Rosanne Raso, RN, CNO Judith Medefindt, RN, AVP, IC ... 1 Rosanne Raso, RN, CNO Judith Medefindt,...
Embed Size (px)
Transcript of Rosanne Raso, RN, CNO Judith Medefindt, RN, AVP, IC ... 1 Rosanne Raso, RN, CNO Judith Medefindt,...
Rosanne Raso, RN, CNO Judith Medefindt, RN, AVP, IC Elizabeth Malone, RN, AD, IC
Christina Mastromarino, RN, ICP Jeanne Carey, MD, Infectious Diseases
Educators Physician Champion
ED Med Surg
CAUTI TEAM STRUCTURE
Catheter Associated Urinary Tract Infections, Oh No!!!
CAUTI TEAM LOGO
4.9 4.9 4.9
4A 4C 4D
CAUTI Rate CDC Baseline
Baseline data collection Nov. 19 to Dec. 31, 2009 Three units:
4A-Intermediate ICU/Respiratory Stepdown/Telemetry
WHERE DID WE START?
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
EMR Order Set
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?
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
HOW FAR DID WE GO?
97 98 96
89 90 95
0 10 20 30 40 50 60 70 80 90
May-10 Apr-11 Sep-11 Dec-11 May-12
Use of a Dedicated Collection Container
Documentation of Indication for Catheter
What About Processes?
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
Complicated patients with multiple co-morbidities End of life issues Patients needing multiple catheter re-insertions for
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