docCaUTI Program at NYMH - NYS Partnership for Patients
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CaUTI Program at NYMH - NYS Partnership for Patients
Implementing a CAUTI Program at New York Methodist Hospital Kathleen P. Treacy, RN, MSN, NEA-BC, Vice President of Nursing Kathleen McNamara, RN, BSN,CIC, Director of Infection Prevention New York Methodist Hospital New York Methodist Hospital 651 Beds 39,000 Discharges CAUTI Programs: Not a new concept Dr. Parry, et al – Stamford Hospital Presented at NYPHS CMO and Infx Control Councils CAUTI - A National Priority CMS, NYS-DOH, NYS-PFP • CMS - Surgical Care Improvement Project • D/C Catheter by PO Day 2 • CMS – Hospital Compare • CAUTI • NYS-DOH • CAUTI a priority • NYS-PFP • HACs by 40% Hence…… ….CAUTI became a hospital priority NYMH as an Outlier • Collected data for NYSDOH NHSN on ICU CAUTI • CAUTI as part of Hospital Compare • Inlier in one report card but outlier in another • Not monitoring/requiring justifications house-wide • No monitoring of catheter days except in ICUs New York Presbyterian Healthcare System W.N.L. • We thought we were Within Normal Limits • We Never Looked to see if we could do better • We were surprised that we were an outlier • • • • • What did we do? Aligned with our rep Discussed / developed a program Needed buy in from the Medical Staff Needed approval from the Medical Executive Committee • Advised them Regulatory Agencies were seriously looking at this and at which hospitals were following CDC best practices • No objections • Most thought it was a good idea • As long as they didn’t have to do much Strategy • Awareness phase • Let everybody know that daily ordering and justification is coming • Design phase (simultaneously with Awareness) • IT, Nursing, Infection Prevention, Medical Staff, ED, ICU, Residents and PAs, etc • Criteria and justification discussed • 13 criteria • Down to 5 • Nursing Foley Catheter Maintenance Bundle • ER – • Foley orders must be entered in ED with justification • Pt not allowed to go to floor unless order/justification • Began 2 years ago Foley Catheter Clinical Workflow 1 • Starts with an MD order to insert a Foley Catheter by selecting the following Orderset: Day 1 – Continue and Justify DAILY PROMPT • After 24 Hours any clinician that opens the chart will be alerted to complete the Form • If selects Continue Foley Catheter, justification becomes required fields • System will place order to Continue Foley Catheter • If selects Discontinue Foley • System will place order to D/C Foley with the following special instructions: • Contact MD/PA/RNP if no void within 4 hours of Catheter d/c. Daily Prompt 1. Next morning at 6:00AM Physicians/PA/RNP will be alerted when opening the chart You are being watched! FC Clinical Workflow 2 1. Foley Catheter Insertion Order Justification Issues • Appropriateness • Residents can enter any of the justification orders and it will be picked up • Ex “ Critically Ill, requires hourly urine output” cannot be restricted to certain units • Ordered on Med/Surg units • Solution / Oversight • Daily oversight by Departmental/Divisional clinical leadership • Lines, Tubes, and Drains (LTD) incorporated into daily interdisciplinary utilization rounds • Infection Prevention/Control Nurses targeted surveillance rounds To Hard Stop or Not to Hard Stop... …That’s a tough question • Concerns over hard stop • Inadvertent discontinuation • need to reinstrument • potential CAUTI due to multiple manipulations • Doc v RN v Administration tension • No hard stop for now What’s in it for them • Mostly resident driven • Residency evaluation for Systems Based Practice • As attending physicians • they will be monitored by third parties for HACS • might encounter financial penalties • What if it was their parents? • Do unto others • It’s the right thing to do • But can you get them to do it? Obstacles • Alert cannot be directed to specific caregiver • All persons accessing physician component of EMR will see the alert until its either justified or D/C • Justifications cannot be restricted to certain units • “Critically Ill, Requires hourly urine output monitoring” cannot be electronically restricted to ICUs Daily Activity Reports - WIP • Daily Activity Report v.1 and v.2 • Report as of 6 am activity daily • Driven off: • Physician order/reorder/justification • Nurse “Assessment of Foley” in EMR • Daily Activity Report v. 3 • Demographics (Name , MR #) • Location • Date/time ordered • Justification • Date/time reordered • Justification • Personnel • Time of last activity • Physician or nursing entry, that foley is still in (as of 6 am). Issues with Activity Report • Its not a real time report • Some foleys are on report as still in but they are out by time report is reviewed • Generated by activity in system at 6 am • Need to do math for duration of foley • Solutions: • Added column that shows duration of foley by hours as of 6 am PDSA - Daily Activity Report v. 1 MRN RACE 4913729 Black 4918560 White 4786285 White 4914454 Black 4916335 Black 987603 Black 4899354 Black 4899354 Black 4899354 Black 4899354 Black 4899354 Black 335125 White 335125 White 335125 White 335125 White 4916258 Asian ADMIT_DT_TM DISCHARGE_DATE SEX 1/3/2013 3:26 1/5/2013 20:40 Female 1/3/2013 5:00 1/6/2013 15:50 Female 1/3/2013 5:00 1/6/2013 13:28 Female 1/3/2013 5:00 1/6/2013 20:22 Female 1/3/2013 5:46 1/5/2013 19:39 Female 1/3/2013 7:35 1/5/2013 15:41 Female 1/3/2013 8:51 Female 1/3/2013 8:51 Female 1/3/2013 8:51 Female 1/3/2013 8:51 Female 1/3/2013 8:51 Female 1/3/2013 10:59 1/8/2013 15:44 Female 1/3/2013 10:59 1/8/2013 15:44 Female 1/3/2013 10:59 1/8/2013 15:44 Female 1/3/2013 10:59 1/8/2013 15:44 Female 1/3/2013 13:43 1/6/2013 20:22 Female AGE 25 Years 31 Years 33 Years 30 Years 27 Years 33 Years 60 Years 60 Years 60 Years 60 Years 60 Years 79 Years 79 Years 79 Years 79 Years 33 Years •Missing Location •Missing Ordering Physician •Missing Duration of Catheter •Only captured those with Physician Orders FOLEY_STATUS Discontinue Fol Discontinue Fol Discontinue Fol Discontinue Fol Discontinue Fol Discontinue Fol Continue Foley Continue Foley Continue Foley Continue Foley Continue Foley Continue Foley Continue Foley Continue Foley Continue Foley Discontinue Fol FOLEY_REASON Urine output monitoring critically Urine output monitoring critically Urine output monitoring critically Urine output monitoring critically Urine output monitoring critically Chronic Urinary Retention Chronic Urinary Retention Chronic Urinary Retention Urine output monitoring critically PDSA - Daily Activity Report v. 2 MRN RACE 4926798 Black 4649327 White 987603 Black 4142825 White 4907832 White 4899354 Black 4918560 White 4786285 White 4914454 Black 4913729 Black 4916258 Asian 4946548 Black 368939 White 4907832 White 4767948 White 4878286 White 4935636 Black 4684384 Black 4479414 Black 4917402 Black 4925198 Black 4647316 Black 4725793 White 368939 White 4001561 Black 4899354 Black 335125 White 4946548 Black ADMIT_DT_TM DISCHARGE_DATE LOCATION 1/3/2013 23:57 1/6/2013 13:19 CP5S 1/3/2013 23:53 BUC4 1/3/2013 7:35 1/5/2013 15:41 CP5S 1/3/2013 23:59 BUC4 1/3/2013 14:26 1/7/2013 7:49 CLBR 1/3/2013 8:51 CP8N 1/3/2013 5:00 1/6/2013 15:50 CP5S 1/3/2013 5:00 1/6/2013 13:28 CP5N 1/3/2013 5:00 1/6/2013 20:22 CP5S 1/3/2013 3:26 1/5/2013 20:40 CP5N 1/3/2013 13:43 1/6/2013 20:22 CP5N 1/3/2013 19:06 MIN6 1/3/2013 23:44 CP7N 1/3/2013 14:26 1/7/2013 7:49 CLBR 1/4/2013 11:17 1/7/2013 11:43 CP5N 1/4/2013 15:51 INF5 1/4/2013 15:28 MIN8 1/5/2013 1:09 1/8/2013 23:11 INF6 1/3/2013 23:50 1/5/2013 16:41 CP7S 1/3/2013 14:23 BUC5 1/4/2013 2:16 1/6/2013 3:28 MIN6 1/4/2013 17:24 1/8/2013 16:49 CP7S 1/4/2013 12:56 1/7/2013 12:45 CP5S 1/3/2013 23:44 CP7N 1/4/2013 13:48 MIN6 1/3/2013 8:51 CP8N 1/3/2013 10:59 1/8/2013 15:44 INF7 1/3/2013 19:06 MIN6 SEX Female Female Female Female Female Female Female Female Female Female Female Male Female Female Female Female Female Female Male Female Female Female Female Female Female Female Female Male AGE 25 Years 84 Years 33 Years 91 Years 38 Years 60 Years 31 Years 33 Years 30 Years 25 Years 33 Years 90 Years 98 Years 38 Years 43 Years 86 Years 81 Years 93 Years 100 Years 41 Years 84 Years 73 Years 33 Years 98 Years 86 Years 60 Years 79 Years 90 Years FOLEY_STATUS Discontinue Fol Continue Foley Discontinue Fol Continue Foley Continue Foley Continue Foley Discontinue Fol Discontinue Fol Discontinue Fol Discontinue Fol Discontinue Fol Continue Foley Continue Foley Discontinue Fol Discontinue Fol Discontinue Fol Continue Foley Continue Foley Continue Foley Discontinue Fol Continue Foley Continue Foley Discontinue Fol Continue Foley Continue Foley Continue Foley Continue Foley Continue Foley •No insertion date/time •No duration of catheter •Still only shows up if physician order FOLEY_REASON FOLEY_DC PERFORMED_BY Comfort "End of Life Care" Morelli (MD) , Anthony Comfort "End of Life Care" Perioperative use for surgical proc Urine output monitoring critically Morelli (MD) , Anthony Fazeli (MD), Amir H Quadir (MD) , Amreen Chronic Urinary Retention Alshangiti (MD), Abdulraheem A Assist pressure ulcer healing Urine output monitoring critically Urine output monitoring critically Benson (MD), Max Zaid (MD) , Musaab A Mikhno (MD), Lyudmila Assist pressure ulcer healing Manage acute urinary retention/obst Wong (MD), Ivan Mikhno (MD), Lyudmila Assist pressure ulcer healing Assist pressure ulcer healing Urine output monitoring critically Chronic Urinary Retention Assist pressure ulcer healing Mikhno (MD), Lyudmila Wong (MD), Ivan Bui (MD) , Jeffrey P Katri (MD) , Yakoub Wong (MD), Ivan v. 3 – Sorted By Duration of FC LOCATION CP7S BUC5 INF4 CP5N EROV CP7N CLBR CP5N CP5N CP5S CP7N CP5N M3IC MIN8 ICU II ICU II INF4 CP7N CP5N CP5S CP7N INF6 ICU II PATIENT_NAME GOYKHMAN, POLYA ABRAMS, SYLVIA GEORGE, CLAUDETTE HOLLOWAY, ANDREA VICTOR, ALTAGRACE THOMAS, GEORGE REVERON, NILDA SIFFORD, ELENA FELIX, THERESHIA HITRON, NANY LEARY, ANGELA TUCCILLO, LYNNE ANANSINGH, PATRICK USUPHOVA, SHINAMID SMITH, MARJORIE VAN COTT, ROBERT SMITH, NORVILL GARCIA, IRIS EICHENSTEIN, RAIZEL JOTWANI, LEENA WANG, RUTH MCGUIRE, MARGARET SANABRIA, CESAR MRN ADMIT_DT_TM INSERTION CONTINUE ORDERED_BY RN_REVIEW LATEST_ACTIVITY LATEST_ACTIVITY_TYPE 4972231 6/3/2013 15:41 6/3/2013 16:36 Dubrovsky (PA) , Yuliya 6/3/2013 23:02 MD Discontinue Order 4969837 5/31/2013 20:55 6/3/2013 19:33 Plumb (MD), Imran A 6/3/2013 21:01 6/3/2013 21:01 RN Documentation 4944009 6/3/2013 5:00 6/3/2013 23:06 Patel (MD), Rakhee 6/3/2013 13:39 6/3/2013 23:06 MD Order 4860850 6/2/2013 14:59 6/3/2013 0:07 Bell (MD), Brandon 6/3/2013 11:23 MD Discontinue Order 7032383 6/3/2013 20:14 6/3/2013 21:34 Balk (MD), Andrew 6/3/2013 21:34 MD Order 566642 6/3/2013 23:54 6/3/2013 21:00 Moss (MD) , Dubenion Joseph 6/3/2013 21:00 MD Order 4770541 6/3/2013 12:42 6/3/2013 20:52 Neystat (MD) , Anna 6/3/2013 21:49 6/3/2013 21:49 RN Documentation 4944983 6/3/2013 6:37 6/3/2013 19:31 Arnold-Leahy (CNM), Elizabeth 6/3/2013 19:02 6/3/2013 19:31 MD Order 4931266 6/2/2013 23:55 6/3/2013 2:06 Bell (MD), Brandon 6/3/2013 9:12 6/3/2013 16:15 MD Discontinue Order 4937752 6/3/2013 15:22 6/3/2013 17:56 Sosa (MD), JLeise 6/3/2013 17:56 MD Order 751462 6/3/2013 5:00 6/3/2013 15:03 Keaty (MD) , Kathryn 6/3/2013 15:51 6/3/2013 15:51 RN Documentation 4969014 6/3/2013 5:00 6/3/2013 12:55 Lyles (MD) , Leslie 6/3/2013 21:48 6/3/2013 21:48 RN Documentation 4971838 6/2/2013 13:24 6/3/2013 12:44 Adjiashvili (PA), Abe 6/3/2013 22:54 6/3/2013 22:54 RN Documentation 4971372 5/31/2013 21:19 6/3/2013 12:29 Goehring (MD), Anna 6/3/2013 21:20 6/3/2013 21:20 RN Documentation 4818690 6/3/2013 13:20 6/3/2013 12:19 Fan (MD) , Liqi 6/3/2013 14:44 6/3/2013 14:44 RN Documentation 4780778 6/3/2013 8:52 6/3/2013 10:26 Caldwell (MD) , John Reed 6/3/2013 20:45 6/3/2013 20:45 RN Documentation 4852056 6/3/2013 7:00 6/3/2013 9:23 Akkerman (PA), Reuven 6/3/2013 15:18 6/3/2013 15:18 RN Documentation 4965985 6/3/2013 7:00 6/3/2013 8:18 Von Walstrom (MD) , Genevieve 6/3/2013 18:31 6/3/2013 18:31 RN Documentation 4952757 6/3/2013 3:46 6/3/2013 7:48 Sosa (MD), JLeise 6/3/2013 7:48 MD Order 4879944 6/3/2013 2:03 6/4/2013 1:20 Bartalot (MD), Ashley 6/3/2013 10:37 6/3/2013 20:32 RN Discontinue Documentation 665851 6/2/2013 23:52 6/3/2013 3:55 6/3/2013 6:09 Woodley (NT) , Anaceita 6/3/2013 21:41 6/3/2013 21:41 RN Documentation 907398 6/2/2013 3:15 6/2/2013 9:44 6/3/2013 9:47 Williams NT, Dorothy 6/3/2013 20:28 6/3/2013 20:28 RN Documentation 493559 6/2/2013 3:21 6/2/2013 3:52 6/3/2013 19:05 Vaidya (MD) , Ami 6/3/2013 17:09 6/3/2013 19:05 MD Order REASON Urine output monitoring critically Manage acute urinary retention/obst Perioperative use for surgical proc Perioperative use for surgical proc Urine output monitoring critically Urine output monitoring critically Perioperative use for surgical proc Perioperative use for surgical proc Perioperative use for surgical proc Perioperative use for surgical proc Perioperative use for surgical proc Perioperative use for surgical proc Urine output monitoring critically Manage acute urinary retention/obst Urine output monitoring critically Urine output monitoring critically Perioperative use for surgical proc Perioperative use for surgical proc Perioperative use for surgical proc Perioperative use for surgical proc Manage acute urinary retention/obst Manage acute urinary retention/obst Critically ill, hourly urine output • Still only shows up if there is a physician order • Need to know time from last Physician Activity (adding column in v.4) DC_ORDER DC_DT 6/3/2013 23:02 6/3/2013 10:13 DURATION 0 Days 06:26 0 Days 09:19 0 Days 10:01 6/3/2013 11:23 0 Days 11:15 0 Days 11:33 0 Days 12:07 0 Days 12:15 0 Days 13:37 6/3/2013 16:15 0 Days 14:09 0 Days 15:11 0 Days 18:04 0 Days 20:12 0 Days 20:23 0 Days 20:38 0 Days 20:48 0 Days 22:41 0 Days 23:44 1 Days 00:49 1 Days 01:19 6/3/2013 0:00 1 Days 01:20 1 Days 05:12 1 Days 23:23 2 Days 05:15 Further glitches • IT • Patients with foleys dropping off the list even if there is a RN documentation in EMR • Underestimated patients with foleys. • How did this happen? • HOW DID WE FIX IT? • As of June 10, 2013 – Still a work in progress IT is Just a Tool • Only provides information • Doesn’t eliminate responsibility and oversight • Each department has assigned a monitor • Reviews their daily list • Is there a justification • Is justification appropriate? • Ex: Inappropriate: “Critically ill, requires hourly monitoring” on a regular med/surg floor • Daily Utilization Rounds • LTD (Lines, Tubes, and Drains) • Targeted IPC Nurse Surveillance Its Not Just About Foleys F O L E Y C V P A N I T C O A G S A N I T B I O T I C S R E S T R A I N T S Need to design a single alert linked to an Alert Page that shows all open alerts to be addressed on an individual patient DASHBOARD – Good Idea? Who is going to monitor this? Probably Nobody Patient Alert Page Results – General House • Unable to compare pre / post intervention foley days • Documentation deficiencies • MD and RN • Especially when inserted and d/c’d without an order • Ex: April 2013 • 74 patients with documentation missing • Solution • Leadership and Oversight •As mentioned previously Results – All Adult ICUs Foley Catheter Utilization Rate Dec 2012 (Pre) Patient Days FC Days Utilization 964 624 65% Mar 2013 (Post) 941 501 53% ______________________________________________________ CCU (Pre) 172 84 49% CCU (Post) 173 40 23% ED Audit • Double secret monitoring over a 2 day period in May 2013 • Only 7 catheters inserted over 2 days • 583 ED patients • 143 admissions • 6/7 appropriate • All reviewed by ED and IC staff • None developed CAUTI • Post audit meeting with Medicine • CHF patient not going to Critical Care do not require catheters, • ED thought it was how patients were monitored on the floor • ED working with Medicine to identify other opportunities Thank You Questions?
