Advocate South Suburban Hospital

Presentation Notes

Quality Improvement poster presented at Nursing Passion: Re-Igniting the Art & Science, Advocate Aurora Health Nursing & Research Conference 2022; November 9, 2022; virtual.


Project Background: About 75% of hospital urinary tract infections are related to prolonged indwelling catheter use. Assessment of the need for and prudent removal of catheters are key steps in prevention of Catheter Associated Urinary Tract Infection (CAUTI.) A best practice is utilizing a nurse driven catheter removal algorithm.

Local Problem: After a 2021 systemwide audit, the site team recognized that nurses’ use of criteria for indwelling urinary catheter insertion and removal was inconsistent. Root causes were lack of awareness of the AAH Urinary Catheter Management/Removal Algorithm by some nurses and delay in catheter removal per the algorithm.

Method: The site CAUTI team selected criteria for catheters as a focus for the system Rapid Cycle PDSA (Plan-Do-Study-Act) CAUTI Prevention project.

PDSA Cycle 1 Education of nurses using existing resources.

PDSA Cycle 2 A systematic plan to review all catheters and verify documentation of care with report to site Device Huddle 5 times a week.

PDSA Cycle 3 High Risk Huddle to review the algorithm with nurses prior to catheter insertion.

Conclusions: PDSA Cycle 1 documentation of criteria decreased from 74% in the baseline audit to 60%. The plan was revised to provide oversight of catheter usage as well as to create a sense of urgency in removing catheters.

PDSA Cycle 2 resulted in 100% documentation compliance and prompt removal of catheters. The team saw an opportunity to reduce catheter utilization. The plan was adapted with addition of a catheter insertion resource.

PDSA Cycle 3 Trained 43 High Risk Huddle champions. Standardized Device Utilization for urinary catheters improved from 0.1226 in June to 0.1092 in August. The plan was adopted.

Implications for Practice: Through education, systematic review and collaboration, the site went 200 CAUTI-free days. Use of Device Huddle and High Risk Huddle supports interventions for other infection prevention initiatives.

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