CAUTIon With Our Patients: The Development and Implementation of a CAUTI Tracer Program

Abstract

BACKGROUND The most common hospital acquired infection is catheter associated urinary tract infection (CAUTI). Approximately 75% of urinary tract infections acquired in the hospital are associated with urinary catheters. CAUTI increases the length of stay by two days and incurs unnecessary costs to the patient. Our nosocomial CAUTI SIR (Standardized infection ratio) in 2017 was 1.161 which is above the Center for Medicare and Medicaid services Hospital Value- Based Purchasing (CMS VBP) benchmark of 0.822. The purpose of this project is to reduce nosocomial CAUTI SIR and to increase catheter bundle compliance. METHODS We utilized a multidisciplinary approach partnering with our corporate Infection Preventionist. We performed a gap analysis using the Targeted Assessment for Prevention (TAP) report to identify our units with opportunities for improvement. We built a CAUTI tracer tool that can be utilized to measure compliance of catheter care and a report can be generated for analysis. A tip sheet was developed and education was provided on all of the bundle components including alternatives for external urinary devices. For sustainment we engaged senior leadership and the units identified with opportunities were required to perform daily catheter care audits until CAUTI free for four months. RESULTS After the process changes were initiated in quarter 1 2018, the hospital acquired CAUTI SIR started to show a steady decline. The 2018 quality year January through September CAUTI SIR is at 0.883 which is a 28% reduction from 2017. With the implementation of the tracer tool, bundle compliance was observed to increase from 80% to 95%. CONCLUSIONS Initiation of the education tip sheet and the CAUTI tracer tool were successful interventions in reducing hospital acquired CAUTI's. Support from both corporate and entity leadership has proven to be effective towards deployment, reduction and sustainment.