The CAUTI Prevention and Reduction Journey: Believe in Zero!

Renee Juster, RN, BSN, PHNInfection Prevention Manager

John Muir HealthFebruary 11, 2015

John Muir Health – proprietary and confidential2

Objectives

Upon completion of this presentation, APIC members will be able to:

1. Recognize the value of maximizing standardization and minimizing variation to achieve CAUTI reductions through an unwavering commitment to prevention

2. Understand the criticality of collaborative ownership for hospital wide spread of CAUTI prevention and reduction strategies

John Muir Health – proprietary and confidential3

John Muir Health-Walnut Creek and Concord Medical Centers

Walnut Creek:

Concord:

A 572 bed hospitals recognized as one of the nations, state and region’s premier health care providers by U.S. News and World Report for eight consecutive years. Areas of specialty include high- and low-risk obstetrics, pediatrics, orthopedics, rehabilitation, neurosciences, cardiac, emergency, trauma and cancer care.

A 245 bed hospital recognized as a preeminent center for cancer care and cardiac care, including open heart surgery and interventional cardiology. Areas of specialty include cardiovascular services, along with surgical care for a wide variety of conditions, cancer care and emergency services

John Muir Health – proprietary and confidential4

What’s the Goal???

2013 National Prevention Goals Paved the Way 25% reduction in CAUTI in ICU and ward locations or 0.75 SIR(NHSN

data source)-NOT METPrivate and public partnerships form at national and state levels

(Engagement Networks)….more goals!40% reduction in CAUTI and meet NHSN SIR of 1.5

What goals did we want to achieve in 2014? 10% improvement on 2014 Q1 results by end of 2014

Our starting point:

Walnut Creek: Rate 7.2

Concord: Rate 5.2

John Muir Health – proprietary and confidential5

Gain Perspective-But How?

• Make the commitment to improve and go all in!– California Hospital Engagement Network (CalHEN)

• State level– John Muir Device Related Infection Prevention (DRIP) Team

• Local/Internal level– On the CUSP: Stop CAUTI Cohort #8

• United States level; implement Comprehensive Unit-based Safety Programs (CUSP)

– Project Protect Fellowship • Partnership between On the CUSP: Stop CAUTI and four

partner organizations:– Society for Healthcare Epidemiology of America (SHEA)– Association for Professionals in Infection Control and Epidemiology (APIC)– Society of Hospital Medicine (SHM)– Emergency Nurses Association (ENA).

John Muir Health – proprietary and confidential6

Dare to Dream and Seek Miracles

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Don’t Forget the Basics-Start with Something!

• Attack Equipment Issues– Take inventory: Who has what where? How many different choices? – Are these things used in the same way by everyone? Do staff pick

the same equipment for the task at hand? – Are the staff set up for success?

Outcome: Critical Discovery! Barriers to improvement directly related to equipment Barriers to improvement directly related to practice

Take Action:

Maximize Standardization and Minimize Variation in both areas of Critical Discovery!

John Muir Health – proprietary and confidential8

Maximize Standardization and Minimize Variation• Kits-Marry the miracle with what already exists• Storage-Location, Location, Location!• Correct Choice-Maintain Autonomy: Make it a Win Win!

John Muir Health – proprietary and confidential9

Urinary Catheter Care Bundle

Maximize Standardization and Minimize VariationUrinary Catheter Care Bundle

INSERTION BUNDLE

Avoiding catheter insertion

Alternatives to try before insertion: Bladder scanning Condom cath, bedpan, female urinal Scheduled toileting, bedside commode In & out catheter

If an indication for catheter is confirmed:

Pre-clean with recommended agent before opening kit

Use the kit and smallest catheter possible

Use a securement device

MAINTENANCE BUNDLE

Avoiding infection while catheter is in place Assess need for catheter every shift Catheter care with recommended agent Q 8h Tubing

Avoid kinks and dependent loops Keep a closed system; avoid breaking seal

Drainage bag

Keep below bladder, not touching floor Prevent contamination of spigot Empty before transport

Urine Testing

Consider urine testing only if systemic signs of UTI - consult with physician

Order as “UA with microscopic (C&S if indicated)”

If catheter in place >72 hrs, change catheter prior to specimen collection (if not placed by urologist or other contraindications)

Obtain specimen(s) from sampling port using sterile technique and yellow tube

Take specimen to lab immediately Changing Catheter: Consult with MD……

If catheter present on admission and still indicated, consult with physician regarding replacement

REMOVAL BUNDLE

Safe removal & avoidance of re-insertion

To facilitate removal:

Assess need for catheter every shift

Utilize Nurse-Driven Protocol

Ensure adequate hydration

Post removal:

Assess for adequate urinary output To avoid reinsertion: Condom caths, bedpan, female urinals Encourage voiding every 2 - 4 hours if

patient has not already voided Scheduled toileting, bedside commode Bladder scanning In & out catheter

This document is available on the JMH intranet at: Cross Campus > Quality Management > Infection Prevention > IP Resources

GUIDING PRINCIPLES

Hand hygiene before and after all activities

Use aseptic technique as appropriate

Use Mosby Skills as the procedural resource

Provide patient/family education SPEAK Up if any aspect of bundle is breached

2/5/15

John Muir Health – proprietary and confidential10

Success!

• Yes, but skepticism remained– Will equipment standardization coupled with minimizing practice

variation and use of an innovative product be enough?

CAUTI Prevention= Practice + Product

John Muir Health – proprietary and confidential11

Walnut Creek Campus Critical Care Units- CAUTI rate

John Muir Health – proprietary and confidential12

Walnut Creek Campus Critical Care Units- Days between CAUTI

2 pack wipes

Foam and Bath wipes-1 out of 3 units

All Critical Care Units-Wipes, Foam, Bath

John Muir Health – proprietary and confidential13

Walnut Creek Campus Critical Care Units- CAUTI rate

Concord Campus Critical Care Units- CAUTI rate

2 pack wipes

John Muir Health – proprietary and confidential14

Fast Forward-2014 Comes to an End

Goal: 10% improvement on 2014 Q1 results by the end of 2014.

CAUTI – GOAL MET

Q1 2014 Q2-Q4 2014 • Concord 5.2 3.4 (35% reduction)

• Walnut Creek 7.2 5.1 (29% reduction)

• Combined 6.4 .5 (30% reduction)

We did hit ZERO on both campuses at one point or another but expecting ZERO to be sustainable over

time is not realistic. The rigor becomes more important.

John Muir Health – proprietary and confidential15

Most Valuable Lessons Learned

• Patience is a virtue• Don’t assume they see what you see

Tell the Story• Data, Data, Data plus what’s happening in the market• Crunch the Numbers• Collaboration/Partnership

– DON’T FORGET THE WOUND CARE NURSES

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Don’t Give Up- Look Up!“In most cases, the arrival of

innovation, like a quality improvement

initiative, forces us to contemplate

changing the way we live in some

way, large or small. Often our

reaction is annoyance. We don’t

want to be bothered; We are doing

nicely without this idea. Find members

of the group who are admired, trusted

and believe in the idea and set them loose on the group”

-Preventing Hospital Infections: Real World Problems, Realistic Solutions

Sanjay Saint, Sarah L. Krein with Robert W. Stock Oxford University Press 2015

John Muir Health – proprietary and confidential17

Questions?

Thank You!