Lisa Morrill

Ferris State University

 Healthcare

associated conditions (Hartmann

et al., 2012)

CAUTI
Evidence

based practice
Catheter Bundle(policy, assessment,
interventions, metrics, education &
evaluation)

Policy evaluation
Decrease of:

Catheter

use
Catheter dwell time
Catheter days
Catheter associated infections

Nurse driven catheter removal protocol

(Roser, Altpeter, Anderson, Dougherty & Walton, 2012,
Mori, 2014, Patrizzi, Fasnacht & Manno, 2009)

Goal 1:
Analyze and modify current policy for catheter use at
Spectrum Health Ludington Hospital (SHLH) To
develop evidence based/best practice policy for
catheter usage

Goal 2:

Utilize current evidence based guidelines to design

and develop process and framework for nurse driven
protocol and documentation for EHR. Obtain all
approvals.
Include staff in approval process
Educate staff in process

 Spectrum

Critical

Care Unit

Health Ludington Hospital

 Kathleen

Saxton RN, MSN

Quality
Informatics

5 whys
Hospital
Catheter

Use
Caregiver

 Anticipated
Creating

Failure Modes/Obstacles

high level of urgency for necessary

approval

Administration
Physicians
Staff

Availability

of resources
Ability to create documentation in current
EHR

 Pre

and post implementation

Catheter

use
Catheter appropriateness
Catheter days
Catheter associated UTIs

 Assumption

One: Decrease number of

catheter days in CCU

Assumption
Assumption

Two: Decrease CAUTI rates

Three: Increased awareness of

appropriate use of catheters

 Change

Theory-Lewins Theory of Change

Unfreezing
Moving
Refreezing
(Shirey, 2013; Wirth, 2004)

Leadership

Theory-Transformational

Leadership
(Marshall, 2011, Frederickson and Nickitas, 2011)

 QSEN

Evidence based practice

Quality Improvement
Teamwork and collaboration

ANA

Competencies

Standards

Assessment
Planning
Research

Frederickson, K., & Nickitas, D. (2011).Chief nursing officer executive

development a crisis or a challenge? Nursing Administration Quarterly,
35(4), 344353.

Hartman, C. W., Hoff, T., Palmer, J. A., Wroe, P., Dutta-Linn, M. M., &
Lee, G. (2012). The Medicare policy of payment adjustment for health
care-associated infections: Perspectives on potential unintended
consequences. Medical Care Research and Review, 69(1), 45-61. doi:
10.1177/1077558711413606

Marshall, E. (2011). Transformational leadership in nursing: From expert

clinician to influential leader. (1st ed.). New York: Springer Publishing
Company, LLC.

Mori, C. (2014). A-voiding catastrophe: Implementing a nurse-driven

protocol. MedSurg Nursing, 23(1), 15-28, ISSN (10920811).

Patrizzi, K., Fasnacht, A., & Manno, M. (2009). A collaborative, nurse

driven initiative to reduce hospital-acquired urinary tract infections.
Journal of Emergency Nursing, 35, 536-539. doi:
10.1016/j.jen.2009.04.017

Roser, L., Altpeter, T., Anderson, D., Dougherty, M., & Walton, J. (2012). A
nurse driven Foley catheter removal protocol proves clinically effective
to reduce the incidents of catheter related urinary tract infections.
American Journal of Infection Control, 49(5), e92-e93. doi:
10.1016/j.ajic.2012.04.161

Shirey, M. (2013). Lewins theory of planned change as a strategic

resource. JONA, 43(2), 69-72. doi:10.1097/NNA.0b013e31827f20a

Wirth, R. (2004). Lewin/Scheins Change Theory. Retrieved from:

http://lab4.psico.unimib.it/nettuno/forum/free_download/lewinschein
_181.pdf