Post on 18-Dec-2015
Using NSQIP Data and Best Practices to Reduce Urinary Tract Infections Among Surgical Patients
at Peace Arch Hospital
Paula GabrielDana HaywardDeb Sperandeo Nicole Moen
November 16, 2012
Team Composition
Alana Bajtkova, Surgical Staff Nurse Susann Camus, NSQIP Quality
Improvement Consultant Kelly Dixon, Surgical Staff Nurse Kirsten Emly, Infection Control
Practitioner, Infection Control Sharlene Enos, Clerk, Surgery Paula Gabriel, Surgical Staff Nurse Dana Hayward, Clinical Nurse
Educator, Surgery
Laura Holmes, PAH Surgical Clinical Reviewer
Alix Kite, Clinical Nurse Educator, Operating Room
Anna Lidberg, Surgical Staff Nurse Jenifer McDuff, Clinical Nurse
Educator, Surgery Nicole Moen, Surgical Staff Nurse Wendy Newson, Surgery Manager &
Team Sponsor Deb Sperandeo, Surgical Staff Nurse &
Team Leader
Why preventing Catheter Associated Urinary Tract Infections (CAUTIs) matters
80% of UTIs in surgical patients are CAUTIs Potentially life threatening for patients Costly for health authorities
Context
Non-risk adjusted data from NSQIP suggested UTI rates among Peace Arch Hospital postsurgical patients were higher than the NSQIP average
Multidisciplinary team led by a frontline nurse established in April 2012 to lead efforts to reduce CAUTIs
Team Goals
Reduce catheter-associated urinary tract infections (CAUTIs) as a postsurgical infection among PAH surgery patients by 50% between April 1 and October 31, 2012.
This means reducing non-risk adjusted CAUTI rate from 3.4 to 1.7%.
Interventions to Date
Development of a team Charter Implementation of Best Practices from NSQIP and from
Fraser Health’s CAUTI Prevention Guideline Staff huddles and contests Factoids posted on unit walls,
in washrooms PDSA Cycles Silver tipped catheter trial in
hip fracture patients
Interventions to date
– Drainage bag placement, loop integrity
– Replace plastic containers with biodegradable Vernacare containers
– Patient education– Document Foley Catheter Plan
of Care in Kardex binders
Plan-Do-Study-Act (PDSA) cycles to test effectiveness of small changes
Measurement
PDSA cycles test how well we are implementing best practices
Staff participation in huddles and quizzes are indicators of staff engagement
NSQIP data helps the team track progress
Quality Dashboard – Foley Plan of Care
Quality Dashboard – Containers
Lessons Learned
QI Consultant helpful to facilitate meetings, teach us how to apply quality improvement methods, and document processes
Having the data for comparison purposes and an SCR to put the rates in context
Understanding change management theory Multidisciplinary team Get practical arrangements in place before starting (e.g.
booking time off to attend meetings)