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.