Catheter Related Infections

Rules and AlertsOctober 2018

Catheter Related Infections Solution

• Evidence-based best practices for assessment, documentation and management of central lines and urinary catheters

• Goals:

– Reduce overall line days

– Reduce Urinary Catheter - associated urinary tract infections (CAUTI)

– Reduce Central Line- associated blood stream infections (CLABSI)

– Reduce peripheral line days

– Early detection of signs of infection

Central Line Insertion• If the following lines (Central, Arterial, PA Catheter, LA line, IABP) has

documentation for: Assist with procedure, First assessment new site, Insert, or Present on admission, an alert will fire to suggest the Invasive Line EBP IPOC.

Central Line Indication

An alert icon will populate on the Lines Tubes Drain MPage if:

– A Central line was inserted or present on admission > 6days

– Procedure Result = Insertion successful

– Site condition documentation in the EHR

– No indication has been documented in 6 days

Central Line Reassessment – Lower Acuity

• If a Transfer Patient Order is placed for a lower level of care and the following are documented:

– Central Line Activity = Insertion, Present on admission, or Assist with procedure

– AND there is no Discontinue Central IV order

• The following alert will fire to reassess lines on transfer:

Central Line Discontinue Order• New order created for physicians to discontinue central lines.

When this order is placed, a rule with cancel all other orders/task

associated with the central line.

Urinary Catheter Reassessment – Increased Activity

– Urinary Elimination or Urinary Catheter Type =

Indwelling catheter/Indwelling/3-way indwelling within

16 hours.

– Early and Progressive Mobility Assessment = Level 4

and Activity status ADL Level 4 = ambulating in hall,

ambulating in room, and up ad lib

Urinary Catheter Insertion

• If Urinary Catheter is documented as inserted or present on admission, an alert will fire to suggest the Urinary Catheter Care EBP IPOC

Urinary Catheter: Indwelling, 3Way

• Urinary Catheter Activity Type Documentation:

– Insert or Present on admission

• Urine Catheter Output > 0

• AND NO Insertion order for 3-Way Indwelling Urinary Catheter or Insert

Indwelling Urinary Catheter

• The following alert will fire:

Sterile Field Violation

• Central IV Activity = Insertion

• Procedure Type = Emergent

• Sterile Field = Not maintained,

• The following alert will populate to D/C the line and insert

new device:

Lines/Tubes/Drains MPageAny documented lines, tubes, and drains that are dynamic groups will display on this MPage if there is activity documentation for Insert, Present on Admission, or Assessment.

New Dynamic Groups and Updates• The following documentation has been updated to dynamic groups or updated to

include additional questions such as Activity, or Indications.– Peripheral IV

– Arterial Line

– Left Atrial Line

– PA Line

– IABP

– Epidural

– Urinary Catheter

– Gastric Tube

– Artificial Airway

– Chest Tube

– Surgical Drain

– Arteriovenous Access

– Enteral Tube Assessment

– CSF Drain

– Arterial Venous Sheath

– GI Tube

– Dialysis Device