Deploying a Nurse Driven Protocol for Foley Removal NDPFR: One Hospital s Experience

1. Deploying a Nurse Driven Protocol for Foley Removal (NDPFR): One Hospital�s Experience Joyce E. Wenger MSN, RN Lancaster General Hospital, Lancaster, Pa jowenger@lghealth.org

2. Catheter Associated Urinary Tract Infection (CAUTI) �Hot topic� since October 2008 CMS* no longer allows for increased reimbursement for diagnosis and treatment of CAUTI Considered by CMS* as a �Never Event� * Centers for Medicare & Medicaid Services

3. CAUTI: THE PROBLEM CAUTI reportedly ? hospital mortality 3-fold Each CAUTI adds $500 - $2000 to costs of hospitalization 1- 3 % risk for hospital acquired BSI or urosepsis (>100,000 cases/yr) Enormous reservoir of antibiotic-resistant pathogens, especially VRE, resistant GNRs and yeasts. Biofilms protect the bacteria Maki , VHA teleconference

4. Evidence Based PracticeHow to Prevent CAUTI SHEA Supplement October 2008 Infection Control & Hospital Epidemiology HICPAC & CDC Guideline (2009) IDSA Guideline March 2010 Clinical Infectious Disease

5. Initiatives to DecreaseCAUTI Rates @ LGH A Three Tiered Approach Education Quality Product Nurse Driven Protocol

6. Education & Re-education Collection of Urine Specimens Addressed clean catch, mid stream technique Insertion Sterile technique Securement Maintaining closed system Location of bag at all times Not on floor Lower than bladder

7. Quality Product Closed System Tamper Evidence Seal (Bard Medical) Securement Device LGH chose Statlock Antimicrobial Catheters LGH chose Bard Medical Silver alloy Collection of urine specimen direct transfer device LGH chose BD Diagnostics

8. Rationale for Education & Product Upgrade before NDPFR Contaminated urine specimens Rate was too high to track valid results of any progress If all specimens are collected as contaminated, CAUTI rates would be Zero Looks good on paper Not helpful �to anyone� for �any purpose� No way to assess progress (or lack thereof)

9. Rationale . . . (continued) No protocol will compensate for poor Foley care Do not forget the basics!!! If product upgrades are forthcoming, education on product use should occur General education will occur at the same time Advisable to not change multiple things at one time as impact of changes difficult to evaluate

10. The Process: timely small steps of change

11. Our Journey @ LGH Occurred over several years Required nurses to think differently about Foley catheter necessity Nurse�s role in management of Foley catheters

12. Nurse Driven Protocol Challenges Nurses are hesitant to remove Foley without physician order Definitions on tool are expanded (by nurses)to keep Foley longer than necessary Foleys are kept in for convenience and tool left blank

13. Considerations Protocol criteria should be measurable Criteria to be clearly defined that every nurse will conclude the same outcome for the same patient Educate physicians and hospital administration before deployment Physician champions required to address physician questions Obtain approval from appropriate nursing and physician leadership teams

14. QuestionsorComments