PCMH Journey to Reduce

1. PCMH Journey to Reduce Catheter-Associated Urinary Tract Infections 2007 � 2010

2. UTI Task Force Goal: Eliminate infections as measured by a reduction in device-related infections Staff Education Bundle UTI Toolkit Data Dictionary UTI Audit Form Nursing Grand Rounds

3. Foley Bundle 1. Foley Insertion Rational & Documented Patient requires relief of anatomic or physiologic outlet obstruction Patient is undergoing surgical repair of genitourinary tract. Patient is critically ill, postoperative, or with unsure volume status with need for strict I&O. Patient is debilitated, paralyzed or comatose with stage 2 or higher skin breakdown. Palliative care for patient comfort per patient request. 2. Foley bag is kept off the floor at all times. 3. Foley bag is below the level of the bladder at all times?

4. Foley Bundle 4. Daily review for necessity and prompt removal if insertion criteria unmet Additional Foley Issues: MD order for Foley Foley insertion documented under procedures Foley care documented Foley tube secured to patient

8. Automation: Foley Panel Order (Include 250, 300, 400 as a range to be chosen by MD) Bladder scan � If no void 4-6 Hours or Uncomfortable at Anytime, perform bladder ultrasound. If PVR < 250, 300, 400 ml, monitor q hour for spontaneous void of bladder volume is > 250, 300, 400 ml, -add drop down box: - Notify MD - Straight Cath - Foley (Indwelling) Catheter Foley (Indwelling) Catheter I & O Catheter I & O Catheter to obtain urine specimen

12. Best Practice Alert BPA � 48 hours after foley catheter order (Reminder to every provider once until action is taken by a provider) D/C indwelling catheter Continue catheter for another 48 hours Maintain chronic urinary device (change date range to stop BPA reminder)

17. Head of Bed Reminders/Prompts Examples Foley Catheter No BP/Sticks Right Arm Anticoagulant Therapy Goal: Organized/consistent approach to have HOB reminders to communicate with multidisciplinary team throughout PCMH

18. Small Tests of Change Foley 101 Pre-attached catheter drainage kits Implemented wider range of male external catheter sizes Weekly drill down reports Bye-Bye UTI listserv Rounding with a purpose 90 day action plans Education Kits: Train-the-Trainer

19. CAUTI Reduction: Effective Actions Rounding with a Purpose- each shift to determine continued need for catheters Perform perineal hygiene utilizing approved hospital perineal foam cleanser prior to all urinary catheterizations and daily to reduce bacterial load. Eliminate use of diapers with patients who have foley catheters and diarrhea. Consult Skin nurses for use of alternatives such as pouching systems, etc Weekly reports and drill down from ICP of CAUTI Review patterns of CAUTI development on your unit. For a pattern of CAUTI development within 7 days of insertion, reassess staff insertion skills.

20. Challenges Nurse Driven Protocols Microbiology � reflexive urinalysis Interpretation of insertion criteria (strict I&O) Refine documentation systems. Incorporate HICPAC 1A recommendations into upcoming action plans Trial of new Bladder Management System

21. Meet the Challenge 2010 continuedMOVING FORWARD CAUTI 90 Day Focus August 2010

22. AIM Statement How Good? By When?

23. 90 day focus Revised BPA Foley Friend Transparency � Unit door graphs Weekly Bundle Compliance Last date of UTI for this unit Device Days RCA Drill Down Tools for all CAUTIs Products Bard New Product and Kit Condom cath In & Out kit

24. BPA in Healthspan Discontinue Foley Catheter is pre-checked on the alert Alert will fire every 24-36 hours Do not d/c foley between 4pm and 4 am Foley orders change to: In & Out Cath Condom Cath 3 Way Urinary Cath Foley Cath Lists reason for order (hospice, relief, strict I&O every 2 hrs, Surgery/Trauma/Procedure, skin breakdown stage 2 or greater, other: specify)

25. 2 staff members are present with all foley insertions, one must be an RN Opportunity to assist staff Opportunity to call the question if needed Opportunity to review competency/skills Foley Friend

26. UHS Bundle Revisions insertion criteria effective Oct 2010 Based on HICPAC Guidelines Patients with acute urinary retention or bladder outlet obstruction Patients undergoing surgical repair of genitourinary tract Frequent and Urgent measurements of urinary output in critically ill patients To assist in healing of open sacral or perineal wounds in incontinent patients To improve comfort for end of life care, if needed To avoid potential compromise of unstable structural injuries (eg unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures For Healthspan drop down: 1. relief 2. GU surgery 3. Critical I&O 4. sacral/perineal wounds 5. Hospice 6. pelvis/spine (acute)

27. Summary Best way to prevent a CaUTI is not to insert a foley Does the pt meet the necessity for insertion of a foley? Does the pt meet the necessity for continuation of a foley � daily review Opportunities exist at insertion

28. Vicki Kinzie was awarded an NC-APIC Educational Scholarship to attend the APIC-NC Fall Conference in 2009. She created this slide presentation as a condition of that award. Note from Vicki: I would like to thank NC APIC for the opportunity to attend the 2009 conference. I learned so much�from the presentations and enjoyed getting to meet and network�with other NC APIC members and presenters. Please contact me if you have any questions about my presentation: Vicki Kinzie, RN, BSNPitt County Memorial Hospital�Infection Control Department Greenville NC Phone: 252-847-9141 Email: vkinzie@PCMH.COM