1

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

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

2

Team Leader

Infection Control

Practitioners Nurse

Educators Physician Champion

Nurse Managers

ED Med Surg

Critical Care

CAUTI TEAM STRUCTURE

3

Catheter Associated Urinary Tract Infections,

Oh No!!!

CAUTI TEAM LOGO

4

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?

5

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

6

EMR Order Set

7

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?

8

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

9

HOW FAR DID WE GO?

10

0

90

97 98 96

52

98

89 90 95

0102030405060708090

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?

11

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

12

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

urinary retention

CHALLENGES WE ARE FACING