Our Journey Towards CAUTI Freedom Johnson City Medical Center
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
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
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
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
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)
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
CAUTI RIE Team November 18 th -22 nd
A3 Metric size of paper =11x17 9 boxes Designed to tell the event story
CAUTI RIE A3-Box 1 Reasons for Action
CAUTI RIE A3-Box 2 Initial State
CAUTI RIE A3-Box 3 Target State
CAUTI RIE A3-Box 4 Gap Analysis
CAUTI RIE A3-Box 5 Solutions Approach
CAUTI RIE A3-Box 6 Rapid Experiments
CAUTI RIE A3-Box 7 Completion Plan
CAUTI RIE A3-Box 8 Confirmed State
CAUTI RIE A3-Box 9 Insights
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
Destination CAUTI Free
Rodeo Drive Burning Platform
Camp CAUTI Physician Order Entry
Oui Oui Bistro Nurse Driven Protocol
Sochi Indwelling Urinary Catheter Insertion
Outer Space Bladder Scanner and Daily Maintenance
Oh the Places You Will Go Documentation
Baggage Claim Transportation
Destination: CAUTI Free
Destination: CAUTI Free
The Mountain States Star
On the CUSP: Stop CAUTI ED ICU - 2600, 2700, 2800, 2900 Participating in Coaching Calls 31
Physician Order Entry 32
Scheduled Nursing Assessment 33
Nurse Driven Protocol
Nurse Driven Protocol
Then, the Fun Begins. Discovering Issues 36
Indwelling Urinary Catheter Orders with No Nurse Driven Protocol Attached
Indwelling Urinary Catheter Order Never Been Seen
Multiple Ways to Order Indwelling Urinary Catheters
Indwelling Urinary Catheter Order Inside of Order Sets
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
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
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
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
Issues Addressed Electronic POE go-live occurred in ED IP was granted access to front-line nurse view of EHR 45
Issues Addressed 46
Issues Addressed 47
Issues Addressed 48
One More Time For Good Measure Discovering More Issues 49
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
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
Appropriate Indications Reminder 52
Computer Based Learning Updated 53
IUC Catheter Care Fact Sheet 54
IUC Utilization Graph 55
IUC Appropriate Indication Validation 56
So, Did It Work Results 57
ED CAUTI CUSP Results 58
IUC Utilization Before and After Initiative 59
IUC Utilization Before and After Initiative 60
CAUTI Rate Before and After Initiative 61
CAUTI Rate Before and After Initiative 62
August 2014 IUC Utilization 63
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
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
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
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
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
Lessons Learned/What You Need Be flexible Be persistent Never give up 69
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
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
Questions Thank you for allowing me the opportunity to share our story (thus far) with you 72