1. MHA Immersion Pilot Project
Capital Region Medical Center CAUTI Immersion Project

2. 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

3. 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

4. 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

5. 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

6. 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

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

8. Results
Immersion Project started
Zero CAUTIs for 383 days

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

10. 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

11. 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

12. Questions?