D159

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Western Governors University *

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D159

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Health Science

Date

Dec 6, 2023

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docx

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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.

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