Using NSQIP Data and Best Practices to Reduce Urinary

Tract Infections Among Surgical Patients at Peace Arch Hospital

Susann Camus,Paula Gabriel,

Deb Sperandeo,

February 28, 2013

Team CompositionEunice Bradford, Surgical

Staff NurseSusann Camus, NSQIP QI

ConsultantSharlene Enos, Clerk,

SurgeryPaula Gabriel, Surgical

Staff NurseDana Hayward, Clinical

Nurse Educator, SurgeryLaura Holmes, PAH

Surgical Clinical ReviewerWendy Newson, Surgery

Manager & Team Sponsor

Irma Picache, Surgical Staff Nurse

Deb Sperandeo, Surgical Staff Nurse & Team Leader

Plus input from PAH staff in the Emergency Department, Infection Control, and the Operating Room

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Why we created a team

PAH began collecting data through NSQIP in July 2011.

Non-risk adjusted data from NSQIP suggested UTI rates among PAH postsurgical patients were higher than the NSQIP average.

Multidisciplinary team established in April 2012to reduce CAUTIs.

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Team goals (2012)

Reduce CAUTIs among postsurgical patients at PAH by 50% between April 1 and Dec 31/12 by applying evidence-informed practices (NSQIP & FH CAUTI Bundles).

This means reducing the non risk-adjusted CAUTI rate from 3.4% to 1.7%.

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Team goals (2012)

Reduce CAUTIs

Provide an educational opportunity for staff

Empower nurses

Increase team building & collaboration within the unit and among disciplines

Provide opportunity for changing practice

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Interventions to date

Developed a Team Charter

Implemented NSQIP CAUTI Best Practices and the FH CAUTI Prevention Guideline

Held staff huddles and a CAUTI contest

Posted factoids posted on walls and in bathroom stalls

Did PDSA Cycles & displayed results using Quality Dashboards

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Interventions to date: Plan-Do-Study-Act cycles to test the effectiveness of small changes

Drainage bag placement & loop integrity

Container labeling

Patient and staff education

Document Foley Plan of Care in Kardex binders

Silver tipped catheter trial in hip fracture patients

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Silver Tipped Catheter Trial, July/12 – Jan/13Context: 5/27 patients

with fractured hips (18.5%) had UTIs between Jan and March 2012.

6 month trial

Patients given a silver tipped catheter on admission in ER, in OR, or in Surgical Unit

Results available in May 2013

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Measuring changes with the Quality Dashboard

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Ishikawa Problem Solving Tool

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Revamping our KardexesNeed was identified ~10 years ago

NSQIP as the catalyst for change

Making it relevant to nurses

Improving thehandover of keyinformation

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How are we doing now?NSQIP data

indicates we’re on the right track

In-unit communications are improving

Buzz about NSQIP

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Lessons learned

QI Consultant helps keep us on track

NSQIP data is essential for gauging progress

Getting the right people on board facilitates rapid change

A supportive manager makes a huge difference

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Questions?