The session will include an overview of a successful PDCA project to reduce CAUTI rates led by the hospitals nursing council. Tools used to understand root causes included 5 Why Analysis and a Driver Diagram. Best practice interventions supported by literature and how they were successfully implemented and sustained will be shared. After interventions, the average CAUTI Standard Infection Ratio (SIR) decreased from 1.10 to 0.18 with 0 CAUTIS in 12 out the 13 months post intervention.
Tool: Tools utilized to understand root causes during the PDCA project included 5 Why Analysis and a Driver Diagram.
Problem: Between January 2022 and January 2023, the hospitals catheter associated urinary tract infection (CAUTI) standard infection ratio (SIR) rate was 1.10, above the 0.8 benchmark. CAUTI infections impact length of stay, costs, and risk of mortality.
Tool Selection: The DMH Nursing Performance and Outcomes Council led a PDCA (plan, do, check, act) project to reduce CAUTI rates to a SIR better than benchmark. 5 Why Analysis and a Driver Diagram allowed the team to understand root causes which included variation in bathing practices and products used.
Usage: A driver diagram identified primary drivers to reduce CAUTI rates including catheter utilization, insertion, and maintenance. Analysis of patients with CAUTIs identified that infections were occurring >4 days after insertion, indicating an opportunity for improved maintenance. 5 why’s analysis allowed the team to drill down to maintenance related contributing factors.
Results: After policy revision, education, and competency on standardized CHG bathing and foley care, sharing a FAQ addressing common barriers, placing bathing product and practice grids next to supplies, and nurse leadership support, CAUTI rates decreased from 1.10 to 0.18 with 0 CAUTIS in 12/13 months post intervention.
