We have a CAUTI…now what?

1. We have a CAUTI…now what? Mary H. Holmes, MT, CIC Infection Prevention Specialist Ginny Ledbetter, RN, MSN, APRN-BC Clinical Nurse Specialist Roper St. Francis Healthcare Wednesday, August 22, 2012

2. Objectives • After this presentation the participant will be able to: • Articulate one approach to identifying possible factors contributing to the development of a CAUTI • Understand the importance of a CAUTI review process • Understand how the CAUTI Analysis form is used

3. Background • Roper St. Francis Healthcare (RSFH) • 3 Hospital Facility • Roper Hospital – 368 beds • Bon Secours St. Francis Hospital – 204 beds • Mt. Pleasant Hospital – 85 beds • 5 Emergency Departments • 3 contained within the hospitals • 2 free-standing

4. CAUTI Prevention • Multidisciplinary CAUTI Team with representatives from all hospitals and ED • Subgroups • Necessity and Timeliness of Removal • CAUTI review process and communication • Foley supply standardization • Education

5. Goals of the CAUTI Team • Prevent hospital acquired CAUTIs • Identify possible causative factors through chart review once a CAUTI is determined • Develop action plan to address gaps in practice • Communicate, communicate, communicate • Nurses • Physicians

6. How do we prevent hospital acquired CAUTIs? Adhere to CA-UTI Bundles (per IHI*) • Avoid unnecessary urinary catheters • Insert using aseptic technique • Maintain catheters based on recommended guidelines (daily care) • Review catheter necessity daily and remove promptly * Institute of Healthcare Improvement

7. We have a CAUTI…now what? • Even with everyone focused on CAUTI prevention, we still have hospital acquired CAUTI’s • Our approach to CAUTI prevention has evolved over the past couple of years • 2010 – reported # of CAUTI’s • 2011 – CAUTI Team subgroup developed and revised the Infection Prevention Analysis (IPA) form • 2012 – Began reporting CAUTI specific data to the physicians and continue to revise the IPA form

8. Current Process • Infection Prevention Specialist determines that criteria for CAUTI have been met • Clinical Manager and Clinical Nurse Specialist (CNS) are informed of CAUTI via email and receive copy of CAUTI Analysis form • Chart is reviewed, the CAUTI Anaylsis form is completed and is returned to Quality Department • Information is entered into the Midas database • Report is generated • Information is shared at CAUTI meeting

9. The CAUTI Analysis form ……a moving target • The CAUTI Analysis form is forever changing • Data elements have been removed and added based on their relevance

10. CAUTI Analysis Data Elements • The IPA form is populated by the Infection Preventionists and Nurses • Infection Preventionist provides: • The Nursing Unit the CAUTI is attributed to • Facility • Patient information • Physician information • Urine culture information • Nurse provides: • Clinical information See CAUTI Analysis Form Handout

11. Page 1 – CAUTI Analysis form

12. Page 2 - CAUTI Analysis Form

13. An actual CAUTI Analysis form

14. Midas Report

15. Are there trends? • Surprisingly, not really • It seems we have a different “trend” and discussion topic each month • Organism type • Unit where foley inserted • Staff who inserted foley • # days to + culture • Attending MD • Unit with CAUTI

16. # days from catheter insertion to + culture

17. Are there surprising findings? • Yes • May was an interesting month • 5 CAUTI’s • All at one hospital • 3 of the 5 were placed in the OR and 2 were by the same staff member • All surgical patients who had Foley removed within 2 days for SCIP measure • 4 of the 5 had a + culture within 2 days of insertion and the other 1 had a + culture within 3 days of insertion • All were female (72% female YTD)

18. What was follow-up for May? • Spoke with OR Manager who in turn spoke with staff members • They recall nothing out of the ordinary • Adherence to proper insertion procedure was maintained • Key CAUTI team members (Physician, Nurse Executive, Infection Preventionist and CNS) discussed possibility of these being POA and undetected • Should we implement process to get U/A and possibly a C&S on “high-risk” patients • Continue to discuss if incontinence wipes are warranted to standardize catheter/pericare – especially for women

19. What has the data told us? • We have opportunities for improvement: • Nursing: • Complete documentation • Pericare • Foley removal • Placement of Necessity/Removal order form on chart • Use of fecal management device for incontinent patients

20. What has the data told us? We have opportunities for improvement: Physician: Intermittent catheterization instead of Foley reinsertion Utilization of the Urinary Retention Protocol ? Foley necessity for fractured hip

21. How do we communicate the CAUTIs? • Nurses • Monthly Infection Dashboard • Monthly Quality Scorecard • Staff meetings • Physicians • Monthly Quality letter • Division meetings • Medical Executive Committee

22. What’s working well? • The process has facilitated a stronger collaborative relationship between Nursing, Infection Prevention and the Midas Report writer • Chart reviews involve clinical staff which brings the CAUTI “home” • Even thought the process isn’t perfect, it is an approach to keeping CAUTI and CAUTI prevention in everyone’s mind

23. What’s working well? • We’re very close to having the Midas report format finalized • The Midas report can be exported to Excel so data can be sliced and diced • We’ve been able to tailor our educational posters to address gaps in practice • Necessity not an Accessory • Alternatives to catheterization • Get the Plastic Out

25. What are limitations of our process? • Our process to determine a CAUTI is manual and very labor-intensive • Our chart reviews are retrospective and not concurrent • We not quite ready to utilize the Midas report

26. In Summary • CAUTI Prevention is a major focus at RSFH • We take each CAUTI seriously and perform a chart review to see if possible causative factors can be identified • We continue to tweak the process and reports so they provide meaningful information to drive process improvement efforts

27. Questions? • Thank you for your attention • We’re happy to answer any questions • We’d also love to hear comments regarding how you approach data review in your facilities