Publication Title
OREGON NURSING RESEARCH & QUALITY CONSORTIUM
Document Type
Article
Publication Date
3-2025
Abstract
Problem Statement: Our 539-bed tertiary care center observed an increase in the Catheter Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio (SIR) from 0.88 to 1.28 when comparing October to December of 2023 to 2024. CAUTIs are associated with increased patient discomfort, mortality, morbidity, length of stay, and cost. Methods: Using ProvIQ methodology, process confirmation cards were introduced in eight pilot units, including critical care, medical-surgical, and maternal-child specialties, from October to December 2024. ProvIQ is an evidence-based quality improvement methodology including a basket of measures from Lean, Six Sigma, and change management. This program was developed by Quality Management and was presented via Workshop to participating departments. The process confirmation cards consisted of CAUTI Prevention Maintenance Bundle and peer-to-peer feedback standard work questions. Two registered nurses (RNs) completed a process confirmation card every twelve hours for each patient with an indwelling urinary catheter (IUC). The expected number of process confirmation cards was adjusted to reflect IUC insertion or removal mid-shift. Process confirmation card completion and adherence were monitored using a unit-level visual process tracker and Daily Management System. Unit Champions and Quality Management mentors offered guidance to bedside nurses and nurse managers. Results: A total of 2,374 process confirmation cards were completed during the pilot, with an overall completion rate of 66%. Adherence to the process confirmation questions varied between 88% and 98%, with the lowest adherence observed in peri-care and catheter care. Only 52% of the process confirmation cards met full peer-to-peer feedback adherence. The analysis of the impact on post-pilot CAUTI rates and SIR will be completed prior to the conference. Conclusion: RNs reported a high level of CAUTI Prevention Maintenance Bundle adherence. They identified the need to improve peer-to-peer feedback to ensure adherence to CAUTI Prevention best practices.
Specialty/Research Institute
Nursing
Specialty/Research Institute
Quality
Comments
References
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