CAUTI “Back to Basics” Lindsey Bruchhaus MSN, RN, CPHQ June 1, 2017

“Back to Basics” CAUTI Background: Problem: Objective: According to the CDC, urinary tract infections (UTI) are the most commonly reported and approximately 75% are catheter related. The prolonged use of an indwelling urinary catheter puts patients at increased risk for infection. Problem: Increase in catheter associated urinary tract infections (CAUTI) Objective: To implement an evidence-based practice project that would reduce catheter associated urinary tract infections and reduce indwelling urinary catheter (IUC) utilization.

First steps Literature review Policy and Procedure Case analysis Published guidelines High performing organizations Best practices Policy and Procedure Gap analysis Case analysis Opportunities for improvement Analyzed trends

Facility assessment Issues Identified The risk of CAUTI is directly related to the duration of catheterization Issues Identified Urinary catheters in place that are not indicated Infection during the maintenance phase Staff knowledge deficit of clinical indications Indwelling Urinary Catheter Who: ER most frequently inserts IUC What: IUC not removed timely Where: ICU has highest utilization When: Infection in maintenance phase Why: Strict I&O & urinary retention

“back to Basics” Inter-professional approach TEAM Infection Control Practitioner Staff Nurses Leadership Patient Care Assistants Educators Physicians

No Foley=No CAUTI CAMPAIGN Empower Nursing Stake holder “Buy-in” The team launched a hospital wide No Foley=No CAUTI campaign. This campaign included awareness, education, and celebration for success. Stake holder “Buy-in” Nurse-driven protocol Visible support of leadership and physicians

implementation Awareness Poster board on CAUTI prevention Video created by staff portrayed potential causes and the negative outcomes of a CAUTI and included CAUTI prevention methods Indications for use easily available by pocket card, documentation system, and computer wall paper “Back to Basics” team members went to all department staff meetings, medical staff meetings, and leadership meetings to create awareness Video Real stories shared Pledge- No Foley, No CAUTI Days since Last CAUTI posted on Units Story telling sticks to people You are more likely to remember the lesson from the story over listing facts. We provided learning through story telling.

implementation Interventions Critical care units remove IUC before transfer to MedSurg if in place for strict I&O ER performs a straight catheterization for urinary retention Daily surveillance of device utilization and indication for use through an audit tool Enhanced dialogue between care givers and between the patient and care giver through a pamphlet

implementation Interventions Daily rounds included discussion on urinary catheter plan for discontinuation Critical care added invasive lines assessment to the tool for interdisciplinary rounds MedSurg Charge Nurse asked the question during interdisciplinary rounds, “why is the invasive line in place?” CHG bathing for all patients with IUC

Tools NO FOLEY = NO CAUTI

VIDEO NO FOLEY=NO CAUTI Tools VIDEO NO FOLEY=NO CAUTI

Each day the Foley catheter remains, the risk of A CAUTI increases 5%. If they don’t need it, pull it! Only keep Foley if… Neurogenic Bladder Acute urinary retention or bladder outlet obstruction STRICT I&O every 1-2 hours: Critical Care Only Traumatic injuries (eg: unstable spine, pelvic fracture) To promote healing of OPEN sacral or perineal wound Comfort for end of life care Urologic, gynecological, or genitourinary surgery Anticipate patient is going to surgery Assess Every Shift Nurses, remove that Foley!

tools QUICK REFERENCE

Tools

TOOLS

results Summary Pre Data 1 year post intervention >50% increase in CAUTI from prior year >50 % reduction in CAUTI Indwelling urinary catheter utilization decrease by 16% Sustained 50% reduction in CAUTI Sustained decreased utilization rate The pre-data results showed 14 catheter associated urinary tract infections in a one year time frame.( .50% increase) One year after implementation (ending the year with 5 infections) Urinary catheter utilization fell 12% 2014-2015 (2014-2016 16% decrease) + 36 beds + 36 beds + 36 beds

results Timeline Pre data Q1 2015 intervention Post data + 34 beds

Results ICU best in system : Days without CAUTI We measure days since last infection. We have competition with sister facilities

results Q1 2015 intervention According to NHSN we are better than national benchmark Q3 2016 began using step down unit for IUC beds MedSurg started doing IMU level care Action Item: IC alerts managers/Charge nurses of long length Foley catheters

KEY TO SUCCESS Staff buy-in & nurse engagement Accountability Timely feedback Physician champion Nursing leader champion Celebrate success Message: Everyone makes meaningful contributions to mission The different methods used to implement change were innovative and created an awareness that has led to sustainable improvement. The project included staff buy in and accountability to create a culture of patient safety. We have used this model to for CLABSI prevention. We dropped our infection rate and utilization>50%.. and now OR back to basics

Keeping Momentum 7 CLABSI for 2 years prior …. 2016 3 CLABSI

CLABSI “Back to Basics” Intervention First steps: best practice, case analysis (lines in place longer than indicated, scrub the hub (multiple access per day), and policy & procedure gap analysis Awareness: shared real stories, displayed days since competition, different avenues to create a knowledge of indications Interventions: rounding structure (Critical care and MedSurg), removal of central line before leave critical care, daily surveillance to assess maintenance and indications, dialogue with patients on infection prevention, appropriateness of PICC were closely looked and Midlines were made available. ** CHG bath and Alcohol bathing caps

Reference Falconio-West, M. (2011). CAUTI Prevention: Craking the Case. The OR Connection, 6(2), 62-74. Retrieved from https://www.medlineuniversity.com/DesktopShell.aspx?tabId=5&documentCategoryId78=171&searchOrCat=category Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & H. (n.d.). GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009. Retrieved January 30, 2015, from https://www.cdc.gov/hai/pdfs/cautiguideline2009final.pdf Fakih, M. G., Rey, J. E., Pena, M. E., Szpunar, S., & Saravolatz, L. D. (2013). Sustained reductions in urinary catheter use over 5 years: Bedside nurses view themselves responsible for evaluation of catheter necessity. American Journal of Infection Control, 41(3), 236-239. doi:10.1016/j.ajic.2012.04.328 How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: Institute for Healthcare Improvement; 2011. (Available at www.ihi.org). Lo, E., Nicolle, L., Coffin, S. E., et al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute are Hospitals: 2014 Update. Infection Control and Hospital Epidemiology. 2014; 35(5):464-479.doi:10.1086/675718 retrieved from http://www.jstor.org/stable/10.1086/675718 Meddings J, Rogers MA, Macy M et al. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clinical Infectious Disease 2010;51:550–60 Meddings, J., Rogers, M.A., Krein, S., Fakih, M., Olmsted, R., Saint, S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter associated-urinary tract infection: an integrative review. BMJ Quality & Safety 2013; 0:1-13.doi:10.1136bmjqs-2012- 001774 Scott, R. A., Oman, K. S., Makic, M. F., Fink, R. M., Hulett, T. M., Braaten, J. S., & ... Wald, H. L. (2014). Reducing Indwelling Urinary Catheter Use in the Emergency Department: A Successful Quality-Improvement Initiative. JEN:Journal Of Emergency Nursing, 40(3), 237-244. doi:10.1016/j.jen.2012.07.022