Our Journey Towards CAUTI Freedom. Johnson City Medical Center

Transcription

1 Our Journey Towards CAUTI Freedom Johnson City Medical Center

2 Objectives List two of the HICPAC appropriate indications for indwelling urinary catheters List two obstacles we encountered that prevented us from being CAUTI Free List two interventions we implemented to reduce catheter utilization

3 Johnson City Medical Center Located in East Tennessee 445 bed regional tertiary referral center and Level 1 trauma center Affiliated with East Tennessee State University and James H. Quillen College of Medicine 3

4 Previous Attempts at CAUTI Prevention Program Paper reminder placed in chart for physician Mostly Infection Prevention driven Lack of frontline team buy-in Electronic alert for physicians informing them patient still has indwelling urinary catheter

5 Value Optimization System (VOS) Accelerate achievement of Patient Centered Care to meet the patient s expectations of high quality, high satisfaction, and efficient care in the future health care state Uses the Simpler Business Model/Lean Methodology

6 Value Stream Analysis Reload VSA is a tool for mapping out current process in order to identify waste, unevenness, and overburden, speaking with data, sizing the opportunity for improvement, creating the plan of action and predicting the improvement results. VSA Reload is performed periodically to reassess current state and determine what needs to be implemented in order to achieve ideal state (10/15-10/17)

7 CAUTI Rapid Improvement Event (RIE) A 4-5 day process utilizing a team based methodology to apply the lean tools for seeing waste and making immediate improvement Our Team was made up of representatives from Nursing Administration, Infection Prevention, Frontline Nursing, Transportation, and Information Systems

8 CAUTI RIE Team November 18 th -22 nd

9 A3 Metric size of paper =11x17 9 boxes Designed to tell the event story

10 CAUTI RIE A3-Box 1 Reasons for Action

11 CAUTI RIE A3-Box 2 Initial State

12 CAUTI RIE A3-Box 3 Target State

13 CAUTI RIE A3-Box 4 Gap Analysis

14 CAUTI RIE A3-Box 5 Solutions Approach

15 CAUTI RIE A3-Box 6 Rapid Experiments

16 CAUTI RIE A3-Box 7 Completion Plan

17 CAUTI RIE A3-Box 8 Confirmed State

18 CAUTI RIE A3-Box 9 Insights

19 Destination: CAUTI Free February 10 th -14 th Weeklong education for ALL Team Members - Monday-Wednesday 7am-8pm - Thursday-Friday 7am-3pm 8 stations focused on different elements of CAUTI Prevention Educated around 1300 Team Members

20 Destination CAUTI Free

21 Rodeo Drive Burning Platform

22 Camp CAUTI Physician Order Entry

23 Oui Oui Bistro Nurse Driven Protocol

24 Sochi Indwelling Urinary Catheter Insertion

25 Outer Space Bladder Scanner and Daily Maintenance

26 Oh the Places You Will Go Documentation

27 Baggage Claim Transportation

28 Destination: CAUTI Free

29 Destination: CAUTI Free

30 The Mountain States Star

31 On the CUSP: Stop CAUTI ED ICU , 2700, 2800, 2900 Participating in Coaching Calls 31

32 Physician Order Entry 32

33 Scheduled Nursing Assessment 33

34 Nurse Driven Protocol

35 Nurse Driven Protocol

36 Then, the Fun Begins. Discovering Issues 36

37 Indwelling Urinary Catheter Orders with No Nurse Driven Protocol Attached

38 Indwelling Urinary Catheter Order Never Been Seen

39 Multiple Ways to Order Indwelling Urinary Catheters

40 Indwelling Urinary Catheter Order Inside of Order Sets

41 Issues Encountered How are nurses to know that retention is no longer an issue in order to remove IUC? Regular GU Assessments needs updated appropriate indications for continuation Device Days not being put in accurately Patient s coming through ED do not have order for IUC in electronic orders

42 Issues Encountered Order being entered for Urinary Catheter Removal Protocol, but not triggered BID assessment on Schedule Assessments list for nurse GU Assessment lost it s place for Discontinuation date/time when the Nurse Protocol was released Inability to see what front-line nurses actually see on their Scheduled Assessments list Nurses completing IUC order, deletes assessment

43 Issues Encountered Physician orders IUC and states it s for: - on Lasix and difficult for patient to get to toilet/patient request - - which allows them to enter the order without acceptable reason - urine output in critically ill patient (ICU only) Patient was never admitted to ICU

44 Issues Addressed IS added removal protocol to each IUC order, including order sets IS updated assessments to reflect appropriate criteria IS began working on automated device day report 44

45 Issues Addressed Electronic POE go-live occurred in ED IP was granted access to front-line nurse view of EHR 45

46 Issues Addressed 46

47 Issues Addressed 47

48 Issues Addressed 48

49 One More Time For Good Measure Discovering More Issues 49

50 Issues Encountered Nurses go through the motions of completing assessment Completing assessment, deletes remaining assessments Computer based learning out of date Frontline unaware of IUC Utilization numbers 50

51 Issues Encountered Witnessed discrepancies in catheter care Inappropriate indications for IUC in ED Nurses are still not clear on appropriate indication for IUC continuation - Two point restraints - Incontinence - Altered mental status - Patient request - Difficulty moving 51

52 Appropriate Indications Reminder 52

53 Computer Based Learning Updated 53

54 IUC Catheter Care Fact Sheet 54

55 IUC Utilization Graph 55

56 IUC Appropriate Indication Validation 56

57 So, Did It Work Results 57

58 ED CAUTI CUSP Results 58

59 IUC Utilization Before and After Initiative 59

60 IUC Utilization Before and After Initiative 60

61 CAUTI Rate Before and After Initiative 61

62 CAUTI Rate Before and After Initiative 62

63 August 2014 IUC Utilization 63

64 Lessons Learned/What You Need Administrative support Physician support, input and buy-in from beginning Process to educate physicians Process defined for how to deal with physicians who repeatedly do not use appropriate criteria

65 Lessons Learned/What You Need IS support and resources available Identify all ways to order IUC Ensure all orders and assessments have matching appropriate criteria 65

66 Lessons Learned/What You Need Have access to see exactly what the front line nurses see they use EHR Ensure all education materials are up to date Have mechanism in place to know when orders for IUC are placed 66

67 Lessons Learned/What You Need Engage frontline team members Identify champions to coach peers through process Ensure frontline team members are aware of CAUTI rates and utilization numbers 67

68 Lessons Learned/What You Need Have nurses demonstrate skills for IUC insertion, maintenance, including perineal care and catheter care Coach and empower nurses to critically think and make decisions about when to remove catheters based on criteria 68

69 Lessons Learned/What You Need Be flexible Be persistent Never give up 69

70 The Future For Our Program IUC Rounds in ICU each morning during multidisciplinary rounds Remove IUCs before moving patient out of ICU Utilizing new condom catheter - 5 sizes IUC Necessity Validation Rounds 70

71 The Future For Our Program Workflow to be built with automated assessments Simulation lab to demonstrate insertion of IUC and pericare/catheter care Dedicated IP for CAUTI Prevention temporarily 71

72 Questions Thank you for allowing me the opportunity to share our story (thus far) with you 72