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*) 1.Avoid unnecessary urinary catheters 1.Insert using aseptic technique 1.Maintain catheters based on recommended guidelines (daily care) 2.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 RemovedAdded BMI Reviewed with Attending Free text fields changed to check boxes when possible Specific CDC Criteria for infection Time from Foley insertion to + culture Physician order present Necessity/removal order present Physician documentation of necessity Nurse/PCT documentation of pericare

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