AIM Statement Next Steps Run Chart Reduce CAUTIs from 2011 baseline

Transcription

AIM Statement Next Steps Run Chart Reduce CAUTIs from 2011 baseline
Catheter Associated Urinary Tract Infections Reduction
Barton Memorial Hospital
South Lake Tahoe, CA
November, 2014
AIM Statement
Run Chart
• Continue surveillance.
Reduce CAUTIs from 2011 baseline
by 40% by December 2014.
Baseline = 4.59, AIM = 2.75 by 12/14
2014 YTD Performance: 0 CAUTIs
• Revise indwelling urinary catheter insertion
bundle to include orders for urine analysis
and urine culture with initial insertion.
• Develop guidelines for use of silverimpregnated urinary catheters for select highrisk populations.
Interventions
2010:
Team Members
• Workgroup convened.
• Patient Safety Officer: Dawn Evans, RN
2011:
• Evidence-based review for best practices on usage,
product, insertion bundle and insertion technique.
• Multiple urinary catheter policies identified throughout
hospital. Standardized to one and revised.
• Infection Preventionist: Vicki McKenna, RN
Data Source: Comprehensive Data System-HRET as of 09-09-2014
• VP Nursing: Sue Fairley, RN
• Department Directors:
• ED: Beth Brown, RN
• Education module with return demonstration
developed for new hire orientation.
• Home Health/Hospice: Barbara Kaufman,
RN
• Daily indwelling urinary catheter necessity rounding by
Infection Control department staff implemented.
• Perinatal Services: Carla Sells, RN
2012:
• Quality Management: Christine O’Farrell,
RN
• Continued surveillance exhibited sustained reduction
and compliance.
• Outpatient Services: Deborah McCarthy,
RN
• Workgroup disbanded.
2013:
• Order for “Urine analysis, culture if indicated” with
initial insertion added to indwelling urinary catheter
bundle.
2014:
• Workgroup reconvened.
• Urinary catheter care once per shift staff reminders.
• Re-implement paper indwelling urinary catheter safety
insertion checklist.
• Skills fair educational update.
• Implement use of “Red card”.
• Urologist: Dr. Bradley Anderson, MD, FACP
• Hospitalist: Dr. Stefan Schunk, MD
• Staff education on revised policy, new product,
bundle, insertion practices.
• Hand Hygiene initiative started with front line staff
serving as their departments “hand hygiene
champions”.
Next Steps
• Laboratory Services: Julie Kline
• Acute Care: Shannan Birkholm, RN
Lessons Learned
• Implementation of the electronic medical record led to a
loss in the use of the safety insertion checklist tool that is a
part of the CAUTI prevention bundle.
• Need to obtain urine culture with initial indwelling urinary
catheter insertion.
• Staff uncomfortable at times approaching others who are
noncompliant and having a discussion. Identified the need
for a “Red card” that they can hand to the person. This
states an opportunity was identified and outlines the correct
process.
• Clinical Educator: Kelli Teteak, RN
• Wound Care Coordinator: Karen Wilson, RN
Resources
• HQI CAUTI Harm Elimination Toolkit is
available on the HQI website at
hqinstitute.org < Tools and Resources.
• Questions: Contact Mahsa Farahani, Project
Manager, HQI at 916-552-7521, email
mfarahani@hqinstitute.org.