1 / 64

On the CUSP: Stop CAUTI Cohort 8

On the CUSP: Stop CAUTI Cohort 8. Mapping the Journey: Hospital Unit Team Informational Webinar. January 30, 2014. Today’s Presenters. Tina Adams, RN Clinical Content Lead HRET Barbara Meyer Lucas, MD, MHSA Project Consultant Michigan Health & Hospital Association

anneke
Télécharger la présentation

On the CUSP: Stop CAUTI Cohort 8

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. On the CUSP: Stop CAUTI Cohort 8 Mapping the Journey: Hospital Unit Team Informational Webinar January 30, 2014

  2. Today’s Presenters Tina Adams, RN Clinical Content Lead HRET Barbara Meyer Lucas, MD, MHSA Project Consultant Michigan Health & Hospital Association Keystone Center for Patient Safety and Quality Rose Rosales, BSN, MPA, RN, CCRN, CPHQ East Orange General Hospital

  3. Agenda

  4. Objectives for today • Understand the inpatient unit catheter associated urinary tract infection (CAUTI) prevention program including the comprehensive unit safety program (CUSP) • Understand the collection and use of outcome and process measures data • Understand the role of the unit’s Team Leader

  5. National Project Goals The Project Goals for CAUTI are to: • reduce mean CAUTI rates in participating clinical units by 25 percent; and • improve safety culture as evidenced by improved teamwork and communication by employing CUSP methodology.

  6. Resources, CAUTI Website • CAUTI prevention:http://www.onthecuspstophai.org/on-the-cuspstop-cauti/ • CUSP patient safety culture modules: http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/ • Emergency Department Improvement Intervention:http://www.onthecuspstophai.org/on-the-cuspstop-cauti/toolkits-and-resources/emergency-department-improvement-intervention/

  7. National Project Team HRET – Health Research & Educational Trust MHA – Michigan Health and Hospitals Association, Keystone Patient Safety Center U of M – University of Michigan St John – St. John Hospital and Medical Center Extended Faculty Network: APIC – Association for Professionals in Infection Control and Epidemiology, Inc. SHEA – Society for Healthcare Epidemiology of America SHM – Society of Hospital Medicine  ENA – Emergency Nurses Association All biographies located here: http://www.onthecuspstophai.org/about-us/key-personnel/

  8. National Project Partnerships & Dissemination Model CAUTI National Project Team HRET MHA UM/St. Johns JHU State Hospital Associations, Partners & Coalitions Extended Faculty Network State Leads, Quality Improvement Organization, Hospital Engagement Network,- Coaching/CUSP/ Recruitment/Project Liaison National & Regional CAUTI Faculty APIC, SHEA, SHM, ENA Coaching/Recruitment/ Endorsement Hospitals/Units

  9. Learning the Project Language • Cohort • “State” or “Regional” Lead • Unit CUSP Team and Team Leader • Unit Survey Coordinator • Outcome Measures • Process Measures

  10. First 7 Cohorts, 42 States, ~962 Hospitals

  11. Registered Unit Type

  12. Key Components of Intervention What will you be doing in this project? Technical (Clinical) • Catheter Insertion • Appropriate vs. Inappropriate Indications • Process to Evaluate Urinary Catheter Need Socio-Adaptive (Cultural) • Teamwork and communication improvements surrounding the unit’s patient safety culture

  13. Key Components of Intervention 2) Socio-Adaptive (Cultural) continued • Comprehensive Unit-based Safety Program (CUSP) • Unit CUSP Team formed • Requires a Team Leader • Meets regularly (weekly or at least monthly) • Composed of engaged frontlinestaff who take ownership of patient safety (e.g. bedside nursing staff) • Includes staff members who have different levels of experience • CUSP Team includes nurse manager, physician, senior executive • CUSP Team may include infection control/prevention, central supply staff member, PT/OT staff, discharge planner • Tailored to include members based on clinical intervention

  14. What will be provided? Educational events: Teleconferences, webinars, in-person meetings (with video conferencing) • For example: 6 Onboarding Calls, Monthly Content Calls, and 3 Learning Sessions Materials: Implementation guide with tools (guidelines, posters, forms, educational materials) Coaching: National and regional supported calls Data: On-line secure collection and reporting Site visits: NPT determined

  15. Cohort 8 Timeline

  16. Next Steps – Cohort 8 • Hospital Unit Informational Webinars – January 27 and 30, 2014; same content offered twice, recording available online • Recruitment of hospital units: January – March, 2014 • Team registrationdeadline: April 1, 2014 • Learning Session (LS) #1: March 17 – 31 at the state/sponsor level • LS #1 NPT Office Hours – April 2, 2014 from 3-4pm ET • Onboarding Webinar Series (6) – Begin early April through min June

  17. On the CUSP: Stop CAUTI CAUTI Project Data: An Overview for Unit Teams Barbara Meyer Lucas, MD, MHSA, CPPS Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety and Quality

  18. DATA COLLECTION: Why is it crucial to the project? Project’s data elements will help you: • Stay on course to achieve BOTH project goals • reduce your unit CAUTI rate by 25% • improve your unit’s culture of safety • Track your use of recommended technical work and CUSP interventions • Identify barriers to your progress

  19. DATA COLLECTION: Where is it housed? MHA CARE COUNTS DATA BASE: • Each registered unit will have protected access • MHA will provide webinar training and technical support for: • entering your data • running your own reports

  20. CAUTI PROJECT DATA ELEMENTS: • Background/Culture Data: • Readiness Assessment • HSOPS: Baseline and Follow-up • Ongoing Data Submission: • Outcome data • Process Data (optional) • Team Checkup Tool

  21. BACKGROUND/CULTURE DATA: Readiness Assessment • PURPOSE: Tells us about your unit: • Size, type, patient demographics, etc. • LOGISTICS: • Completed ONCE at start of project • Done via Survey Monkey by ONE person per unit

  22. BACKGROUND/CULTURE DATA: Hospital Survey on Patient Safety (HSOPS) • PURPOSE: Standardized measure of safety culture for individual patient care unit (NOT hospital-wide) • LOGISTICS: • Done twice: at the start of the project, and after the project intervention • Given to all unit staff

  23. ONGOING DATA COLLECTION:Outcome and Process Data • OUTCOME DATA: What impact have we made on our 2 project goals: • reducing the CAUTI rate by 25% and • improving our unit’s culture of safety • PROCESS DATA (optional): Are we changing our daily work activities to reduce the risk of infection and make care safer, via BOTH: • technical work re: catheters • CUSP work (unit culture change)

  24. CAUTI OUTCOME DATA: What Do We Collect? For the entire month (not just M-F) each enrolled unit must collect and submit: • Total # of patient days for that unit • Total # of indwelling urinary catheter days for that unit • Total # of CAUTI’s for that month Result: CAUTI Rates and Catheter Prevalence

  25. CAUTI OUTCOME DATA: What Infrastructure Do Teams Need? • Someone to collect the data • Should be knowledgeable about NHSN criteria • Should resolve any “questionable CAUTI” issues before entering data • Good resource: ICP • Someone to enter the data • Either into Care Counts or NHSN (if state level data will be imported from NHSN into Care Counts)

  26. CAUTI OUTCOME DATA: When is it due? Starts in MAY, with Three Phases • BASELINE (Monthly submission) May, June, July 2014 • IMPLEMENTATION (Monthly submission) August and September 2014 • SUSTAINABILITY: (1 month per quarter) Dec 2014; March and June 2015

  27. PROCESS DATA (optional submission): What Do We Collect? DAILY, following the submission schedule: • # of patients on the unit that day • # of catheterized patients on the unit that day • Main reason why patient has a catheter TODAY • Where the catheter was inserted (on the floor, off the floor, unknown) Result: Catheter Appropriateness Information

  28. PROCESS DATA: When is it due? Starts in JULY, with Three Phases Submit to Care Counts database on specific scheduled dates: • July 2014:M-F for 3 weeks • August and September 2014: on 16 scheduled days • After that: M-F for one week per quarter (December 2014; March and June 2015) Note: Process data submission is optional

  29. CAUTI PROCESS DATA: What Infrastructure Do Teams Need? • Need a rounding process (not record review) • IDEAL: piggyback on existing unit rounds • We provide a model audit tool • Need a designated point person to: • Record data • Contact physicians for catheter removal order • Submit data to Care Counts

  30. CAUTI PROCESS DATA: What Infrastructure Do Teams Need? • EXPECTATION: • Rounding for catheter appropriateness goes on daily, regardless of whether you choose to submit that data. Remember: This rounding process IS the intervention!!!

  31. ONGOING DATA COLLECTION:Quarterly Team Checkup Tool (TCT) What it assesses: • Implementation of CUSP and CAUTI reduction activities • Team functioning • Barriers to project progress Submit to Care Counts database at MHA

  32. TEAM CHECKUP TOOL: When Is it Due? Starts in AUGUST 2014 • Team submits their consensus response quarterly • Reflects the team’s work for the previous 3 months • Schedule: due quarterly AUGUST 2014 (reflects work of May-July), then: Nov 2014; Feb and May 2015

  33. TAKE HOME MESSAGE: • Data Collection Process: • Is front-end loaded, but manageable • You will have support from the national team • Remember: Data drives change! Daily rounding for catheter presence and appropriateness IS the intervention!

  34. Unit CUSP Team’s Goal • Develop and or expand capacity at the hospital unit level to support improvement by: • CUSP content expertise • CAUTI prevention expertise Reduce CAUTI and Improve Safety

  35. Where do we start? • Select a CUSP-CAUTI Program Team Leader • Characteristics: • Seen as an leader by bedside staff • Go-to person to get questions answered • Able to influence others

  36. Team Leader Tasks • Review Implementation Manual • Attend all program educational opportunities • Develop a CUSP-CAUTI team (bedside caregivers) • Schedule regular CUSP-CAUTI Team meetings • Educate CUSP-CAUTI Team • Involve all Team members in Team tasks • Provide feedback to Team members • Communicate with Senior Executive • Assure data/survey results submitted

  37. Unit Team Tasks Attend and participate in CUSP Team meetings Provide bedside staff member’s perspective Implement CUSP-CAUTI program by sharing responsibility for the Team’s work • Participate in design of processes to prevent CAUTI and to employ CUSP interventions on your unit • Educate staff, physicians, patients and families • Champion effort, provide feedback to bedside staff • Data collection and submission • Celebrate successes along the way

  38. Unit Team Success Story: East Orange General Hospital Rosemarie D. Rosales BSN, MPA, RN, CCRN, CPHQ Administrative Director of Nursing Operations East Orange General Hospital East Orange, NJ

  39. East Orange General Hospital

  40. East Orange General Hospital • This hospital is a 212-bed community hospital located in Essex County in Central New Jersey. • Primary Service Areas are cities of East Orange and Orange. • The unit chosen for the project is a 29 bed medical-surgical, renal and oncology unit.

  41. Project Team Members President & CEO – Kevin J. Slavin, FACHE Hospital Executive Champion • Mary Anne Marra, RN, MSN, NEA-BC - VP of Patient Care Services and CNO Physician Champion • Dr. Elizabeth Mammen- Prasad - Physician Chair of IC Committee • Dr. Samya Shafi – ID Section Chair Project Team Leader • Rosemarie D. Rosales, BSN, MPA, RN, CCRN,CPHQ Adm. Director of Nursing Operations

  42. Project Team Members Infection Preventionist or Epidemiologist • Juliet Brown, CIC- Manager of Infection Control Process Data Collector • Elizabeth Entzminger, LPN -IC Surveillance Nurse Data Entry and Report User • Aldyth Stanford, RN – IC Coordinator • Charina Silvera, RN – Clinical Coordinator Other: ED Nurse Manager – Benson Kahiu, RN, BSN PI Coordinator - Sharon Lawson-Davis , BSN, RN

  43. Why we Joined the NationalOn the CUSP Collaborative CAUTI is one of the never events as identified by both CMS and TJC. Our institution is committed to succeed in our quest for our project initiative “LEANING to ZERO”.

  44. Our JOURNEY • Join the NJHA state calls • Chose unit – the most CAUTI in 2011 • Educate the Leaders of the designated unit – 2 West on the CAUTI initiatives • Presented the project to the Infection Control Committee • Collaboration of the Infection Prevention Team, ED Team and 2 West Leaders

  45. CAUTI – Initiatives • ED surveillance of patients with Foley coming from other facilities. • Foley change and doing C&S if criteria met for Foley maintenance by ED staff. • IC surveillance nurse along with clinical coordinator/designee doing daily Foley rounds • Foley Policy & Procedure revised to include change of Foley after two weeks and to do urine C&S as ordered by MD • Foley Bag with Orange Sticker to indicate Foley insertion date, reason for Foley, date of Foley change if applicable

  46. CAUTI Goals • Establish criteria for having a Foley • Decrease CAUTI by 50% on the designated unit from 2011 but aim for ZERO as CAUTI is one of the NEVER Events. • Obtain support of Medical Staff Leadership with approval of the Automatic • Discontinuation of Foley if it does not meet criteria

  47. Criteria Established For Foley Insertion and Maintenance • Strict Intake & Output • Stage 3 or 4 sacral pressure ulcers • Bladder outlet obstruction • After urological surgeries or other surgeries requiring Foley • End of Life Care • Foley maintained after 24-48 hours of surgery requiring MD notation or orders

  48. PLAN • Patients assessed for Foley on admission – Foley changed and urine C&S obtained • AUTOMATIC DISCONTINUATION OF FOLEY CATHETER UNLESS REORDERED WITH SPECIFICREASON • WRITTEN REMINDER ORDER PUT ON CHART • 24 – 48 HOURS AFTER ADMISSION • REMINDER SYSTEM FOR NURSES: Hand off communication or Incorporate into change of shift report i.e. continued need / discontinue use of Foley catheter

  49. PLAN • Educate all staff on the CAUTI initiatives and the CAUTI Bundle • Include Foley Care, CAUTI Initiatives and CAUTI bundle in Nursing Competencies • Placing an Orange Sticker on the Foley bag with the date of insertion as a reminder • Foley catheter change if Foley is maintained after two weeks

  50. Barriers to success for the initial rollout: • Nurses perception of the need for foley vs. using the criteria for foley insertion. • Patients were not regularly assessed for the need for the device. • Foleys were not consistently changed in the ER if they came in with foleys. • UA and Urine C & S were not routinely part of the admission labs for those with foleys. • Staff not familiar with the Indications for foley and the automatic discontinuation

More Related