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

2. 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

3. 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

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

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

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

7. 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

8. 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

9. 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.