Spotlight on Rounding: Dashboards Reveal Discrepancies Between Ips and Nursing Leadership

Session Description: In 2020, our 317-bed facility was facing a surge in healthcare-associated infections (HAIs). With traditional paper rounding audits, we struggled to identify key areas for improvement related to central venous catheters (CVCs) and indwelling urinary catheters (IUCs). In 2021, our Infection Preventionists (IPs) in partnership with a data analyst, transitioned paper audits to Microsoft Forms which captured rounding data electronically and integrated into Microsoft Power Business Intelligence (BI) dashboards.
The CVC dashboard is comprised of key information such as: observer role, shift, overall compliance rate, dressing integrity, catheter securement, tubing labeling, and inactive ports being capped. From January 2021 to July 2023, a total of 14,932 CVC observations have been recorded. Discrepancies were identified when comparing overall compliance rate between nursing leadership (98%), vascular access team (93%), and IPs (92%).
The IUC dashboard data components focus on observer role, shift, catheter insertion date, unobstructed flow, urinary bag and tubing being off the floor, compliance with perineal care documentation, clinical indication for IUC, etc. From January 2022 to July 2023, a total of 6,239 IUC observations have been recorded. For IUCs the overall compliance rate also varied depending on the observer: nursing leadership (99%), and IPs (89%).
The digitalization of rounding audits has enabled the aggregation of data, immediate identification of compliance trends, and has illuminated the differences in compliance between nursing leadership and IPs observations. The variance in compliance based on the observer role led our facility to investigate potential causes such as: differences in compliance between shifts, pressure to document positive data, and understanding of rounding criteria. Our target audience is IPs and nursing teams, and our goal is to bring awareness in variance of rounding to improve patient outcomes and prevent HAIs.