{"id":1945,"date":"2025-02-20T09:54:45","date_gmt":"2025-02-20T17:54:45","guid":{"rendered":"https:\/\/nursingncal.kaiserpermanente.org\/annual-report\/?p=1945"},"modified":"2025-03-05T14:30:21","modified_gmt":"2025-03-05T22:30:21","slug":"kaiser-permanente-santa-rosa-focuses-on-cauti-prevention-through-cusp-committee-initiatives","status":"publish","type":"post","link":"https:\/\/nursingncal.kaiserpermanente.org\/annual-report\/empirical-quality-outcomes\/kaiser-permanente-santa-rosa-focuses-on-cauti-prevention-through-cusp-committee-initiatives\/","title":{"rendered":"Kaiser Permanente Santa Rosa focuses on catheter-associated urinary tract infection prevention through CUSP Committee initiatives"},"content":{"rendered":"<p><span data-contrast=\"auto\">In 2022, the ICU CUSP (Comprehensive Unit-based Safety Program) Committee conducted a meeting centered on addressing the 2022 catheter-associated urinary tract infection (CAUTI) rate and analyzing a CAUTI case identified in July 2022. The team conducted a thorough chart review to identify gaps and opportunities for improvement. Key findings included:<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:240,&quot;335559739&quot;:240}\">\u00a0<\/span><\/p>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"70\" data-aria-level=\"1\"><span data-contrast=\"auto\">Inconsistent Documentation: Daily necessity documentation for the catheter was incomplete.<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<\/ul>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"71\" data-aria-level=\"1\"><span data-contrast=\"auto\">Missed Care Opportunity: One instance of missed catheter care was noted.<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<\/ul>\n<p><span data-contrast=\"auto\">These insights informed the development of an action plan designed to enhance CAUTI prevention practices. The CUSP team established a comprehensive strategy, emphasizing the reinforcement of existing practices and introducing targeted improvements:<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:240,&quot;335559739&quot;:240}\">\u00a0<\/span><\/p>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"72\" data-aria-level=\"1\"><span data-contrast=\"auto\">Multidisciplinary Rounds:<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:240,&quot;335559739&quot;:240}\">\u00a0<\/span><\/li>\n<\/ul>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"73\" data-aria-level=\"1\"><span data-contrast=\"auto\">Morning rounds include the interprofessional care team: ICU physician, primary nurse, respiratory therapist (RT), occupational therapist (OT), and physical therapist (PT).<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<\/ul>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"74\" data-aria-level=\"1\"><span data-contrast=\"auto\">The primary nurse reviews patient lines, prompting discussion of necessity, including for indwelling urinary catheters.<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<\/ul>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"75\" data-aria-level=\"1\"><span data-contrast=\"auto\">The team prioritized daily assessments and timely removal of Foley catheters.<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<\/ul>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"76\" data-aria-level=\"1\"><span data-contrast=\"auto\">High-Risk Patient Review Process:<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:240,&quot;335559739&quot;:240}\">\u00a0<\/span><\/li>\n<\/ul>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"77\" data-aria-level=\"1\"><span data-contrast=\"auto\">Introduction of a practice change to identify high-risk patients for hospital-related infections, including CAUTI.<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<\/ul>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"78\" data-aria-level=\"1\"><span data-contrast=\"auto\">Criteria included: indwelling lines\/catheters, ICU length of stay, and comorbidities.<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<\/ul>\n<ul>\n<li data-leveltext=\"\uf0b7\" data-font=\"Symbol\" data-listid=\"13\" data-list-defn-props=\"{&quot;335551500&quot;:10496915,&quot;335552541&quot;:1,&quot;335559685&quot;:810,&quot;335559991&quot;:360,&quot;469769226&quot;:&quot;Symbol&quot;,&quot;469769242&quot;:[8226],&quot;469777803&quot;:&quot;left&quot;,&quot;469777804&quot;:&quot;\uf0b7&quot;,&quot;469777815&quot;:&quot;hybridMultilevel&quot;}\" data-aria-posinset=\"79\" data-aria-level=\"1\"><span data-contrast=\"auto\">Assistant nurse managers reviewed these criteria daily to identify prevention opportunities, with findings communicated to the clinical nursing team.<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:0,&quot;335559739&quot;:0}\">\u00a0<\/span><\/li>\n<\/ul>\n<p><span data-contrast=\"auto\">In late 2022, the CAUTI reduction action plan was presented to the ICU department highlighting the reduction strategies developed collaboratively by the interprofessional team. The practices have been maintained since and following the introduction of the CUSP-driven strategies, the KP SRO ICU has not had a CAUTI for over 857 days (as of December 1<\/span><span data-contrast=\"auto\">st<\/span><span data-contrast=\"auto\">, 2024).\u00a0<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;134245418&quot;:true,&quot;134245529&quot;:true,&quot;335559738&quot;:281,&quot;335559739&quot;:281}\">\u00a0<\/span><\/p>\n<p><span data-contrast=\"auto\">The initiatives demonstrate KP SRO\u2019s dedication to improving patient outcomes through evidence-based practice, multidisciplinary collaboration, and continuous learning. These efforts reflect a proactive approach to enhancing patient safety and quality of care.<\/span><span data-ccp-props=\"{&quot;134233117&quot;:false,&quot;134233118&quot;:false,&quot;335559738&quot;:240,&quot;335559739&quot;:240}\">\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>In 2022, the ICU CUSP (Comprehensive Unit-based Safety Program) Committee conducted a meeting centered on addressing the 2022 catheter-associated urinary tract infection (CAUTI) rate and analyzing a CAUTI case identified in July 2022. The team conducted a thorough chart review to identify gaps and opportunities for improvement.<\/p>\n","protected":false},"author":2,"featured_media":2741,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_custom_body_class":"","_custom_post_class":"","footnotes":"","_links_to":"","_links_to_target":""},"categories":[1],"tags":[],"ncal_area":[97],"site_only":[],"report_year":[58],"class_list":["post-1945","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-empirical-quality-outcomes","ncal_area-santa-rosa","report_year-58","entry","has-media"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Kaiser Permanente Santa Rosa focuses on catheter-associated urinary tract infection prevention through CUSP Committee initiatives - Kaiser Permanente Northern California 2024 Annual Nursing Report<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/nursingncal.kaiserpermanente.org\/annual-report\/empirical-quality-outcomes\/kaiser-permanente-santa-rosa-focuses-on-cauti-prevention-through-cusp-committee-initiatives\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Kaiser Permanente Santa Rosa focuses on catheter-associated urinary tract infection prevention through CUSP Committee initiatives - Kaiser Permanente Northern California 2024 Annual Nursing Report\" \/>\n<meta property=\"og:description\" content=\"In 2022, the ICU CUSP (Comprehensive Unit-based Safety Program) Committee conducted a meeting centered on addressing the 2022 catheter-associated urinary tract infection (CAUTI) rate and analyzing a CAUTI case identified in July 2022. 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