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Reducing Hospital Acquired Indwelling Urinary Catheter-Associated Urinary Tract Infections through Multidisciplinary Team and Shared Governance Practice Model
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American Journal of Infection Control June 2011
Device-Related Infections and/or Site Specific Infections Presentation Number 13-130
Investigation of Bariatric Surgical Site Infections Rosemary Holtzman, CLS, MBA, CIC, Infection Preventionist, Orange Coast Memorial Medical Center, Fountain Valley, CA Issue: A Bariatric Surgical Site Infection is defined as a patient having Bariatric Surgery in the 4th quarter of 2009, with a recognized pathogen isolated from culture within 30 days postop. In addition, two of the following symptoms must be present: purulent drainage, pain, localized swelling, redness, heat, spontaneoous dehiscence of the incision, or fever. A cluster was confirmed by comparing the rate of infection in Quarter 4 2009 to the background rate for the facility in 2007, 2008, and the first three quarters of 2009. Although this rate was below the NNIS rate, there was a significant increase when compared to the background. Project: The five cases were analyzed for commonalities that contributed to the development of surgical site infection. The following elements were studied: Preop Body Wash porcedure, CHG prep, Patient Warming, Surgeon, Anaesthesiologist, Circulating Staff, Patient Weight, ASA Score, Organism Isolated, Site of Infection, Extent of Infection, Number of Days Postop, Preop Antibiotics, Pre and Post Op temp, Length of Procedure, Preop Blood Gloucose, Wound Class, OR Room Number, and Ins/ Outs. Results: Streptococcus species was isolated from superficial incisional infections. After anaylsis of the data, three hypotheses emerged: Employee carrier of a pathogen, Environmental Source of Contamination, and Preoperative Preparation of the Surgical Site. Each hypothesis was tested, and it was found that the preoperative preparation was the source of the infections. The perioperative staff used a procedure that varied with the patient, with the variables being: 1) Different numbers of CHG wiping cloths were used; 2) Some nurses asked the patient to wipe themselves, then assisted with the unreachable areas; 3) Some nurses do all the wiping for the patient; 4) Some nurses handed the wipes to the patient, and left; 5) The numbers of cloths used were inadequate according to manufacturer’s directions, but contrary training had been given by the product representative. Lessons Learned: A standardized procedure for the wiping was written, the staff was inserviced, and followup monitoring for compliance was conducted. The occurence of further infection was closely monitored to assess the effectiveness of the intervention. Better documentation of the preparation procedure was developed, which included both the home total body bath and the perioperative process. No further infections have occurred through Quarter 3 2010. Presentation Number 13-131
Reducing Hospital Acquired Indwelling Urinary Catheter-Associated Urinary Tract Infections through Multidisciplinary Team and Shared Governance Practice Model Elaine R. Flynn, RN, MSN, CIC, CRRN, Infection Preventionist; Karen Zombolis, RN, MHA, Quality Improvement Coordinator; Albert Einstein Healthcare Network, Philadelphia, PA Issue: Hospital-acquired catheter-associated urinary tract infection (HA-CAUTI) can impact patient safety & facility finances. In November 2008, our network initiated a multidisciplinary team who utilized shared governance to adopt care practices to reduce HA-CAUTI. Project: Our .500 bed system is a network with acute, rehabilitation, & long-term care facilities. The CatheterAssociated UTI Prevention Team (CAUTI-Team) included nurses who participate in shared governance practice model and physicians. CAUTI-Team goals were to reduce indwelling urinary catheter (IUC) usage & number of HA-CAUTI. CAUTI-Team completed a failure mode & effects analysis (FMEA) to identify key elements for
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focus. The team divided into 4 work groups: Bladder Management Practice guideline, Documentation Guidelines/ Order sets, Urologic Equipment, and Education. CAUTI-Team actions: 1) identified a UTI Prevention workflow process to facilitate the appropriate ordering, placement, maintenance and removal of IUC, 2) created best practice CAUTI Prevention Bundle, 3) selected new IUC products & stabilization device, 4) revised care & management of IUC procedures, 5) developed a nursing CAUTI Prevention self-learning module. The CAUTI Prevention Bundle includes: a) physician order set with clinical necessity indicators for IUC, b) competency for staff who insert IUC, c) daily assessment for IUC necessity, d) educational materials for patient & family. The CAUTI interventions were introduced in December 2009. The CAUTI-Team used the self-governance approach to determine best practice & to implement changes. Council members monitored clinical practice & served as liaisons in reporting CAUTI Prevention bundle compliance as well as HA-CAUTI outcomes to their areas. Results: The synergy of shared governance in collaboration with the CAUTI-team produced evidence-based practice guidelines for use, insertion/maintenance of IUC. HA-CAUTI rate decreased from a pre-intervention mean of 3.09 to 0.84/1000 IUC days and 15% reduction in IUC usage. 90% of the network nursing staff completed the competency with 90% Post test score. These changes have resulted in significantly lower number of patient experiencing harm from a HA-CAUTI. Lessons Learned: Physician input & the shared governance approach resulted in a significant reduction in HAI & decrease in IUC utilization. Collaborative teamwork and communication make changes sustainable.
Presentation Number 13-132
Beyond the Bundle: The ICU Initiative to Decrease the Incidence of Central Line Associated Bloodstream Infection Janet Briggs, RN, BSN, CIC, Infection Prevention; Lori Ross, RN, MBA, Vice President of Clinical Quality Improvement; Robert L. Burnaugh, MD, FCCP, Chief of Staff, Intensivist; Kelly A. Arashin, RN, MSN, CCNS, CEN, Clinical Nurse Specialist; Beth Gasiorowski, BA, JD, Director of Risk Management and Patient Safety Officer; Hilton Head Hospital, Hilton Head Island, SC Issue: The CABSI rate in the ICU remained constant despite the implementation of the IHI Central Line Bundle. In 2008 the rate of CABSI was 4.88 per 1,000 device days; by the end of the 2Q2009, the infection rate increased 66% to 7.43 per 1,000 device days. Four CABSI were identified in the ICU between March and May 2009. Concerned with the unusual and sudden increase in the number of CABSIs, a BSI team was formed to examine all aspects of central line practices. Project: The BSI team joined the Johns Hopkins STOP BSI Initiative. Identifying process defects resonated with the team because there was a strong feeling that the bundle approach recommended by IHI was already in place yet BSIs continued to occur. The team included: nursing staff from ICU, surgery and emergency departments; anesthesia, pharmacy, wound care, infection prevention, quality, and materials management. Regular meetings with the frontline staff drove the process changes at the unit level, including: 1) Assembled multiple central line insertion supply boxes and made them readily available to enhance compliance with insertion bundle; 2)
American Journal of Infection Control June 2011
Device-Related Infections and/or Site Specific Infections Presentation Number 13-130
Investigation of Bariatric Surgical Site Infections Rosemary Holtzman, CLS, MBA, CIC, Infection Preventionist, Orange Coast Memorial Medical Center, Fountain Valley, CA Issue: A Bariatric Surgical Site Infection is defined as a patient having Bariatric Surgery in the 4th quarter of 2009, with a recognized pathogen isolated from culture within 30 days postop. In addition, two of the following symptoms must be present: purulent drainage, pain, localized swelling, redness, heat, spontaneoous dehiscence of the incision, or fever. A cluster was confirmed by comparing the rate of infection in Quarter 4 2009 to the background rate for the facility in 2007, 2008, and the first three quarters of 2009. Although this rate was below the NNIS rate, there was a significant increase when compared to the background. Project: The five cases were analyzed for commonalities that contributed to the development of surgical site infection. The following elements were studied: Preop Body Wash porcedure, CHG prep, Patient Warming, Surgeon, Anaesthesiologist, Circulating Staff, Patient Weight, ASA Score, Organism Isolated, Site of Infection, Extent of Infection, Number of Days Postop, Preop Antibiotics, Pre and Post Op temp, Length of Procedure, Preop Blood Gloucose, Wound Class, OR Room Number, and Ins/ Outs. Results: Streptococcus species was isolated from superficial incisional infections. After anaylsis of the data, three hypotheses emerged: Employee carrier of a pathogen, Environmental Source of Contamination, and Preoperative Preparation of the Surgical Site. Each hypothesis was tested, and it was found that the preoperative preparation was the source of the infections. The perioperative staff used a procedure that varied with the patient, with the variables being: 1) Different numbers of CHG wiping cloths were used; 2) Some nurses asked the patient to wipe themselves, then assisted with the unreachable areas; 3) Some nurses do all the wiping for the patient; 4) Some nurses handed the wipes to the patient, and left; 5) The numbers of cloths used were inadequate according to manufacturer’s directions, but contrary training had been given by the product representative. Lessons Learned: A standardized procedure for the wiping was written, the staff was inserviced, and followup monitoring for compliance was conducted. The occurence of further infection was closely monitored to assess the effectiveness of the intervention. Better documentation of the preparation procedure was developed, which included both the home total body bath and the perioperative process. No further infections have occurred through Quarter 3 2010. Presentation Number 13-131
Reducing Hospital Acquired Indwelling Urinary Catheter-Associated Urinary Tract Infections through Multidisciplinary Team and Shared Governance Practice Model Elaine R. Flynn, RN, MSN, CIC, CRRN, Infection Preventionist; Karen Zombolis, RN, MHA, Quality Improvement Coordinator; Albert Einstein Healthcare Network, Philadelphia, PA Issue: Hospital-acquired catheter-associated urinary tract infection (HA-CAUTI) can impact patient safety & facility finances. In November 2008, our network initiated a multidisciplinary team who utilized shared governance to adopt care practices to reduce HA-CAUTI. Project: Our .500 bed system is a network with acute, rehabilitation, & long-term care facilities. The CatheterAssociated UTI Prevention Team (CAUTI-Team) included nurses who participate in shared governance practice model and physicians. CAUTI-Team goals were to reduce indwelling urinary catheter (IUC) usage & number of HA-CAUTI. CAUTI-Team completed a failure mode & effects analysis (FMEA) to identify key elements for
www.ajicjournal.org Vol. 39 No. 5
E29
focus. The team divided into 4 work groups: Bladder Management Practice guideline, Documentation Guidelines/ Order sets, Urologic Equipment, and Education. CAUTI-Team actions: 1) identified a UTI Prevention workflow process to facilitate the appropriate ordering, placement, maintenance and removal of IUC, 2) created best practice CAUTI Prevention Bundle, 3) selected new IUC products & stabilization device, 4) revised care & management of IUC procedures, 5) developed a nursing CAUTI Prevention self-learning module. The CAUTI Prevention Bundle includes: a) physician order set with clinical necessity indicators for IUC, b) competency for staff who insert IUC, c) daily assessment for IUC necessity, d) educational materials for patient & family. The CAUTI interventions were introduced in December 2009. The CAUTI-Team used the self-governance approach to determine best practice & to implement changes. Council members monitored clinical practice & served as liaisons in reporting CAUTI Prevention bundle compliance as well as HA-CAUTI outcomes to their areas. Results: The synergy of shared governance in collaboration with the CAUTI-team produced evidence-based practice guidelines for use, insertion/maintenance of IUC. HA-CAUTI rate decreased from a pre-intervention mean of 3.09 to 0.84/1000 IUC days and 15% reduction in IUC usage. 90% of the network nursing staff completed the competency with 90% Post test score. These changes have resulted in significantly lower number of patient experiencing harm from a HA-CAUTI. Lessons Learned: Physician input & the shared governance approach resulted in a significant reduction in HAI & decrease in IUC utilization. Collaborative teamwork and communication make changes sustainable.
Presentation Number 13-132
Beyond the Bundle: The ICU Initiative to Decrease the Incidence of Central Line Associated Bloodstream Infection Janet Briggs, RN, BSN, CIC, Infection Prevention; Lori Ross, RN, MBA, Vice President of Clinical Quality Improvement; Robert L. Burnaugh, MD, FCCP, Chief of Staff, Intensivist; Kelly A. Arashin, RN, MSN, CCNS, CEN, Clinical Nurse Specialist; Beth Gasiorowski, BA, JD, Director of Risk Management and Patient Safety Officer; Hilton Head Hospital, Hilton Head Island, SC Issue: The CABSI rate in the ICU remained constant despite the implementation of the IHI Central Line Bundle. In 2008 the rate of CABSI was 4.88 per 1,000 device days; by the end of the 2Q2009, the infection rate increased 66% to 7.43 per 1,000 device days. Four CABSI were identified in the ICU between March and May 2009. Concerned with the unusual and sudden increase in the number of CABSIs, a BSI team was formed to examine all aspects of central line practices. Project: The BSI team joined the Johns Hopkins STOP BSI Initiative. Identifying process defects resonated with the team because there was a strong feeling that the bundle approach recommended by IHI was already in place yet BSIs continued to occur. The team included: nursing staff from ICU, surgery and emergency departments; anesthesia, pharmacy, wound care, infection prevention, quality, and materials management. Regular meetings with the frontline staff drove the process changes at the unit level, including: 1) Assembled multiple central line insertion supply boxes and made them readily available to enhance compliance with insertion bundle; 2)