HIMSS Nicholas E. Davies Award of Excellence Case Study Nebraska Medicine October 10, 2017
Nebraska Medicine $1.2 billion academic health system 8,000 employees More than 1,000 affiliated physicians Primary clinical partner of University of Nebraska Medical Center Two hospitals, anchored by tertiary/quaternary academic medical center, Nebraska Medical Center 39 specialty and primary care clinics, offering 50 specialties and subspecialties Partial ownership of two rural hospitals and one specialty hospital 809 licensed beds in Omaha and Bellevue 31,004 discharges 426,923 outpatient visits (primary and specialty) 91,800 ER visits
Striving Toward Zero Harm: Reducing Catheter-associated Urinary Tract Infections Julie Fedderson, MD, MBA, FACP Chief Patient Safety & Compliance Officer Nicole Turille, BSN, RN Director, Quality & Patient Safety
Background Local Problem Further investigation revealed: Staff were not always aware of indication for catheter Catheters were not being removed in a timely manner Catheter cares were not being performed and documented consistently Urine culture and sensitivity studies were being ordered inappropriately
Background Local Problem 5.0 4.5 CAUTI Rate per 1000 Catheter Days 4.6 4.0 3.5 3.0 2.5 2.0 1.5 2.7 3.7 2.1 3.1 3.1 2.3 3.2 3.0 FY2013 FY2014 FY2015 1.0 0.5 0.0 Nebraska Medical Center Nebraska Medical Center - ICU Nebraska Medical Center - MedSurg
Background Local Problem Indwelling Urinary Catheter Days 35000 30000 30157 33003 29349 Catheter Days 25000 20000 15000 10000 5000 0 FY13 FY14 FY15
Quality Governance Design and Implementation Nebraska Medicine Advisory Board Board Quality Committee Patient Safety & Quality Steering Medical Staff Physician Quality Committee Nursing Quality Core Event Review Team Patient Outcomes Committee Clinical Effectiveness Peri-Op Quality Committee Ambulatory Care Committee Patient Experience Bellevue Medical Quality Committee Education & Practice Support
Design and Implementation Patient Safety & Quality Steering CAUTI Task Force CAUTI Protocol Development Team CAUTI EHR Implementation Team Quality Steering established goals for the Task Force: Reduce the number of Indwelling Urinary Catheters (IUCs) placed Reduce the number of days the IUC is in place Decrease the overall incidence of CAUTI Evaluate literature and implement best practice
Timeline of Events Design and Implementation Nov. 2014 Dec. 2014 Jan. 2015 Feb 2015 March 2015 April 2015 Task force met to create action plans and outline next steps Task force met to finalize IUC protocol and create implementation and education plan Team obtained approval from all necessary governing bodies Nursing Practice Council: Jan. 15 Nursing Quality Council: Jan. 13 Clinical Content Informatics: Jan. 22 Clinical Governance: Feb. 12 Education with frontline staff HIT Go-live (control plan monitoring begins) Current State (Define) ~ 12 weeks Design Implementation Benefit Realization (Analyze) ~ 4 months (Improve) ~ 6-9 months (Control) ~ 6 months Data Analytics Process (Measure) occurs throughout
CAUTI Task Force Design and Work Design and Implementation Define CAUTI rate higher than peer groups Measure Determined baseline CAUTI rate Analyze Identified best practices and evaluated solutions within EHR Literature Reviews Gap Analysis Improve Established implementation plan and received approval from governance structure Control Tracked and monitored progress
Solutions Implemented Design and Implementation Indwelling Urinary Catheter (IUC) Protocol Infection Prevention and Department Manager Rounds Urine Culture Order Modifications Skills Validation Nursing and Patient Care Technicians
How Health IT was Used Clinical Process Require order with standard set of organizationallyapproved indications for IUC placement System Tools Standard Order Creation Nurse documents IUC placement and status Improved Documentation Nurse able to view IUC dwell time, indication order and link to the protocol if needed Nurses and department leadership able to quickly evaluate patient s with IUC, review catheter maintenance and length of dwell time Team leads and operational leadership able to view departmental opportunities Decision Support Tools Real-time Evaluation Nursing Dashboards Reflex order panel displays to clinician desiring urine cultures Reflex Order Algorithm
Reduce Number of IUCs Placed Indication is now a mandatory field and more visible How Health IT was Used System Tools Standard Order Creation Improved Documentation Decision Support Tools Real-time Evaluation Nursing Dashboards Reflex Order Algorithm 2017 Epic Systems Corporation. Confidential.
Reduce Number of Days the IUC is in Place & Standardize Documentation How Health IT was Used System Tools Decision support to aid in catheter care completion Standard Order Creation Improved Documentation Decision Support Tools Real-time Evaluation 2017 Epic Systems Corporation. Confidential. Nursing Dashboards Reflex Order Algorithm
Reduce Number of Days the IUC is in Place & Standardize Documentation Decision support to promote timely catheter removal How Health IT was Used System Tools Standard Order Creation Improved Documentation Decision Support Tools Real-time Evaluation 2017 Epic Systems Corporation. Confidential. Nursing Dashboards Reflex Order Algorithm
Reduce Number of Days the IUC is in Place & Evaluate Documentation How Health IT was Used System Tools Standard Order Creation 2017 Epic Systems Corporation. Confidential. Improved Documentation Decision Support Tools Real-time Evaluation Nursing Dashboards 2017 Epic Systems Corporation. Confidential. Reflex Order Algorithm
Reduce Number of Days the IUC is in Place & Standardize Documentation How Health IT was Used System Tools Standard Order Creation Improved Documentation Decision Support Tools Real-time Evaluation Nursing Dashboards 2017 Epic Systems Corporation. Confidential. Reflex Order Algorithm
Decrease False Positive Culture Results Urinalysis automatically reflexed for culture and sensitivity only if certain parameters are met in initial results Urine culture and sensitivity order no longer available for inpatients How Health IT was Used System Tools Standard Order Creation Improved Documentation Decision Support Tools Real-time Evaluation Can only select one Nursing Dashboards 2017 Epic Systems Corporation. Confidential. Reflex Order Algorithm
Decrease False Positive Culture Results How Health IT was Used System Tools Standard Order Creation Improved Documentation Decision Support Tools Real-time Evaluation 2017 Epic Systems Corporation. Confidential. Nursing Dashboards Reflex Order Algorithm
45 40 35 30 25 20 15 10 5 0 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Markers of Success: Number of Urine Cultures Value Derived Urine Cultures per 1000 Patient Days UCX Algorithm Implemented Pre-Intervention Post-Intervention % Decline P UCX/1000 PD 36.9 18.4 50% >.0001 Contaminated UCX/1000 PD 3.25 1.58 49% <.0001
Markers of Success: CAUTI Rate Value Derived CAUTI Rate & Line Days 3.5 35000 CAUTI Rate (Results x 1000 for Rate) 3 2.5 2 1.5 1 0.5 30000 25000 20000 15000 10000 5000 Catheter Days Catheter Days CAUTI Rate 0 FY14 FY15 FY16 FY17 Fiscal Year of Infection 0 Reduction in CAUTI rate: 47% Reduction in catheter days: 29%
Markers of Success: Realized Cost Reduction Value Derived $1.4 Million in Savings Catheter-associated Urinary Tract Infection Direct Cost July 2013 - June 2017 $1,200,000.00 $1,000,000.00 $800,000.00 Direct Cost $600,000.00 $400,000.00 $200,000.00 $- FY14 FY15 FY16 FY17 Fiscal Year of Infection
In Progress Continued Optimization Focus on removal and provider role in removal Created a daily checklist that focus on all quality measures Daily assessment of line removal
Our Patients Expectations Don t hurt me. Help me. Be nice to me. Health IT is helping us pave the way.