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

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

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

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

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

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

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

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

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

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 2/9/2012 12:30 2/9/2012 14:30 Gyn LAVH 2/9/2012 15:33 2/10/2012 5:15 Gyn LAVH 2/10/2012 17:45 2/13/2012 3:00 Sur Right axillary brachial bypass 2/10/2012 15:35 2/11/2012 10:55 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 2/10/2012 17:00 2/12/2012 6:34 Sur Multi trauma 2/9/2012 15:00 2/15/2012 18:01 Y Sur PSBO/Xlap/Colostomy 2/9/2012 21:44 2/13/2012 16:16 Y Uro Robotic Prostatectomy 2/10/2012 9:33 Y Sur SBR 2/13/2012 20:00 2/17/2012 14:00 Y Uro R ureteral implant 2/13/2012 16:45 2/16/2012 7:00 Y Sur Lap Sigmoid Resection 2/13/2012 15:00 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

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

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

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

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

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

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

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??

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

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

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

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

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

ICU Reporting January 2012- ICU reporting begins QA and Infection Prevention collaboration

CAUTI

Catheter Utilization

House wide Foley Days

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

Questions???