CAUTI Team Update Armando Paez, MD Feb. 14, 2019

Team Insights from Process Mapping DEFINE MEASURE ANALYZE IMPROVE CONTROL Team Insights from Process Mapping Urine Culture Ordering Insertion and Re-Insertion Maintenance Removal Several options for physicians to select and variation which one to select Alternative methods for urine collection not standard across the organization Emptying and maintenance varies by unit Post removal protocol not consistently followed Physician challenges with interpreting UA results to determine need for UC, not standard guidelines Different views that criteria has been met for foley re-insertion after bladder scanning or removal, varying practices whether to straight cath Varying practices with clamping when transferring or ambulating patient Not everyone consistently following nurse driven protocol: some people do not understand and some do not initiate refer to physician changing this from nurse driven to order driven Patient presents with fever, tradition to order UC prior to determining if necessary through review of UA Different views on the interpretation of what critical output monitoring means Not randomly validating peri-care cleansing process Difference in opinion around the criteria for removal mostly around critical output Both nursing and physician understanding of the terminology when documented as frequency, urgency and dysuria and how it relates to what is expected versus what is abnormal Not standard practice for 2 people participate in foley insertion No standard irrigation protocol: with equipment, orders, process Patient or family request foley when not medically necessary Order missing impacts daily charting

Data Collection: Nurse Driven Foley Removal Protocol DEFINE MEASURE ANALYZE IMPROVE CONTROL Data Collection: Nurse Driven Foley Removal Protocol Nurses at BMC should be able to remove a Foley catheter based on a Nurse Driven Protocol I have a working knowledge of the details of the current Nurse Driven Protocol for Foley removal at BMC

Data Collection: Myths DEFINE MEASURE ANALYZE IMPROVE CONTROL Data Collection: Myths

Data Collection: Myths DEFINE MEASURE ANALYZE IMPROVE CONTROL Data Collection: Myths

Data Collection: Myths DEFINE MEASURE ANALYZE IMPROVE CONTROL Data Collection: Myths

Tests of Change Test 1: Post CAUTI Deep Dive Test 2: Appropriate use of Critical Output Monitoring Test 3: Intubated patients admitted from ED with Foleys appropriately Test 4: Urinary Retention Monitoring and Post Removal Protocol

Test 1: Post CAUTI Deep Dive Aim: To implement formal Root Cause Analysis review with care team (who provided care within 48 hours of the CAUTI) for identified CAUTI cases within 1 week unit notified of the case. Prediction: Increase collaboration amongst care team members for learning and prevention Identify trends Decrease in CAUTI number Test: Implement a timely (within 1 week), formal review of CAUTI cases for root cause(s). Infection Preventionist will send CAUTI information template with their portions completed and rest of the template is completed by unit designee (within 2 calendar days) as determined by the NM. Unit designee sends completed form to Infection Preventionist and shares with care team members and as a team is prepared to discuss missed opportunities and any trends. Test Units: Any unit CAUTI identified

CAUTI Data 2018: 43 CAUTI with 25 UA with reflex ordered Q1: 11 CAUTI, 8 UA with reflex Q2: 6 CAUTI, 5 UA with reflex Q3: 14 CAUTI, 9 UA with reflex Q4: 12 CAUTI, 3 reflex 2019: 5 CAUTI with only one UA with reflex ordered.