2,060 catheter days, which works out to 3.4 for each thousand catheter days, and catheters were in use on nearly a quarter of its patient days, half again the share seen on sister medical units.

A weekday morning audit found 26 catheters, nine without any documented indication. Catheters typically stayed in for four days after admission, and nurses reported that they often recognized a catheter was no longer needed overnight but had to wait for morning rounds, or longer, for an order. What the unit lacks, then, is not knowledge but a gap between what nurses know and what they are allowed to do.

Significance

For patients, infection brings fever, confusion, antibiotics and longer stays; even an uninfected catheter limits movement and causes discomfort. For the hospital, these infections carry costs that Medicare no longer reimburses and rates that are publicly reported. For nursing, the issue sits at the center of professional practice, since the daily judgment that a catheter is still needed is a nursing assessment. A generalist master's-prepared nurse is well placed to lead the change because it requires clinical knowledge, systems thinking and the ability to work across disciplines.

Framework

Two frameworks guide the project. Donabedian's model of structure, process and outcome shapes the measures: the protocol and electronic prompts are structures, daily reviews and timely removals are processes and catheter days and infections are outcomes. Because unit infection counts are small, improvement in processes provides earlier and more stable evidence of change. The catheter life cycle, which divides a catheter's course into placement, maintenance, removal and reinsertion, locates the intervention at removal, the stage nurses can most directly influence, with bladder scanning addressing reinsertion.

Review of the Evidence

The guideline from Gould et al. (2010) defines when a catheter is justified: acute retention or obstruction, precise output monitoring in critical illness, selected operations, sacral or perineal wounds in incontinent patients, long periods of enforced immobility and end-of-life comfort care. It urges early removal once the indication ends and endorses reminder systems and nurse-initiated removal.

Meddings et al. (2014) reviewed strategies to cut unnecessary catheter use and found that prompting removal went along with lower infection rates and shorter catheter use, with no sign of harm, leading them to recommend reducing use before turning to specialized devices. Durant (2017) examined nurse-led removal protocols specifically and found that most studies reported fewer catheter days, infections or both, while cautioning that nearly all were uncontrolled comparisons in which education and feedback accompanied the protocol. Saint et al. (2016) reported that a national program that joined a daily question about each catheter's need with work on teamwork and safety culture cut infection rates by roughly a third on units outside intensive care, though intensive care units did not improve significantly.

The evidence is moderate in strength and consistent in direction. It supports nurse-led removal on a medical floor if it is introduced with education, feedback and leadership support and evaluated carefully.

Intervention

Four steps make up the protocol, which the physicians' governing committee has approved. First, during a review built into the electronic record at the start of each night shift, the nurse checks each catheter against the guideline's indications. Second, if none applies, the nurse removes the catheter and sends a message to the responsible physician. Third, the nurse scans the bladder if the patient has not voided within six hours, or sooner if uncomfortable, and follows a retention algorithm that uses intermittent catheterization before any new indwelling catheter. Fourth, the nurse documents the review result, removal time and scan volumes. Night-shift timing was chosen because nurses there already assess every patient and because catheters removed overnight are gone before the day's mobility goals begin.

Implementation

Taylor et al. (2014) found that many published improvement projects described their work as PDSA-based yet ran one large change without repeated measurement, which undercuts learning. This project uses four short cycles instead: one night-shift champion on her own patients, then one hall for two weeks, then the whole unit on day shifts and finally all shifts. Each cycle begins with a written prediction and ends with a team decision to adopt, adapt or abandon specific elements. Education consists of short huddle sessions and a video, and two night-shift champions support colleagues. A hospitalist co-lead addresses physician questions, and the nurse manager protects time for the work.

Stakeholder engagement was planned with an implementation framework and a change model. The main barriers expected are uncertainty about authority, doubts that catheter infections are serious and fear of blame if a catheter must be reinserted. Leaders will address the last with a written statement that nurses following the protocol act within policy.

Evaluation

Outcomes are tracked on run charts with a twelve-month baseline. The primary outcome, infections counted against each thousand catheter days, is followed monthly for at least six months after full rollout. The intermediate outcome, catheter days per 1,000 patient days, is plotted weekly. Process measures include daily review completion, documented indications and hours from a negative review to removal. Balancing measures include reinsertion within 48 hours, retention volumes on bladder scans and incontinence-associated skin damage. Implementation measures include staff acceptability, adoption across nurses, fidelity to scanning and notification and whether reviews are still being done at the three- and six-month marks once the student has stepped away. Probability-based run chart rules distinguish real change from ordinary variation.

Table 1. Evaluation Measures

Note. Targets draw on published program results and unit baseline.

Sustainability

Sustainability depends on moving the protocol from a project to a routine. The daily review lives in the electronic record rather than on paper, the protocol enters nursing orientation, the nurse manager takes over monthly feedback and the champion role rotates each year. The infection prevention committee will receive quarterly updates, and a second medical floor will be invited to test the protocol if results hold.

Limitations

The design is a single-unit time series without a control group, so background trends or other initiatives could influence results. Infection counts are small, making monthly rates unstable. Education and feedback accompany the protocol, so its independent effect cannot be separated. The project also cannot change catheter placement in the emergency department, though it will share data on catheters arriving without indications.

Conclusion

This capstone brings together the core outcomes of the MSN generalist program: defining a problem with data, appraising and applying evidence, leading change across disciplines and designing evaluation that could show whether care improved. A nurse-led removal protocol closes the gap between what nurses know about a catheter and what they may do about it, and the project's measures will show whether that gap was worth closing.

References

Durant, D. J. (2017). Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: A systematic review. American Journal of Infection Control, 45(12), 1331-1341. https://doi.org/10.1016/j.ajic.2017.07.020

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

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

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

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