We have a CAUTI…now what?

Mary H. Holmes, MT, CICInfection Prevention Specialist

Ginny Ledbetter, RN, MSN, APRN-BCClinical Nurse Specialist

Roper St. Francis Healthcare

Wednesday, August 22, 2012

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

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

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

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

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

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

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

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

Removed Added•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

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

Page 1 – CAUTI Analysis form

Page 2 - CAUTI Analysis Form

An actual CAUTI Analysis form

Midas Report

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

# days from catheter insertion to + culture

0123

4567

89

Days1 2 3 4 5 6 7 8 9 10 11 12 13 >25

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)

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

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

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

How do we communicate the CAUTIs?

• Nurses– Monthly Infection Dashboard– Monthly Quality Scorecard– Staff meetings

• Physicians– Monthly Quality letter– Division meetings– Medical Executive Committee

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

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

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

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

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