On the Road to Eliminating CAUTI at a Community Hospital Lessons Learned

Transcription

1 On the Road to Eliminating CAUTI at a Community Hospital Lessons Learned

2

3 Getting Started CDC guidelines LeverageIT Capabilities Ordering, documenting and tracking Develop education SimLab observations Develop Nurse Driven Guideline House wide monitoring Nursing Competency Literature Review

4 A Few Findings! Communication (Foley present, Care plan, rounds, removal date) was limited or vague Insertion observations revealed aseptic technique opportunities Catheter care was not delegated or performed in a standardized way Staff unaware CDC guidelines Nursing workflow changes

5 Opportunities! Competency and Education Nurse-Driven Guideline for Removal IT/EMR/CPOE MD engagement and education Epidural use Surveillance, feedback and tracking

6 Epidural Use Literature Review Anesthesia involvement and peer feedback SCIP measures Sticker for documentation developed Revisit after rollout ACTION: Leave Foley in place until epidural is removed, surgeon is responsible for discontinuing or use NDG

7 Lions and Tigers and Competency (oh my!) 10 insertions /10 catheter care episodes filmed Review of current P&P, orders and practice Literature review/cdc guidelines Reviewed films with SME Developed Education plan Developed Rollout plan

8 The Plan Filmed video of aseptic catheter insertion Created Power Point/post-test education Catheter care added to annual mandatory LNA education in the Simlab Catheter insertion added to RN annual competencies Skills fair review of bladder scanning Pending: Competency checklists for insertion

9 Teachable Moments Occur daily! Multiple staff meetings, Unit Practice Council, Critical Care Committee, Practice, P&P, Nurse Educators, Clinical Ladder RNs, Nursing Leadership and many others! 1:1 follow up Methodical rollout vs. Big Bang Theory

10 IT/EMR/CPOE Create report that lists all patients with catheters on every unit Create catheter intervention report Spreadsheet to track unit Foley days Gyn LAVH 2/9/ :30 2/9/ :30 Gyn LAVH 2/9/ :33 2/10/2012 5:15 Gyn LAVH 2/10/ :45 2/13/2012 3:00 Sur Right axillary brachial bypass 2/10/ :35 2/11/ :55 2:00 13:42 57:15 19:20 Sur Exc of leg melanoma 2/9/2012 9:11 2/13/2012 9:15 Sur Lap Sig colon resect 2/10/ :00 2/12/2012 6:34 Sur Multi trauma 2/9/ :00 2/15/ :01 Y Sur PSBO/Xlap/Colostomy 2/9/ :44 2/13/ :16 Y Uro Robotic Prostatectomy 2/10/2012 9:33 Y Sur SBR 2/13/ :00 2/17/ :00 Y Uro R ureteral implant 2/13/ :45 2/16/2012 7:00 Y Sur Lap Sigmoid Resection 2/13/ :00 2/15/2012 9:30 96:04 37:34 147:01 90:32 ########## 90:00 62:15 42:30 Pt refused to have foleyout 2/12. educated on UTI and pt consented today Hematuria-3way inserted

11 IT/EMR/CPOE Review CPOE options and consider hard stop Add order for Foley removal per NDG/clinical reference library Documentation changes

12 Documentation Changes RN documentation We added an option for nurses to chart Foley Interventions per guideline.

13 Order changes Foley removal order We created an order in our electronic order entry system that nurses enter when a patient catheter is removed per guideline -- reporting for frequency of usage -- empowers nurses

14 Surveillance, Feedback and Tracking Foley days measured by unit since 2008! Review NHSN criteria (moving target!) and process for Infection prevention review Data-unit level BOT met Created spreadsheet on the K drive for CAUTIs to be tracked

15 Infection Prevention Unit Admit Date Culture Date Culture Does it meet NHSN criteria Notes 6S 1/9/2010 1/14/2012 E. coli YES ICU 12/27/2011 1/3/2012 P. Mirabilis YES ICU 1/22/2012 1/29/2012 CAN Staph YES 3S 1/13/2012 1/15/2012 K. pneumoniae YES foley placed in OR on 1/11, +Temp, cx positive >100,000 Foley placed in OR on 12/30/11, no temp, pt c/o painful urination, cx positive >100,000 Foley in place, Suprapubic tenderness, CX positive >100,000 cfu/ml (Foley placed while in ED on admit) Foley inserted in ED on 01/13/12, +Temp, cx positive >100,000

16 Nurse-Driven Guideline for catheter removal Tool to give RNs autonomy to make the decision for catheter removal Clear criteria for cathcontinuation & discontinuation Specific protocol for bladder scanning & PRN straight cath after Foley removal Guidelines for informing MDs of catheter removal & patient s voiding status

17 Nurse-Driven Guideline CDC guidelines/literature Review Subgroup of workgroup (MD/Nursing) created a draft More meetings! How can we pilot this??? 6S-med/surg with urology and renal focus 2 willing surgeons, a unit full of patients and nurses willing to give it a try.what could go wrong??

18 Pilot May baseline data on 6S Foley use Final draft of NDG, reviewed with various surgeons and physician customers Kicked off the pilot in July Gradually added surgeons until all were on board! Tracking daily Review of outliers

19 Results Nursing & MD acceptance good No adverse events on 6S No significant decrease in catheter days Patient population: Urology Surgery (SCIP) Expanded to 4E & 5E November 2011

20

21 Challenges RN comfort level with making the decision to remove the catheter, even with clear indications Gray area patients on each unit Data Changing the catheter culture

22 MD Engagement and Oversight Joint Chiefs Conference Presentation with approval Urologist as MD champion and collaborated to create NDG CMO is a urologist (always a plus!) Supported by intensivistsand Culture of Safety work the right thing to do

23 MD Education JCC Hospitalists Surgical/Urology meetings Family Health Center Residents March 29 th Orthopedic Section Meeting April Board of Trustees Quality and Patient Safety in June Connecting with key physician groups during rollout

24 ICU Reporting January ICU reporting begins QA and Infection Prevention collaboration

25 CAUTI

26 Catheter Utilization

27 House wide Foley Days

28 Parking Lot Re-visit epidural opportunities Look for urology opportunities IV poles Competency Checklists for insertion Train competency experts (starting in April) Patient Education HEO/Lab UA on insertion

29 Questions???