By Anna Laurae Kruse, RN, MSN, PHN, Robin Welte, RN, MSN, CEN, and Teri DeLaMontanya, RN, BSN, CEN
This is a story about nursing education – both academic and clinical. It’s a powerful example of how one can impact the other, and how both can lead to a new evidence-based best practice that benefits patients and their providers. It’s also about nursing compassion, and a willingness to change a culture in order to prevent patient suffering.
The John Muir Medical Center, Walnut Creek campus is a Magnet-designated 572-bed facility with a Level II Trauma center serving Contra Costa and Solano counties in northern California. Since May 2012, the facility has had a device-related infection prevention (DRIP) team with Donna Brackley, senior vice president of patient care services and chief nursing officer at John Muir Health's sister medical center in Concord, as its champion. The team includes the quality management medical director, the director of patient safety and accreditation, the director of professional practice, and representatives from infection prevention, critical care nursing, and staff leadership. During the last two years, the work of the DRIP team has included weekly case reviews to help identify sources and solutions. They also developed three evidence-based document “bundles” to be placed at the site of patient care; one for catheter insertion, one for maintenance and one for catheter removal. Each bundle contains a set of practices and behaviors that help reduce the risk of infection. When a pattern of catheter-related urinary tract infections (CAUTI) in trauma patients emerged, the infection prevention and emergency department teams sprang into action.
In addition to the work already in progress, the case review findings and trauma patient trend became the springboard for a research project. Anna Laurae Kruse, a former John Muir Health emergency room employee who was pursuing her masters in clinical nurse leadership, approached the hospital's administrative team to ask if she could conduct a performance improvement project in the facility to complete her studies. The project had to address a problem that could be solved to help the facility achieve a clinical and financial improvement.
Kruse had researched government requirements for healthcare providers; specifically, the 2008 Hospital-Acquired Conditions Reduction mandates for infection control. She had identified UTI as a national metric that could be greatly improved through the efforts of individual facilities. These infections comprise 34 percent of all healthcare-acquired infections, cost the nation’s hospitals at least $4.7 million in lost revenue annually, and threaten to cost $1.1 billion in Medicare reimbursements beginning in 2015. She learned that CAUTI were the largest offenders, but also among the easiest and least costly to prevent. Furthermore, John Muir Health was already following national best practices through its DRIP team and its focus on evidence-based protocols to help reduce CAUTI, so a CAUTI performance improvement project would have the necessary support to be successful.
The case reviews and joint focus on CAUTI created a perfect opportunity for both the student and the facility, so the go-ahead was given to pursue a performance improvement study in the emergency department (ED). Kruse worked with Renee Juster, RN, infection prevention manager, Robin Welte, RN, interim ED educator, and members of the IP team, ED staff and nursing leadership, to conduct a root cause analysis that was designed to answer the question: Why are trauma patients experiencing CAUTI? To collect information for the study, Kruse observed and documented the activities in the ED during trauma cases and interviewed the ED nursing staff to gather their thoughts on the question. Since everyone’s goals were aligned with the patients’ best interest, there was no blaming – it was treated more like a fact-finding mission by everyone involved.
Kruse’s investigation and observations led to a number of discoveries. As shown in Figure 1 (to request this diagram, send an email to [email protected]), there were cultural, logistical and clinical issues that contributed to the situation. The staff had been open and honest in their evaluations of the department because they were genuinely interested in finding a successful long-term solution. Once the true root causes of CAUTI were identified and documented, the solutions were relatively simple and cost-effective to execute. As Figure 1 shows, many solutions involved simple evidence-based educational refreshers for the staff, to bring them up-to-date with the most current best practices.
The root cause analysis, infection data and updated best practices presented to ED staff as a result of this study were eye opening for them. The culture in many emergency departments evolves from an intense focus on keeping patients alive. Their jobs revolve around immediacy rather than what happens after the patients leave their care and are admitted to the hospital for days or weeks thereafter. This study tied the work of the ED into the follow-up care in the hospital. It made the ED staff aware of the connection between how and when they inserted Foley catheters into trauma patients, and what the consequences were later in that care event. The ultimate priority of the ED nurses was, and is, the same as that of all their John Muir Health colleagues; to prevent unnecessary infections and suffering and help achieve optimal patient outcomes. Now that they were more aware of their direct impact on these outcomes and the resulting financial consequences for their health system, they were enthusiastic about participating in the solutions.
In order to determine whether a patient arrived at the ER with a UTI, it was important to educate ED staff about the value of testing for urinary infection upon admission and making the test part of the trauma panel. UA has now been added to the standard trauma test panel in the facility’s new electronic medical record platform.
The Walnut Creek ED was fortunate to have a highly experienced, consistent and longstanding nursing staff. However, when a professional has been doing a job for many years, habit can creep into a culture and a routine can be set over the years. After they were made aware of the most current evidence-based practices related to catheters, the nurses realized they were not all up to date. For example, not all trauma patients need a catheter, or need one inserted immediately. Clinical evidence has shown that the risk of infection can be reduced if clinicians take their time and follow best insertion practices. Rather than rushing to insert a catheter into every patient during the immediate emergency as a standard procedure, it’s valuable to assess the patient and be aware of other options available for use, such as female urinals. If a catheter does need to be placed, it can be done after the patient is stable and sufficient time can be applied to ensure a full and complete procedure.
Catheter size and type also matters. A 14F catheter is optimal in this environment, but the supply stocked in the ED included various sizes and types that were not optimal for trauma patients, and staff was using whatever was available. Once the supply department and nurses were aware of the clinical benefits of the 14F catheter, they could assure that the correct sets were stocked at all times. Kruse worked closely with Welte to develop and deliver in-services to the department. They also produced a video refresher course that can now be used to keep everyone in the department sharp on their technique and to train new employees.
Performing the optimal patient prep before insertion is a critical factor in eliminating infections. John Muir Health had completed a clinical trial using unique silver-based specialty care packs for perineal prep before each catheter insertion and noted a remarkable reduction in CAUTI. For this reason, John Muir Health had already begun supplying these packs to the Walnut Creek ED as part of each catheter kit. The packs were attached with tape to each insertion set. However, the packs were not being consistently used for two reasons: they were falling off the sets and being set aside, and the nurses had not received formal training on the use of the wipes. The solution was simple: work with the supply department to find a better way to attach the packs to the kits; provide an extra supply of packs in the department in case they are dropped; and provide training on proper use of the wipes for catheter prep.
Since implementing these educational, logistical, procedural and practical CAUTI reduction interventions in the Walnut Creek ED, the number of insertion-related CAUTI has been drastically reduced. In the four months immediately after the study, the number of documented ED-related CAUTI went from approximately 3 to less than 1.5, and their related costs (conservative estimates based on nationally reported figures) from $11,400 down to $3,800. During one of those months, the number of CAUTI and related costs was zero. In the months since, ED-related CAUTI have remained very low. Although there are causal factors beyond the control of the department, their ultimate goal is to consistently achieve zero CAUTI.
There has also been a significant shift in the Walnut Creek ED culture. It is now a patient care approach that, in addition to saving lives, includes consideration for the staff’s impact on the patient’s continuum of care. In the case of catheter use, the new philosophy in the ED is “You’re never going to save a life with a urinary catheter, so if you can’t take the time to complete the insertion correctly, don’t insert it until you can do it right.” When a catheter is deemed to be necessary, it is inserted only when there is sufficient time to follow all procedures and use aseptic technique.
In addition, during the study it came to light that ED staff would like to know about the progress of trauma patients after they leave the department. They feel it is important to their work to make the connection between their actions and the patients’ outcomes. The day-to-day reality doesn’t allow the ED staff to participate in critical care rounds, but they are now integral participants in case reviews of all CAUTI deemed to be insertion-attributable (a positive urine culture on or before the third day after catheter insertion and not present on admission) who were admitted from the ED, including the trauma patients.
Now that the department has achieved this success, they want to keep it going. In order to sustain and continue to improve the department’s performance, recommendations from the study include:
• Conducting bi-annual CAUTI prevention in-services for staff that include any updates to evidence-based practice
• Assuring that CAUTI prevention education is given to new staff during orientation
• Following up on additional Theraworx Specialty Care Pack clinical trials and applying the results to the current ED catheter insertion protocol
• Stocking all rooms with female or universal urinals
• Supplying the ED with extra Theraworx packs and sterile gloves in several sizes
• Continuing to monitor ED-related CAUTI
• Assuring that UA orders appear on the electronic medical record and are automatically ordered with all urinary catheter orders
In addition to achieving best CAUTI practices in the ED, the John Muir Health stakeholders involved in this study gained some additional insights that can be applied to their future efforts. First, they realized how many departmental and functional silos had evolved over time, and how counterproductive this was for communicating and collaborating. They have established some regular communication efforts that will improve the flow of information, especially when it concerns CAUTI incidents. They also learned that transparent leadership and honest assessment begins with active listening and engagement of the hands-on care team members. This is critical to meaningful and lasting results. By acknowledging their actual challenges and accepting responsibility, they were able to be more productive in their problem solving.
Finally, they realized that they all had the same ultimate goal, which was the best possible care for John Muir Health patients. Once they all had the same information, they could pull together toward the same positive patient outcomes. As long as everyone’s focus is on the patient’s continuum of care, infections are preventable.
Anna Laurae Kruse, RN, MSN, PHN, holds a bachelor of arts degree in sociology from the University of California at Los Angeles. She recently completed the Nursing and Clinical Nurse Leadership master’s program at the University of San Francisco. In addition, she is in the process of completing Lean and Six Sigma certifications.
Robin Welte, RN, MSN, CEN, is the interim emergency department educator and staff nurse at John Muir Health, Walnut Creek Campus. She holds an associate degree in nursing from Mt. San Jacinto College, a bachelor of science and master of science in nursing from the University of Phoenix, and a second master of science in nursing from the University of Cincinnati. She is also a certified nurse specialist candidate (CNS(c)). Welte is a member of the Emergency Nurses Association and the National Association of Clinical Nurse Specialists.
Teri DeLaMontanya, RN, BSN, CEN, is the director of emergency services at John Muir Medical Center, Walnut Creek Campus. In 2012, she received the Bev Jones Compassionate Leader Award at John Muir Health. She holds an associate of arts degree from Diablo Valley College and a bachelor of science in nursing from St. Mary’s/Samuel Merritt College. In addition, she is a member of the Emergency Nurses Association and the Association of California Nurse Leaders.
1. Burnett K, Erickson D, Hunt A, Beaulieu L, Bobo P and Shute P. (2010). Strategies to prevent urinary tract infection from urinary catheter insertion in the emergency department. J Emerg Nurs. 36(6), 546-550.
2. Centers for Disease Control and Prevention. Guideline for prevention of catheter-associated urinary tract infection. Retrieved from http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
3. Centers for Medicare and Medicaid Services. (2013). CMS final rule to improve quality of care during hospital inpatient stays. Retrieved from http://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2013-fact-sheets-items/2013-08-02-3.html
4. Centers for Medicare and Medicaid Services. (2009). Hospital Compare. Retrieved from http://www.medicare.gov/hospitalcompare/profile.html#profTab=3&ID=050180&loc=94598&lat=37.8961825&lng=-121.9814354
5. Herman B. (2013, April 26). CMS proposes 0.8% boost in medicare inpatient rates for 2014.Beckers Hospital Review. Retrieved from http://www.beckershospitalreview.com/cms-hhs/cms-proposes-08-boost-in-medicare-inpatient-rates-for-2014.html
6. Huckfeldt R, Mikkelson D, Finley P, Lowe C and Robertson J. (2009). The development of an all natural solution designed to enhance and nourish skin while providing advanced antimicrobial protection. [abstract] Proceeding of the John A. Boswick Burn and Wound Care Symposium; 2008 Feb. 18-22; Maui,HI.
7. Parker D, Callan L, Harwood J, Thompson D, Wilde M and Gray, M. (2009). Nursing interventions to reduce the risk of catheter-associated urinary tract infection. Part 1: catheter selection. J Wound, Ostomy Cont Nurs. 36(1), 23-34.
8. Reed D and Kemmerly S. (2009). Infection control and prevention: A Review of hospital-acquired infections and the economic implications. The Oschner Journal. 9:27-31.
9. Saint S, Meddings J, Calfee D, Kowalski C and Krein S. (2009). Catheter-associated urinary tract infection and the medicare rule changes. Ann Intern Med. 150(12), 877-W155.
10. Scott R, Oman K, Makic M, Fink R, Hulett T, Braaten J, Severyn F and Wald H. (in press) Reducing indwelling urinary catheter use in the emergency department: a successful quality-improvement initiative. J Emerg Nurs.