Nassau University Medical Center IPRO CAUTI Prevention Initiative November 6, 2013 New York Hotel, NY

Joined IPRO CAUTI Prevention Initiative in August 2011 Medical Intensive Care Unit was designated to participate in the initiative Sunrise (EMR) modified to include RN driven protocol to prompt nurses to get order to d/c foley catheter FC Insertion Indication: MD order set follows CDC accepted indications

CAUTI Index YTD September 2013 Total CAUTI/total # device days x 1000 Annual Index Adult ICU CAUTI Index YTD September 2013 Total CAUTI/total # device days x 1000 Annual Index Adult ICU Adult ICU population only. **All unit surveillance began Jan 2012.

Hospital-wide CAUTI Rate 2012-YTD September 2013

MICU CAUTI RATE 2009-YTD September 2013 NHSN mean1.7

MICU FC Utilization Ratio 2012 vs. YTD September 2013

Nassau University Medical Center Infection Prevention and Control Department Foley Catheter Maintenance PI INDICATORSMICUSICUCCU7th8th9th11E11WPedsBURNOverall 6ECompliance # Survey done Insert Order 16/16=100 % 15/15=100 %6/6=100% 14/14=100 %3/3=100%6/6=100%4/4=100% 10/10=100 %1/1=100% 76/76=100% 2-Appropriate Indication 16/16=100 % 15/15=100 %6/6=100% 14/14=100 %3/3=100%6/6=100%4/4=100% 10/10=100 %1/1=100% 76/76=100 3-FC with Maintain Order9/15=60% 3/6=50% 14/14=100 %3/3=100%6/6=100%1/4=25%9/9=100%1/1=100% 56/74=76% 4-FC Insertion Documented13/16=81% 15/15=100 %5/6=83% 10/11=91% *3/3=100%5/6=83%4/4=100%8/10=80%1/1-100%1/1 =100%65/73=89% 5-Daily Doc. Medical Necessity 16/16=100 % 15/15=100 %6/6=100% 14/14=100 %3/3=100%6/6=100%4/4=100% 10/10=100 %1/1=100% 76/76=100% 6-Doc. Pt/Family Education 12/16=75/ %12/15=80%6/6=100%12/14=86%3/3=100%5/6=83%3/4=75% 10/10=100 %0/1=0%1/1=100%64/76=84% 7-FC Securement/No kinking 16/16=100 %14/15=93%6/6=100%11/14=79%3/3=100%6/6=100%2/4=50% 10/10=100 %1/1=100%na*69/76=91% 8-Tamper Resistant Seal Intact (Closed Drainage) 16/16=100 %12/15=80%6/6=100% 12/12=100 %3/3=100%6/6=100%3/4=75%9/10=90%1/1=100% 69/74=93% 9-Labeled Ind. Collection Bottle (stored bedside/covered)15/16=94%12/15=80%2/6=33%12/14=86%3/3=100%5/6=83%4/4=100% 10/10=100 %1/1=100%0/1=0%64/76=84% 10-Urinary Catheter Bag below level of bladder 16/16=100 %14/15=93%6/6=100% 14/14=100 %3/3=100%6/6=100%4/4=100% 10/10=100 %1/1=100% 75/76=99% 11-Urinary bag off the floor 16/16=100 % 15/15=100 %6/6=100% 14/14=100 %3/3=100%6/6=100%4/4=100% 10/10=100 %1/1=100% 76/76=100% 12. The outlet spigot kept in the housing 16/16=100 % 15/15=100 %6/6=100% 14/14=100 %3/3=100%6/6=100%4/4=100% 10/10=100 %1/1=100% 76/76=100% 13-Doc. Of daily FC and perineal care 16/16=100 % 15/15=100 %6/6=100% 14/14=100 %3/3=100%6/6=100%4/4=100% 10/10=100 %1/1=100% 76/76=100% Total Compliance/ Unit 193/207=9 3% 178/195=91 % 70/78=90 % 169/177=9 5% 39/39=10 0% 75/78=96 % 45/52=87 % 126/129=98 % 12/13=92 %11/12=92%918/980=94% * POA *burns legs

Strategies for CAUTI/HAI Prevention 1.FC Insertion Checklist Completion/Compliance 2.FC Maintenance checklist PI monitoring 3.Data shared with the Executive Board, Nursing Leadership, IP&CC and nursing units thru monthly meeting and one-on-one with the nurse Managers by respective IPs 4. Multidisciplinary team approach RCA conducted for each identified CAUTI… to identify cause/improve practice

5.Unit-based HAI Rates distributed monthly via report cards to all units to be shared with staff and displayed in all units 6.We celebrate !!!!! Success Certificate of Recognition awarded to units that achieved Zero Infection associated with any device utilization 7. Work in progress: Trial with Hibiclens for perineal wash to be expanded to MICU if successful Strategies for CAUTI/HAI Prevention

3Q 2013 MICU Through commendable infection prevention and control practices and teamwork, you have achieved Zero CLABSI and CAUTI Infection

THANK YOU