CAUTI Reduction Team Members: Eileen Phillips (lead), Emily Hunt, Susan Heimsoth, Christine Shaw Executive Sponsors: Dr. Kristin Hahn-Cover, John Hornick Advisors: Eric Franks, Anne Hackman MHA Candidates: Amber Romstad, Amanda Boone, Evan Camden, Thaddeus Wakeman

As discussed, CAUTI rates high As discussed, CAUTI rates high. Our team created a fishbone diagram to help us decide where to focus: The four areas identified are insertion of catheter, daily maintenance, removal of catheter and patient factors. We started our focus on removal of catheter and have moved to other parts of the fishbone. We realized that we did not know what our utilization of catheters was and that data was available.

Outcome Measures Duration of catheters per patient CAUTI rates Catheter utilization rates

Interventions EMR (initial and revised) nursing and physician Champions in the ICU Education – CBT, Immersion week, incontinent skin care Rewards Nurse removal protocol – MICU Audit tool for CAUTI’s Reporting Modified HOUDINI Surveys identified difficulty defining and applying the HOUDINI by nursing. A modified HOUDINI was created based on input from nursing and the medical directors in each ICU. H= Gross hematuria O= Obstruction (anatomical), catheter placed by Urology Service, urinary retention, epidural, or edema U= Urological surgery D= Stage 3 or 4 decubitus ulcer in the perineum/buttock area in incontinent patients I= Intake and output critical for patient management; hemodynamic resuscitation in the last 48 hours, hyperosmolar therapy, IV diuretic therapy, and diabetes insipidus N= Nursing end of life care, palliative/supportive I= Immobility impacting elimination, unstable fracture, spine not clear, paraplegia, quadriplegia, respiratory or hemodynamic instability with turning, and ventilated and sedated patient Champions in ICUs for each shift were added to the team and frequent communication is sent to them via e-mail (October-ongoing). Indications were added to nursing documentation when voiding per “Foley” for elimination was selected. If patients do not meet HOUDINI criteria, a task is generated to recommend catheter discontinuation (December). This same indications list was added to the physician orders as a mandatory field (March). Education of the modified HOUDINI, skin care for incontinent patients, and updates on CAUTI rates and utilization were developed and circulated monthly. In February, all new nurses were individually trained on the modified HOUDINI. A mandatory computer-based training module reinforcing the modified HOUDINI, care of catheters, and the system goal to reduce CAUTI was launched (March-May). Staff using best practice by discontinuing unnecessary urinary catheters were rewarded with culture of YES cards (December-ongoing). MICU trial to discontinue urinary catheters per medical staff approved protocol (January-ongoing). All data is sent to ICUs including the 25%ile goals for CAUTI and utilization rates (December-ongoing). Development of a post-catheter removal protocol (April-ongoing).

Modified HOUDINI H O U D I N Gross hematuria Anatomical obstruction-catheter placed by Urology Service, urinary retention, epidural, or edema U Urological surgery D Stage 3 or 4 decubitus ulcer in the perineum/buttock area in incontinent patients I Intake and Output-Critical for patient management-hemodynamic resuscitation in the last 48 hours, hyperosmolar therapy, IV diuretic therapy, and diabetes insipidus N Nursing end of life care, palliative/supportive Immobility impacting elimination-unstable fracture, spine not clear, paraplegia, quadriplegia, respiratory or hemodynamic instability with turning, and ventilated and sedated patient Surveys identified difficulty defining and applying the HOUDINI by nursing. A modified HOUDINI was created based on input from nursing and the medical directors in each ICU. H= Gross hematuria O= anatomical obstruction-catheter placed by Urology service, urinary retention, epidural, or edema U= urological surgery D= Stage 3 or 4 decubitus ulcer in the perineum/buttock area in incontinent patients I= Intake and Output-Critical for patient management-hemodynamic resuscitation in the last 48 hours, hyperosmolar therapy, IV diuretic therapy, and diabetes insipidus N= nursing end of life care, palliative/supportive I= Immobility impacting elimination-unstable fracture, spine not clear, paraplegia, quadriplegia, respiratory or hemodynamic instability with turning, and ventilated and sedated patient Trovillion E, Skyles JM, Hopkins-Broyles D, Recktenwald A, Faulkner K, Rogers AD, Babcock H, Woeltje KF. (2011) Development of a nurse-driven protocol to remove urinary catheters. Presented at SHEA, 1–4 April 2011. Abstract 592.

Measure – Duration Graph 1: Sample of monthly mean duration of catheters per patient per unit over a 5 month period. These samples represent patients who received care in an ICU during their hospital stay. Duration of catheter was collected on each patient from the time in the ICU to the time of discharge. MICU and NSICU have had a steady decrease in duration of catheter.

Measure – Utilization Foley catheter utilization rates (Foley days/patient days) for all units combined. The rate has dropped from high of .36 to .28

Measure – Utilization Utilization rates per unit. Sixty percent of the units are at or above the goal.

Measure – CAUTI Rate of infection (number of infections/number of Foley days * 1000) for all units combined. We have actually seen an increase. We have decreased out utilization and are working on more cycles of improvement .

Next Steps Review insertion techniques and decisions to insert in specific locations. CAUTIs that have occurred based on insertion location FY2013-current.

Next steps Form system-wide CAUTI reduction committee to focus on monitoring, reporting, education, rewards, and communication Develop communication plan with Public Relations Finalize post-catheter removal protocol Implement improved specimen collection device