CAUTI TEAM

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CAUTI Reduction Team

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CAUTI ReductionSWOT AnalysisTeam Review

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CAUTI Reduction SWOT AnalysisStrengths

Only place caths when necessary (i.e. narcotic spinals, intubated ICU patients, TURPs)

Daily foley rounds (Leadership and Infection Prevention)

Preprinted Surgical Post-op orders specific to Foley discontinuation day

Physicians are very receptive to the implementation of renewing Foley orders every 24 hours and removing Foley as soon as they are no longer medically necessary.

CEO is SUPER supportive. Monday-Friday morning huddle includes

discussing every patient that has a Foley and assessing if the Foley is still needed.

Hospitalists agreeable to get Foleys out ASAP

Enthusiasm from Quality Leadership engagement Less insertion in ED already in place Criteria for insertion posted in ICU Everyone here today!

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CAUTI Reduction SWOT AnalysisWeaknesses

Sterile technique New residents placing Foleys on patients

when they’ve never been educated on how

Broken/lack of sterile technique No nurse driven discontinuation protocol No pre-printed Foley orders for non-

surgical admissions Lack of physician champion. Some “old school” physicians are not as

interested in changing their catheter use.

Nurses feel it is safer to put a Foley in than leave a patient in a wet brief due to the shortage of staffing and not being able to get to the patient in a timely manner.

Lack of education for everyone Documentation on bag No foley review by quality on Saturday and

Sunday Poor documentation when foley discontinued Staff not aware of criteria for insertion Staffing when foley is for convenience

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CAUTI Reduction SWOT AnalysisOpportunities

Sterile technique refresher – Foley insertion practice station

Education on why removal ASAP is so important Insert less catheters in the ED Catheters discontinued at the end of surgery

instead of the next day. Unit champions Nurse driven protocols Improve documentation for catheter care Education on proper cath size Evidence based practices for labor epidurals Competency checklists

Correct supplies available to staff when inserting a Foley.

Not break drainage system to change catheter size.

Securement devices used on all Foleys Keep collection bag below the bladder to

prevent backflow. Increase # and availability of bladder scanners Consistent charting of initiation date and time Review with bedside nurses foley placement

on patient Evaluate and standardize supplies

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CAUTI Reduction SWOT AnalysisThreats

Physician and staff education – when to insert, how to insert, when to remove

Lack of support from Urology staff Keeping supplies filled Adequate staffing so nurses are

not rushed while performing catheter insertion

Staff no accepting change

Nurses too busy to participate in successful implementation.

MDs and RNs taking short cuts with sterile technique

Lots of new nurses and new grads

Catheter occasionally inserted prior to obtaining order

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Trace your process to visualize what really happens!

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• System-level tracer questions• Patient-level tracer questions•Interview staff•Review patient records•Talk to patient and family if possible

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Tracer FindingsGood Physicians aware of “Foley

Nazi” Awareness of foley need and

need for CAUTI reduction Starting to use checklist for

order Decrease use in OR

Inconsistent Dependent loops Bag higher than foley No stabilizer Communication with patient not

appropriate or adequate Documentation of insertion,

maintenance, DC Breaks in technique Use for nurse convenience,

criteria inappropriate Assistance use to maintain sterile

field

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Process Mapping

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Process Map of Current State with Risk Points

EducationMaintenance Discontinue/MonitorReview of NecessityInsertion

-Get order-Report off onother patients-collect supplies-educate patient-wash hands-position andundress patient-establish sterilefield and glove-check equipmentand set up kit-drape patient-wash meatus-insertfoley-get urine return-blow up balloon-secure tube-document insertion timeon bag-send urine for analysisif ordered-placefoley below bladder-discard trash-document in medical record-wash hands

-hand hygiene-sterile field set up-patient education-sequencing of events-insertion may be difficult-supplies not appropriate-no criteria for order orcriteria not met-order obtained afterprocedure-documentation not complete-labeling placement info notconsistent

-Every morning, quality runs areport of patients withfoleys tosee if it matches documentationand core measures-Hospitalists discuss necessity oftheir patients'foleys at 7:15 (~90%)-Charge nurse identifies patientson their unit that havefoleys andreview for necessity. hold unitbased huddle with staff nurses,charge nurses and director-at 9:00 the directors and leadershave a safety huddle to discussthese patients.-Nurse leaders go back to unit anddiscuss necessity with staff andpatients' physician if leaders feelit should be removed-if leadership determinesfoleynot necessary, there is followup to see if removed and if not, why not.-Feedback to private physicianswho do not removefoleys-checklist is signed by physicians

-No standardized time forreview-May be signed by MD > 24 hrs.-Review by quality M-F-Foley report accurate for dayprior but not morning of review-ICU uses standardized criteria,but not all units use it. ICU notconsistently using criteria-L&D uses pre-printed ordersfor necessity-No medical staff approvedcriteria forFoleys-Feedback to private MDsnot consistent-checklist not consistently used-does 24 hour start on orderor on insertion?

-Implement bundles(peri care,stabilization,no dependentloops, bag below bladder,individual emptyingcontainers, do nottouch spout whenemptying)-Document maintenance

-formal bundles notdefined and implemented;no bundle checklist-charting not consistent

-criteria for removalmet-removefoley-monitor patient forresidual if ableto void with bladderscanner. Document-Check patient withbladder scanner if notable to void. Document-straightcath patientif needed and ordered-document removal

-multiple straightcaths-not enough bladderscans-no criteria for straightcath-no defined # straightcaths

-Patient and familyeducation-competency determinations(nursing,techs, physicians,residents)-ancillary staff education(related to dependent loops,etc)

-do we have all of the appropriatepolicies to build education-competencies not well defined-preceptors/educators (in someareas) not well defined-inexperienced nurses (new grads)-resident turnover-no defined education process forresidents/oversight-no simulation lab-not sure what ancillary staff getrelated toCAUTI-patients not being educated priorto insertion to advocate for self-patients not consistently getting handout-families not being present for educationor understanding education

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Gallery Walk InstructionsPurpose: To Create the Cause and Effect Diagram

1. Assemble a few people at each flip chart

2. 2 minutes at each chart until you get to your originating chart (consultant is timing

and will instruct you to move to the next chart).

3. Silently write one factor per post it note and write as many factors related to the

topic in 2 minutes as you can. Try to state the factor in neutral terms (for

example, rather than say physicians “lack of knowledge about ABC”, say

“Physicians’ knowledge about ABC”)

4. Move to the next flip chart when the facilitator tells you to and read the Post it

notes already there. Do not repeat

5. When you return to your original flip chart, group can talk and arrange post it

notes into common themes and then name each group (what is the theme?) 11

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Gallery Walk

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CAUTI Reduction Cause & Effect Diagram

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use checklists

Reasons forplacement

reasonsto discontinue

Use STAR andARCC if needed

When to question

clear communicationof when to keep

current andavailable

physicianchampions

when to replace

when to usestraightcath

and how often (limits)

when to drawurinalysis

checklist

evidence basedcontraindications

supportstaff

Evidence basedbest practices New Infection

Preventionist

when to call MD

Friendly competition

Knowledge andUse of criteria

Rep visitsto learn

Ancillary stafftraining/crosstraining

Unit champions

Physicianchampions

Nurse drivenprotocols/empowerment

Competency/Education (insertiontechnique, bundles,criteria)

provide unitspecificCAUTI data

(rates and cost) Staff involvement inCAUTI prevention

staff follow up whenpolicy/documentation

complete/accurate/correctMonitoringof Ancillary staff

committeesreported to

consistency

Unit champions

rewards

physician followupwhen criteria not met

daily review

physicianchampion

Rates (outcome/process)

resident involvementand accountability

Software -accuracy ofcerner reports, data mining who conducts

chart audits

Assistance andsupplies available

Bladder scan preprocedure

Bladder scanfor monitoringpost procedure

No interruptions

Handwashing

positioning

checklists

Privacy

Appropriateorders (criteria)

Patient educationSterile technique

Surveillance

Procedure

Indications

Staff

CatheterAssociatedUTI

Prevention

Patient

Consistent

Include MD inpatient education

Advocacy(when to tell there

is a problem,sharing of experiences,patient onCAUTI team)

Level ofunderstanding

postcath(how to void,s/s of infection,when to call MD/RN)

Hydration

Education(bundles, whyinserted, whenDC, discomfort,when to call RN,hydration,alternatives, etc)

Supplies andEquipment

Appropriate for unit

vendor aspartner

suppliesstandardized

urimeters

set up area

educationon appropriateness

discardingwaste

availability

Fit on bed

adequate # ofbladder scanners

(one/unit)

Evidence basedcriteria

Adequate # onunits

Adequatesizes

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Solution Generation

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Potential Solutions Votes

Revise and consistently implement Foley order form, including definition for "strict I&O" 4Develop standardized bundles and checklist 3Improve physician accountability and responsiveness 2Revise policy - evidence based and available 1Work with Vendor to evaluate supplies and develop criteria for us of urometer 1Define and implement competencies 1Develop and implement nurse driven foley catheter removal protocols 1Improve nurse accountability, especially in relation to incontinence 1Scripting responses as part of rounding in relation to toileting 0Implement bladder scanners on each unit 0Unit based champions 0Provide unit specific rates 0Build alerts in Omnicell for medications that may cause retention 0

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Writing a 3 W Workplan When writing the action plans each ‘what’ should start with a verb, such as

“Collate all forms currently used to teach heart failure to the patient.”

The ‘who’ can be anyone on the team, not just the subgroup working on the

particular issue. This is the name of person on this performance improvement

team who will be responsible for seeing that this action item gets completed.

The assigned “who” does not necessarily DO all the work associated with the

action item, rather – they assure that it is done and may participate in the work

too.

Allow time for each subgroup to present to each other, for any additional tips,

editing, points of clarification etc. Good practice prior to leadership

presentation too.

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CAUTI Reduction Deployment– 3W Plan

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WHAT WHO WHEN

Revise and consistently implement Foley order form, define “strict I&O”

Heather/Debra Sept. 30

Standardize bundles and implement checklist Educator/Project List

Jan. 1

Improve physician accountability and responsiveness-Use ARCC-Define chain of command for Foleys

Dr. Mehta Sept. 30

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CAUTI Reduction Deployment– 3W Plan

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WHAT WHO WHEN

Use vendor to evaluate supplies and develop criteria for urometer use

Becky/Sheila Sept. 30

Define and implement competencies Educator TBD

Develop and implement nurse driven foley catheter removal protocols

Anabelle/Susan

Jan. 1

Improve nurse accountability-removal-incontinence management

Nursing Directors

Sept. 1

Revise policy Cynthia/Becky Ongoing

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Possible Leading metrics (Process metrics) Urinary catheter removed post op day 1 or 2

Time delay of removal identification and removal

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CAUTI ReductionPlus/Delta EvaluationPLUS Gallery walk – great way to

generate ideas Allowing free and safe

conversation Great presentation to C-Suite Very interactive – action taken

towards goal Great start for the leadership Learning lots of new techniques Great techniques to use with

other projects and department meeting issues

DELTA None

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Summary

The PfP Campaign is a national, high-priority effort to prevent harm to inpatients

The JCR HEN is prepared to assist you achieve the “40/20 by ’14” goal

Your PfP project infrastructure will serve as a foundation for strong PI work

You will be successful and your results will be sustainable!

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CAUTI TEAM

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