EP - Exemplary Professional Practice

EP7EO: Care Delivery System(s)-Describe and demonstrate two (2) improvements in the practice setting that occurred as a result of the use of internal experts or external consultants.


Example 1: Medical Equipment Reprocessing: a practice improvement due to the use of an external consultant was not demonstrated:

  • Two years of continuous data were presented, but the time period of intervention that involved the external consultant and nurses was not specified. Therefore, pre and post implementation data could not be determined to demonstrate improvement

Example 2: Insulin Drip Protocol: a practice improvement due to the use of an internal expert wan not demonstrated

  • The graphed data presented was not dated but appeared to be, from the narrative description between May and June 2010 which was before many interventions described between June and November, 2010. No data after the interventions were provided
  • It was not clear how the graphed data related to the stated goal of the initiative


Example 1:

  • The requested timeline has been supplied
  • Additional data provided

Example 2: Has been replaced

Example 1: External Consultants – Medical Equipment Reprocessing


Decrease usage of reprocessing items at JCMC contributing to increase costs and environmental waste


  • Lower medical device and equipment cost
  • Increase use of reprocessed equipment
  • Reduce amount of environmental waste


A team of nurses and external consultants were formed in January of 2010. Mark Muller an external consultant from STERILMED provided extensive support and guidance during this process. Several months were spent selecting and evaluating devices and providing education ( Appendix EP7E0-A and EP7EO-B ) to the nurses and physicians affected by the change in products. All products selected for reprocessing was implemented in phases. In addition, educational opportunities, product evaluation, and trouble shooting of products maintained on going throughout the post intervention period




Pre-Intervention Data 

Reprocessing 9/09 to 8/10

Estimated Savings 9/09 – 8/10

Estimated Savings 9/09 – 8/10

Estimated Savings 9/09 – 8/10


Reprocessing 9/10 to 8/11

Reprocessing 9/10 to 8/1 

Estimated Savings 9/10 – 8/11

Estimated Savings 9/10 – 8/11 

Reprocessing 9/11 to 8/12

Reprocessing 9/11 to 8/12  

Estimated Savings 9/11 – 8/12

Estimated Savings 9/11 – 8/12 



Example 2 –  New Example – Decreasing Foley Catheter Days on 7W using “On The CUSP – Stop CAUTI” methodology.

Purpose and Background

The Jersey City Medical Center partnered with the New Jersey Hospital Association (NJHA) and joined a quality/safety initiative in preventing catheter -associated urinary tract infections (CAUTIs). It is part of the NJHA Institute for Quality and Patient Safety and uses evidence-based interventions and the Comprehensive Unit-based Safety Program (Appendix EP7EO-C). The CUSP methodology is transforming care and patient safety in hospital units by improving patient safety culture and practices.

Urinary tract infections are commonly associated with the increased usage of indwelling urethral catheters. Nurses at JCMC must advocate for the appropriate use of indwelling urethral catheters to promote best patient outcomes. Reducing urinary catheter days and ensuring appropriate care of the catheter are key components that must be imbedded in everyday nursing practice.


  • Reduce urinary catheter days
  • Reduce the incidence of CAUTI
  • Maintain below NHSN Median benchmarks


Vickie DeChirico MSN, RN, Director of Infection Control Department functioned as the internal expert who led and coordinated this effort. 7W was chosen as the pilot unit for this initiative as a result of their high CAUTI rates and urinary catheter days. On the CUSP –Stop CAUTI was started in 2012 on 7 West, under the direction of Claire Cinelli BSN, RN, Nurse Manager, and Unit Champions Coleen Calero BSN, RN, Charge RN and Yvette Bryant MSN, RN, Staff nurse

Methods or Approach

Education was provided to all staff nurses on 7W regarding “On the CUSP-Stop CAUTI” initiative including strategies for CAUTI prevention and daily evaluation of catheter necessity (Appendix EP7EO-D).

Under the guidance of Ms. DeChirico indications for urinary catheter use were standardized to include the following:

  • Perioperative use for selected surgical procedures
  • Urine output monitoring in critically ill patients
  • Management of acute urinary retention and urinary obstruction
  • Neurogenic bladder
  • Assistance in pressure ulcer healing for incontinent residents
  • Hopice/Palliative Care at patient request to improve comfort (i.e. end of life care)

In addition, CAUTI bundles were reinforced. The Bundles included the following:

  • Avoiding unnecessary urinary catheterization
  • Insertion of catheters using aseptic technique
  • Ensuring urinary catheter is secured to patient
  • Maintaining the drainage bag below level of bladder
  • Assessing quality of urine output
  • Reviewing daily for catheter necessity
  • Removal of Catheter as soon as possible

In addition to the application of the bundle by all nursing staff, Ms Callero and Ms. Bryant make rounds on a daily basis to review catheter necessity and indication for use. They make recommendations to the healthcare team regarding early removal of the catheter when appropriate. A rounding tool is utilized (Appendix EP7EO-E)


The below graph reflects reduced Foley days by 423 and 0 CAUTIs on 7 West for 2012. A reduction from 4 infections in 2011 to zero infections in 2012 was also achieved. This led to a reduction of CAUTI rates below NHSN median Benchmark. Due to the success of this initiative, all medical surgical units are now adapting this methodology

Baseline Data 2011

Baseline Data 2011 

Post Intervention Data 2012

Post Intervention Data 2012