Safe Table Webcast - Reducing CAUTI - Washington State Hospital ...

Washington State Hospital AssociationPartnership for PatientsSafe Table Web ConferenceHealthcare-AssociatedInfections: CAUTIApril 11, 2013

Washington State Hospital Association PresenterAmber TheelDirector, Patient SafetyPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

10 Targeted StrategiesInfection Reduction:• Catheter-associated urinary tract infections (CAUTI)• Central line-associated blood stream infections (CLABSI)• Surgical site infections (SSI)• Ventilator-associated pneumonia (VAP)Nursing Care:• Injuries from falls and immobility• Pressure ulcersHigh Risk:• Adverse drug events• Obstetrical adverse events• Venous thromboembolism (VTE)Care Continuum:• Prevention of readmissionsPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Julie McAllister, RN, MN, CVRN, FACCNDirector, ICU & PCUCentral Washington HospitalJackie, Whited, RN, BSNClinical Manager, Intensive Care UnitCentral Washington Hospital

Central Washington HospitalNorth Central Washington’sRegional Medical CenterPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

North Central WashingtonRegional ServiceAreaPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Statistics• 1350 + Employees Over 440 Bedside RNs• 26,513 ER visits• 1,276 Births• 40,711 Admissions• 3.56 Acute IP LOS• 1.65 Case Mix Index• 6,854 Surgical Cases• 40,936 Physician Services Visits* 2012 Data• 1,042Active/ActiveProvisional/Referring Medical Staff(214 other)Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

ICU• 20 beds• All Ages: med/surg, CV surgery,occasional pediatric patient• Approximately 3,800 patient days/yearPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Foley Days• Average percentage Foley device days– 2011 65-75%– 2012 75%– 2013 76%Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Qualis Action Network SummaryPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Actual CAUTI• 2011 4• 2012 2– (Jan & Oct – Oct questionable, no new sx probably asympbacteriuria, MD called CAUTI)• 2013 YTD 0Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Education:Keys to Success• Nursing - Identified and empowered a frontline staff RNwith a “Passion for Pee” to research and share bestpractices with her peers. She created a power point, shepresented it at staff meetings, and talked to staff one-onone.• Hospitalists – were provided education at their monthlymeeting about CAUTI prevention and detection by one ofthe providers.Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Product Review:Keys to Success• Stat Lock securement device trial: Staff liked the trialdevice – we chose a different device, but with education,staff are more compliant with utilizing a device.• Reviewed kits that had “prevention guidelines” includedbut decided not to change products.• Found that the OR was routinely breaking the seal to placea urometer on the Thermistor Foley for our open hearts.They purchased a kit that had the correct Foley alreadyconnected to a urometer.Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Keys to SuccessContinued reminders used:• Used a poster reminder of appropriate reasons for aFoley in the clean supply room next to thesupplies.• Continued need for Foley is addressedin multidisciplinary rounds as aformal item.• Continued to remind staff at staff meetings of ourcurrent results and to get Foleys out as soon aspossiblePresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Roadblocks Encountered• Data Collection – our device days are allcollected by hand – feasible in ICU, not on thegeneral units.• Perception that it is easier for nursing andbetter for patients if there is a Foley in place.Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

EMR RN DocumentationPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

EMR – MD Order EntryPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Questions?Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

St. Clare Hospital Partnering toPrevent CAUTIPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

St. Clare Hospital• Part of the Franciscan Health System• Part of Catholic Health Initiatives, a nonprofit healthcaresystem• 106 bed community hospital located in Lakewoodserving South Puget Sound communities• Services provided: Adult acute care patients in ICU,PCU, Ortho/Surgical and Medical Telemetry• 24 hour Emergency Services for all ages• Older building under remodelPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

PresentersPictured from Right to Left• Laura Staubitz RN MA CIC Infection Prevention St. Clare Hospital• Julie Ley RN CCRN ICU Educator St. Clare Hospital• Patty Spencer RN BSN BC, ONC Medical Surgical Educator St.Clare Hospital• Daidre West RN BSN Risk Manager St. Clare Hospital• Marion Ray RN CIC Director of Infection Prevention FranciscanHealth Systems (not pictured)Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

CHI EBP CAUTI Reduction Project• Championed by Risk and Clinical Effectiveness.• Work Group composed of Nurse Managers,Educators, Infection Prevention and ClinicalStaff to improve CAUTI rates.• 9 month duration of project using PDCA process(plan, do, check, adjust).• EBP workgroup provided tracking andaccountability.Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

2009 Creation of CAUTI EBP Bundle1. Avoid unnecessary catheteruse.2. Use proper technique.3. Review daily and removepromptly.4. Engage patients and families5. Participate in system widereporting.Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

New SCIP Quality MeasureStarted with October 2009 discharges• Urinary catheter removed on postop day 1OR• Postop day 2 with day of surgery being day zero– Excluded:• Patients who had a urological, gynecological orperineal operation performed.• Explicit physician documentation of a reason to notremove on postop day 1 or postop day.Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

2009 CHI Directive to Reduce CAUTIActions taken:•UAR orders– Obtain UAR at the time of catheter insertion– Repeat UAR prior at 48 hours post insertion– Standardized order sets•Urinary Catheter Protocol #967.00•Catheter daily needs assessment and documentation•Clinician education and competency verification•Patients/families receive educationPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Identification of UTI’s within 48 Hours• Quality VP directive to assist MD withdetermining colonization vs. true infection– UAR - Urinalysis with Culture if Indicated uponcatheter insertion for baseline– Additional UAR obtained at 48 hours(detect occult urinary tract infection?)Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Urinary Catheter Protocol (967.00)Developed & ApprovedThe CAUTI Formis to be used forall patients with aretention catheter,not only SCIP core measurepost-op patientsEvaluateevery patient,everyday,for criteriato remove orindications to continuea urinary retention catheterIf the patient has a Foley,use a CAUTI FormPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Original Urinary Retention Catheter Needs Assessment1. Assessment of needfor retention catheteron daily basiscompleted by RN2. Documentation ofclinical indication tocontinue catheter3. Surgeon signature onPOD1 and POD2 ifclinical indication tocontinue RC4. If none of the clinicalindications apply, theprovider will becontacted to obtainD/C orderPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Employee On-Line Education• Use of Indwelling Catheters: Insertion, Maintenance andRemoval for Nurses, mandatory course in LEARN• Course Length = 20 minutes• Target Learner - Nursing staff whose role involves:– Determining when to insert an indwelling catheter– Inserting a urinary catheter– Providing care to a patient with an indwelling catheter in place– Supervising the care other team members provide to patientswith indwelling catheters– Monitoring the status of a patient with an indwelling catheter inplace for complications and for readiness to have the catheterremoved• Post Test – 100% required to pass33 Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Patient/Visitor Education• WORKINGTOGETHER forSAFE andEFFECTIVE CAREbooklet.Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

CMS Guideline Change• Beginning Jan. 1, 2012, CMS allows nursing-onlydocumentation on POD 1 & 2 if a “Medical StaffApproved UC Protocol”– exists in a facility– is referred to in the patient chart (on CAUTI Form)– directs UC assessment and documentation(pre/postop orders)• The nursing Urinary Catheter Policy 967.00 has been– changed to a “Protocol”– approved by Standards (May 2 nd )– approved by MEC (May 10 th )= Nursing-only documentation will now satisfy SCIP UCcore measure documentation requirementsPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Creation of New Form - Purpose forRevisionNurses are “Doing it Right”• Nursing-only documentation on CAUTI Form =better core measure performance• Documentation analysis over last 6 quarters revealed:– nurses are completing CAUTI Form correctly when it is placed onchart– providers are not co-signing daily assessment on POD 1 or 2(causing urinary catheter measure variances)ResultsPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Updated Urinary RetentionCatheter Need Assessment-Nurse DrivenWith Approval by theMedical ExecutiveCommittee of theUrinary CatheterProtocol:RN signature onPOD1 and POD2 ifclinical indication tocontinue RetentionCatheterPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

St. Clare Hospital ICU2 YEARS CAUTI FREE!Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Current PracticeICU Intensivist Rounds– Multidisciplinary– Template fordiscussion includesbest practicemeasures– Patient goalsincluded– Daily discussion ofcontinued need forretention catheterPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Current Practice• Hospital wide“Lightening Rounds”• 0900-1030 daily• All patients seen byProvider, CareManager and primaryRN• Continued need forretention catheteraddressed daily.Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Current Practice• Educators review post-op patients dailyfor the SCIP bundle including retentioncatheter usage.• Reminders and updates on daily shifthuddles.• Charge nurses continue to focus onpatient goals with regard to retentioncatheter usage as part of shift report.Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Partnering to Sustain the GainsInfection Preventionongoing staff educationseries called “BugBytes”Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Partnering to Sustain the GainsInfection Preventionannual focus basedon Risk Assessment–2011 focus on UTIand CAUTIpreventionPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Executive Summary Manager Response• NEW –quick summary• Lists Outstanding issues at SCH• Calls out Hand Hygiene scores

Hospital Wide HAI Accountability• Monthly Executive Summary to Board, SeniorLeadership• Monthly comprehensive hospital and unit specific IPreport to Managers• Managers post their results on their Quality Boardsmonthly• A patient incident report (IRIS) is completed for all HAIs• Manager required to investigate, document and follow up• Risk and Infection Prevention review all HAI responsesPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Risk Management -An HAI is an EventManager’s CAUTI review includes:Meets 95% compliance for Unit Hand Hygiene scoreObtained initial UARMeets catheter insertion criteriaCorrectly completed Catheter Insertion ChecklistObtained 48hr UARDocumented catheter careDiscontinued catheter timely per protocolCompleted and documented education (Patient/Family)including patient’s self care abilityPresented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013

Questions and Resources• WSHA Website• References, tools, SafetyAction Bundles• Upcoming Events• Webcast: Reducing ColonSSI June 19, 2013• Webcast: Reducing CLABSIMay 2, 2013Presented at Washington State Hospital Association Safe Table Web Conference, April 11, 2013