™

Infections Due to Devices Improvement Collaborative:UHC CAUTI Workgroup Coaching Call # 3August 29, 2012

Dial in: 1-866-469-3239

Passcode: 664 803 879

2™

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

™

SME’s and Guests Speakers

4

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

™

Review of Activities for CompletionPhase 2

6™

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)

7

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

8™

CAUTI Outcomes Data Collection

™

Site Updates

10™

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

™

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

™

AIM Statement Developed

Decrease CAUTI rates by no less than 25% within 18 months

™

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

™

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%

™

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

™

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

™

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

™

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

™

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.

™

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.

™

Nurse Driven Foley Catheter Protocol

About Beaumont Health System

Very large, busy health system in Metropolitan Detroit Michigan

™

Protocol Development

3 Hospitals

– Clinical Informatics Nurses

– Quality and Safety Nurses

– Nursing Educators

Protocol Workflow and Development

Education and Approvals

Implementation and Ongoing Monitoring

™

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

™

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

™

Implementation

Mandatory Nursing Education

Approval at each hospitals Medical Executive Committee

Ongoing support by Clinical Informatics

Bits and Bytes Nursing Education

™

Ongoing Monitoring

Nursing Dashboard

Core Measure Compliance

MHA Keystone unit monitoring

UHC HEN

CMS CAUTI reporting for ICU and Rehab

™

Nursing Dashboard

™Phase 1Phase 2

Questions?

™

Action Items

39™

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

40™

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

41

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

42

Looking Ahead: Process Data Collection

Manual Data Collection Tool - utilize when making rounds and enter daily (ideally)

43™

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

44™

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

45™

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

™

SHM Project Manager Contact Information

Jenna Goldstein, MASr. Project Manager, SHM

(267) 702-2679jgoldstein@Hospitalmedicine.org

JoAnne Resnic, MBA, BSN, RNDirector, Special Projects, SHM

(267) 702-2673jresnic@HospitalMedicine.org

4646