NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

NURS FPX 8030 Assessment 5

NURS FPX 8030 Assessment 5

Hospital Policy Template

Subject/Title of Policy: “Protocol for Prevention of Hospital-Acquired Infections in

Acute Care Hospitals”


It is important to note that the main goal of this policy is to have technology in place on a wide scale basis in order to change the medical centre’s approach to bladder catheterisation and hence decrease the frequency of CAUTIs. HAIs are greatly contributed by CAUTIs, which in turn result in increased hospital stays as well as costs. Lack of compliance with the quality improvement measures and relevant guidelines on catheter insertion and rationales, appropriate care, and timely removal plays a major role in the development of CAUTIs.

Findings from the current literature back up the aspects presented in the study stating that a comprehensive strategy is more efficient in the elimination of CAUTI. For instance, a systematic review showed that the use of the evidence-based protocols significantly reduces CAUTI prevalence to varying up to 50% (Meddings et al., 2019). The data was collected through a comprehensive search of available literature that contained information on the evaluation of measures to prevent CAUTI.

The revised PICO(T) question guiding this policy is: In patients in the hospital who have indwelling urinary catheters (P), does the use of an organised CAUTI prevention process (I) reduce the number of CAUTIs as compared to no organised process (C) within six months (T)? Initiating action to implement this policy became imperative in maintaining equanimity in the practical application of these best practices which would eventually lead to improvements in the general safety of patients as well as the overall load on the system of CAUTIs.

Population Affected by the Policy:

The target population for this intervention entails adults of or over 18 years admitted to the acute care setting which may be medical, surgical, or an intensive care unit, an instance where they will undergo indwelling urinary catheterization for over 48 hours. These patients are more vulnerable to contracting Catheter-Associated Urinary Tract Infections [CAUTIs] because the procedure is invasive and the usage period long, which raises the chance of bacteria multiplication and infection (Meddings et al., 2019).

The following patients are, however, excluded from this policy:

•Pediatric patients. This is because children are not like adults when it comes to catheterisation needs and the risks that come with it in almost every case, hence requiring different policies and protocols. Further, the intervention does not embrace patients in Long-term care facilities since the study is conducted in Acute care settings only. Patients who use self-catheterization are also eliminated out because this protocol only covers the approaches to help minimise and prevent infections associated to Foley catheters. Due to the identification of included and excluded populations in the policy, there is an enhanced ability to focus on the right targeted population that at one probability may be at high risk of developing CAUTIs in the acute care setting, hence improving patient safety and outcomes.


Here A detailed description of terms is specified, which might be unfamiliar to persons who do not work in the sphere of healthcare.

NURS FPX 8030 Assessment 5 Creation of Policy or Procedure

CAUTI (Catheter-Associated): This paper identifies CAUTI as an infection that occurs at any point in the urinary system because of a urinary catheter. This type of infection may develop when bacteria invade the urinary system through the catheter; thus, it results in symptoms such as fever, increased urge to urinate, and pain during the process (Meddings et al., 2019).

Indwelling Urinary Catheter: An F. I. V. E: An indwelling urinary catheter is a soft tube through which urine is emptied directly from the bladder without. They are commonly employed in patients with conditions that prevent them or who require surgical intervention, thereby making them unable to urinate independently. Toner et al. (2017) defined that arteriovenous fistulas allows a longer duration of access for endovascular interventions as the catheter stays in the body for an extended time for urine to drain out.

Aseptic Technique: Aseptic technique, on the other hand, entails practices that are performed to ensure that medical procedures are done in a sterile manner, thus reducing the chances of the growth of pathogenic organisms. This entails proper and effective hand washing, wearing sterile gloves and other apparatus, and ensuring that the area around the patient is clean to help avoid extra unwanted infections.

Policy Statement:

The purpose of this policy is to decrease the rate of Catheter-associated urinary tract infections (CAUTIs) in our medical center by establishing an improved monitoring process for using, maintaining, and removing the indwelling urinary catheter.

This quality improvement project will involve ensuring agreement to specific guidelines known to reduce proximity to CAUTIs that compromise the patient’s safety. It classifies clear actions on how this would be achieved and implemented including; aseptic practice, conventional catheter evaluation as well as staff development that is aimed at standardising practices among the numerous departments.

In summary, our main goal is to reduce CAUTIs, ultimately contributing to the positive patients’ prognosis, shortened hospital stays, and reduced expenses related to these complications.

This approach is based on available research and guidelines in an ideal setting to provide a clear understanding of how multiple intervention approaches can significantly reduce the rates of CAUTI.

As part of my implementation plan, we need to continue educating and training the healthcare providers about catheter management, constant assessments and reconsiderations for catheter utilisation, and timely discharge or removing catheters in which their usage is no longer required.

This policy aligns us with our health care system’s guiding principle of quality enhancement in patient care agriculture through the implementation of standardised as well as peer-reviewed practices that span the health of patients locally as well as globally.


Step 1 Training and Education

These are other important elements for the development of the security industry, and this is the main reason why this kind of training is very important. The initial process starts with educational activities that are aimed at all categories of personnel, including the nursing staff, physicians, infection control specialists, and teaching/clinical nursing faculties.

It is important to include educational materials, training modules, and tools designed for scheduling the staff. Beginning interventions consist of training sessions where health care professionals would be informed on the new protocol of the project, the guidelines for the use of aseptic procedures, proper ways of implementing the catheter and others as well as when a catheter should be removed. Repetition is also another method that will be done every three months to be certain that all the healthcare providers are still compliant and have the details dance in their minds (Meddings et al., 2019).

Step 2: Evaluating Necessity for Catheter

It will be expected that attending physicians and the nursing staff will do the physical assessment for each patient in order to determine the need for an indwelling urinary catheter on admission and daily fulfilment of this assessment via a special checklist.

Such records and assessment checklists should be stored as important tools required for this step of the process. Authorization of insertion of the catheter needs to be recorded in the patient files and the catheter should be removed whenever it is no longer needed. This step reduces the occurrence of catheters thus practicing their use when it is necessary in order to minimise the incidents of CAUTIs (Meddings et al., 2019).

NURS FPX 8030 Assessment 5

Step 3: Catheter Insertion

The process of catheter insertion will be done under sterile conditions using specially designed catheter insertion kits, standard operating gloves, masks, and sterile gauze soaked with antiseptic liquid. The steps include hand washing and the use of the right personal protective equipment.

The sterile catheter insertion kit and the antiseptic solution are then presented and the insertion site is wiped with the antiseptic solution. Following a strict aseptic procedure, the catheter is then s. c, unpinned, preeignet and placed in position, all equipment used in the process must remain sterile. The catheter is then sutured appropriately to minimise its movement and, thus, any chance of urethral injury (Meddings et al. , 2019).

Step 4: Ongoing Catheter Care and Maintenance

This continues to be our experience on ongoing catheter care and maintenance.

Catheter management and care are considered routine in nursing. Thus, it will remain the responsibility of the nursing staff to manage and maintain the catheter with appropriate supplies, which include sterile gloves, antiseptic solutions and catheter maintenance supplies, among others. The staff uses sterile gloves and washes their hands before touching the catheter on the kid.

It is recommended that the site of catheter insertion should be washed with antiseptic solution, and after defecation. Special attention should also be paid to catheter tubing because of kinking and tension; the catheter tubing should be free from kinks and must be secured properly. Keeping the drainage system closed and ensuring constant scrutiny of signs of infections or blockages are essential features of this process. Any catheter-related care or assessments performed are required to be recorded in the patient record.

Step 5: Catheter Removal

The catheter will be needed each day, and the decision to keep the catheter in place will be made by the nursing staff and the attending physicians on each day. If the catheter is no longer required, then hand hygiene needs to be followed, along with putting on sterile gloves, using a syringe to remove the air from the balloon part of the catheter, and then pulling the catheter out and throwing it in a medical waste container. Patients should be observed for any post-procedure temporal side effects if any, and the removal process has to be well-documented in the patient’s medical history file (Meddings et al. , 2019).

Step 6: Monitoring and Evaluation

These 55 Monitoring and Evaluation High-level strategic objectives Achieving high-level strategic objectives reflect an organization’s overall perspectives, and completing these goes hand in hand with the accomplishment of project objectives by ensuring the implementation of minor and major tasks, including monitoring and evaluating achievements.

Dissemination and evaluation unit Infection control specialists and nursing management will ensure that they monitor CAUTI rates /catheter use frequently. The indicators of monitoring destination sustainability involve the use of monitoring tools, data collection forms, and evaluation software.

These will be in the form of audits, and the outcome of the audit will be presented to similar staff, and appropriate corrective action will be taken. This protocol will be used to revise each section of the policy annually, using the existing evidence and the current rates of infections (Meddings et al., 2019).

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NURS FPX 8030 Assessment 4


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