Exemplary Professional Practice CARE DELIVERY SYSTEM(S)

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1 Exemplary Professional Practice CARE DELIVERY SYSTEM(S) EP7EO s systematically evaluate professional organizations standards of practice, incorporating them into the organization s professional practice model and care delivery system. Provide one example, with supporting evidence, of an improvement resulting from a change in clinical practice due to the application of professional organizations standards of nursing practice. The example provided may be at the unit, division, or organizational level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Background/ Problem The reduction of Healthcare Acquired Infections (HAI) is a major initiative of hospitals nationally. The importance of this effort has been underscored by the requirement to report HAIs externally to the Center for Medicare and Medicaid Services (CMS). Urinary Tract Infections (UTIs) represent the most common of these HAIs. The Society for Healthcare Epidemiology of America (SHEA) reports that 70-80% of hospital acquired UTIs are associated with the use of an indwelling urinary catheter. SHEA also estimates that 12-16% of hospitalized adult patients have a catheter during their stay (Lo et al., 2014). Therefore, the reduction of catheter use becomes a primary goal in any Catheter Associated Urinary Tract Infection (CAUTI) outcome improvement project. The Center for Disease Control (CDC), Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), Association for Professionals in Infections and Epidemiology (APIC), The Joint Commission, and SHEA collaborated in 2008 to determine best practices, and published the Compendium of Strategies to Prevent Healthcare Associated Infections in Acute Care Hospitals. A Compendium Update was published in Laurel Mode, BSN,, Infection Preventionist/ Specialist and Pam Bierbaum, BSN,, CIC, Infection Prevention Coordinator, are both active members of APIC and strive to ensure ABMC nursing practices comply with current infection control standards. Having a strong professional relationship with the Advocate BroMenn Medical Center (ABMC) CAUTI team, Laurel and Pam partnered with the team. The HAI prevention strategies in the section titled Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals were reviewed and compared to ABMC practice. The ABMC CAUTI team had been evaluating surveillance data and implementing practice changes since Practice changes initiated from 2009 through 2014 included a nurse driven urinary catheter removal protocol (2009), a practice survey and assessment followed by associate education (2012), product evaluations and revisions in associate orientation and education (2013), and establishment of catheter insertion criteria based on the Healthcare Infection Control Practices Advisory Committee EP7EO Advocate BroMenn Medical Center 1

2 (HICPAC)/ CDC Guideline (2014). These efforts succeeded in reducing the ABMC CAUTI rate from 7.45/1000 device days in second quarter 2009 to.70/1000 device days in second quarter Despite this significant progress, a spike in the ABMC CAUTI rate to 2.01/1000 device days in fourth quarter 2014 prompted the CAUTI team to review the newer best practice guidelines, including the SHEA/IDSA 2014 Compendium Update. Through a review of professional standards, the CAUTI team identified opportunities to enhance clinical excellence related to appropriate catheter use and prompt catheter removal. When developing an action plan, the ABMC CAUTI team also reviewed On the CUSP: Stop CAUTI Implementation Guide (Health Research & Educational Trust, 2013), a detailed manual developed by the Health Research & Education Trust for the Agency for Healthcare Research and (AHRQ) and the U.S. Department of Health and Human Services (HHS). This guide was designed to assist teams in the implementation of a CAUTI reduction program. The CAUTI team determined that the greatest opportunity for reduction of CAUTIs existed on the Progressive Care Unit (PCU). PCU had one CAUTI in May 2015 and one CAUTI July The PCU monthly CAUTI rate varied from 0 to from May to July Goal Statement To consistently reduce the monthly CAUTI rate on PCU. The outcome measure utilized was the monthly CAUTI rate (number of CAUTIs/1000 device days). Description of the Intervention/Initiative/Activities The On The CUSP: STOP CAUTI Implementation Guide (Health Research & Educational Trust, 2013) identified three intervention steps to prevent CAUTIs: Appropriate catheter use Proper catheter insertion and maintenance Prompt catheter removal PCU s greatest opportunities were related to appropriate catheter use and prompt catheter removal. Appropriate Catheter Use Intervention PCU identified that patients were received from other departments with catheters that did not meet the criteria for insertion. Investigating the issue revealed that ABMC s electronic medical record did not include insertion criteria documentation for the Emergency Department, Cardiac Catheterization Laboratory or Operating Room. To align with the Professional Practice Model and The Advocate value of clinical excellence and to correct this issue, catheter insertion criteria was added to the EP7EO Advocate BroMenn Medical Center 2

3 electronic medical record documentation in August 2015 for these three procedural areas and associate training was provided immediately prior to implementation. Prompt Foley Removal Interventions: Although acute urinary retention is an appropriate indication for catheter use, validation of urinary retention prior to catheter insertion is important. Bladder scanning (portable bladder ultrasound) is a simple, non-invasive tool for ensuring that the patient has sufficient urinary retention to justify catheterization. Assessment of current practice demonstrated that bladder scanning was not consistently employed on PCU. The 2015 annual Skills Days held in August and attended by all PCU nurses, included a professional development CAUTI education module which reviewed: Bladder scanning indication and training on use Indications for one-time or intermittent straight catheterization Indwelling catheter removal trial to assess patient bladder functioning related to retention Updated indwelling catheter continuation criteria To support the use of bladder scanning, additional bladder scanners were purchased for medical center units that did not have one. Although PCU had a bladder scanner, other units frequently borrowed it so the additional bladder scanners made the one on PCU more readily available for nurses to consistently use. Reporting of Catheter Usage in Daily Leadership and Unit Safety Huddles: ABMC leaders meet every morning for a Daily Safety Huddle to identify actual and potential issues that may affect the safety or quality of patient care delivered that day. The leaders then proactively address potential issues. In August 2015, the need to increase awareness of overall catheter usage, CAUTIs, and individual accountability was considered critical to reducing the incidence of CAUTIs. A practice was implemented requiring all inpatient units (including PCU) to report the number of indwelling catheters on the unit and the number of indwelling catheters that have been in place longer than 48 hours, including the clinical rationale for use, at the Daily Safety Huddles. Procedure areas report the number of indwelling catheters inserted in the previous 24 hours. To further support this initiative, the days since the last CAUTI was added to the daily huddle reporting. PCU conducts a unit safety huddle each shift. To promote clinical excellence and as part of the care delivery process, indwelling catheter usage and a discussion of the rationale for continued catheter use were added to the PCU huddle. The result was an increased awareness of the safety risk of indwelling catheters by all levels of nursing from the clinical nurse to nurse leader. The unit huddle has the same goals as the ABMC Leader Daily Safety Huddle but with the focus being on the specific unit s patients. EP7EO Advocate BroMenn Medical Center 3

4 Participants Name & Credentials Discipline Title Department Medical Oncology Theresa Bailey, MSN, Specialty Unit/ Manager Pediatrics/ Outpatient Infusion Lindsey (Loni) Benedict, Clinician II-Weekender 6West Surgical Unit Pam Bierbaum, BSN,, CIC Coordinator, Infection Prevention Lori Harper, MBA, MSN,, NE-BC Mary Ann Kirchner, MSN, Michael Mandrell, BS, BSN,, CC, CEN, CPEN, CPN Laurel Mode, BSN, Director, Practice and Mother Baby Unit Documentation Improvement Specialist- Educator Infection Preventionist/ Specialist Administration Emergency Department Kristin Peterson, MSN, Johanna Samara, BSN, Shelly Yoder, BSN, Manager/ Stroke Coordinator Manager Manager Progressive Care Unit Informatics Cardiovascular Care Unit/ Intensive Care Unit/ Central Telemetry EP7EO Advocate BroMenn Medical Center 4

5 Outcomes Pre-intervention Intervention The implementation of the three interventions into the delivery of patient care on PCU produced the desired outcome. The result was zero CAUTIs in PCU from September 2015 through March Reporting catheter usage at the ABMC Leadership Safety Huddle helped the leaders maintain a focus on CAUTI reduction. The daily PCU safety huddle discussions increased individual nurse accountability, leadership, patient centered care, and clinical excellence to ensure indwelling catheter appropriateness and timely discontinuation References Health Research & Educational Trust (2013). On the CUSP: Stop CAUTI Implementation Guide: Lo, E., Nicolle, L.E., Cofin, S.E., Gould, C., Maragakis, L.L., Meddings, J., Yokoe, D.S. (2014). Strategies to Prevent Catheter Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update. Infection Control, 35, , doi: / jlm EP7EO Advocate BroMenn Medical Center 5