Infections Due to Devices Improvement Collaborative: UHC CAUTI Workgroup Coaching Call # 3

1. Infections Due to Devices Improvement Collaborative:UHC CAUTI Workgroup Coaching Call # 3 August 29, 2012 Dial in: 1-866-469-3239 Passcode: 664 803 879

2. Teleconference Agenda • Introductions of Subject Matter Experts (SME’s) and Guest Speakers • Site Updates • Review activities for completion • Presentation - On the CUSP: Stop CAUTI Experience - University of Medicine and Dentistry, New Jersey (UMDNJ), Cohort 3 Participant • Presentation of Nurse Driven Nurse Driven Foley Catheter Protocol – Beaumont Health System • Action items • Looking ahead • Next call

3. SME’s and Guests Speakers

4. CAUTI Workgroup SME’s and Guests

5. Review of Activities for Completion Phase 2

6. Modified timeline

7. CAUTI DATA REQUIREMENTS:Reduce CAUTIs OUTCOME DATA: CAUTI Rates/Catheter Prevalence • Total # of patient days for that unit • Total # of indwelling urinary catheter days for that unit • Total # of CAUTIs for that month • Ideally, all data are entered into MHA Care Counts by the last day of each month

8. CAUTI Outcomes Data Collection

9. Site Updates

10. CAUTI Workgroup Participants

11. On the CUSP: Stop CAUTI Experience Presentation - UMDNJ, Cohort 3 Participant

12. CAUTI CUSPCOHORT 3 September 12, 2011: Hospital Commitment Letter to Participate in On the CUSP: Stop CAUTI signed November 14, 2011: Kick Off Session Pilot unit chosen; Trauma SICU 2° high infection rates

13. AIM Statement Developed • Decrease CAUTI rates by no less than 25% within 18 months

14. CAUTI CUSP team Established • Senior Sponsor: Vincent Barba, MD, FACP, FHM – Chief Quality Officer • Physician Champion : Alicia Mohr, MD – Medical Director, Surgical ICU • Team Leader: Director of Infection Prevention & Control • Critical Care Nursing Director • Nurse Manager • Technical Expert: Infection Preventionist • Staff Nurse • CNA

15. Prevalence December, 2011 Foley Catheter Prevalence conducted on the pilot unit. Outcome: % of patients with indwelling Foley catheter = 100% % of patients that had daily assessment for need = 0% % of patients with documentation showing the patient met the criteria for foley use = 0%

16. Getting Started Baseline data was collected for a period of 3 months. • January 2012 • February 2012 • March 2012 Patient Safety Surveys completed during January and February 2012

17. Education • Foley Catheter vendor conducted re-education for proper use of catheter securement device • Verified that pilot unit had adequate numbers of the securement device on hand in the clean utility room • Made available for staff viewing 3 patient safety videos

18. Plans for Change Established • Implement the CAUTI Bundle • Daily assessment of need using a daily goals sheet • Establish pre-printed order set for nurse driven discontinuation of catheters • Educate staff • Nursing documentation every shift re-bundle compliance • Assess any patient with foley catheter for need prior to transfer

19. Stumbling Blocks • Poor meeting attendance by members • March 1, 2012 Team Leader resigned her position at UMDNJ. • The IP serving as a team member took the lead • Only the IP team leader participated in the boarding calls • Poor involvement on all levels from team members, IP was doing all the data collection, inputting data, and education • Physician resistance related to nurse driven protocol for discontinuing foley catheters

20. New Direction • On May 1, 2012 a new Director of Infection Prevention & Control was hired. • The new Director created a partnership with house wide CAUTI reduction team.

21. Where Are We TODAY • At the end of the 2nd quarter of 2012 we have seen fluctuating infection rates, and a decreasing trend in utilization rates.

22. Nurse Driven Foley Catheter Protocol

23. About Beaumont Health System

24. Very large, busy health system in Metropolitan Detroit Michigan

25. Protocol Development • 3 Hospitals • Clinical Informatics Nurses • Quality and Safety Nurses • Nursing Educators • Protocol Workflow and Development • Education and Approvals • Implementation and Ongoing Monitoring

26. Development • What is best practice? • What CMS required • Work with Michigan Hospital Association Keystone Center • Working with Infection Control Leadership • Weekly workgroup meetings • Nursing leadership buy in and support critical • EPIC is our electronic Health Record • Needed to develop within nursing documentation flow within EPIC

27. Process • Indication required when ordering a Foley catheter • Daily assessment by nursing of continuation criteria (lack of continuation criteria meets removal criteria) • Acceptance by Medical Staff of Nurse-Driven aspect to protocol (phased in)

28. Nursing Documentation for Foley Placed

29. Indication Options Required for Documentation

30. Foley Continuance Criteria

31. Continuance Selection Form Expanded

32. Implementation • Mandatory Nursing Education • Approval at each hospitals Medical Executive Committee • Ongoing support by Clinical Informatics • Bits and Bytes Nursing Education

34. Ongoing Monitoring • Nursing Dashboard • Core Measure Compliance • MHA Keystone unit monitoring • UHC HEN • CMS CAUTI reporting for ICU and Rehab

35. Nursing Dashboard

36. Phase 1 Phase 2

37. Questions?

38. Action Items

39. Action Items: Activities for Completion • Phase 1 of the collaborative consists primarily of registration and onboarding activities. The registration process includes completion of: • On-line registration with HRET • CEO commitment letter • Unit team commitment letter • Data use agreement

40. Action Items: Activities for Completion • Phase 2of the collaborative focuses on planning, assessment and data collection. Key activities that you have or will complete include: • Complete baseline outcomes data in MHA CareCounts • Confirm/monitor data entry results • Complete administration of HSOPS • (Survey closes September 7) • Staff education • Watch the Science of Safety video • Provide educational materials • Attend monthly national Content calls and monthly Coaching calls

41. Looking Ahead: Key Priorities • Sites will continue collection of outcome data and lay the foundation for process data collection • Who will collect data? • Same time each day – when? • What tool will you use to collect data? • Begin the collection of prevalence and appropriateness (process) data • Assess for presence of a urinary catheter • Record the reason for the catheter • Daily, Mon-Friday, September 3rd, through Septmber 21st. • Sites are expected to complete the Team Check Up Tool (October) • Sites will initiate team meetings • Workgroup members will continue to attend monthly Coaching Calls and monthly national Content Calls

42. Looking Ahead: Process Data Collection Manual Data Collection Tool - utilize when making rounds and enter daily (ideally)

43. Action Items: Activities for Completion • CAUTI Workgroup Monthly Status Report • Goal: • Quickly communicate progress • Identify Barriers for Subject Matter Experts to Address • Identify Successes to Share

44. Action Items: National Content Calls and Collaborative Coaching Calls

45. Next Coaching Call • NEW TIME AND DAY! • September 27, 2012 • 12:00 PM Eastern • Planned Topics • Review best practices and implementation advice • Considerations for selecting an initiative • Additional suggestions from Workgroup members

46. SHM Project Manager Contact Information Jenna Goldstein, MA Sr. Project Manager, SHM (267) 702-2679 jgoldstein@Hospitalmedicine.org JoAnne Resnic, MBA, BSN, RN Director, Special Projects, SHM (267) 702-2673 jresnic@HospitalMedicine.org