EP21EO - Nurses are involved in implementing and evaluating national or international patient safety goals.
Provide one example, with supporting evidence, of nurses' involvement in activities that address national or international patient safety goals that led to an improvement in patient safety outcomes. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
2014 National Patient Safety Goal (NPSG) NPSG.07.06.01Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
NAME OF INITIAVE
Reducing Catheter-Associated Urinary Tract Infection (CAUTI)
BACKGROUND/PROBLEM
The reduction of urinary tract infections caused by indwelling urinary catheterization during hospitalization is a national patient safety goal of The Joint Commission for Accreditation (The Joint Commission, 2014). Eighty percent of hospital-acquired infections are due to indwelling urinary catheterization (The Joint Commission, 2011). The excess cost for each case of hospital acquired urinary tract infection ranges from $1,200 -$2,700, at a rate of approximately $400 million annually. Nurses, who provide much of the care to hospitalized patients with indwelling catheters along with other health care providers, can be instrumental players in the prevention of CAUTI and its associated costs.
In September 2011, Homestead Hospital Infection Control Manager Wendy Rey, RN attended a meeting of the System Infection Control Committee (SICC) in which it was determined that Baptist Health South Florida (BHSF) entities, including Homestead Hospital, would implement the Florida Department of Health’s (FDOH) CAUTI Collaborative prevention strategies. This collaborative was composed of 16 hospitals, of which Homestead Hospital was a member. The FDOH CAUTI Collaborative prevention strategies have been demonstrated to decrease the rate of CAUTI by 35% in participating facilities (Florida Department of Health, No date). Included in the prevention strategies (CAUTI BUNDLE) were:
1. Insertion of catheters only for appropriate indications.
2. The removal of unnecessary catheters.
3. The performance of hand hygiene in compliance with Centers for Disease Control and Prevention or World Health Organization.
4. Provision of education on proper insertion and maintenance.
5. Limitation of insertion of catheters to trained personnel.
6. The insertion of catheters using aseptic technique and sterile equipment.
7. The proper securing of indwelling catheters after insertion to prevent movement and urethral traction.
8. Maintenance of a closed drainage system.
9. Maintenance of unobstructed urine flow.
10. Cleaning the meatal area with antiseptic solution was unnecessary; routine hygiene was appropriate.
11. Removal of catheter within 48 hours following surgical procedure or document reason for extended use.
12. Implement and promote alternatives to indwelling urinary catheterization.
Nurses Involved in Implementing National Patient Safety Goals
In April 2012, Homestead Hospital’s Infection Control Committee, chaired by Rey, decided to implement all the components of the CAUTI Bundle to improve Homestead Hospital’s CAUTI rates. Several units had CAUTI rates above national unit-specific benchmarks of the National Healthcare Safety Network (NHSN). Rey formed and led a CAUTI taskforce consisting of clinical nurses working in the intensive & progressive care units (ICU/PCU), as well as unit practice council (UPC) members from a medical-surgical floor (3 South/MS3).
GOAL STATEMENT(S)
The purpose of the taskforce was to decrease CAUTI rates at Homestead Hospital by raising awareness of CAUTI among staff and the implementation of evidence-based prevention strategies recommended by the FLDOH.
Outcome Measures
The hospital routinely collected device days monthly by department and the results of urine cultures daily for the entire hospital for both monitoring and reporting purposes. Rey reported CAUTI rates monthly to the NHSN.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
The taskforce searched evidence-based recommendations from several reputable sources in addition to that of FDOH’s. The taskforce decided that the CDC’s algorithm for the prevention of CAUTI would be used to help guide the implementation of prevention strategies and the development of a prevention bundle at Homestead Hospital. The CDC’s algorithm called for a shift-by-shift evaluation of the need for an indwelling urinary catheter thus decreasing the risk that patients would be exposed to them beyond the period of necessity (CDC, 2014). Additionally, CDC recommended the use of bladder scanners. Homestead Hospital joined with the SICC in implementing it as part of the CAUTI bundle.
In January 2012, the taskforce began the process of education for the CAUTI Bundle, including the use of bladder scanner, as a preventative strategy. In May 2012, Rey presented the CAUTI Bundle to the Clinical Practice Council (CPC) and the Nurse Governance Council (NGC) for approval. Thereafter, Homestead Hospital’s Central Supply Department purchased the equipment for the entire hospital’s use. Surgical Services department stored the machine. Clinical nurse educators and a product representative provided educational sessions to all nursing staff in May 2012 via staff meetings. They completed the training in May 2012. In the same month, Hospitalists Frank Fernandez, MD and Mark Hernandez, MD, who were physician champions for the project, presented the new order sheet (Form 619 Physician Justification for an Indwelling Urinary Catheter) to the Medical Executive Committee for approval. The taskforce developed the order sheet as a tool for physicians to be aware of the need for urinary catheters and their timely removal. It also gave the nurses a guideline when to use the bladder scanner as a preventative measure. The order sheet was initially developed on paper format. It was transferred to the electronic physician order entry format in late May 2012, which included a daily reminder for the physicians to reevaluate the need for the indwelling urinary catheter. The bladder scanner also went live May 2012.
The UPCs in each of the nursing departments took ownership of their CAUTI rates and were instrumental in the integration of the CAUTI bundle at the unit level. The ICU/PCU and MedSurg 3 South UPC were the early adopters of the bundle. In the April 2012 NGC meeting, they presented their ongoing projects to share some lessons learned. For example, the 3 South UPC noted that patients’ urinary bags were being placed on top of patients while they were being transported from one location to another. They recommended that bags need to be drained before patient transfers and placed below patient’s hip. The ICU/PCU UPC shared that one-on-one in-services by the UPC members and their Clinical Nurse Specialist facilitated in integrating the CAUTI bundle into practice. They also utilized CAUTI champions, identified by a CAUTI button, to reinforce the bundle.
Data collection and Evaluation
Under Rey’s guidance, the clinical nurse educators from various units assisted in collecting catheter days which were reported monthly to Rey. This enabled Rey to calculate the CAUTI rate. She used the NHSN as the comparison benchmark. She then regularly reported back the CAUTI rates to the Infection Control Committee, CPC and later on to the Nursing Quality Council.
PARTICIPANTS
The members of the CAUTI Taskforce were:
Name/Credentials |
Title |
Department |
Role in the Team |
Wendy Rey, RN, CIC |
Manager |
Infection Control |
Team Leader |
LaQuinta Roberts, BSN, RN, CCRN |
Clinical Nurse |
ICU/PCU |
Member |
Karen Ramnarine Williams, RN |
Clinical Nurse |
ICU/PCU |
Member |
Giovanna Valdes, RN, ONC |
Clinical Nurse |
3 South |
Member |
UPC Members |
Clinical Nurses |
Various inpatient departments |
Facilitated integration of CAUTI bundle |
Frank Fernandez, MD |
Hospitalist |
Medicine |
Physician Champion |
Mark Hernandez, MD |
Hospitalist |
Medicine |
Physician Champion |
OUTCOME(S)
Exhibit EP21EOa: Inpatient CAUTI Rates per 1000 Device Days
Analysis: Above graphs portray that the CAUTI Taskforce has exceeded its goal of decreasing CAUTI rates hospital-wide since the implementation of the CAUTI bundle with sustained results well below national benchmark for 9 consecutive quarters among 5 reporting departments.
References
Centers for Disease Control and Prevention [CDC]. (2014). Surveillance for urinary tract infections. Retrieved from http://www.cdc.gov/nhsn/acute-care-hospital/CAUTI/index.html
Florida Department of Health. (No date). Catheter-Associated Urinary Tract Infection (CAUTI) Prevention. Retrieved from http://www.floridahealth.gov/diseases-and-conditions/cauti-catheter-associated-urinary-tract-infection/index.html
Centers for Disease Control and Prevention [CDC]. (2014). Surveillance for urinary tract infections. Retrieved from http://www.cdc.gov/hicpac/CAUTI_fastFacts.html
The Joint Commission. (2014). National patient safety goals – 2014. Retrieved from http://www.jointcommission.org/assets/1/6/2014_hap_npsg_e.pdf
The Joint Commission. (2011). R3 report on catheter-associated urinary tract infections. Retrieved from http://www.jointcommission.org/assets/1/18/R3_Report_Issue_2_9_22_11_final.pdf
Summary of Attachments/Hyperlinks/Evidences
Exhibit EP21EOa: Inpatient CAUTI Rates per 1000 Device Days