Current Initiatives

Safety Attendant

Implementation of AvaSure and decision making regarding sitter use

AvaSys is a remote patient observation system that enables audio and visual monitoring of patients at risk for falls. It is the first line of defense for patients at risk, allowing staff to immediately and directly intervene when a patient is at risk of self-harm. The technology is deployed as a portable, wireless unit.

Project manager: :

Elizabeth Sin, MS, BSN, CCRN, Unit Director, Centralized Telemetry/Vascular Access Team


  • Florlina Agudelo, BSN, RN, BMTCN, Unit Director, Adult Hematology, Oncology and BMT
  • Julie Anderson, RN, Clinical Nurse, Adult Hematology, Oncology and BMT
  • Brett Austin, RN, Unit Director, Nursing Hospital Supervisors
  • Karri Ballard, RN, Assistant Patient Care Manager, Adult Hematology, Oncology and BMT
  • Lindsay Bolt, MS, RN, CMSRN, Clinical Nurse Educator, Adult Acute and Transitional Care
  • Irish Criseno, BSN, RN, Unit Director, Central Resource Group
  • Amy Dunne, MS, RN, ACCNS-AG, CCRN, Adult Critical Care Clinical Nurse Specialist
  • Kiran Gupta, MD, MPH, Assistant Professor of Medicine
  • Craig Johnson, MSN, RN-BC, FNP, Clinical Nurse Informaticist
  • Sudha Lama, BSN, RN, Clinical Nurse, 8L Neurosciences Acute Care
  • Melissa Lee, MS, RN, CNS, Adult Acute and Transitional Care Clinical Nurse Specialist
  • Michelle Macal, MS, RN, CNS, Adult Acute and Transitional Care Clinical Nurse Specialist
  • Carrie Meer, MS, RN, CNS, CPHQ, Interim Director, Nursing Performance Improvement
  • Jennifer Miranda, MSN, MBA, RN, Unit Director, 15L Acute Medicine
  • Mary Moore, MS, RN, CPHQ, Performance Improvement Nurse
  • Annette Neill, BSN, RN, SCRN, Assistant Patient Care Manager, 8L Neurosciences Acute Care
  • Andrea Plati MSN, RN, OCN, Unit Director, Adult Hematology, Oncology and BMT
  • Mary Reid, BSN, RN, NE-BC, Unit Director, 6L Adult Neurological Transitional Care and 8L Neurosciences Acute Care
  • Stephanie Rogers, MD, MPH, Assistant Professor of Medicine, Division of Geriatrics
  • Krystle Rowlands, RN, Clinical Nurse, 8L Neurosciences Acute Care
  • Katie Segev, MS, RN, OCN, Assistant Patient Care Manager, Adult Hematology, Oncology and BMT
  • Marjorie Smallwood, MPH, Manager, Workplace Violence Prevention Program
  • Julie Vavuris, BSN, CCRN, Assistant Unit Director, Central Resource Group

Reduce Use of CXRs for PICC Placement Confirmation

Project manager: 

  • Elizabeth Sin, MS, BSN, CCRN, Unit Director, Centralized Telemetry/Vascular Access Team


  • Sheila Antrum, RN, MHSA, President, UCSF Medical Center, Senior VP, Adult Services, UCSF Health
  • Tina Mammone, PhD, RN, CENP, NEA-BC, Vice President and Chief Nursing Officer


Adult Vascular Access Team members:  Anna Liang, MS, RN, CPNP-AC, VA-BC; Lynne Tom, MSN, RN, VA-BC; Michele Nomura, MSN, RN, VA-BC;  Yunhee Lee, BSN, RN, VA-BC; Todd Dayton, BSN, RN; Vivian Phan, RN; Kenichi Uyeda, RN, VA-BC; Shannon Sutherland, RN, VA-BC


Elimination of confirmatory chest x-ray in selected patient population for tip location of Peripherally Inserted Central Catheter (PICC) utilizing electrocardiogram (ECG) based technology. This methodology is endorsed by the Infusion Nurses Society as it allows greater accuracy, more rapid initiation of infusion therapies, and reduction of radiation exposure as well as reduces costs for patient care.  

How the Neurological Intensive Care Unit at UCSF Decreased CAUTI events by 28%

Neurological patients in the critical care setting are uniquely at risk for CAUTI due to cognitive, motor, and sensory deficits. In fiscal year 2016, the Neurological Intensive Care Unit had 32 CAUTIs, which contributed to 42% of the total adult hospital-wide CAUTI harm events.

Beginning FY2017, 8/11 NICU’s goal was to support the institution’s effort to reduce harm events by decreasing CAUTI incidence from FY2016’s baseline of 32 events by at least 2 events (5%).

Team Members:   

  • Theresa Mueller, MS, RN, CCRN Assistant Patient Care Manager 8/11 Neurological Intensive Care Units
  • Susan Chim, MAT, Associate Lean Consultant
  • Janice Elzinga, MSN, RN, CNL, CCRN, Assistant Patient Care Manager 8/11 Neurological Intensive Care Units
  • Kelly Bushman, BSN, RN, CNRN, Unit Director 8/11 Neurological Intensive Care Units
  • Amy Dunne, MS, RN, ACCNS-AG, CCRN Clinical Nurse Specialist – Adult Critical Care
  • Nerissa U. Ko, MD, MAS, FANA, FNCS, Professor of Neurology, UCSF Neurovascular and Neurocritical Care, Medical Director of 8/11 Neurological Intensive Care Units

•        #1 Barrier/Root Cause: Due to an increased risk of urinary retention, incontinence, and altered mental status, patients with acute and chronic neurologic disorders often have extended durations of urinary catheterization. This is problematic considering the duration of catheterization is itself an important risk factor in the development of CAUTI. The risk of acquiring a CAUTI increases 3-7% each day the catheter remains indwelling. The average LOS in this NICU is 3 calendar days with 30% of neurological patients staying 72 hours or greater, often with indwelling urinary catheters in place.

•        Hypothesis: If we can prevent bacterial growth in patients with indwelling urinary catheters, then we can decrease CAUTI.

•        Intervention: Silver alloy coated catheters have natural antimicrobial properties. While evidence is equivocal on their efficacy, these catheters are recommended in clinical populations with a high incidence of CAUTI. For this project, these special catheters were used for patients with a length of stay greater than 72 hours.

•        #2 Barrier/Root Cause: 8/11 NICU had 2nd highest number of urine cultures ordered per 100 pt days across all inpatient units; possibly contributing to high rates of CAUTI due to high volumes of urine specimens sent for culture. Inappropriate ordering of urine cultures may also result in false-positive results, i.e. a colonized catheter or bladder

•        Hypothesis: If urine cultures are reserved for only those patients with positive urinalysis, number of false-positive urine cultures.

•        Intervention: The unit workflow was revised to wait for positive urinalysis results prior to ordering and sending urine specimens for culture. This ensured only urine specimens with a positive urinalysis were cultured, reducing false positive urine cultures results due to colonization.

•        #3 Barrier/Root Cause: Since FY15, greater than 50% of all positive CAUTIs in 8/11 NICU contained E. Coli or enterococcus bacteria, which are bacteria primarily found in stool.

•        Hypothesis: If we can prevent urinary tract contamination from stool, we can decrease the number of CAUTIs.

•        Intervention: One on one clinical bedside education of all RNs and PCAs was provided in situ by unit CAUTI champions and focused on fecal management strategies, proper urinary catheter and perineal cleaning techniques, and appropriate indications of indwelling urinary catheter necessity. 

•        #4 Barrier/Root Cause: There was minimal real-time feedback to front line clinicians on compliance with project interventions as outlined above.

•        Hypothesis: If nursing staff receive real-time feedback on areas needing improved compliance, they can adjust their behaviors to course-correct.

•        Intervention: Distributed information to staff on “root cause” of each CAUTI event in the NICU. This information and feedback provided increased awareness of the project and the progress being made. Additionally, this information serves to empower nurses to effectively advocate to other members of the inter-professional team that may not be aware of unit initiatives. 

Outcome: By addressing the identified barriers and root causes of CAUTI, the NICU decreased CAUTI events by 28% from 32 events in FY2016’s to 23 events in FY 2017.


    STEADI Implementation and Evaluation at UCSF Medical Center

    • Daphne Stannard, RN, PhD, Co-PI
    • Andy Auerbach, MD, Co-PI
    • Stephanie Rogers, MD, Investigator
    • Melissa Lee, RN, MS, CNS-BC, Investigator
    • Laurie Kramer, PT, Investigator

    The STEADI Implementation and Evaluation project at UCSF Medical Center is both a quality improvement initiative and a research project.  Sponsored by the Centers for Disease Control (CDC), the aim of this project is to implement and evaluate the effectiveness and feasibility of the CDC STEADI Algorithm in an inpatient hospital setting to reduce falls in the elderly population. 

    Start Small: The Premie Project

    An Interdisciplinary Project to Improve Neurodevelopmental Outcomes in the ELBW.

    • Robin Bisgaard RN, MSN
    • Tanya Kamka RN, MSN
    • Samantha Wynn BSN
    • Kathryn Morrison BSN
    • Amber Mason BSN
    • Ana Estrada Yost BSN
    • Sara Paredes BSN
    • Melissa Liebowitz MD
    • Elizabeth Rogers MD

    The Preemie Project is a quality improvement project to improve neurodevelopmental outcomes in our smallest patients (less than 28 weeks gestation or less than 1500 grams). Interdisciplinary teams set out to examine the current evidence and implement a bundle of practice changes.

    Interdisciplinary teams included nurses, physicians, nurse practitioners, respiratory therapists, physical therapists, occupational therapists. Teams were formed based on areas of professional interest and expertise. The initial resuscitation, the first 72 hours, respiratory management, blood pressure management, nutrition and developmental care were the primary groups. An additional group of neurodevelopmental team members consulted in a broader purpose for the overall project. An additional group examined periviability counseling and communication between OB services and the Intensive Care Nursery. Teams reviewed current literature and proposed relevant practice changes; these changes were implemented as a “Premie Project” bundle and included education for each discipline. Nursing education coincided with Annual Review, almost 100% of nursing staff received the education course. Additionally, interdisciplinary teams traveled to other departments, including radiology and echocardiography for education presentations.

    Project successes have shown significant improvement in the incidence of Intraventricular hemorrhage (IVH) in our patients less than 28 weeks, from 12.8% in the year prior to 10.0% in first six months of the protocol. Change in practice is often met with some resistance. The interdisciplinary approach and engagement has helped the team work together in formulating and following guidelines One challenge we have noted is in the initial resuscitation; as new staff are trained, ongoing mentoring and education is needed.  The initial project focused primarily on a chronological timeline from antenatal through the first 2 weeks. Next steps will focus on best practices based on current evidence for the less than 28 week infant after the first 2 weeks of life.

    “The project holds us accountable across disciplines”  Respiratory Therapist

    “My care practices can make a big difference in our smallest patients”  Nurse

    “This project is great, we are all on the same page”  Nurse

    “Purple power…I love knowing that my daughter’s team is doing everything they can to help her outcome”  Mother