Infections Due to Devices Improvement Collaborative: UHC CAUTI Workgroup Coaching Call # 3
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Transcript of Infections Due to Devices Improvement Collaborative: UHC CAUTI Workgroup Coaching Call # 3
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Infections Due to Devices Improvement Collaborative:UHC CAUTI Workgroup Coaching Call # 3August 29, 2012
Dial in: 1-866-469-3239
Passcode: 664 803 879
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Teleconference Agenda
Introductions of Subject Matter Experts
(SME’s) and Guest Speakers
Site Updates
Review activities for completion
Presentation - On the CUSP: Stop
CAUTI Experience - University of
Medicine and Dentistry, New Jersey
(UMDNJ), Cohort 3 Participant
Presentation of Nurse Driven Nurse
Driven Foley Catheter Protocol –
Beaumont Health System
Action items
Looking ahead
Next call
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SME’s and Guests Speakers
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CAUTI Workgroup SME’s and Guests
Marlene Bokholdt, BSN, RN, CPEN, CCRN Nursing Education EditorEmergency Nurses Association (ENA)CAUTI Extended Faculty
Ian Jenkins, MDHealth Sciences Associate Professor of Medicine, UCSDCAUTI Extended Faculty
Linda Booth, RN CICDirector of Infection Prevention & ControlUMDNJ-University Hospital
Paula Levesque, RN, MSA Vice President Quality and Patient Safety Beaumont Health System Royal Oak, Michigan
Kathy DeSnyder, MPH Manager, Quality and Safety Beaumont Health System Royal Oak, Michigan
Wina Padilla, RN Infection Prevention & Control DepartmentUMDNJ-University Hospital
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Review of Activities for CompletionPhase 2
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Modified timeline
June July August September October November December January February March April May July August October November
Q2 - 2012 Q3 - 2012 Q4 - 2012 Q1 - 2013 Q2 - 2013 Q3 - 2013 Q4 - 2013
Phase 2: PlanningPhase 3: Execution
(Part 1)Phase 4:
Sustainability
Activities to Complete:
Complete registration process
View/join 4 On-boarding calls
Attend monthly coaching call
Phase 1:Start Up
Activities to Complete:
Complete Readiness Assessment
Begin baseline data collection (Outcome data)
Administer HSOPS
Educate Staff - Watch the Science of Safety video and provide educational materials
Attend monthly Coaching calls
Attend monthly national Content calls
Lay foundation for data collection
Activities to Complete:
Begin team meetings
Learn from defects (with team and unit staff)
Complete baseline data collection and then begin ongoing data collection (after implementation)
Complete Team Check-Up tool (quarterly)
Attend monthly Coaching calls
Attend monthly national Content calls
Activities to Complete:
Continuing staff education
Continue to learn from defects (with team and unit staff)
Complete ongoing data collection (after implementation)
Continue team meetings
Consider "spread" to other areas in the hospital
Complete Team Check-Up tool (quarterly)
Readminister HSOPS
Attend monthly Coaching calls
Attend monthly national Content calls
UHC CAUTI WORKGROUP TIMELINE
Phase 3: Execution(Part 2)
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CAUTI DATA REQUIREMENTS: Reduce CAUTIs
OUTCOME DATA: CAUTI Rates/Catheter Prevalence
• Total # of patient days for that unit• Total # of indwelling urinary catheter days for that unit• Total # of CAUTIs for that month • Ideally, all data are entered into MHA Care Counts by the last day of
each month
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CAUTI Outcomes Data Collection
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Site Updates
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Barnes-Jewish Hospital (IQ, HEN, BPBC)
Beaumont Health System - Royal Oak (HEN, BPBC)
Hallmark Health Hospital (HEN)
Howard University (IQ, HEN, BPBC)
Indiana University Health (IQ, HEN)
Louisiana State University Health Sciences Center – Shreveport (IQ, HEN)
Massachusetts General Hospital (IQ, HEN, BPBC)
MD Anderson Cancer Center
Medical University of South Carolina (IQ, HEN, BPBC)
The Methodist Hospital (Texas) (IQ, HEN)
UCLA Health System (IQ, HEN, BPBC)
University Hospital –UMDNJ (IQ, HEN, BPBC)
University of Arizona Health Network (The University of Arizona Medical Center – University Campus) (IQ, HEN)University of Iowa Hospitals and Clinics (IQ, HEN, BPBC)
University of Rochester Medical Center - Strong Memorial Hospital (IQ, HEN, BPBC)University of Texas Medical Branch (UTMB Health) (IQ, HEN)
University of Toledo Medical Center (IQ, HEN)
University of Washington Medical Center (IQ, HEN, BPBC)
West Virginia University Hospital (IQ, HEN, BPBC)
Hospital/Project Liaison Hospital/Project Liaison
Barnes-Jewish Hospital Cody Gowler, Performance Improvement Specialist
University of California, Los Angeles (UCLA) Health System, Melissa Moore
Hallmark Health Hospital Kathy Charbonnier, Director of Quality and Patient Safety
University of Arizona Health Network (The University of Arizona Medical Center – University Campus) Susan Bohnenkamp, Clinical Nurse Specialist
Howard University Mary Staples, Senior Director, Quality and Process Improvement
University of Iowa Hospitals and Clinics Jill Lacey, Quality and Op Improvement Coordinator
Indiana University Health Suzi Tolliver, Manager Infection Control
University of Texas Medical Branch (UTMB Health) Susan Seidensticker, Quality Management Specialist
Louisiana State University Health Sciences Center – Shreveport, Leisa Oglesby, Quality Assurance Director
University of Toledo Medical Center, Sandra Hensley, Infection Control Practitioner
Medical University of South Carolina Linda Formby, Manager, Infection Prevention and Control
West Virginia University Hospital, Lori Sisler, Infection Preventionist
CAUTI Workgroup Participants
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On the CUSP: Stop CAUTI Experience Presentation - UMDNJ, Cohort 3 Participant
CAUTI CUSPCOHORT 3
September 12, 2011:
Hospital Commitment Letter to Participate in On the
CUSP: Stop CAUTI signed
November 14, 2011: Kick Off Session
Pilot unit chosen; Trauma SICU 2° high infection rates
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AIM Statement Developed
Decrease CAUTI rates by no less than 25% within 18 months
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CAUTI CUSP team Established
Senior Sponsor: Vincent Barba, MD, FACP, FHM – Chief Quality Officer
Physician Champion : Alicia Mohr, MD – Medical Director, Surgical ICU Team Leader: Director of Infection Prevention & Control Critical Care Nursing Director Nurse Manager Technical Expert: Infection Preventionist Staff Nurse CNA
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Prevalence
December, 2011 Foley Catheter Prevalence conducted on the pilot unit.Outcome:
% of patients with indwelling Foley catheter = 100%% of patients that had daily assessment for need = 0%% of patients with documentation showing the patient met the
criteria for foley use = 0%
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Getting Started
Baseline data was collected for a period of 3 months. January 2012 February 2012 March 2012
Patient Safety Surveys completed during January and February 2012
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Education
• Foley Catheter vendor conducted re-education for proper use of catheter securement device
• Verified that pilot unit had adequate numbers of the securement device on hand in the clean utility room
• Made available for staff viewing 3 patient safety videos
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Plans for Change Established
Implement the CAUTI Bundle Daily assessment of need using a daily goals sheet Establish pre-printed order set for nurse driven
discontinuation of catheters Educate staff Nursing documentation every shift re-bundle compliance Assess any patient with foley catheter for need prior to
transfer
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Stumbling Blocks
• Poor meeting attendance by members• March 1, 2012 Team Leader resigned her position at UMDNJ. • The IP serving as a team member took the lead• Only the IP team leader participated in the boarding calls• Poor involvement on all levels from team members, IP was
doing all the data collection, inputting data, and education• Physician resistance related to nurse driven protocol for
discontinuing foley catheters
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New Direction
• On May 1, 2012 a new Director of Infection Prevention & Control was hired.
• The new Director created a partnership with house wide CAUTI reduction team.
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Where Are We TODAY
At the end of the 2nd quarter of 2012 we have seen fluctuating infection rates, and a decreasing trend in utilization rates.
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Nurse Driven Foley Catheter Protocol
About Beaumont Health System
Very large, busy health system in Metropolitan Detroit Michigan
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Protocol Development
3 Hospitals
– Clinical Informatics Nurses
– Quality and Safety Nurses
– Nursing Educators
Protocol Workflow and Development
Education and Approvals
Implementation and Ongoing Monitoring
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Development
What is best practice?• What CMS required• Work with Michigan Hospital Association Keystone Center
Working with Infection Control Leadership
Weekly workgroup meetings
Nursing leadership buy in and support critical
EPIC is our electronic Health Record• Needed to develop within nursing documentation flow within EPIC
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Process
Indication required when ordering a Foley catheter
Daily assessment by nursing of continuation criteria (lack of continuation criteria meets removal criteria)
Acceptance by Medical Staff of Nurse-Driven aspect to protocol (phased in)
NURSING DOCUMENTATION FOR FOLEY PLACED:
Required
Nursing Documentation for Foley Placed
Indication Options Required for Documentation
Foley Continuance Criteria
ONCE DOCUMENTATION IS DONE THE NURSE CLICKS ON ‘FILE’ TO COMPLETE FILING OF THE DOCUMENTATION
Continuance Selection Form Expanded
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Implementation
Mandatory Nursing Education
Approval at each hospitals Medical Executive Committee
Ongoing support by Clinical Informatics
Bits and Bytes Nursing Education
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Ongoing Monitoring
Nursing Dashboard
Core Measure Compliance
MHA Keystone unit monitoring
UHC HEN
CMS CAUTI reporting for ICU and Rehab
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Nursing Dashboard
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Questions?
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Action Items
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Action Items: Activities for Completion• Phase 1 of the collaborative consists primarily of registration and
onboarding activities. The registration process includes completion of:
- On-line registration with HRET- CEO commitment letter- Unit team commitment letter- Data use agreement
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Action Items: Activities for Completion• Phase 2 of the collaborative focuses on planning, assessment and
data collection. Key activities that you have or will complete include:
• Complete baseline outcomes data in MHA CareCounts Confirm/monitor data entry results
• Complete administration of HSOPS (Survey closes September 7)
• Staff education Watch the Science of Safety video Provide educational materials
• Attend monthly national Content calls and monthly Coaching calls
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Looking Ahead: Key Priorities
• Sites will continue collection of outcome data and lay the foundation for process data collection
- Who will collect data?- Same time each day – when?- What tool will you use to collect data?
• Begin the collection of prevalence and appropriateness (process) data- Assess for presence of a urinary catheter- Record the reason for the catheter - Daily, Mon-Friday, September 3rd, through Septmber 21st.
• Sites are expected to complete the Team Check Up Tool (October)• Sites will initiate team meetings• Workgroup members will continue to attend monthly Coaching Calls
and monthly national Content Calls
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Looking Ahead: Process Data Collection
Manual Data Collection Tool - utilize when making rounds and enter daily (ideally)
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Action Items: Activities for CompletionCAUTI Workgroup Monthly Status Report
Goal: Quickly communicate progress Identify Barriers for Subject Matter Experts to Address Identify Successes to Share
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Action Items: National Content Calls and Collaborative Coaching Calls
Call Number and Subject Date and Time Dial inInformation
Description/Links
National Content Calls – September
9/11, 12 PM ET Dial-in: 1-877-410-5657 Pass Code:28128
National Content Call: Focusing on Appropriate Catheter Insertion
Coaching Call – September 9/27
12 PM ET Dial-in: 1-866-469-3239 Pass Code: 669 559 415
Click Link to Register
National Content Calls – October
10/9, 12 PM ET Dial-in: 1-877-410-5657 Pass Code: 28128
National CUSP Call: Learning from Defects
Coaching Call – October
10/24, 2:30 PM ET
Dial-in: 1-866-469-3239 Pass Code: 660 574 949
Click Link to Register
National Content Calls – November
11/13, 12 PM ET Dial-in Number: 1-877-410-5657 Pass Code: 28128
National Content Call: Preparing for the Future – Setting up for Sustainability
Coaching Call – November 11/28 2:30 PM ET
Dial-in: 1-866-469-3239 Pass Code: 664 363 384
Click Link to Register
National Content Calls – December
12/11, 12 PM ET Dial-in: 1-877-410-5657 Pass Code: 28128
National CUSP Call: Engaging Senior Leadership
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Next Coaching Call
NEW TIME AND DAY!
September 27, 2012
12:00 PM Eastern
Planned Topics• Review best practices and implementation advice
o Considerations for selecting an initiative
• Additional suggestions from Workgroup members
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SHM Project Manager Contact Information
Jenna Goldstein, MASr. Project Manager, SHM
(267) [email protected]
JoAnne Resnic, MBA, BSN, RNDirector, Special Projects, SHM
(267) [email protected]
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