ROOT CAUSE ANALYSIS- CAUTI PREVENTION 1

Root Cause Analysis- CAUTI Prevention

Michelle Deane

Bon Secours Momorial COllege of Nursing

NURS 3241: Quality and Safety Nursing Practice

Dr. Rani Sangha DNP, MSN,MBA,BSN, BHSM

February 5, 2022

I pledge…
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Root Cause Analysis- CAUTI Prevention

Introduction

CAUTIs are issues that affect the optimal outcome for the patients we are caring

for during their hospitalization. CAUTIs if not caught early on during hospitalizations, could

subject the patient to serious complications from kidney infections to sepsis. CAUTIs are the

main cause of about 17% of nosocomial blood infection along with a 10% mortality rate all

related to urinary catheter insertions (Khera, 2019). Many hospitals have made radical peer-

reviewed case study approaches to counter the occurrences of CAUTIs. Measures such as is no

foley insertion in the Emergency Department and two persons at bedside to assist with helping

maintain sterile technique, can help reduce CAUTIs. Forty percent of CAUTIs were due to the

insertion of the foley catheter while in the Emergency Department (Ohanian & Gaines-Hill,

2019). Developing a clear-cut approach regarding measures needed to be taken to prevent

CAUTIs is critical along with the planning, implementation, and evaluation of the practices.

Problem Statement

The Agency for Healthcare Research and Quality showcased a case study in CAUTI

presented by the Emergency Nurses Association. In the case study, an 80 yr. old woman who

arrived in the emergency department from an assistive living facility in respiratory distress. Upon

arrival the patient was complaining of shortness of breath, had bilateral crackles to both lungs,

oxygen saturation was in the 80s, and patient was using her accessory muscles. Labs were

obtained showing an elevated BNP and the chest x-ray showed cardiac enlargement plus lung

consolidation. The ED doctor ordered diuretics along with a foley catheter insertion order. Two
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days after the initial insertion, the patient’s urine had an odor, was cloudy, and patient spiked a

fever. Urine analysis taken showed that patient had a UTI.

Causes of Problem

The ED doctor and nurse lack patient driven care by not following the least invasive

procedures first. The nurses on the floor did not follow a foley removal plan or discharge

planning for removal prior discharge. The hospitalist and medical providers taking care of the

patient should have had in place foley care and removal plan in place upon admission. The

quality and safety manager along with management leaders, did not develop an foley removal

initiative based off of patient’s acuity. The lack of education regarding procedures that would

reduce the risk of CAUTI was not shared or if shared, may have not been implemented correctly.

Contributing Factors

Upon arrival to ED the order to insert a foley catheter may not have been

necessary as there could have been other methods that could be used such as a pure wick devise.

The nurse should have spoken up for her patient based off the knowledge that the least invasive

procedure is always best. She may have also had issues with speaking up, being assertive, or

feeling confrontational. The hospitalist or ED doctor could be challenged on giving appropriate

rationale as the patient has the ability to ambulate to the bathroom however, the argument of

having accurate recording of input and output is rationale. There was no initiative or plan in

effect that was focused on patient centered care of foleys and initiative to remove them. If

nursing leadership had instituted a protocol for insertion, they would see a drastic reduction in

CAUTIs.

Recommendations
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Prior to having any foley insertion, there must be a review of the necessity for the foley

catheter and there must be a justifiable rationale to why it is needed. Having a tool that would

have the provider and nurse can go through to see if the patient meets requirements based off

their ESI acuity level. There must be a patient focused nursing protocol and guidelines regarding

proper care. Implementing every 8-hour perineal care, educating on proper foley care, educating

on the signs and symptoms of infection, and developing a foley policy protocol to obtain a

urinalysis upon foley insertion are all ways to help decrease CAUTIs. Having clinical

competencies and setting up procedural policy regarding strict follow through with foley

catheter. Measures like having two nurses present during foley inserting would help maintain

sterile technique along with a focus for the ED not to insert foley catheters can also help reduce

the risk of CAUTI development. There should also be a clinical competency based off of CAUTI

education and prevention that should be successfully completed yearly.

Nurse Role in Recovery Process

Nurses have been noted to be the most trusted profession for the last 20 years due

to the ability to connect with their patients in a respectful manner leading with empathy and

compassion (Lewis et al., 2014). The nurse maintaining strict sterile procedure during foley

catheter insertion is one of the biggest ways nurses can help reduce the risk for CAUTIs. The

nurse should advocate for the least invasive procedures based off the patient’s conditions such as

use of the pure wick for women. Once the patient is assessed and there is a plan of care initiated,

the next and main focus should be discharge preparation. The goal of discharging the patient

without the foley catheter is the focal point especially if the patient did not come in with one.

Developing a standardize policy with CAUTI reduction/prevention as the main point, can help

implement a patient centered foley removal plan after a 24 re-assessment by the provider.
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Patient
Characteristics
Patient received a foley
catheter in the ED
upon admission and
was diagnosed with an
UTI 2 days later.
Team Factors
No one evaluated the
necessity of foley
administration
There was no foley removal
initiative or plan in place

Development
of a CAUTI

Org. and Work

Managemental Environment
Factors The nurse lacked
The lack of a foley the initiative to
Task Factors protocol regarding
Not maintaining correct voice alternative
insertion criteria methods
sterile technique upon There is a need for a
insertion The environment
patient based CAUTI did not foster or
Not maintaining adequate prevention plan
perineal care help build better
communication
between
caregivers
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References

Epstein, S. E. (1985). Cost-effective application of the centers for disease control guideline for

prevention of catheter-associated urinary tract infections. American Journal of Infection

Control, 13(6), 272–275. https://doi.org/10.1016/0196-6553(85)90028-8

Khera, R. (2019). Update on urinary tract infections (1st ed.). Jaypee Brothers,Medical

Publishers Pvt. Ltd.

Lewis, L., Shanahan, M., & Andrus, V. (2014). Nurses leading the way. JONA: The Journal of

Nursing Administration, 44(9), 441–443. https://doi.org/10.1097/nna.0000000000000105

Ohanian, S., & Gaines-Hill, S. (2019). Reduction of cauti rates organization wide begins in the

emergency department. American Journal of Infection Control, 47(6), S37.

https://doi.org/10.1016/j.ajic.2019.04.086