Good morning and welcome to the Hospital Acquired Infections Affinity Call. Offices
events are in a listen only mode. If you need assistance, press the*key followed by 0.
After the presentation today there will be an opportunity to ask questions. To ask a
question you make press star 1 on your touchtone phone. To withdraw, press star 2.
This event is being recorded. I will now turn the conference over to [indiscernible]
Good morning, everyone. Good morning to this month topics call. This is the first one
of the year. We are excited to get started. I wanted to start off by saying that today
there is an evaluation with our call at the end. It should pop up at the end. If not, it is
on the meeting webpage. On the HEN network webpage. If you want to receive
CPUs, -- CEUs, complete your evaluation. If you just want a recognition, complete
one and valuation for each hospital.
Today we have a team from Emory [indiscernible] presenting. We had discussions at
our kickoff about CAUTI and I think we all know the how -- the evidence-based
practices, but everyone wanted to hear about how you got the staff engaged,
especially with decreasing utilization of urinary catheters and changing the attitude of
staff toward CAUTI. Today the team from Emory Johns Creek will present for us.
They do not have anything to disclose as far as conflict of interest nor do I I would
like to start off ugly and ask if anybody has any positive [indiscernible] that you
would like to share with the group. Press star six to share this order. In the chat box.
Excuse me -- it is *1.
If you have something positive to share, put it in the chat box or press *1 and we will
give you a few seconds to do that.
I want to share that there is something positive on the state level -- we just pulled
down the delete data on urinary tract infections for CAUTI and the rate has decreased
from the previous quarter. I think we are making headway with that.
If we have no stories to share, that is the positive story to start with. Gary, it has
anyone chimed in?
No.
Let's move on. I want to introduce the team from Emory Johns Creek -- Marsha
[indiscernible] is the infection present in this.
Karen [last name indiscernible] is the nurse manager on the medical unit and Lynn
Talmage is the charge nurse in the ED. I will now turn it over to Marsha.
Thank you.
We are a small community hospital. We are affiliated with the every system. We have
110 bats and we opened in February 2007 so we are new. We have a medical unit and
a surgical unit and ICU. We have women's services. We deliver babies. We have a
level III NICU and we do cardiac catheters. We are a diverse hospital with a lot of
different patients and we are community physicians. It is not an academical medical
center.
This is our team. It consists of nurses and physicians from all different areas of the
hospital and we also have PCT and tax as the team. There are no directors. We felt
that we do better with staff involvement because they know what is going on and they
can help make a change. In January of 2012 we noticed an increase in CAUTI
occurring across the hospital. We decided as a team to meet at 8 AM so we could get
the night and day staff to me. We have a call in the numbers of people can call in on
their days off and dissipate. This is very good. All team members have to participate
in audits and education. We teach new staff about the protocol and the use of bladder
scanners. Several of the team managers are working on special projects. This is a
wonderful group of champions and it has been great working with all of them. Next -We had to do to start was go through Med Exact and get the physician champion to
get the physicians to agree on the indications for inspecting an indwelling catheter.
This is not easy. It took several months to of going back and forth. Everybody wants
to The door for a different reason. It wasn't until the Department of cardiology said -if the patient is not in ICU we do not need a Foley catheter see if the patient has fluid
overload. We can measure this in other ways. I wait and other things. Unless the
patient is in ICU, we do not need to measure urinary output. This stopped a lot of the
insertions. And nephrology said unless they are in ICU we do not need a urinary
catheter. It's not that critical. We had these gone. This decreased the use of urinary
catheters in the 36 bed medical unit. Started to have alternatives such as good a daily
weight and keeping the physician informed of fluid overload with other methods. We
did a good job of keeping the Foley's out of those groups.
Next Lynn will talk about the use of decreasing the urinary catheter in the emergency
room. If it's not., We can't keep him. Talk about what you did, Lynn, to stop the
Foley's from being inserted.
Good morning, everybody. One of the big things in the emergency room was to get all
of the doctors and PAs and meant level staff to stop ordering them. Don't they want
them on the floor? Anybody that got Lasix they wanted it only four. -- A Foley.
The doctors recognized we did not need to do this anymore. That cut down. We
started on the staff. We put up a sign in the room by the Foley's. When you went to
get a Foley you saw the screen up there now -- the emergency room catheter insertion
indications. We asked them to take a sheet and let out on every patient that got a
Foley. Put it in a box so we could see the justification.
The other thing -- why are you putting in the Foley? There was some resistance. This
is what we usually do. This is how we've always done it. We changed it so that the
patient didn't get Foley if they were here for a broken hip and maybe we did
something different. We would help them with a urine or all or use a condom catheter.
We tried to change some of the ones going to surgery. Most of them going to surgery
from ER got a Foley. We started doing that and worked with the Omar team on that.
A lot of it was remembering look at the sheet.
We have this into places. The reasons for the indwelling catheters. Once in the nurses
station and once by the Foley catheters so that they have to see that they are doing it.
It has been a several month gold we see somebody putting in a catheter -- is it
necessary? We cut back a lot even with the ICU patients. They really don't need it.
We haven't been doing it.
Now Karen will talk about -- once they get on the floor -- the reason that every day we
would assess to see if they still needed the Foley catheter.
Next slide.
Good morning. When the patients come to the floor, we don't have a lot of patience
the Foley's. It is mostly the patients coming from ICU or usually those with chronic
only from home. Of have to do is change the Foley catheter. Every day we have
reviewed the reasons why the patients need to have a Foley catheter. Looking at this
slide -- there are reasons for indwelling catheters.
When a patient's comes out of ICU, they need to be accurate. When they go to the
floor it doesn't mean that they are -- they need to be on a Foley catheter. We have
options on the floor that we try to offer the patient. Sometimes they don't like it
because they can't get up or they've been on Lasix and they have to be owing to the
bathroom a lot. They will get tired of that. Sometimes we use a condom catheter. We
have something new we are using -- a purple pad that can hold up to 1 L of fluid. This
is good because the patients wouldn't feel that even though they are using that. We
also provide some diaper skills. If you want accurate intake and out but especially
when the cardiologist wants to see this -- you can way be put had -- weigh the purple
pad.
Of instruction of the urinary tract -- if the patient has a history of obstruction, that is a
good reason that we try to keep it on. We focus more on these reasons. This is not for
nursing convenience. At first it was hard for the nurses. Especially when they have
patients in heart failure. If there is no Foley catheter -- they complain. We can do the
correct [indiscernible]. After that, the goal is -- it is in another slide -- the nurses
attitude towards not having the patient on Foley catheters.
Everything is there on that slide. The reasons. We make sure that the next day when
the patient comes from ICU we have to review the reasons and if it is not a category
for a catheter, we have to take it out.
All patients have a laminated card that explains to the patient and family that -- mostly
the have to be considering the family -- they will say my mom will be tired getting out
of bed. If you could keep the catheter on -- we have to explain to the family the reason
that we have to take it out to prevent infection. We have to make sure that we educate
them aside from the laminated cards and the patient rooms. It is all in the rooms of the
patients. At least they read their reasons and the risks for patients with catheters.
What happened with the third floor? I try to ask people -- it was hard for them to have
patients without a Foley catheter especially if they restrict I and O. They said it would
be hard and they have a lot of patience. That changed because they want the patients - they don't want their patient to get an infection. That is a big thing.
For them, they really know the importance. It is going to be for faster recovery of the
patient. That is why we encourage this. We have other options to assist them. We can
use help to bring patients to the toilet. As mentioned earlier, the purple pad is a big
help. It absorbs 1 L of fluid. It is easy to change the patient. Especially those that are
incontinent. It is easy to move the pad without changing the whole bed. As I
mentioned, it is also a big thing with cyber rounds -- this is one thing they discussed -to pick a designated indication to keep the indwelling catheter in place.
So far I have a good response from the nurses and after a while -- if there are two
weeks with no catheter on the floor -- it is a big thing to consider. We just need a
catheter for those who need them.
Thank you.
This shows the graphics of how much the CAUTI rates have gone down for patients
with indwelling catheters. We started out having a lot. We still get about one per
month. We have few catheter days -- one a month increases the rate. We've almost
gone for years on the 36 that medical floor without a CAUTI. I think -- Karen and her
group does that.
The next slide shows the utilization on the the units. The goal is the capital and capital
HM goal. Want to be in the green. Every unit -- including ICU -- to decrease the use
of urinary catheters. We want to be in the green. If you don't have a catheter, you
cannot get a CAUTI. That is our goal for the last year and a half and we have done a
great job to get the CAUTI rates down.
Next slide shows the next big project -- the nurse driven indwelling catheter removal
protocol. We are on electronic medical records. The physicians will default to
ordering the nurse driven protocol. The only ones that will not is urology. The nurse
cannot remove the protocol without asking the urologist.
Everyday vendors will say to the patient me the indications that Karen talked about?
Rather than getting a physicians order, there nurse will take up the Foley right then.
They will yield look for symptoms of urinary retention and they will do it bladder
scan. We do a lot with training in this. It is less than 300 mL -- they will wait and
rescan. If they have more than 300 mL, they will do an intervention. If they do
Intermittent catheters and the person still has retention, we will get a physician
involved and they may order a Foley catheter. So far we have not gotten to 3 in the
patient was able to avoid on their own. This is going to start in May. We will be able
to see a definite decrease in urinary catheter usage.
Last slide -- great culture change as Karen and Lynn talked about. Acceptable but they
had to have -- a Foley catheter -- no, they really don't and the patient is fine in the
nursing care is fine. We are not feeling the need to put in a catheter on everybody.
When somebody does get a CAUTI, everyone is upset. What do we do? Reported in?
Why was it in for so long tax we evaluate each one. We have changed the attitude
toward placing a Foley and having a CAUTI. It is not something that just happens -- it
upsets us each time.
If there are any questions, we would be happy to take them. Thank you, Denise.
We will now begin the two and a session -- to ask a question, press *1.
To withdraw a question, press *2. At this time we will pause momentarily to assemble
the roster.
I have a question for the team. You to bedside handovers -- shift report? Is it
mentioned -- to the nurses ask each other about meeting the criteria at that time?
Yes, on that medical floor -- surgical and [indiscernible] -- we do this. We have a
pool. -- A tool. It is mentioned then. Because we do bedside rounds, when you
mention this, you also present it to the next staff -- by patient has a Foley. You show
it. Even with [indiscernible]. We do walking rounds -- room to room. The text has a
bedside report that they give to the next shift. It is included in the report.
Okay.
What is cyber report?
SIBR?
Structured into disciplinary bedside report.
Something to look at -- devices.
Is that done daily with all patients?
Yes. Hospitalist, nurse, charge nurse, dietary, infection prevention, and for all
hospitalist patients.
I was would to say -- how do you do all of the patients?
For the majority -Yes.
And ICU.
Any questions?
Not at this time. *1 If you have a question, please press.
I had another question. How long did it take to see the change in attitude -- the nurses
attitude toward -- and the tax? How long did it take -- the Techs?
It didn't take very long. Every time we told them -- everybody followed along. I didn't
hear any complaints. I don't know how long it took. I think they adapting to whatever
we presented to them.
We have a good team. They are always willing to do whatever is best for the patients.
You connect them back to -- excellent patient care.
Whenever I do a survey -- they have new things -- we have to do a catheter bundle -they say when you have a patient in a catheter picture you have the story in the room.
Change the [indiscernible] everyday. The nurses say okay, this is good for the
patients. They follow that. I did not hear any complaints.
The only thing I heard -- for patients with [indiscernible] -- when patients are 80 mg
of Lasix -- that was a big thing.
After we had the purple pads, this helped. For those that are incontinent, we can get
the weight on of the diaper scale.
Who is the manufacturer?
I don't know. I can send it to you.
Yes.
We changed processes and products all at the same time and offer them a new way of
doing something rather than stopping what you're doing. We gave them an
opportunity to do something differently. It was a process change that helped the
attitude change. Not just changing your attitude about something you've been doing
all the time.
How do you involve patients -- at engaging the patients -- educating the patient and
family -- you go over this when you are rounding or the bedside shift report? This is
the reason that you don't need the catheter anymore. Anything like that?
Would include the patients and families. And in the rounding. We are told what time
the rounding will take place so the families know when to be there. This is discussed
with them at that time.
Now we have several questions.
The first question is from Tammy [last name indiscernible] with Meadows regional
medical center.
Hello. I have a question -- we had our medical executive pass a nurse driven protocol
and we have a policy. But the quality manager and see and oh question does. -Question does. A question to implement the standing orders since CMS is you have to
have a doctor give the order to implement a standing order.
It is approved -- as long as we have it approved by an easy, we can go ahead. As the
default, the Dr. goes to the nurse driven protocol. In every patient's chart except for
the patients that have a urologist, it will automatically populate.
That is why we can do that. It is compliant with -- what if they leave it in and the
nurse put [indiscernible] in a doesn't comply? If there is not an order for a nurse
driven protocol and the nurse is one of the reasons appropriate, it will comply with
Skip. So it was not missed.
I thought so, too. They didn't think so. They thought they interpreted the CMS
differently. I will tell them to look at it again.
Yes.
This is being used all over the country. As long as you have proof that [indiscernible]
approves it and it is referred to in order for the urinary catheter and default, you are
good.
We have all of that. We have a good one. But they were hesitant because it didn't
specifically say on the nurse driven to call to implement the order itself.
I will have them look at it again.
Okay.
Thank you.
The next question is from Edmund [last name indiscernible] It's not a question. I just
wanted to thank you for presenting your excellent work. I am excited. There are a lot
of things that I think would be worthwhile trying to adopt here. I like the patient
education very much.
I like the education -- the flyer that you did about the indications for the Foley.
PICU.
Pick you for your feedback.
Great job.
The next question comes from Monica tenant with Emery Midtown please go ahead.
I wanted to celebrate my colleagues on the wonderful implementation you've done. I
know Marcia from working with the systemwide protocol. Congratulations.
The second question that we are struggling with at our Midtown campus -- can you
walk us through your true RCA process -- who is there? Is that the table next to you
far amount different pieces of the RCA form to fill out? When you say be RCA
process, that means a lot of different things to different hospitals.
Thank you. This is a short many wanted.
-- mini.
It happened within the first three days, it is the person that into the did. We go over
what happened and if there's anything they can think of that was different. It is a short
RCA and takes about 45 min.
PICU.
Do you use the [indiscernible] pool or some kind of form to share?
We have not use that.
The next question comes from Perry Corelle with Hamilton medical center.
Thank you for a wonderful presentation. My question has been addressed. Were going
to ask about the purple pads.
We will find out about that and get it to you.
We changed from blue to white purple.
Next comes from Katrina with University.
This is Katrina. I also wanted to reiterate my thanks for presenting such a great
PowerPoint and information. I want to find out about getting some of the details of it - at the PowerPoint will be made available to us. The manufacturer of the purple pads
-- is it okay to use that information in trying to implement in our facility?
The PowerPoint is available on the HEN website for this meeting if you go to the
GHA website -- under the quality It was a hospital engagement network. The
combating go to Affinity topics. The combating go to HAI and click on meetings. You
will have the PowerPoint there.
Marcia is asking if it's okay to use some of your materials like the patient education
form or the education [indiscernible] Feel free.
When we get the name of the manufacturer, we will let you know.
The RCA that the caller referred to -- is that process going to be outlined in the
PowerPoint that we pull up?
No, we don't have a specific defect. Is that on the website --?
The tool?
Yes.
I can put it up there.
Okay.
Thank you.
Once again, if you have a question press Asterix 1.
-- *1
Eva Payne with will the Morrill hospital has a question.
I didn't quite catch what SIBR stood for.
Structured interdisciplinary bedside rounding.
Thank you.
You're welcome.
We are at the end of the half-hour. I would love to thank the team from Emory Johns
Creek -- Karen, Marcia, and Lynn for presenting this excellent, concise information to
us. I wanted to also remind you that this data is to March 15. The surgical site
infection data is due April 1. If you are not putting this information into
[indiscernible], go to the date of submission website and we have data submission
tools on that.
I want to thank you again for joining us today. This is the end of the call. Thank you.
Don't forget to do the evaluation.
PICU.
-- Thank you.