CAUTI Prevention

1
CA-UTI Prevention

• Ann Sheets RN, BSN

2
(No Transcript)
3
MidMichigan Medical Center-Gladwin

• 25 Bed Critical Access Hospital
• Located in the middle of Michigan
• One medical/surgical unit
• Emergency Room
• One OR Suite
• Do not have an ICU

4
Foley Patrol

• We have been monitoring catheter insertions for
  many years as a result of a cluster of catheter
  associated urinary tract infections (CA-UTI)
• We see improvement, however, we struggle with
  sustainability!!!!

5
Foleys-Foleys-Foleys!!!!!

• Where do they all come from???
• What do you do when you identify inappropriate
  use?
• Do a drill down!!!
• Identify trends by nurses and/or physicians
• Units (Where are they being inserted?)
• What was the reason for insertion?

6
What Did We Find?

• The majority of the catheter insertions occur in
  the emergency department
• Once the Foley has been inserted it is difficult
  to get it removed
• The attending physician is unaware
• Sometimes the Foley catheter is not ordered on
  the admission ordersso it gets overlooked
• Nurses are not always advocates for
  removal.convenience factor

7
Percentage of Patients with Foley by Physician
8

• 51.4 of all Foley catheter insertions were
  ordered in the Emergency Room during the 30 day
  study

9
Foley Catheter Monitor Top 4 Patient Diagnosis
10
FOLEY CATHETERS PER GENDER
11
What Did We Do Next? Reduction Strategies

• Shared information with the medical staff
  nurses
• Updated our policy and listed the appropriate
  criteria for catheter insertion.
• To relieve urinary tract obstruction
• To permit urinary drainage in patients with
  neurogenic bladder dysfunction and urinary
  retention
• To aid in urologic surgery
• To obtain accurate measurement of output in
  critically ill patients
• Stage 3 or 4 sacral decubitus ulcer (only if the
  patient is incontinent)
• Hospice/comfort care/palliative care

12
Reduction Strategies

• Physicians did not want an automatic DC protocol
• Physicians requested that we create a reminder
  sticker for the chart
• Education and stats provided at department
  meetings
• Daily Foley Patrol- that is when we coined the
  saying
• We are at Triple F Status
• Purchase bladder scanner

Foley Catheter in 48 Please D/C
13

• FOLEY FREE FACILITY

14
We Improve-Then Regress!!

• What do we do???

15
Keystone Bladder Bundle

• We did not do the point prevalence study-it was
  problematic due to low volumes (we are not
  formally submitting our data)
• We do share our data at the Infection Prevention
  Control Committee Meeting
• We used the bundle because we continue to
  struggle with inappropriate catheter insertions
• Even one CA-UTI caused by inappropriate use is
  too many
• We strive to improve patient outcomes
• We needed buy in from the physicians and nurses

16
Dedicated Project Lead-Ann

• Sometimes referred to as our Keystone Cop
• walking the beat on Foley Patrol!

17
Drill-Down
18
Sometimes you have to be a detective!!
19

• The Infection Control Committee recommended that
  each inappropriate Foley catheter insertion be
  documented on a variance report to allow for
  tracking trending by ordering physicians and
  nurses
• Follow up with each unit manager and individual
  nurses

20
Bladder Scanner

• A Bladder Scanner was purchased In hopes of
  reducing the likelihood of inappropriate use of
  catheter insertion
• All of the staff nurses were trained on how and
  when to perform a bladder scan
• During the Drill-Down I found that our Bladder
  Scanner Protocol was not being implemented or
  followed

21
Why, Why, Why

• Inappropriate orders that stated
• Bladder Scan
• Insert Foley Catheter
• The Drill-Down revealed that the nurses were not
  aware that a Bladder Scanner Protocol existed
• Lack of Communication
• Education was done
• Appropriate order- Bladder Scan follow Bladder
  Scanner Protocol
• Walking rounds
• Quality corner postings
• Nurse link
• Net Learning (Computer based learning modules)

22
Bladder Scanner Protocol

• Check all that apply
• Hx of frequent small voids (volumes of 50-100 ml
  urine every 30-60 minutes, or more frequently
• Urinary incontinence not due to stress or urge
  incontinence
• Documented patient unable to void when attempted
• Urinary catheter in place suspect blockage
• 1. Small amount of urinary output
• 2. Patient complains of urge to void and/or has
  
• distention or discomfort

23
Protocol continued

• If residual volume is gt 300 ml, perform a
  straight cath to drain and empty bladder contents
• If residual volume gt to 200ml patient has
  documented complaints of pelvic/abdominal
  discomfort, feels unable to void, or unable to
  empty bladder, perform straight cath to drain and
  empty bladder contents

24
Force Function

• If we want the protocol followed it has to be
  convenient
• Copies of the Bladder Scanner Protocol was placed
  in a folder that was attached to the Bladder Scan
  itself for convenience
• I personally make sure it is kept filled

25
Where Are We Now ???

• The creation of the Neon Pink Ticket arrives

• Indication for Appropriate
  Foley Use
• Urinary Tract Obstruction/Neurogenic Bladder
  Dysfunction
• I O On Critically Ill Patient
• Stage 3 or 4 Sacral Decub (Only If Pt. Is
  Incontinent)
• Hospice Care
• Check appropriate indicator and place in
  Infection Control Mailbox
• 
  Addressograph

26
Neon Pink Tickets

• Education was done with each department on the
  neon pink tickets
• I personally attached a ticket to every Foley
  Catheter Kit in each department
• Tickets allow us to identify which patients have
  catheters and the indication for insertion
• I personally do rounds to collect the tickets
• Chart review continued

27
Problems

• Making sure that every time catheters are
  restocked they have a ticket attached
• I currently do rounds to attach tickets
• I was replacing tickets, however, they were not
  being submitted to infection control
• We continue to EDUCATE!

28
Chart Review

• If indication is found that the patient did not
  meet criteria for insertion the physician was
  contacted and the Foley Catheter was discontinued

29
Results

• A decrease in Foley insertions in the Emergency
  Room (ER) on admission patients
• When a Foley is inserted in the ER it is usually
  for a critically ill patient being transferred
  out or inserted for a procedure and then
  discontinued

30
Foley Insertions-Appropriate vs. Inappropriate
31
Foley Insertions by Department
32
What Do We Do Now ???

• Continue to reinforce the Bladder Scanner
  Protocol
• Write a variance for each inappropriate order for
  Bladder Scan that does not follow the Protocol,
  and Foley insertion that is not indicated
• Continue Chart Review
• Education

33
Successes

• Decrease in ER Foley insertion
• Increased awareness of the appropriate
  indications for Foley use

34
Struggles

• Still working with nurses in regards to Bladder
  Scanner Protocol

35
Questions??????

• Contact Information
• ann.sheets_at_midmichigan.org