Rosanne Raso, RN, CNO Judith Medefindt, RN, AVP, IC ... 1 Rosanne Raso, RN, CNO Judith Medefindt,...

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Transcript of Rosanne Raso, RN, CNO Judith Medefindt, RN, AVP, IC ... 1 Rosanne Raso, RN, CNO Judith Medefindt,...

  • 1

    Rosanne Raso, RN, CNO Judith Medefindt, RN, AVP, IC Elizabeth Malone, RN, AD, IC

    Christina Mastromarino, RN, ICP Jeanne Carey, MD, Infectious Diseases

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    Team Leader

    Infection Control

    Practitioners Nurse

    Educators Physician Champion

    Nurse Managers

    ED Med Surg

    Critical Care

    CAUTI TEAM STRUCTURE

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    Catheter Associated Urinary Tract Infections, Oh No!!!

    CAUTI TEAM LOGO

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    14.2

    16.6

    11.6

    4.9 4.9 4.9

    0

    3

    6

    9

    12

    15

    18

    4A 4C 4D

    CAUTI Rate CDC Baseline

     Baseline data collection  Nov. 19 to Dec. 31, 2009  Three units:

     4A-Intermediate ICU/Respiratory Stepdown/Telemetry

     4C-Surgical  4D-Med-Surg

    WHERE DID WE START?

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     Literature review  Prevention procedures, acceptable indications, benchmarks

     Equipment review  Tubing securement devices, catheter kits

     Revise catheter insertion and care policies  Develop order set with indications for catheter insertion,

    stop date/time  On paper first, then transition to EMR

     Nursing worksheet (Kardex)  Insertion date/stop date and time

     Incorporate SCIP Foley findings with team efforts  24-48 hour removal/documentation

    GETTING STARTED

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    EMR Order Set

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     Surveillance Rounds…..“Three units at a time”  Lessen burden of surveillance  Unit staff highlight Foley patients on census sheet for IC staff

    for denominator data  Units with three consecutive months of zero CAUTI’s “leaves”

    surveillance rounds and next unit “enters”  Daily review of positive urine culture report by

    Infection Control practitioners  Mini RCA on each confirmed case of CAUTI

     Followed NHSN established criteria

    HOW DID WE GATHER THE DATA?

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     Standardize Nursing documentation requirements  Progress notes, patient education record, nursing standard

     Staff education  Nursing staff – “Best Practices” teaching poster  Transport staff – positioning of drainage bag

     White board unit rounds  Daily team meetings at “white board”

     Assess continued need for catheter

     Develop case review form for CAUTI mini Root Cause Analyses  Presentations/discussions at monthly meeting

     Distribute a monthly communications flyer to all stakeholders  Results, lessons learned

    ONGOING WORK of the TEAM

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    HOW FAR DID WE GO?

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    0

    90

    97 98 96

    52

    98

    89 90 95

    0 10 20 30 40 50 60 70 80 90

    100

    May-10 Apr-11 Sep-11 Dec-11 May-12

    Use of a Dedicated Collection Container

    Documentation of Indication for Catheter

    What About Processes?

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     Sample of quarterly updates for each unit Quality board

     Poster Presentation at the LMC Research Fair May, 2011

     Pinnacle Award Submission 2011

     Presentation to our Board Commitee

    COMMUNICATING RESULTS

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     Complicated patients with multiple co-morbidities  End of life issues  Patients needing multiple catheter re-insertions for

    urinary retention

    CHALLENGES WE ARE FACING

    Reduction of Catheter Associated Urinary Tract Infections at �Lutheran Medical Center CAUTI TEAM STRUCTURE CAUTI TEAM LOGO WHERE DID WE START? GETTING STARTED EMR Order Set HOW DID WE GATHER THE DATA? ONGOING WORK of the TEAM HOW FAR DID WE GO? What About Processes? COMMUNICATING RESULTS CHALLENGES WE ARE FACING