February 5, 2012

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Bundle of ideas improves patient safety and reduces bladder infections

Plan, Do, Study, Act

FRIDAY, NOVEMBER 21, 2008

Department: The 3N and 2N Medical-Surgical units and the progressive care unit, or PCU, at Sunnyside Hospital (Northwest), along with Infection Control

Problem: Urinary tract infections, or UTIs, caused by catheters, which often lengthen hospital stays and complicate a patient’s recovery. The Centers for Medicare and Medicaid Services (CMS) has announced that starting in Nov. 2008, it will no longer reimburse for treatment of catheter-associated UTIs.

Value compass: Best quality, affordability

Metric: Number of bladder infections per days each patient is catheterized

First small tests: The teams created a bundle of initiatives and procedures: For each patient with a catheter in place, charge nurses used an evaluation checklist to determine whether the catheter was medically necessary and properly secured. All registered nurses and certified nursing assistants were re-educated on catheter use and how to minimize factors that cause bladder infections, such as improper location of the Foley bag, which collects the urine. Physicians were encouraged to refrain from administering a catheter when it wasn’t necessary and to take catheters out at the earliest opportunity.

Result: Decreased number of bladder infections—from nearly 20 infections per 1000 catheter days in March down to near zero as of September.

Next step: Extend the pilot initiatives hospital-wide and use KP HealthConnect to help collect data on when a catheter is administered, daily observations on the catheter’s correct placement and attachment, criteria for removal and infection rates. Work closely with physicians to create criteria for more consistent use of Foley catheters. The team also hopes to incorporate more use of bladder scanners as a tool to help determine when catheters are needed.

Labor co-leads: Cheryl Milton, RN, OFNHP; Olivia Devers, certified nursing assistant

Management co-leads: Mynell Harper, nursing manager; Cathy Raven, director of medical-surgical services

Project manager co-lead: Dana Barron, infection control and prevention manager

Physician co-leads: Tom Lawrence, MD; Rick Beam, MD

Biggest challenge: “Getting nursing to make it part of their routine,” Barron said, and “to make sure all elements of the ‘bundle’ are in place for every patient who has a Foley catheter. And document it so we can give nurses feedback on how they’re doing. Because it’s really time consuming and one more thing added to their plate, which is a very full plate.”

Stricker, RN, seconds that notion, adding: “My priority is patient care and I had to learn that it (exhaustive data collection) is part of patient care even though it doesn’t seem like direct patient care.”

Advice to other teams: “Study the prevalence of the problem and have an accurate baseline to work with. How else are you going to be able to tell you’re doing better?” Barron said.
Harper credits thorough education as essential for success—ensuring everyone on staff understands what needs to be done and why.

On the value of partnership: ”It takes a lot of time to collect the data…and my manager is always willing to help if I can’t get it done,” Stricker said. “All staff physicians are involved as well. Good partnership was necessary because all the disciplines were involved—from physicians to physical therapists.”