Nursing Paper on Safety Score Improvement for Massachusetts General Hospital

Patient Safety Issue

Massachusetts General Hospital is major tertiary care referral hospital in the United States with over 1000 bed capacity with a significant occupancy rate. Nevertheless, there has been a noticeable increase in the hospital safety score in the emergency department. Public information on the high cases of Catheter Associated Urinary Tract Infection (CAUTI) has ignited the need for an unprecedented step to mitigate the impact of CAUTI on the hospital which ranges from distrust to loss of revenue in the long run.

Importance of Nursing Leadership in CAUTI Prevention

Nursing leadership plays a vital role in the prevention of CAUTI because the leaders are responsible for decision making and changing of policies that will aim at mitigating the health issue. The nursing leadership have a critical aspect during the design and implementation of programs to prevent the infection. Given that CAUTI prevention will require a multipronged approach and dedication of resources from the highest levels of management, cooperation of the nursing leadership is highly recommended. The nursing leadership is responsible for all the regulatory issues and healthcare quality thus it cannot be neglected. In addition, the nursing leadership together with the senior management are responsible for the implementation of a safety culture which affects patients and frontline staff. The nursing leadership is responsible for engaging the juniors in identifying safety concerns and proposing of possible solutions. In the event that the nurses feels unsupported by the nursing leadership, then implementation of improvement processes can be difficult in one way or another. In the implementation of the prevention program, it is crucial that the nursing leadership serves in the CAUTI prevention activities and this is the reason for their importance.  Specific data or concerns are also supposed to be channeled to the nursing leadership for purposes of analysis and thus the leadership matters a lot in the program.

How Current Policies and Procedures Affects CAUTI

            The current unit policy and procedures affects the health issue on CAUTI as the policy provides for technological strategies such as computerized orders tailored in the emergency department. There are little restriction protocols which affects multimodal interventions and procedural setting. There have been cases where the nurses have disagreed with catheter policy or desire to reduce frequency of patient contact. For example, there is an increased pressure on nurses on mitigation of hospital acquired pressure ulcers and thus there may be a perception that urinary catheters could reduce the risk associated with skin breakdown.



Proper Technique for Urinary Catheter Insertion

There shall only be one individual who shall be properly trained to insert catheters using the required technique. The trained individual shall insert the catheter to a patient by applying aseptic technique and a sterile equipment which is well secured. The indwelling catheter shall be properly secured with the purpose of preventing urinal tractions (Giacomo, 2012). Velcro-type device will be discouraged because the device can easily and possibly cause an irritation at the meatus as well as act as a possible transmission mechanism for microorganisms. When the different types of securement are being reviewed, then the skin is considered so that one does not cause skin breakage in the event of following the evidence support for the securement. Materials such as hydrocolloid and any other material that causes skin breakdown shall be considered. To prep for skin protection and adhesiveness, then anything that is tactile with an adhesive remover shall be removed. A closed drainage systems is supported by evidence based science. If the patient is required to be transferred to the ICU, then it will be critical to place a catheter that is connected to the drainage bag (Hobgood & Wears, 2009). It is crucial that the bag is placed below the bladder’s level and the device should be regularly changed whenever a patient is at risk.

Strategy to Collect Information

Information shall be collected on catheter days and patient-days catheter insertion indication for a particular period of time. The table below illustrates how this shall be achieved.

Table 1

Data Rates Rate(Monthly)
(Infection per 1000 Cather days)
(Total number of CAUTIs / Total number of catheter days) x 1,000. No catheter days
Ratio of Utilization (Number of catheter days / Number of resident days) x 100 0
Urine Culture

(Cultures per 1,000 resident days)

(Number of collected urine cultures / Number of resident days) x 100 0
Measure definitions Monthly Total
CAUTIs: CAUTIs are counted on the first date that the cluster of signs and symptoms, lab reports and the presence of a catheter for more than 2 days are found together. CAUTI is an event which may continue for days or even weeks, but it is counted only once, not each day. 0
Resident Days: Every day a resident is in the facility equals one resident day. This includes all residents, whether or not they have a catheter. This should be collected at the same time each day. 0
Resident Catheter Days: Every day a resident has an indwelling urinary catheter that is through the urethra is equal to one catheter day. This should be collected at the same time each day. 0
Urine Cultures: Urine cultures that are collected for all the residents 0


Note. Table retrieved from American Nursing Society .Copyright 2010 by American Nursing Society.

            Appropriate Indicators for indwelling urethral catheter use

  • Acute urinary retention and obstruction to bladder outlet
  • The need for urinary output accurate measurement to patients who are critically ill
  • Improved comfort for end-of-life care
  • Healing of open sacral for incontinent patients

Inappropriate uses of Indwelling Catheters

  • Used a substitute in the care of patients or residents with incontinence
  • Used a means of urine to be used for culture or any other relevant tests when a patient can voluntarily void
  • Used in prolonged postoperative durations with lack of appropriate indicators

Monitoring and Provision of feedback on Catheter Use and CAUTI rates

            The inappropriate use of the urinary catheter is simple to start but hard to break. Efforts to reduce CAUTI shall incorporate regular feedback and participation of urinary use and CAUTI rates. The CAUTI rate shall incorporate device utilization ratio and periodic improvements and placement. It is vital to develop strategies aimed at reducing the effort and resources that will be required to monitor CAUTI rates. Datasets should be carefully selected and developed for CAUTI events reporting (Simmons & Foster, 2010).

Policies and Procedures that need to be changed

The use of outdated policies is some of the reasons for increased CAUTI rates. Typically, the proposed standards of practice can help in reducing CAUTI rates:

  • Provision for assessment of patients and incorporating an alternative urinary catheter use. The alternatives include use of intermittent catheterization.
  • Strict adherence to aseptic technique during maintenance of indwelling urinary catheters. Such techniques involves hand hygiene, closed drainage system maintenance and use of a trained personnel.
  • Provision for the discontinuation of urinary catheters once the indicators expire.



Educating the Staff

            The competence of the staff should be improved in order to achieve the set objectives. The staff should be engaged at every section of implementation. The ANA CAUTI tool will be the best in engaging the staff during training. The prevention tool comprises of three sections which gives specific outlines and gives criteria to be used before, during and after insertion of IUC. The training also offers nurses the opportunity to know the maintenance practice to be implemented to achieve reduced CAUTI rates. The maintenance includes timely removal of and hygiene practices in indwelling urinary catheter.




Giacomo, P. C. (2012). Accidents: Risk factors, health outcomes, and safety measures.                               Hauppauge, NY: Nova Science Publishers.

Hobgood, C., & Wears, R. L. (2009). Patient safety in the emergency room. New York:                             McGraw-Hill Medical.

Simmons, D., & Foster, J. (2010). Safety. Philadelphia, Pa: Saunders.