Wipe Out CAUTI!

December 17, 2014    |   By: Calevir

A success story from Golden Valley Memorial Hospital, Clinton, Missouri

Indwelling urinary catheters lead to both infectious and non-infectious complications. Despite these potential harms, various studies have reported that initial catheterization was inappropriate 21% to 50% of the time and that continued catheter use was inappropriate almost half of the days that patients are catheterized.

Four years ago Golden Valley Memorial Hospital (GVMH) took on elimination of catheter-associated urinary tract infections (CAUTI) as their rate was as high as 4.9/1000 catheter days with a catheter prevalence rate that averaged between 25-30% organization-wide and up to 39% in the ICU. While their initial CAUTI improvement team made some progress, they were unable to achieve their goal of zero infections. Determined to be successful as a member of the HRET-Hospital Engagement Network (HEN), GVMH realigned their team and joined the CUSP initiative to eliminate CAUTI’s lead by the Center for Patient Safety.

Front-line staff joined the improvement team; strict protocol aligned with APIC’s Guide to Preventing Catheter-Associated Urinary Tract Infections and the CDC’s Indications for Urinary Catheters was implemented; insertion competencies were verified for all staff who insert catheters; in-depth CAUTI Prevention education and training was provided to all patient care staff; a CAUTI Prevention Bundle was developed and implemented; departmental and organization results became transparent; along with a little fun.

Through participating in the HRET-HEN CUSP initiative to eliminate CAUTI project, it was learned that there is a prevailing culture to insert catheters in Emergency Departments across the nation. Data collected by the GVMH team showed that most Foley catheters present in its medical and ICU patients had been placed in the Emergency Department prior to admission. While auditing medical records of patients being admitted from the ED, it was also learned that often the receiving physician did not know the catheter had been placed in the ED and inpatient unit nurses did not communicate the presence of the catheter to them either. This lack of communication contributed to increased length of catheterization which, in turn, increased the risk of patients developing a CAUTI. The team went to work immediately to engage the ED and added emergency room staff to the improvement team. The ED’s commitment to changing their culture related to excessive catheter usage became a catalyst to the success that GVMH has achieved.

When catheter prevalence in the ICU remained high despite the team’s efforts, it was learned that the ICU had a standing admission order for a Foley Catheter PRN and chart audits revealed that many catheters were being inserted by nursing without an appropriate indication. This led to the Medical Staff eliminating this PRN order which resulted in a breakthrough reduction in inappropriate catheter usage in the ICU. To ensure that new processes were hardwired, the infection prevention nurse began weekly audits of all patients with a Foley catheter and provided consistent feedback reports to department managers for follow-up with nurses not following the protocol. To sustain the gain, quarterly validation audits continue in all inpatient units at GVMH.

Any initiative is more successful with senior leader support and champions. At GVMH, the hospital’s leaders stepped up to ensure proper use of Foleys. In addition, a certified nurse assistant from the medical floor became a natural champion as she cheerfully and convincingly asked nurses and physicians why Foleys were being used for specific patients and if they could be removed. She was effective! The medical floor decreased catheter utilization from approximately 25% to 8% and has sustained this for over a year.

GVMH has gone 402 days without a CAUTI.   They recommend the following interventions leading to success:

  • Engage front-line staff as members of the improvement team as all caregivers must “own” the process. Don’t forget to include staff from the ED, OR, and ancillary departments such as PT/OT and imaging in any CAUTI improvement efforts.
  • Make sure all caregivers understand and practice the CDC’s Indications for Urinary Catheters and APIC’s Guide to Preventing Catheter-Associated Urinary Tract Infections.
  • All Foley catheter orders require the reason for use, which must meet the medical staff approved CDC criteria.
  • Foley insertion requires the presence of two nurses to ensure aseptic insertion.
  • Assess and document (at least daily) the continued need for a catheter and the indication.
  • Promptly remove catheters that do not have an appropriate indication. A nurse-driven Foley removal protocol is ideal.
  • Remove any PRN Foley orders from order sets/admitting orders.
  • Measure, measure, measure and display results publicly by nursing unit.
  • Be transparent as it increases accountability.
  • Root cause analysis required for any CAUTI, using standardized form
  • Make it fun and recognize success (see sidebar story).

GVMH is committed to sustaining their goal of zero CAUTIs. For more information, contact GVMH Infection Preventionist, Mary Oyler RN, BSN, [email protected]

Fred and Fran Foley live at Golden Valley Memorial Hospital, moving from unit to unit as determined by the best CAUTI rate each month. They seem to hang out a lot on the medical floor who has had no CAUTIs for 688 days. The Surgical floor has gone 564 days! Senior leaders formally recognize staff and physicians for their excellent care resulting in no CAUTIs for the last 402 days across the entire hospital! Kudos to Golden Valley Memorial Hospital!



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