MHA Immersion Pilot Project Capital Region Medical Center CAUTI Immersion Project

Project Focus/Problem Statement We wanted to lower our CAUTI rates We had the desire to embed evidence-based practices into the care of all acute care patients with an indwelling urinary catheter We wanted to implement a nurse driven urinary catheter removal protocol

What initial barriers were identified to project implementation? Did not have a process to audit maintenance bundle compliance Were not utilizing a nurse driven catheter removal protocol Alternative methods to catheterization were not being routinely considered Catheters were left in greater than 3 days

Capital Region Medical Center Team Members 100 bed rural hospital 1500 employees 4,810 admissions Team consisted of VP Nursing, Infection Preventionist, nurse manager, 2 bedside nurses, IT, physician (surgeon), nurse educator

Key Solutions Implemented Compliance Audits – Performed routine audits of compliance with maintenance bundle Nurse Driven Protocol – Developed and implemented a nurse driven catheter removal protocol Alternate Methods – Educated staff on alternate methods, purchased additional bladder scanners, obtained condom catheter option Catheter Securement – Evaluated current securement device, educated staff on proper use of securement device Foley Days – decreased number of days catheter was left in place

Key Lessons Learned Daily maintenance bundle audits heighten staff awareness Important to involve bedside staff & physicians in protocol development Nurse protocol embedded into electronic medical record aids early discontinuation of catheter Allow adequate time for staff & physician education Revised process for ED based on whether patient was discharged home or admitted

Results CAUTI per patient day: Baseline = 0.19 (2015) Goal = .11 (40% reduction) Current = .05 (AWESOME!)

Results Immersion Project started Zero CAUTIs for 383 days

Decrease in number of device days Results Nurse protocol implemented Decrease in number of device days

Team Accomplishments Embraced a leadership and accountability structure across the organization Implemented process improvement based on evidence-based best practices that demonstrated measureable results Enhanced patient safety through improved outcomes

Next Steps/Future Plans Daily maintenance bundle audits will continue Provide supportive environment and just in time education as staff & physicians become comfortable with using nurse catheter removal protocol Reducing patient harm is part of organization dashboard

Questions?