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We have a CAUTI…now what?
Mary H. Holmes, MT, CIC
Infection Prevention Specialist
Ginny Ledbetter, RN, MSN, APRN-BC
Clinical Nurse Specialist
Roper St. Francis Healthcare
Wednesday, August 22, 2012
Objectives
• After this presentation the participant will
be able to:
– Articulate one approach to identifying
possible factors contributing to the
development of a CAUTI
– Understand the importance of a CAUTI
review process
– Understand how the CAUTI Analysis form is
used
Background
• Roper St. Francis Healthcare (RSFH)
– 3 Hospital Facility
• Roper Hospital – 368 beds
• Bon Secours St. Francis Hospital – 204 beds
• Mt. Pleasant Hospital – 85 beds
– 5 Emergency Departments
• 3 contained within the hospitals
• 2 free-standing
CAUTI Prevention
• Multidisciplinary CAUTI Team with
representatives from all hospitals and ED
– Subgroups
•
•
•
•
Necessity and Timeliness of Removal
CAUTI review process and communication
Foley supply standardization
Education
Goals of the CAUTI Team
• Prevent hospital acquired CAUTIs
• Identify possible causative factors through chart
review once a CAUTI is determined
• Develop action plan to address gaps in practice
• Communicate, communicate, communicate
– Nurses
– Physicians
How do we prevent hospital acquired
CAUTIs?
Adhere to CA-UTI Bundles (per IHI*)
1. Avoid unnecessary urinary catheters
1. Insert using aseptic technique
1. Maintain catheters based on recommended
guidelines (daily care)
2. Review catheter necessity daily and remove
promptly
* Institute of Healthcare Improvement
We have a CAUTI…now what?
• Even with everyone focused on CAUTI
prevention, we still have hospital acquired
CAUTI’s
• Our approach to CAUTI prevention has evolved
over the past couple of years
– 2010 – reported # of CAUTI’s
– 2011 – CAUTI Team subgroup developed and
revised the Infection Prevention Analysis (IPA) form
– 2012 – Began reporting CAUTI specific data to the
physicians and continue to revise the IPA form
Current Process
• Infection Prevention Specialist determines that criteria for
CAUTI have been met
• Clinical Manager and Clinical Nurse Specialist (CNS) are
informed of CAUTI via email and receive copy of CAUTI
Analysis form
• Chart is reviewed, the CAUTI Anaylsis form is completed and
is returned to Quality Department
• Information is entered into the Midas database
• Report is generated
• Information is shared at CAUTI meeting
The CAUTI Analysis form ……
a moving target
• The CAUTI Analysis form is forever changing
• Data elements have been removed and added
based on their relevance
Removed
•BMI
•Reviewed with Attending
•Free text fields changed to check boxes
when possible
Added
•Specific CDC Criteria for infection
•Time from Foley insertion to + culture
•Physician order present
•Necessity/removal order present
•Physician documentation of necessity
•Nurse/PCT documentation of pericare
CAUTI Analysis Data Elements
• The IPA form is populated by the Infection Preventionists
and Nurses
• Infection Preventionist provides:
–
–
–
–
–
The Nursing Unit the CAUTI is attributed to
Facility
Patient information
See CAUTI Analysis
Physician information
Form Handout
Urine culture information
• Nurse provides:
– Clinical information
Page 1 –
CAUTI
Analysis
form
Page 2 CAUTI
Analysis
Form
An actual
CAUTI
Analysis
form
Midas Report
Are there trends?
• Surprisingly, not really
• It seems we have a different “trend” and
discussion topic each month
–
–
–
–
–
–
Organism type
Unit where foley inserted
Staff who inserted foley
# days to + culture
Attending MD
Unit with CAUTI
# days from catheter insertion to + culture
9
8
7
6
5
4
3
2
1
0
Days
1
2
3
4
5
6
7
8
9
10
11
12
13
>25
Are there surprising findings?
• Yes
• May was an interesting month
– 5 CAUTI’s
• All at one hospital
• 3 of the 5 were placed in the OR and 2 were by the same
staff member
• All surgical patients who had Foley removed within 2 days for
SCIP measure
• 4 of the 5 had a + culture within 2 days of insertion and the
other 1 had a + culture within 3 days of insertion
• All were female (72% female YTD)
What was follow-up for May?
• Spoke with OR Manager who in turn spoke with staff
members
– They recall nothing out of the ordinary
– Adherence to proper insertion procedure was maintained
• Key CAUTI team members (Physician, Nurse Executive,
Infection Preventionist and CNS) discussed possibility of
these being POA and undetected
– Should we implement process to get U/A and possibly a C&S on
“high-risk” patients
• Continue to discuss if incontinence wipes are warranted
to standardize catheter/pericare – especially for women
What has the data told us?
• We have opportunities for improvement:
– Nursing:
• Complete documentation
– Pericare
– Foley removal
• Placement of Necessity/Removal order form on
chart
• Use of fecal management device for incontinent
patients
What has the data told us?
• We have opportunities for improvement:
– Physician:
• Intermittent catheterization instead of Foley
reinsertion
• Utilization of the Urinary Retention Protocol
• ? Foley necessity for fractured hip
How do we communicate the CAUTIs?
• Nurses
– Monthly Infection Dashboard
– Monthly Quality Scorecard
– Staff meetings
• Physicians
– Monthly Quality letter
– Division meetings
– Medical Executive Committee
What’s working well?
• The process has facilitated a stronger
collaborative relationship between Nursing,
Infection Prevention and the Midas Report writer
• Chart reviews involve clinical staff which brings
the CAUTI “home”
• Even thought the process isn’t perfect, it is an
approach to keeping CAUTI and CAUTI
prevention in everyone’s mind
What’s working well?
• We’re very close to having the Midas report format
finalized
• The Midas report can be exported to Excel so data
can be sliced and diced
• We’ve been able to tailor our educational posters to
address gaps in practice
– Necessity not an Accessory
– Alternatives to catheterization
– Get the Plastic Out
What are limitations of our process?
• Our process to determine a CAUTI is
manual and very labor-intensive
• Our chart reviews are retrospective and
not concurrent
• We not quite ready to utilize the Midas
report
In Summary
• CAUTI Prevention is a major focus at
RSFH
• We take each CAUTI seriously and
perform a chart review to see if possible
causative factors can be identified
• We continue to tweak the process and
reports so they provide meaningful
information to drive process improvement
efforts
Questions?
• Thank you for your attention
• We’re happy to answer any questions
• We’d also love to hear comments
regarding how you approach data review
in your facilities
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