Spotlight on Wagoner Community Hospital’s Catheter Utilization Reduction 

Posted on: 2/14/20


Each of the Excellence in Quality Award submissions will be featured in this column over the coming weeks to highlight and share successful quality initiatives. For each submission, we will describe how the problem was identified, the improvement goal(s), interventions and outcomes. Please feel free to utilize this information, duplicate interventions, and share with your staff.

Wagoner Community Hospital received an Honorable Mention for their Catheter Utilization Reduction initiative submitted by Brandy Moore, director of quality/infection control.

Identifying the Problem: Wagoner Community Hospital identified a higher urinary catheterization rate (26.25%) than their peer group (19.42%) of “small hospitals” in the HRET HIIN project, and also higher than their goal of 10.34%. This rate is calculated by dividing the number of catheter days in all tracked units by the number of patient days in all tracked units.

The Goal: The project was initiated in January 2018. The goal was to decrease unnecessary catheter utilization to a rate of < 10.34% by July 2018 to the established improvement target of the HIIN project.

Interventions:  
  1. A multidisciplinary clinical safety team created a standing agenda item as a focus project implemented across multiple hospital units.  
  2. Referred the issue to the governing board who approved the topic as a hospital-wide strategic initiative.
  3. A nurse-driven catheter removal protocol was developed and referred to the medical executive committee for approval.
  4. Created “Indications for Catheters” educational sheets for nursing reference, defining appropriate use of catheters.  
  5. Utilized HIIN resources to assist with education resource development.
  6. Created unit-based scorecards with monthly updates to show progress to staff.
  7. Utilized scorecard to educate physicians and committees.
The Outcome: Wagoner Community Hospital met their goal in July 2018 and sustained utilization rates at or below goal for eleven months.

Comments: Multiple resources were available to Wagoner Community Hospital through their participation in the OHA HIIN (Hospital Improvement Innovation Network), including the ability to compare catheter utilization rates with over 1,500 similar-size hospitals in the HRET HIIN from across the U.S. Additionally, educational tools and webinars addressing decreasing catheter utilization best practices were available to share/utilize in the hospital.