insert with competence! webinar... · 2/16/2012 · 2/15/2012 7 13 multicare – tacoma general...
TRANSCRIPT
2/15/2012
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Insert with Competence!Make perfect catheter insertion the easy thing to do
A CAUTI Action Network Prevention Series Webinar
February 16, 2012
Jennifer Palagi, MPH, BSN, RN, CIC Quality Improvement Consultant
Tina Schwien, MN, MPHQuality Improvement Consultant
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CAUTI Prevention Pillars
Avoidance
Insertion
Maintenance
Removal
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Today’s Agenda
Patient story
Best practice
Hospital Story
Discussion
Next in Series
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Patient Story
Defect Analysis: What could have prevented this CAUTI?
69 Female w/ metastatic breast cancer & recurrent pleural
effusions
1/10 D/C from hospital after thoracentesis and chest tube placement
1/11 Chemo treatment
1/16 Admitted w/ SOB, arrhythmias
Patient suggests “Foley catheter might be a better option”
RN gets order and inserts Foley
1/21 Worsening hypoxia, increased tachycardia, fever 100.5
Urine culture grows ecoli & enterococus faecalis , both > 100,000
CFU/ML
Hospital acquired CAUTI
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Guiding Principle
Insert urinary catheter using aseptic technique
• If you did a catheter insertion shadow audit today, what would you find?
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Best Practice in Insertion Technique
1. Utilize appropriate hand hygiene practice
2. Insert using aseptic technique & sterile equipment
– Gloves, a drape, and sponges
– Sterile/antiseptic solution for cleaning urethral meatus
– Single-use packet of sterile lubricant jelly for insertion
3. Use as small a catheter as possible
4. Catheter secured
5. Sterile closed drainage system
IHI Improvement Map. Getting Started Kit: Prevent Catheter-Associated Urinary Tract
Infections How-to Guide; HICPAC Guideline for Prevention of CAUTIs 2009
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Education, Training, & Assessment
• Train and verify competency of all clinical staff who may insert urinary catheters
• Do not assume staff are competent
• Standardized education/training materials
• Periodic re-training or assessment
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Approach at St. Joseph Regional
Medical Center (SJRMC)
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St. Joseph Regional Medical Center
SJRMC
Barb Boland RN, BSN, CIC
Infection Prevention Practitioner
Employee Health Nurse
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SJRMC Story Highlights
• Catheter bundle implemented > 5 yrs ago; CAUTIs have decreased >83%
• Online nursing education and testing
• Monthly reports to units
• Case review process, as events are rare
• OR/ER place most, perform well
• Culture of safety among frontline staff
• Ascension Health activities
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MultiCare – Tacoma General Hospital
Luda Lobodzinskiy, RN, BSN
Clinical Educator, Adult
Med/Surg,
253-403-1616
Preventing CatheterPreventing CatheterPreventing CatheterPreventing Catheter----Associated Associated Associated Associated
Urinary Tract InfectionsUrinary Tract InfectionsUrinary Tract InfectionsUrinary Tract Infections
By inserting with competence
Luda Lobodzinskiy, RN, BSN, Clinical EducatorAdult Med/Surg, Tacoma General Hospital
Phone: 253-403-1616Email: [email protected]
Contributor: Jeanette Harris, Infection Control Practitioner
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UTI Reduction:Yes, ZERO is Possible
MultiCare Health System
4 Hospitals – Pierce County
– Tacoma General 334 beds
– Mary Bridge Children's Hospital 72 beds
– Allenmore Hospital 75 beds
– Good Samaritan 278 beds
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Change using PDSA: Six-Sigma
• Deming cycle, or PDSA cycle:
– PLAN: Plan ahead for change. Analyze and predict the results
– DO: Execute the plan, taking small steps in controlled circumstances
– STUDY: Check, study the results
– ACT: Take action to standardize or improve the process.
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Ask for just 10% reduction to begin
P: 5R was the target!
D: Intervention: 5R Starting 9/1/07
• IC Practitioner met with Clinical Director of 5R then staff
• Strategy developed:
– ID all active infections at admit (ASAP <48 hrs)
– Collect urines for culture if suspected UTI ASAP – Use the UTI
Algorithm. Order from physician ASAP after collection (48hr
“golden period”)
– DO NOT culture everyone, only those who meet S&S.
• Heightened awareness by all staff
– Cultures started earlier
– Antibiotics started earlier
– Patients discharged earlier
• Increased vigilance for HAI
– Unit level goals
– Post infection rate charts on the unit
– Monitor performance/provide feedback
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S: Initial Success!
1st intervention
WOW!!!!
A: Report results
� Staff meetings
� Post chart in unit!
� Explain changes
� Whoo Hooo! Success! Party!
� Ask staff…..what’s next? Next steps?
� Keep going…..get to ZERO!
PDSA! All over again
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Creating the “UTI Bundle”
• Identify infections on admit
• Avoid unnecessary urinary catheters
– NO “convenience” Foleys
• PERFECT Foley insertion technique (much unit-based education provided!)
• PERFECT Foley Care
• GET THEM OUT ASAP!
UTI Bundle Education
• In-services: power point education WITH a post test (Copy included)
• Bard video- Preventing UTI: Care and Catheterization Technique
• Skills day (competency verification) with RNs demonstrating insertion techniques
• RCAs
• Case reviews at staff meetings
• Now a required competency for all new staff
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From the ED PP: Prior to Insertion: Is this catheter truly necessary?
• Studies:
– 21% of catheters not indicated at insertion
– 41-58% in place found to be unnecessary
• Catheters
– Are uncomfortable for patients
– Decrease mobility, which may impair recovery and contribute to other complications (e.g., pressure ulcers, deep vein thrombosis)
From the ED PP: Indications for Indwelling Urinary Catheters
ONLY to be placed for medical reasons– Hemodynamic: Critically ill or post-op
patients who need urine output measured accurately
– Obstruction: Anatomic or physiologic outlet obstruction
– Retention: Surgical, postpartum– Neurological: Debilitated, paralyzed, or
comatose patients
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From the ED PP:Catheters and UTIs
• 3 “Ports of Entry”
– Catheter / Meatal
Junction
– Catheter / Tube
Junction
– Outlet Tube
From the ED PP: Appropriate technique for catheter insertion
• Utilize appropriate hand hygiene practice.
• Insert catheters using aseptic technique and sterile
equipment, specifically using:
– gloves, a drape, and sponges;
– sterile or antiseptic solution for cleaning the
urethral meatus; and
– single-use packet of sterile lubricant jelly for
insertion.
• Use as small a catheter as possible that is
consistent with proper drainage, to minimize urethral
trauma.
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From the ED PP:
Tips to remember
• Prepare all items “in the boxed kit” prior to touching patient
• Use the tongs provided and not your handswhen both preparing cotton balls and cleaning patient on initial insertion
• Obtain assistance for heavier patients - to ensure adequate room between legs and aseptic technique for cleaning and insertion of the catheter
From the ED PP:
More tips….
• Do not inflate balloon with more than 10cc on initial
insertion (can cause further urethral trauma and
blockage of periurethral glands)
• Do not inflate balloon to “test” prior to insertion
– All catheters have passed QC prior to packaging
– This practice actually creates micro tears in balloon
fiber that can cause urethral irritation and provide
places for bacteria to grow
• Silver impregnated foley catheters have been proven
to reduce CAUTIs by reducing Biofilm formation ,
BUT……
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From the ED ppt:
NOTHING takes the
place of good Nursing
and Foley care!
Skills Day
– (2) 8 hr days – different start times to accommodate all 3 shifts
– Mandatory
– Nearly 100% participation
– Used female/male pelvic mannequins for return demo in simulated environment.
– Identified and addressed misconceptions and wrong practices:
• Breaks in aseptic technique
• “we’ve always done it this way”
• Convenience Foleys
• “testing” the balloon before the insertion
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ADVANCE Peri-Care Prior To Catheterization
� Because Proper Hygiene Can Vary From Patient To Patient, The Clinician May Need To Clean The Patients Perineal Area.
� New Tray Will Feature A Packet Of 3 Aplicare Castile Soap Wipes To Allow For Proper Cleansing Prior To Catheterization.
� Castile Soap Is An Effective Cleaning Agent Long Known For Its Purity And Mildness.
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ADVANCE Protection for the patient and health care worker
Antiseptic Gel Hand Rinse Included In The BARD ADVANCE Foley Tray
� Used After Peri-urethral Cleansing
� Aplicare Packet: 62% Alcohol Gel Hand Rinse.
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ADVANCE Convenience For The Health Care Worker
� 3 Pre-saturated Aplicare Povidone-iodine Swab Sticks In A Single Package
� To Be Used For One Pass Over The Insertion Site Each & Then Discarded
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5R From the start
# Days since last UTI= 403(as of 1/30/12)
Intervention #2Bundle work + reeducation
Intervention #1education, start bundle
Intervention #3Re-education, urine tubes, refining bundle
Continuous Education/updates
5R Success and Sustainability
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Statistically Significant Results*:
• Pre-intervention:
– UTI rate = 1.91/1000 patient days (PD)
• Post-intervention 2008:
– UTI rate = .70/1000 PD
• Current 2011:
– UTI rate 0.0215/1000 PD
• The intervention provided a 98.87% decrease*• (p< 0.000001)
1.91
0.7
0.24 0.23 0.22
0.0420.041 0.132
0.046 0.09
1.93
2.2
1.69
0.7
0.4
0.3
0.0970.2
-0.5
-0.25
0
0.25
0.5
0.75
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1.25
1.5
1.75
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2.25
2.5
2.75
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3.25
3.5
3.75
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4.25
4.5
4.75
2007 (pre-int)
2008 2009 2010Q1 2010Q2 2010 Q3 2010 Q4 2011 Q1 2011 Q2 2011 Q3
Rate
/1000P
D
MHS UTI Rate Reduction 2007-Present
Good Sam
Tacoma 3 hosps
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Discussion
• What excited you about what you heard?
• What can you do “by next Tuesday”
• What might get in your way?
• Any offers/requests?
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Next Up in the Series
Avoidance
Jan 19, 2012
Insertion
Feb 16, 2012
Maintenance
Mar 15, 2012
Removal
Apr 26, 2012
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Thank You
• Idaho:
Jennifer Palagi, QI Consultant, Patient Safety
(208) 383-5944, [email protected]
• Washington:
Tina Schwien, QI Consultant, Patient Safety
(206) 288-2466, [email protected]
For more information: www.QualisHealthMedicare.org
This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.The contents presented do not necessarily reflect CMS policy. ID/WA-C7-QH-715-02-12