Primary: Implement and assess the effects of a nurse-driven Foley Catheter Removal Protocol on a Tulane Medical Center intensive care unit. Secondary: Lower the CAUTI rate at TMC.

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Limits of Paper-Based Quality Improvement: The use of PDSA cycles to improve both the Protocol and the audit tool was slowed by the need to update paper forms to reflect changes. Also, data collection was hampered by the inability to do retrospective chart reviews. All audits had to be completed at the point-of-care, potentially exposing the audit to bias if a Foley patient was absent from 4W during the audit. Future audits should consider alternative methods for chart reviews, including electronic data capture systems. Need for Rapid Education and Follow-Up: The Workgroup was initially focused on rapid response in the event of a CAUTI; however, it soon became clear that point-of-care provider education was needed to avert inappropriate Foley use (“near misses”). Nursing staff directed questions to medical student auditors that were better answered by nursing and physician supervisors. Clear feedback systems should be in place before new audits to facilitate rapid education of providers.

!The   Tulane   Foley   Catheter-­‐Associated   Urinary   Tract  Infec8on  (CAUTI)  Workgroup  is  an  interdisciplinary  team  of  Tulane  Medical  Center   (TMC)  staff  and  students  who  seek  to  reduce  high  rates  of  CAUTI  at  TMC  (goal:  zero).    

!In   2012,   the   intensive   care   unit   (ICU)   CAUTI   rate   was  6.21/1000  Foley  days,  well   above   the  Na8onal  Hospital  Safety   Network   (NHSN)   benchmark   (2.2/1000   Foley  days).    

!Since   2012,  mul8ple   efforts   have   been   undertaken   to  address  the  high  rate  (Figure  1).    

!Beginning  in  September  2013,  the  Workgroup  piloted  a  nurse-­‐driven   Foley   Catheter   Removal   Protocol   on   the  ICU  with   the  highest  CAUTI   rate,   4  West   (4W;  medical/surgical  major  teaching  ICU).    

!The  Protocol   is  modeled  aXer  the  Keystone  (Michigan)  Bladder  Bundle1  and  recommenda8ons  from  the  Agency  for  Healthcare  Research  and  Quality.2   1Krein  SL,  Kowalski  CP,  Harrod  M,  Forman  J,  Saint  S.  Barriers  to  reducing  urinary  catheter  use:  a  qualita8ve  assessment  of  a  statewide  ini8a8ve.  JAMA  Intern  Med.  2013  May  27;173(10):881-­‐6. 2Agency   for  Healthcare  Research  and  Quality.   Elimina8ng  CAUTI:   Interim  Data  Report.   hbp://www.ahrq.gov/professionals/quality-­‐pa8ent-­‐safety/cusp/cau8-­‐interim/index.html  

Implementation of a Nurse-Driven Foley Catheter Removal Protocol

Andrew L. Wickerham, MPH1, Joshua Hoerger1, Nikhil Teja1, Trevor J. Wojcik1, Rachel Seiler, MPH2, Angela Owings, RN2, Katie Jones, MPH2, Geraldine Ménard, MD1,2 for the Tulane CAUTI Workgroup

1Tulane University School of Medicine, 2 Tulane Medical Center

Background

Aim

Methods

Conclusions Lessons Learned While the Protocol trial continues, this poster reports on the audit period from October 7 to November 19, 2013:  !43 Days Audited  !80 Unique Foley Patients Tracked  !310 Foley Days  !80% Protocol Compliance  !14< Foley Discontinue Orders Written

The effect on Foley catheter utilization and CAUTI rate is unclear. A decline in Foley days was seen in October 2013, but it is too soon to draw conclusions about utilization trends. There were no CAUTIs on 4W during September, and only one CAUTI during October; however, it is unclear if this is a result of the Protocol, other interventions, or a combination. A chart review of the October CAUTI patient may help clarify the role of the Protocol and identify any missed opportunities for CAUTI prevention. Continued assessment of the Protocol will guide expansion to other units at Tulane Medical Center.

New  Orleans  Healthcare    Improvement  Group    A  Joint  LSU  &  Tulane    IHI  Open  School  Chapter    

Figure 2 (Below): Foley Catheter Removal Protocol. The physician-driven side (Reminder Order), activates the nursing-driven side (Removal form).

Figure 3 (Left): Foley Catheter Reminder Order. Completed daily by the rounding physician for each ICU patient with a Foley catheter. An indication to continue indwelling catheter use for a particular patient triggers activation of the Foley Removal Protocol.

Figure 4 (Right): Foley Catheter Removal form. Completed daily by the day shift nursing staff for each ICU patient with a Foley Catheter. Upon activation, the Foley Removal Protocol prompts a nurse to consult a physician regarding potential for catheter removal if no listed reason for continuing catheter use applies.

Trial Period: The Tulane Foley Catheter Removal Protocol was approved for a 90-day pilot study on August 19, 2013. Nursing, physician, and other care delivery staff were educated on the policy changes (i.e., appropriate indications for Foley Catheters) associated with the Protocol. Staff on 4W began using the new Reminder Order and Removal form in September 2013 (Figures 3 and 4). Nursing supervisors edited the forms based on clinical experience.

The Workgroup used Shewart PDSA cycles to implement the new Foley Catheter Removal Protocol and develop a tool to audit compliance with the Protocol, then performed the compliance audits.  

Trial Audits: The Workgroup developed an audit tool to assess compliance with the Foley Catheter Removal Protocol (Figure 2). Medical student auditors and Infection Control staff tested audit tool for two weeks in late-September and early-October 2013 using mini-PDSA cycles. Infection Control staff edited the audit tool, Reminder Order, and Removal form based on clinical experience.

Daily Audits: Medical student auditors completed audit tool daily, beginning October 7, 2013. Infection Control staff looked up Foley catheter insertion location and stored paper audit tools. Medical student auditors alerted nursing supervisors to compliance issues.

Biweekly Status Meeting: The Workgroup holds biweekly meetings to assess the results of the daily audits and discuss problems with the Protocol. Medical student auditors highlight cases for discussion. Infection control staff highlight any patients who develop a CAUTI on 4W. Medical and nursing supervisors provide follow-up education and clarification with staff as needed.

CAUTI Rates and Interventions Prior to Protocol

Protocol Flowchart and Forms

A. Revised surveillance strategy (weekly labs to thrice weekly with overlap in culture results); instituted monthly intra- department inter-relater reliability review (IRR). B. Implemented weekly “Bundle Rounds” for CAUTI maintenance auditing in all four adult critical care areas. C. Performed in-service education with transport department, including appropriate transport procedures for patients with Foley catheters. D. Implemented BD urine collection system housewide (includes culture collection tubes that impede bacterial growth to reduce contamination rates). E. Implemented REDUCE MRSA universal CHG bathing and mupirocin decolonization regimen in all 4 adult critical care areas; daily reminders and compliance scores sent to unit leadership. F. Healthstream education for Foley Statlock (securement device) completed by nursing staff housewide. G. Initiated weekly “Bundle Rounds” for CAUTI maintenance on Med/Surg units on a rotating schedule. H. Disseminated CAUTI prevention newsletter to hospital staff.

Figure 1: Tulane Medical Center CAUTI Rates (Infections per 1,000 Foley Catheter Days)

January 2012-July 2013