CAUTI PreventionBest Practices Update

San Diego/Imperial County APIC Chapter

April 13, 2016

Objectives

O Discuss chapter members experiences and

lessons-learned with RN-driven Foley

Removal Protocols

O Review other methods of CAUTI reduction

being implemented by chapter members

APIC identifies “no RN driven protocols

for Foley removal” = gap in CAUTI

reduction strategies

UCSD’s RN Driven Foley Removal Journey

O Implemented in May 2015

O Multi-disciplinary group to define “necessity” based on CDC guidelines and implement

O Education rolled out to all nursing groups through Clinical Nurse Specialists (CNS)

O Email sent to MD groups to educate

O Random audits by nursing to evaluate appropriate removal – revealed low use of RN Driven Foley removal order (<10%); 38% of patients had Foley in place without meeting any of our approved indications

UCSD Nurse Protocol for Removal of Foley/Post Removal Protocol

MD Order Set

Necessity

indications

2 of 3 choices

allow MDs to hang

on to Foley removal

California Confidential Evidence Code 1157

To date, overall UCSD ICU Foley utilization and CAUTI have remained steady

California Confidential Evidence Code 1157

Nice Work

California Confidential Evidence Code 1157

TICU – No CAUTI for 11 consecutive months

Other TICU Interventions

O 2014 – started Event Case Study

Investigations (CSI) – CAUTI drill down

O June 2015 RN-led inter-disciplinary daily

rounding on each patient – Foley/Central

necessity part of every patient rounding

O 2015 – Rock Star Program – recognition of

RNs with perfect Foley/Central Line bundles

Our challengesO Necessity guidelines vague/open to interpretation

O Example: Prolonged mobility – being interpreted as anyone who doesn’t care to get out of bed when indication is meant to reflect unstable spine or pelvis, maybe hemodynamic instability (post cath)

O Conflict of interpretation of necessity guidelines between physicians and nursingO Ann Arbor Study helpful

O http://annals.org/article.aspx?articleid=2280677

O Lack of use of RN driven Removal ProtocolO MD’s tell us they –

O Did not know we had one of these

O Do not trust RNs to NOT remove Foley prematurely (really?)

O We don’t have a good system of consistent weights for volume status monitoring – cardiac folks – fair point – need to fix

O Multiple choices beside RN driven (call first, critical Foley)

O Lack of consistent auditing/feedback process to determine gaps in education/intervention

Ann Arbor Appropriateness Studyhttp://annals.org/article.aspx?articleid=2280677

Meddings J, Saint S, Fowler KE, Gaies E, Hickner A, Krein SL, et al. The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients:

Results Obtained by Using the RAND/UCLA Appropriateness Method. Ann Intern Med

Your RN-driven Foley Removal Protocol successes/challenges?

Other CAUTI Reduction Interventions for Discussion

O Stop Orders

O Antimicrobial impregnated Foley catheters

O Insertion practice evaluation

O New products

O Change Foley before UTI-suspected urine specimen obtained/administration of antibiotics

O Routinely change Foley

O Bundle surveillance

O Peri-care initiatives

O Others?

CAUTI Scenario

O 35 year old male patient admitted to SICU

on 1/25/16 with spinal cord injury and Foley

catheter is placed. On 2/16 - 2/28/16 the

patient has recorded fever > 100.4. Foley is

removed on 2/25/16 and urine culture

collected on 2/27/16 positive for ≥ 100,000

P. aeruginosa.

O Is this a CAUTI?

Per NHSN, Yes – SUTI1aFoley in from 1/25-2/25

2/22 Foley in, + temp

2/23 Foley in, + temp

Infection

Window Period

2/24 Foley in, + temp (Date of Event)

2/25 Foley removed, + temp

2/26 + temp

Date of Culture 2/27 Date of Pos Culture

Infection

Window Period

2/28

2/29

3/1

The 2/24 fever is the first element to occur within the IWP and is the date

of event. The Foley was in place > 2 days on the date of event, therefore

this meets SUTI 1a: Catheter-associated Urinary Tract Infection (CAUTI).