D159

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Western Governors University *

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D159

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Health Science

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Dec 6, 2023

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D159: Evidenced Based Measures for Evaluating Healthcare Improvement Team Member Collaboration The stakeholders held a meeting to brainstorm ideas to identify data elements necessary to determine the success of the HIP. We identified systems that were already in place to help collect data. Currently the quality team and infection prevention team determine if there were any CAUTIs, then information on the patient is sent to the leader of the unit with a form to fill out. We then conduct an RCA to determine if there were any opportunities. During the RCA we agreed to add information about the nurse driven protocol and if it was used. Knowing if the nurse driven protocol was used when determine if the HIP was successful. During the meeting we determined who would be responsible for collecting the data and who would present the information. Data Elements Trying to decide what data elements we were going to use to measure if our project was a success included: Foley catheter days, reinsertions, and sex. Foley catheter days, female gender and reinsertions are risk factors for increased risk of CAUTI. The most key factor in development of bacteriuria at 3-7% daily is length of time a foley is in (Werneburg, 2022). Having multiple reinsertions of a foley catheter increases the risk of getting a CAUTI. Women have a higher risk of CAUTI than men due to heavy bacterial colonization of the perineum. Included for our data elements would be insertion and removal dates. These would provide us with our number of days a foley were in place. Data Source Data sources for use would be the EMR and employee education sign in sheet. All information about the pt. foley catheter days, any reinsertions and gender would all be in the

EMR. We then would look to see who took care of the pt. and look back to see that they had been provided the education on the new nurse driven protocols. By using the staff education sign in sheet, we would know if the staff who took care of the patient was aware of the new protocol. The EMR would allow us to know if the patient had the foley for multiple days, multiple reinsertions, and their gender. KPI and Benchmarks One Key performance indicator to show this HIP is successful is 90% of staff will have had the education on the new nurse driven protocol and criteria and to reduce CAUTIs by 50% after the education has been completed. We will achieve this goal by developing a nurse driven protocol to help remove unnecessary foley catheters sooner. The patients will have to meet a certain criteria the nurses follow to remove the foley catheters. The national benchmark for CAUTI is 2.55 infections per 1,000 catheter days. My organization is currently sitting at 4 infections per 1,000 catheter days. Data Collection Method and Parameters Data will be collected for all reported CAUTI’s by the quality department. The data will manually be added to an excel form weekly. Foley catheter days, reinsertions and gender will be some the data included in the report the data will be collected weekly for the report. We will be collecting this data from 71/2023 to 12/31/2023. This report would be completed weekly. When collecting the data for foley catheter days we would look at the insertion date and the date it was removed to determine the length the foley was in place. For reinsertions we would check to see if the foley had to be reinserted at all during the hospital stay. Female gender increases the risk of CAUTIs, so when pulling data, we will include gender.

The report would be password protected to prevent any HIPPA violations. Name will also not be included in the report only the data needed to determine if the nurse driven protocol was followed. The quality department and infection prevention team will collect the data and complete RCAs on the CAUTIs with the leader to see if there were any missed opportunities and what was done correctly to prevent the CAUTI. All data will be on adult patients in the hospital. Data Analysis RCA will be completed with the infection prevention team, quality team and unit leadership of any CAUTIs. During the RCAs information about the pt. is gone over, and if there were any opportunities in the care of the patient. Our infection prevention team calculates urinary catheter utilization days and CAUTI rates. To calculate, Urinary catheter utilization ratio, you divide the number of urinary catheter days by the number of patient days. CDC recommendation to calculate CAUTI rates per 1000 urinary catheter days by dividing the number of CAUTIs by the number of urinary catheter days and multiplying the result by 1000. Results Dissemination Plan To interpret data monthly meetings will happen with infection prevention, and quality team. Any relevant information collected from RCAs will be gone over. Opportunities, and what went well would be discussed. Each month the data from the RCA would be collected and put into an excel report with graphs to see if there was a reduction in CAUTI. We would make sure our data included foley catheter days, reinsertions, and gender. Using our data elements of foley catheter days, reinsertions, and gender we could see if our nurse driven protocol is working on reduction of CAUTI. The data would also show if there was any deviation from the HIP. Using bivariate analysis, we could see the relationship between the variable of not using the nursing

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driven protocol to reduce foley catheter days and reinsertions. We would review the findings with the team. A Contextual issue that may result in our data being inaccurate would be if a clean catch specimen were not collected that would cause a false positive. For example, the patient had a foley still in place and there was an order to collect a Urine analysis and the RN collected the urine from the collection bag. Project Closure Plan To acknowledge the corporation and the executive team for allowing me to implement my HIP I would like to present all the data to them and thank them in person for what their support in implementing the HIP. During the presentation I would have each stakeholder that participated in coming up with the ideas, and helping with implementation be up there with me, so I could acknowledge their hard work and dedication as well. During this time, I plan to have them talk about what they provided to the team and what feedback they have. To wrap up the project I plan to have a meeting with the stakeholders to talk about what went well, what we would change and what feedback they have. After completion of this project, we will look at reducing CLABSIs in the hospital.

D159

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