Why Changing the “Catheter

Culture” is a TEAM Sport!

CAUTI

Other Titles…..•A frequent sense of urgency can be a good thing…

•10 burning techniques for creating a positive CAUTI culture…

•Stop CAUTI….go potty!•Live Free and Go Pee!•Holy Moley….is that foley??

Concord Hospital

18,299 total admissions 67,457 ER visits238 CHMG providers3295 staff employed at CH

10/1/11-9/30/11

Robert’s Story10/14 Robert is admitted from the ER with a Dx of abdominal pain• Smoker, diabetic, pancreatitis, ETOH

and ? Narcotic addictionLater in the day he has a seizure• RN inserts foley catheterRobert becomes agitated, confused, forgetful and refuses all care. He is transferred to the ICU

•First hygiene documented is 3 days after admission by SO, nursing performs catheter care

•Robert tries to climb out of bed often, pulls at his catheter and remains restless

•He is transferred back to the floor with his catheter still in place 5 days after admission

He develops blood in his urine• Temp 103• Urine Culture grows MRSA• Blood Cultures + for MRSA• MRSA seeded from urine to blood

from trauma to urethra caused by repeated pulling on the catheter

• He is treated with IV antibiotics and requires follow up for 2 weeks post discharge

How Do We Calculate the Cost?

•Infusion Charges = $2715•Lab Tests = $905•Vancomycin = $1488•ID consult = $1444

•Total $6146 (plus bed charges)

How do we Calculate the Cost?

•Infection developed 10/21•Total Charges from 10/21-10/29 = $23,682

•As of 1/1/12 all these charges are in jeopardy

What is the cost to the

patient?

Objectives•Identify key elements for a implementing a strategy to reduce CAUTI

• Identify potential barriers to staff engagement around organizational efforts to reduce CAUTI

•List ways to engage staff in discussion, activities and education on reducing CAUTI

•Discuss the importance of nurse/physician collaboration across the initiative.

“Elements”•Energize a team•Leverage skills/Resources/Technology•Educate •Measure•Engage nurses and physicians on the “frontline”

•Network•Timeline•Sustain

Energize a Winning Team*You may need to “draft”

•Choose people who have the ability to influence others and communicate effectively

•Leverage “subject matter experts” and creative energy

•Engage a physician champion!•The team commits to being accountable to one another, the timeline and the process

It Takes a TEAM!•Jennifer Barrett- Staff RN•Kristina Dunn- Nurse Educator•Rebecca Thurner-Longley- Nursing Informatics

•Giuliana Thurber- QA•Lynda Caine/Karen Forrest- IP•Diane Allen- CNO and sponsor•Paul Snyder MD•Pam Paris- Nursing Director

CAUTI team picture

Leverage skills/technology/resources

•Understand current state of the use of indwelling catheters

• Audio-visual•Simulation Lab•IT/EMR

IT/EMR/CPOE•Create report that lists all patients with catheters on every unit

•Create catheter intervention report•Spreadsheet to track unit Foley daysGyn LAVH 2/9/2012 12:30 2/9/2012 14:30       2:00  

Gyn LAVH 2/9/2012 15:33 2/10/2012 5:15       13:42  

Gyn LAVH 2/10/2012 17:45 2/13/2012 3:00       57:15  

Sur Right axillary brachial bypass 2/10/2012 15:35 2/11/2012 10:55       19:20  

Sur Exc of leg melanoma 2/9/2012 9:11 2/13/2012 9:15      

96:04 Pt refused to have foley out 2/12. educated on UTI and pt consented today

Sur Lap Sig colon resect 2/10/2012 17:00 2/12/2012 6:34       37:34  

Sur Multi trauma 2/9/2012 15:00 2/15/2012 18:01 Y     147:01  

Sur PSBO/Xlap/Colostomy 2/9/2012 21:44 2/13/2012 16:16 Y     90:32  

Uro  Robotic Prostatectomy 2/10/2012 9:33     Y  #######

###  

Sur SBR 2/13/2012 20:00 2/17/2012 14:00 Y     90:00  

Uro R ureteral implant 2/13/2012 16:45 2/16/2012 7:00     Y 62:15 Hematuria-3way inserted

Sur Lap Sigmoid Resection 2/13/2012 15:00 2/15/2012 9:30       42:30  

Nurse Driven Guideline for Catheter Removal

•Tool to give RN’s autonomy to make the decision for catheter removal

•Clear criteria for catheter continuation as well as discontinuation

•Specific protocol for bladder scanning and straight cath after foley removal

•Guidelines for informing MD of catheter removal and patient voiding status

• Foley removal orderWe created an order in our electronic order entry system that nurses enter when a patient catheter is removed per guideline-- reporting for frequency of usage-- empowers nurses

Order changes

Documentation Changes•RN documentationWe added an option for nurses to chart

Foley Interventions “per guideline”.

FOLEY:

12. foley – discontinue foley pod#1 early morning. If unable to void in 4-6 hours, bladder scan

+ bladder scan – post void residual. If >300cc, straight catheter and follow indwelling catheter removal guideline – adult

13. foley for bilateral knee patients to be removed on pod#2 at 0600. If unable to void in 4-6 hours, bladder scan

+ bladder scan – post void residual. If >300cc, straight catheter and follow indwelling catheter removal guideline – adult

Educate •11+ unit presentations•7 to physician groups or committees•Daily conversations•RN and LNA specific mandatory education

•Availability to problem solve and support when staff are trying to do the right thing, not the easy thing

Measure•Infection prevention and quality assurance collaboration

•ICU CAUTI•House wide CAUTI•Device Utilization rate

NHSN Catheter Utilization Rates: ICUs

ICU Foley Catheter Utilization Ratio

Q3 '11 Q4 '11 Q1 '12 Q2 '120

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0.790

0.860 0.850

0.770

CH Ratio

Mean = 0.71

NHSN CAUTI Rates: ICUs

ICU Catheter Associated Urinary Tract Infection Rates (CAUTI) by CY Quarter

Q3 '11 Q4' 11 Q1' 12 Q2 '120

100200300400500600700800900

1000

0

1

2

3

4

5

6

7

716

869

786818

2.8

1.15

3.823.67

Days

Rate per 1000

Yearly Quarters

Cat

het

er D

ays

Rat

e p

er 1

000

NHSN pooled mean 1.3

Total Infections 2012 Q2 = 3

2012 House Wide Catheter Associated Urinary Tract Infection (CA-UTI) Rate by Month

1 '12 2 '12 3 '12 4 '12 5 '12 6 '120

200

400

600

800

1000

1200

1400

1600

0

2

4

6

8

10

12

141487

1332 13191243 1231

1284

2.69

1.5 1.520.8 0.81

2.34

Days

Rate per 1000

Month

Cat

het

er D

ays

Rat

e p

er 1

000

24 2 1 31Total Infec-

tions

Engage the Frontline•They are the people putting catheters in and taking them out!

•Physician leaders•Support clinical decision making when its good, and coach when a better decision could have been made

•Understand the challenges•Empower the nurse to ask WHY

Network•C.A.S.E. method•Talk to staff, discuss at meetings, go to a conference, read, look for ideas and inspiration outside of your work environment

•Share your ideas!•Be open to ideas from outside your discipline

Timelines•Define a rollout time line (big bang vs structured)

•Set measureable goals•Be accountable and hold the team accountable

•Talk, Talk, Talk

Sustain and Infuse the Culture•Add to Orientation/checklists/simulations

•Share success stories•Involve the C-suite•De-brief every CAUTI•Discuss in patient rounds•Add reminders•Have fun with it

A-HA’s (or Oh NO’S!)•Urinary Retention•OR preference cards•Epidurals•Learn from Defects•Patient Education (CDC toolkit)•Cultural Change•Just when you thought you were clear…

Med-Surg Unit rolloutGoals•Educate RN’s and LNA’s about CAUTI•Pilot and implement NDG•Competency for insertion of foleys•Measure foley days and average LOS•Ensure bladder scanning and straight cath are done timely

ICU rolloutGoals•Convince an ICU RN they do not need a foley!

•Add it to daily patient care rounds•MD engagement•RN/LNA education and competency• Partnership for Patients project starting 9/2012

Prevention of CAUTI “Bundle”• Stop… THINK! Does my patient need a Foley?  The reduction of indwelling catheter days is a cornerstone of CAUTI prevention programs!

• Use straight caths when possible• Insert catheter using aseptic technique and sterile equipment• Use securement device to secure catheter to the leg • Perform hand hygiene before and after touching catheters• Use Standard Precautions and gloves• Maintain closed, sterile system

• Maintain unobstructed urine flow• Ensure that drainage bag hangs below bladder level• Catheter bag must never touch the floor• Obtain samples aseptically from collection port only

• Use creams or powders on perineal area sparingly • Use Fecal Containment Device to contain feces• Document use of catheters including insertion date, indication• Do observations to ensure compliance• Ask every day, “Do we need the Foley?”

ED rolloutGoals•MD order for every foley including reason for insertion

•Every foley order entered electronically

•Track how many foleys are inserted•Educate staff about CAUTI•Competency for insertion of foleys•UA/culture reflex with each insertion

Nurse/Physician Collaboration

•CAUTI Best Friends!•Peer to Peer accountability•Different perspectives add value to the process

•MD champion who is also a urologist adds credibility to the initiative