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Small Tests of Change

Small Tests of Change. Jill Hanson Manager, Quality Improvement WHA Improvement Advisor. Courtesy Reminders: Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) Please do not take calls and place the phone on HOLD during the presentation. Today’s Call.

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Small Tests of Change

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  1. Small Tests of Change Jill Hanson Manager, Quality Improvement WHA Improvement Advisor • Courtesy Reminders: • Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) • Please do not take calls and place the phone on HOLD during the presentation.

  2. Today’s Call • Past 30 days • Catheter lifecycle • PDSA Cycle • Designing tests • Adapt, adopt, abandon • Next 30 days • Continue with small tests of change • Determine how test cycle results will be shared

  3. Past 30 DaysMid-Month Survey Results Have you submitted your monthly CAUTI outcome measure data? 50% - Yes Have you submitted your monthly CAUTI process measure data? 67% - Yes Staff Safety Assessment – In Process – talk about at next month’s webinar

  4. CAUTI Data Submission Outcome measures • Baseline data submission • Aggregate 2011 num/den; 2012 monthly Jan – May • Monthly beginning June 2012 • Option to confer NHSN rights Process measures • Monthly beginning June 2012

  5. Entering Your CAUTI DataWHA Quality Center Live Demo

  6. Appropriate Catheter Insertions Gould C, et.al. Infection Control & Hospital Epidemiology, 2010;31:319-326.

  7. Not Appropriate Indications for Catheter But what about the other well-intended reasons for using catheters? Gould C, et.al. Infection Control & Hospital Epidemiology, 2010;31:319-326. Substitute for incontinence care tasks Means to obtain urine for diagnostic tests when patient can voluntarily void Prolonged postoperative duration without appropriate indicators Routinely for patients receiving epidural anesthesia/analgesia

  8. The Other Reasons • Reduce skin wetness (pressure ulcer risk)? • Decrease fall risk if unsteady gait? • Difficulty turning/lifting patients to provide incontinence care • Weight (obesity, severe edema), combativeness, extreme frailty. • Patient request: fatigue, to avoid pain with walking.

  9. The Other Risks • UTI bacteremia, sepsis, joint infection • “One-point restraint” = decreased mobility: • Blood clots (DVT/PE), pressure ulcers, delirium, pneumonia, deconditioning, fall risk by tripping over catheter. • Patient discomfort, need to retrain bladder Resulting in….. • Longer length-of-stay (more exposure to nosocomial hazards) • Higher risk of death, disability.

  10. Avoid Unnecessary Placement So why is this so hard? To place or not to place? ~ 21-50% catheterizations were unjustified* *Hooton T, et.al. IDSA Urinary Catheter Guidelines. CID 2010;50(1 March):625-663.

  11. Avoiding Unnecessary Placement Challenges • Multiple environments: with different systems of care and different stakeholders/priorities: • Emergency Department, • Pre/Post Operating Room, • Inpatient Unit: acute care, ICU, rehabilitation, long-term care. • No single source for distribution (unlike Pharmacy): more difficult to regulate, monitor and provide feedback regarding use of urinary catheters. • Lack of consensus on appropriate indications for catheters

  12. Catheter Placement Recommendations Insert Catheters only for Appropriate Indications Ensure only properly trained persons insert catheters and insert using aseptic technique and sterile equipment Gould C, et al. Infection Control & Hospital Epidemiology, 2010;31:319-326. Hooton T, et al. IDSA Urinary Catheter Guidelines, CID 2010;50(1March):625-663.

  13. Avoid Unnecessary Placement

  14. Urinary Catheter-Related Infection Prevention Practices

  15. Changing Catheter Use, by Environment

  16. Strategies to Decrease Catheter Use Need to provide resources to address these temptations to use catheters: “People power”: lift teams, care assistants to help with frequent bedside tasks, adjust RN/patient ratios for these tasks. Readily-available supplies for catheter alternatives.

  17. Avoid Unnecessary Placement • Require physicians order for placement. • Require appropriate indications for catheter placement. • Bladder scanners to evaluate/confirm urinary retention. • Catheter orders with Decision Support: • Embed reminders for appropriate indications, • Embed reminders about alternatives to indwelling catheter use • Start clock (24-48 hrs) for catheter removal reminders or stop orders.

  18. Catheter Maintenance Care • Properly secured catheters • Maintain closed drainage system • Obtain urine samples aseptically • Maintain unobstructed urine flow • No kinking of catheter tube • Keep bag below bladder at all times • Empty into separate clean container for each patient, with no contact with non-sterile container.

  19. Ensuring Catheter Maintenance Awareness Daily care checklists More obvious catheter documentation Routine reminders of catheter presence to physicians/nurses

  20. Prompt Catheter Removal Traditional Steps to Catheter Removal: Physician recognizes catheter is present Physician recognizes catheter is no longer needed Physician writes order to remove catheter Nurse sees order and plans to remove the catheter. Urinary catheter is removed. Hooton T, et al. IDSA Urinary Catheter Guidelines, CID 2010:50(1 March:625-663

  21. Catheter Removal Processes Reminder: reminds that a urinary catheter is still in use; may also remind of appropriate indications to continue catheterization. Stop Order: Prompts removal of urinary catheter based on specified time after placement (e.g., 24 hours), based upon clinical criteria. Can be directed at physicians and nurses (reminder vs. empowered) Can be written, verbal or electronic (computer order entry)

  22. Catheter Reminders & Stop Orders Pearls Tailor reminder type to care setting (stickers, electronic, etc.) Embed appropriate indications to guide catheter use Reminder to include catheter alternatives Automated, timed reminder/stop orders Empower nurses to remove without obtaining additional order from physician Pitfalls Reminders often ignored Challenging to sustain impact of reminders/stop orders

  23. Tools to Prevent Catheter Replacement • Urinary retention evaluation protocols; use of bladder scan, straight catheters, without requiring contact with physicians. • Same tools as preventing initial placement: • Catheter-order restrictions • Indication guidance, but with sticking power to survive change in caregivers, nightshifts.

  24. What Will Make Your CAUTI Team Successful? Nurse “buy-in” is extremely important. Reminders and Stop Orders can disrupt the catheter “lifecycle” at all stages: placement, awareness of continued use, prompting removal, and preventing replacement. Champions are crucial for implementation; all these improvements require behavior change. Sustaining change requires monitoring and feedback of catheter use and CAUTI rates. Avoid screening for asymptomatic UTIs, to prevent unintended patient harm.

  25. Poll Question #1 On average, how long does it take your hospital to adopt a new practice, from launch to full implementation? 1 to 2 years or more 6 months to 1 year 3 to 6 months Less than 3 months A couple of weeks – we just do it.

  26. Poll #1 Answer On average, how long does it take your hospital to adopt a new practice, from launch to full implementation? 1-2 years or more 6 months to 1 year 3 to 6 months Less than 3 months A couple of weeks – we just do it.

  27. Why Go So Slow? Engagement is Non-linear

  28. How Do Small Tests Accelerate Change? Decreases the risk of resistance and “backsliding” Increases belief that the change is for the better Determines which, or which combination of changes, drives improvement. Proves that the change will work! Avoids “Do-Overs”!

  29. Scaling Tests

  30. Designing Tests of Change Find a willing “tester” Instruct them in the “what” Determine the when, how long, etc. Conduct the test Gather feedback from the test Learning: Will you adapt it, adopt it, or abandon it?

  31. Documenting Cycles of Testing Keeps the team “on task” Clarifies the reason for testing Clear accountability Assists with the learning from small tests because you can see what happened.

  32. PDSA – Test Documentation Project: Reducing Catheter-Associated Urinary Tract Infections Objective for this PDSA Cycle: Test whether a nurse using criteria for continued need of urinary catheter can determine readiness to remove in concurrence with the physician as a basis for possible nurse-driven protocol.

  33. PDSA - PLAN Develop a list of criteria for continued need of urinary catheters and test with assessment of several patients. Questions Will nurses using the criteria concur with physicians as to whether catheter is ready for removal? Will nurses feel comfortable making recommendations for catheter removal? Will physicians be willing to approve nurse-driven protocol for catheter removal?

  34. Predictions and Plan for Testing Predictions: • Nurses and physicians will concur for patients whom criteria clearly apply. If there is concurrence during testing, nurses and physicians will be more comfortable moving to a protocol. Plan for change or test – who, what, where: • What: Assess two patients with urinary catheters using the criteria and compare nurse recommendation to physician decision about whether to remove catheter. • Who: Bob (nurse), Mary (physician) • Where: 4 North Medical Unit • When: Tomorrow day shift

  35. Measuring the Test Plan for collection of data – who, what, when, where: • Who: Bob • What: Note nurse recommendation using criteria and physician decision. • When: Tomorrow day shift, while assessing patients and then during discussion with physician • Where: 4 North Medical Unit

  36. PDSA - DO Carry out the change or test. Collect data and begin analysis. Bob (nurse) identified two patients with urinary catheters with criteria and determined that patient A met the criteria for continued catheter necessity and patient B did not. He noted that patient B could have the catheter removed. Mary (MD) reviewed Bob’s assessments with him and concurred; she ordered that patient B’s catheter be removed.

  37. PDSA - STUDY Complete analysis of the data • How did or didn’t the results of this cycle agree with the predictions that we made earlier? • Summarize the new knowledge we gained by this cycle • Nurse and physician did concur on whether catheters in these patients should be continued. More testing with other nurses and physicians is necessary to ensure criteria are clear and understood.

  38. PDSA - ACT List actions we will take as a result of this cycle: Train other nurses in use of criteria and test further Monitoring concurrences between nurses’ recommendations and physician’s orders

  39. Plan For The Next Cycle Adapt change, another test, implementation cycle? Test the criteria with three more nurses on day shift Test criteria with three more nurses Goal is to have 20% of those doing the work have a chance to test it, which is…. YOUR TIPPING POINT

  40. The Next 30 Days Tools Available On WHA Quality Center: Test of Change Planning Tool Test of Change Log

  41. Reminder Please complete the three question survey before you close out of today’s webinar. Next Webinar: September 6 at 12 pm Guest Speaker – Stacey Firkus, Riverview Hospital Association Participating CAUTI Teams Report Out Staff Safety Assessments & Small Tests of Change

  42. Thank You! Questions? Jill Hanson Manager, Quality Improvement WHA Improvement Advisor (jhanson@wha.org)

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