FirstLight Health System sought to implement a nurse-driven protocol to remove catheters when no longer necessary and engage staff to ensure they were removed in a timely manner, in an effort to reduce health care-associated infections.
- Used evidence-based best
practices to identify where catheters were appropriate as well as under what
circumstances nurses should continue the use of a catheter.
- Garnered physician support and
approval of policy.
Changes were made to the
electronic medical record to provide a hard stop requiring an approved reason to
order a catheter.
- Built in a daily reminder to
nurses asking whether it was necessary to continue catheter.
- Nurses document if catheter
should continue. If patient does not meet criteria, nurse gets order to
- Conduct coordination of care
meetings every morning and discuss patients with foley catheters and whether
it’s necessary to continue.
It is important to balance the capacity of staff to engage in new improvement efforts. The infection prevention team at FirstLight was already well established, allowing this work to be a natural extension of their efforts.
- FirstLight Health System has had only one CAUTI in each of the last two years.
- Excellent implementation of best practice process measures:
- HAI road map = 91.9%
- CAUTI gap analysis= 93%
- CLABSI gap analysis = 89%
- SSI gap analysis = 100%