100 Day CAUTI Project Data collected 11/1/2013 – 2/28/2014 Question Was the daily assessment for removal of the foley completed? Was peri-care completed twice a day using soap & water or periwash? Was the foley secured with Stat-lock or alternate mechanism? Was the drainage bag maintained below the level of the bladder? No dependant loops observed. Were all 5 elements met to complete the bundle criteria? Totals Numerator Denominator Compliance 154 164 93.9% 152 164 92.7% 151 164 92.1% 159 164 97% 132 164 80.5% 120 164 73.2% 868 984 88.2% Action Plan to begin in March: 1. Unit based CAUTI Champions will continue random safety audits to assess the bundle element compliance two days per month (preferably once on days and once on nights). Monitor all patients on the unit on audit days. Fax the completed data collection tool to Infection Prevention @ 6364 at the end of each month. 2. Implement standardized process and monitoring tool for daily assessment of need for foley catheters and central lines as agreed upon at the meeting with Service Line Administrators and Nurse Managers held on February 19th. 3. CAUTI champs will collaborate with manager to educate staff on the outcome of this audit and ongoing areas of non-compliance or other areas that could be improved upon to prevent CAUTIs.