Saving Lives and Reducing Harm: A CAUTI Reduction Program

Kerri Ann Scanlon, MSN, RN; Celia M. Wells, PhD(c), RN; Launette Woolforde, EdD, DNP, RN-BC; Aradhana Khameraj, MSN, RN; Jennifer Baumgarten, MBA


Nurs Econ. 2017;35(3):134-141. 

In This Article

Process Measures

The cornerstone of this program was teamwork and inclusion of the interprofessional team. While LEAN (Kimsey, 2010), Plan-Do-Study-Act (Institute for Health care Improvement, n.d.), and microsystems strategies were used, experience with TeamStepps® was essential to the outcomes. It was predicted, this strategic approach would yield reductions captured in quantifiable outcomes. A SIR goal of <0.85 would correlate with Northwell Health's target to obtain the CMS 2015 threshold. Using a priority ranking methodology, vulnerable patient entry points that were at risk for obtaining urinary catheters were identified. Target areas included the emergency department, operating room, post anesthesia care unit, and critical care.

Using tests of change, the team was compelled to develop innovative ideas as the literature revealed no new recommendations to the already established CDC guide-lines. Concurrently, nursing leadership identified opportunities to improve how data were reported within the hospital. Knowing this information had to be communicated in a structured, unified process, a hospital-based scorecard was developed which focused on organizational improvement to report data. Each month measures were collected at the unit-level which were then summarized into hospital-level data. Data collection included metrics about quality performance, finances, professional development, and patient satisfaction. Scorecards contrasted data from the previous year to current year-to-date totals and goals. Annual and stretch goals established by the Northwell Health executive leadership team were also included on the scorecard. Scorecards were presented monthly during nursing leadership, quality, and unit-level shared governance council meetings as transparency of data allowed the entire hospital to celebrate achieved outcomes or identify opportunities for improvement.

The project began with an interprofessional CAUTI task force. This group included organizational leadership and those with technical and clinical expertise to develop and strategize best practice guidelines and processes to reduce CAUTI. Team members included the hospital's chief nursing officer, chief medical officer, chief quality office, advanced practice providers, infection prevention, nursing education, frontline nursing leadership, and clinical staff such as registered nurses, physicians, patient care associates, physical therapists, patient transporters, and technicians.

Education then focused on frontline staff, 188 RN CAUTI ambassadors, also known as the clinical army. Each CAUTI ambassador completed education and validation on insertion techniques with return demonstration on mannequins. In addition, ambassadors received instruction about perineal care, maintenance of drainage bags below the level of bladder, the dry bag concept, StatLock® for proper securement, and two-RN mandate for insertion time out. Lastly, ambassador education included a "Train the Trainer" model to validate staff on new protocols.

Next was the development of a straight catheterization algorithm pocket card (see Figure 1). Unlike other states, scope of practice for RNs in New York is defined as executing medical regimens prescribed by a licensed physician, dentist, or other licensed health care provider (New York State Education Department Office of the Professions, 2010). This prohibits nurses from removing catheters without provider orders. There fore, it is essential nurses drive the process for catheter removal. Guide-lines for the protocol were presented to hospital physician and nursing leadership for evaluation and feasibility. Departments (emergency, medicine, surgery, urology, and critical care) evaluated the protocol and made recommendations for change based on patient population. The algorithm included (a) addressing the pathway for straight catheterization utilizing bladder scanning by nursing staff, (b) best practice guidelines for maintenance and removal, and (c) identifying signs and symptoms of urinary retention. To support the straight catheterization protocol, four bladder scanners were purchased for use in the emergency department and ICUs. The bladder scanners were used in tandem with the algorithm and provided nursing autonomy based on a decision tree to communicate their findings and recommend next steps to providers about the patient's plan of care.

Figure 1.

Straight Catheterization Algorithm Pocket Card

Interprofessional participation resulted in innovations that contributed to achieving outcome measures of CAUTI SIR, incidence, catheter days, and cost impact. These innovations were identified as opportunities to educate and change current practice and included CAUTI ambassadors, CAUTI algorithm, CAUTI carnival, CAUTI rounds, CAUTI kickoff, and a CAUTI acronym (see Figure 2).

Figure 2.

CAUTI Reduction Process

Consistent assessment and evaluation of opportunities for improvement led to the development of a monthly CAUTI root cause committee and process. The infection prevention department monitors and generates CAUTI incidence within the hospital. As CAUTI events are identified, notification is sent to senior leadership, unit leadership, and nurse educators. Meetings occur monthly to discuss and evaluate each case in detail in a nonthreatening learning environment. Information acquired during meetings has facilitated policy and procedure development, reinforcement of best practice, and contributed to ongoing CAUTI reduction success. For example, staff used a standard nonmetered collection bag on patients admitted to the emergency department, a previous standard practice. However, if the patient's condition declined necessitating strict intake and output monitoring, a metered collection bag would be exchanged. As such, staff would "break the seal" and replace the standard nonmetered collection bag ($8.45) for a metered-collection bag ($13.47).

This practice of "breaking the seal" can impose an increased risk of CAUTI development, as well as incur a total cost of $21.92 per patient. Although there is an initial cost savings for use of the metered-collection bag on patients requiring its use, there is a potential cost increase for those patients not requiring a metered-collection bag. Understanding this information, senior leadership supported the decision that cost should not dictate best practice and allowed the facility to move forward with utilizing metered-collection bags for all patients throughout the hospital.

Partnership with material operations assured supplies supporting maintenance and insertion strategies were consistently available to staff such as StatLock and condom catheters. Supporting best practice at the bedside was essential to the program's success. Therefore, when staff identified a need to have more choices of condom catheters for male patients, the task force responded immediately. Vendors were invited to the hospital so staff could trial and recommend products. Based on staff recommendations, these products were added to the inventory and are included in the maintenance guidelines.

As the results became apparent, the hospital became the foundation for the Northwell Health CAUTI Steering Committee. The committee included Northwell Health's Vice President of Nursing, Vice President, Infection Disease, and the Deputy Nurse. Beginning September 2014, the team met monthly to collaborate and share best practice successes and opportunities for improvement. The steering committee adopted and implemented system hospital best practices for CAUTI reduction across the remaining 18 hospitals in the organization. Moreover, the steering committee built on the hospital processes to develop additional learning programs. All initiatives were bundled to create a CAUTI prevention toolkit, easily accessible to all employees on the organization's intranet. The final product resulted in an educational video, "Proceed with CAUTIon," which is viewed by new employees during orientation. The steering committee continues to meet quarterly to update members on hospital-specific and Northwell Health outcomes and to address any concerns.