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)