Tuesday, September 24, 2013

One is too many

An excellent story here about Jordan Hospital's success in avoiding catheter-associated urinary tract infections (CAUTIs).  Note the important elements of process improvement, starting right with the governing body.  Note, too, the lack of acceptance of industry benchmarks: The aim is zero. Zero is achieved!


An intensive education program involving the hospital's Board of Trustees and personnel in the Emergency Department, Critical Care Center (CCC) and other units throughout the hospital, has been followed by daily and even hourly assessments of patients with catheters.  The surveillance, discussion, and effort to curb infections are unending and are now ingrained within the hospital's culture.

"We began with the premise that anytime you insert anything into a person's body that they didn't come into the hospital with, it increases their susceptibility to infection," says Kathleen M. Mercurio, R.N., infection preventionist at Jordan.  

The challenge at Jordan was threefold - to reduce catheter associated urinary tract infections in the Critical Care Center (which is what Jordan calls its ICU); to decrease the number of days a Foley catheter stays in a patient (hence decreasing the chance for infection); and to promote alternatives to Foleys that are non-invasive. 

Nurses on each shift have to enter computerized documentation, answering, among other items: When was the catheter inserted? Where was it put in? (In the ED, CCC or on a med/surg floor) and why was it inserted.  To answer the "why," a nurse has to check off on the computer screen one of the CDC-approved guidelines.  Those same questions are answered for each patient when a new shift begins, demonstrating that for a quality-improvement strategy to work, repetition of many tasks is imperative.

"We had to create new strategies and processes easy for everyone involved. Using and incorporating a new process into their daily workflow requires a systematic, sensible approach," Mercurio says.

"Anytime you want to change a person's habits, you have to give that person a reason for the change - a reason that hits something inside of them that makes them value the change," Mercurio says.  For the different cultures throughout the hospital, the reasons she gave varied.

In July and November of 2012 and January and February of 2013, Jordan Hospital had one patient in each of those months who developed a CAUTI.  That's not a terrible track record, but as Mercurio says, "One is too many. One is someone's dad getting an infection."

But from March through August 2013 (the latest full month recorded), Jordan Hospital has had zero CAUTIs. 

And, the number of Foley catheter days - that is, the number of days that patients had catheters - steadily dropped, evidence of the strategy of removing them as soon as possible. The decrease in Foley catheter days occurred even as patient days in the CCC increased. That is, more patients, less days with them having catheters, and less chance of them getting an infection.


Anonymous said...

One of the unspoken reasons for leaving a Foley in is often convenience of the staff, who no longer has to clean up accidents or worry about getting the patient to the bathroom. Overcoming this particular barrier to ensure the staff is truly patient-centered is also very important. Congrats to Jordan hospital on making this work.

nonlocal MD

Anonymous said...

I love the idea that while we set internal performance targets that show incremental improvements, our real targets should be perfection in whatever we are attempting to improve. Yet we settle for adequacy rather than perfection nearly all of the time, because: 1) we do not want to appear to have failed at reaching our goal; 2) we do not want to be held up as inferior to someone who has achieved their target, albeit at a level much lower than perfection; 3) the belief by most that perfection can not be achieved. It is a mark of leadership to set perfection as a goal, and provide the support to achieve it.