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.