American Association of Critical Care Nurses (AACN)  Largest specialty nursing organization in the world  Representing 500,000 nurses  Dedicated to providing knowledge and resources necessary to provide optimal care to critically ill patients

AACN Clinical Scene Investigator (CSI) Program  16 month nursing excellence and leadership program  Team based with education, coaching and mentoring  Leverage the staff nurses’ expertise to enhance patient care and create positive patient outcomes

CSI Academy Objectives  Demonstrate the components of innovative project management.  Develop, plan and implement an innovative project that targets a patient/family or clinical outcome on the unit.  Create measureable improvements in patient/family, clinical or organizational outcomes.  Effective communication, collaboration and innovation.

Meghan Cardona, RN, BSN, CCRN Sherley John, RN, BSN, CCRN Sherry Ann Santarina, RN, BSN, PCCN, CCRN Merin Thomas, RN, BSN, CCRN Take CAUTION!

Purpose and Goals ▪The Neurosurgical ICU experienced elevated CAUTI rates. ▪Goal: To decrease the incidence of CAUTIs in NSCU by 25%, as well as increase and sustain compliance in catheter care and removal. ▪Sept Aug. 2013: ▪Foley days: 3,653 CAUTIs: 19

North Shore University Hospital ▪New York State Designated Regional "Level One" Trauma Center. It offers the highest level of care to the most critically injured patients in the area. ▪Physicians and nurses of the ED care for more than 90,000 patients per year. ▪Employs more than 6,000 highly trained physicians, nurses and other medical staff ▪806-bed teaching hospital on the 58-acre Sandra Atlas Bass Campus ▪Academically affiliated with the Hofstra North Shore-LIJ School of Medicine

Neuro-Surgical Care Unit ▪Neurocritical Care Center at North Shore-LIJ Health System's Cushing Neuroscience Institute features a 16-bed intensive care unit that was established in 2007 North Shore-LIJ Health System ▪Provides expert care via a team approach to the management of patients with subarachnoid hemorrhage, traumatic brain injury, intracerebral hemorrhage, complicated stroke and other disorders ▪Provides 24-7 intensivist coverage for critically ill patients. ▪U.S. News & World Report Ranks North Shore University Hospital Among Top 50 in US for Neurology and Neurosurgery

Money Talks ▪NSCU cost per day: $5,800 ▪Floor cost per day: $3,350 ▪Increased LOS due to CAUTI: $ $4700 ▪Antibiotic cost (5 days): Cipro IV $34.50 ▪Antibiotic cost (7 days): Cefepime IV $74.62 ▪Average Increase in Direct Cost per case w/CAUTI - $22,400

Money Talks Projected savings with a 25% CAUTI reduction: $106,400 ▪NSCU CAUTI Cost for 2013 (19 CAUTIs): $425,600 ▪NSCU CAUTI Cost for 2014 (14 CAUTIs): $313,600 ▪Estimated savings from : $112,000

NSCU CAUTI September Present

NSCU CAUTI

NSCU Device Days (Foleys)

Activities and Key Dates ▪October 2013: Small test of change – Green clip monitor ▪November 2013: (Anti) Foley Cart ▪December 2013: Chart reviews ▪February 2014: CAUTI binder ▪March 2014: Sunflower Visual Aid

Activities and Key Dates ▪April 2014: Pre-survey, incentives ▪May 2014: Why the Foley? Week ▪June 2014: Hospital-wide CAUTI carnival ▪August 2014: Post-survey, incentives ▪September 2014: NSLIJ 7th Annual Nursing Education Conference Poster Presentation

NSCU Straight Catheterization Protocol ▪Female Patients: ▪D/C foley based on LIP order ▪Bladder ultrasound for the first 24 hours after each episode of incontinence, or each episode of voiding ▪If patient does not void… ▪Bladder ultrasound and straight catheterization Q4 hours for volume > 300 mL. ▪If volume is < 300, reassess in 2 hours ▪Straight catheterize at any time the bladder ultrasound shows volumes > 300 mL ▪If patient has volume > 500 mL X 3 straight catheterizations, notify provider and reinsert foley.

NSCU Straight Catheterization Protocol ▪Male Patients: ▪D/C foley based on LIP order ▪If the patient does not void within 4 hours and volume is > 300 mL, perform straight catheterization ▪If < 300 mL, reassess in 2 hours ▪After 2 episodes of straight catheterization, discuss next step as to whether the foley should be reinserted.

Why the Foley? Week!

Hospital-Wide CAUTI Prevention Week! ▪Modeled after NSCU’s Why the Foley? Week ▪CAUTI Carnival ▪Presentation of NSCU Methods ▪Lunch ▪Skill Validation ▪Vendors

Project Outcomes ▪The number of CAUTIs was reduced by 26%. ▪This outcome resulted in a savings of $112,000 since the AACN CSI Academy program was launched.* ▪Using the CMS estimated cost of $6,913 per CAUTI, the savings would be $34,565 ▪The number of device days was reduced by 31%. * Based on the hospital’s calculated cost of $22,400 per CAUTI

Unintended Positive Outcomes ▪NSCU nurses have become CAUTI knowledge experts. ▪We have enhanced our skills in intermittent catheterization. ▪There is a notable surge in staff satisfaction because of hospital wide recognition. ▪There has been an increase in collaborative efforts and camaraderie among the NSCU team.

Expectations ▪Resistance from the team (LIP, RN, and PCA) ▪Resistance from the patient and family members ▪Increasing the need to assess and provide patient care

Momentum and Sustainability ▪In-services via computer software ▪Annual CAUTI Prevention Week ▪CAUTI binder ▪Visual Aids ▪T-shirts ▪CAUTI educational material ▪Additional support

Conclusion Special thanks to our amazing colleagues, the ICU team, management, administration and AACN for their support. Due to our outcomes we have the privilege sharing our success with others. Institute for Health Improvement: Orlando, Florida: November 2014 Society for Critical Care Medicine Phoenix, Arizona: January 2015 AACN National Teaching Institute San Diego, California: May 2015

References ▪Castro E. CAUTI reduction and prevention at North Shore University Hospital Department of Nursing Education, Patient Care Services, Standards, Policy and Procedure Manual ▪Research Triangle Institute for Center for Medicare & Medicaid Services. Analysis report: Estimating the incremental costs of hospital-acquired conditions (HACs) Retrieved from Payment/HospitalAcqCond/index.html. Accessed April 1, (Click Incremental Updated Cost Report). ▪Umscheid C, Mitchell M, Doshi J, Agarwal R, Williams K, Brennan P. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Inf Contr Hosp Epidem. 2011;32(2):