Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI [email protected] On the CUSP: Stop CAUTI 1 Implementing.

Pat Posa RN, BSN, MSASystem Performance Improvement Leader

St. Joseph Mercy Health SystemAnn Arbor, MI

[email protected]

On the CUSP: Stop CAUTI

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Implementing CUSP to Eliminate Catheter-Associated Urinary Tract Infections (CAUTI)

Overview

• Overview of CAUTI

• Comprehensive Unit-Based Safety Program (CUSP) to eliminate

CAUTI

• 4E’s to CAUTI

– Engage: How does this make the world a better place?

– Educate: How will we accomplish this?

– Execute: What do we need to do?

– Evaluate: How will we know we made a difference?

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CUSP & CAUTI Interventions

1. Educate on the science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from Defects

5. Implement teamwork & communication tools

CUSP CAUTI

1. Care and Removal Intervention

Removal of unnecessary catheters

Proper care for appropriate catheters

2. Placement Intervention

Determination of appropriateness

Sterile placement of catheter

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Project Goals

• Reduce CAUTI rates in participating units by 25%– Appropriate placement– Appropriate continuance– Appropriate utilization

• Improve patient safety culture on participating units

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Healthcare-Associated Infections (HAI’s)ENGAGE: Why should we do this?

• CAUTI are the most common HAI, accounting for 35% of all HAI’s

• At least 20% of episodes are preventable; perhaps as much as 70%

(Harbath et al. J Hosp Infect 2003)

• Preventive practices are variably used

• Medicare no longer reimburses U.S. hospitals for the additional costs of certain infections

• CAUTI prevention is part of the 2012 National Patient Safety Goal

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Healthcare Facility HAI Reporting to CMS via NHSN – Current and Future Requirements

HAI Event Facility Type Reporting Start Date

CLABSIAcute Care Hospitals

Adult, Peds, and Neonatal ICUsJanuary 2011

CAUTIAcute Care Hospitals

Adult and Pediatric ICUsJanuary 2012

SSIAcute Care Hospitals

Colon and abdominal hysterectomyJanuary 2012

CLABSI Long Term Care Hospitals * October 2012

CAUTI Long Term Care Hospitals * October 2012

CAUTI Inpatient Rehabilitation Facilities October 2012

MRSA Bacteremia Lab ID Acute Care Hospitals – facility wide January 2013

C. difficile LabID Event Acute Care Hospitals – facility wide January 2013

HCW Influenza Vaccination Acute Care Hospitals January 2013

* Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN

CMS 2012 IPPS final rule released; August 2011 Federal Register

Urinary Catheter-Related Infection: Background

• Urinary tract infection (UTI) causes ~ 40% of hospital-acquired infections

• Most infections due to urinary catheters

• Up to 25% of inpatients are catheterized

• Leads to increased morbidity and costs

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Burden-of-illness

• Of patients who receive urethral catheters:

– Bacteriuria rate is ~5% per day

• Among those with bacteriuria:

– ~10% will develop symptoms of UTI

– Up to 3% will develop bacteremia

• Direct medical costs:

– Symptomatic UTI: ~$600 per episode

– Bacteremia: ~$3000 per episode (Tambyah et al. ICHE 2002; Saint AJIC 1999)

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Clinical Manifestations of CAUTI

• Clinical manifestations vary greatly

• Asymptomatic bacteriuria overwhelming sepsis

• Symptomatic UTI:

– Lower abdominal, suprapubic, or flank pain

– Systemic symptoms: nausea, vomiting, fever

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Pathogenesis of CAUTI• Source: colonic or perineal flora

on hands of personnel• Microbes enter the bladder via

extraluminal {around the external surface} (proportion = 2/3) or intraluminal {inside the catheter} (1/3)

• Daily risk of bacteriuria with catheterization is 3% to 10%; by day 30 = 100%

– Maki DG EID 2001

Intraluminal Extraluminal

Detrusor spasm Shedding of cells Bacteremia

Leakage Obstruction Fever (+) UA Hypotension

Bladder infection with inflammation

Urinary Catheter-Related Infection: Pathophysiology

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The Indwelling Urinary Catheter:A “1-Point” Restraint?

Satisfaction survey of 100 catheterized VA patients:

• 42% found the indwelling catheter to be uncomfortable

• 48% stated that it was painful

• 61% noted that it restricted their ADLs

• 2 patients provided unsolicited comments that their catheter “hurt like hell”

(Saint et al. JAGS 1999)

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Saint S, et al ICHE 2010 13

A Model For Implementation Science

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Core Prevention Strategies:(All Category IB)

Educate: How will we accomplish this?

Catheter Use

InsertionMaintenance

• Insert catheters only for appropriate indications• Leave catheters in place only as long as needed

• Ensure that only properly trained persons insert and maintain catheters

• Insert catheters using aseptic technique and sterile equipment (acute care setting)

• Following aseptic insertion, maintain a closed drainage system

• Maintain unobstructed urine flow

Hand Hygiene

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Quality Improvement Programs

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Make sure the catheter is indicated

• Adhere to general infection control principles (eg, aseptic insertion, proper maintenance, hand hygiene, education, feedback)

• Remove the catheter as soon as possible

• Consider other methods of prevention

Prevention of Catheter- Associated UTI

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Table. 2 Appropriate indications for indwelling urethral catheter use

Patient has acute urinary retention or obstruction

Need for accurate measurements of urinary output in critically ill patients

Perioperative use for selected surgical procedures: Patients undergoing surgery or other surgery on contiguous structures of the GU

tract Anticipated prolonged duration of surgery (these should be removed in PACU) Patients anticipated to receive large-volume infusions or diuretics during surgery Operative patients with urinary incontinence Need for intraoperative monitoring of urinary output

To assist in healing of open sacral or perineal wounds in incontinent patients

Patient requires prolonged immobilization (e.g. potentially unstable thoracic or lumbar spine)

To improve comfort for end of life care if needed

Indwelling catheters should not be used: As a substitute for nursing care of the patient or resident with incontinence As a means of obtaining urine for culture or other diagnostics when the patient can

voluntarily void Prolonged post-operative duration without appropriate indications Routinely for patients receiving epidural anaesthesia/analgesia

Why are Catheters Used Inappropriately?

• Perhaps physicians “forget” that their patient has a urinary catheter

• We determined the extent to which doctors are aware which of their inpatients have catheters

• Surveyed 56 medical teams at 4 sites

(Saint S, Wiese J, Amory J, et al. Am J Med 2000)

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One Reason Catheters Are Used Inappropriately

Level Proportion Unaware of the Catheter

Medical students 18%

House officers 25%

Attending physicians

38%

(Saint S, Wiese J, Amory J, et al. Am J Med 2000)

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Urinary Catheters Often Placed in the Emergency Department: A National U.S. Study

• Catheters often inserted without clear indications and may remain in place for convenience rather than medical necessity

• An Infection Control Nurse: “our other barrier is the Emergency Department and this is where most Foleys are placed. . . . Doctors forget to look under the sheets to say, ‘Oh yeah, there’s a Foley there’ and … the nurses aren’t going to take the initiative. . . ”

(Saint et al. Infect Cont Hosp Epid 2008)

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QUESTION ???

What barriers are you facing—or anticipate to face related to these indications?

• In the ICU?• In the ED?• With specific patient populations?

– IE: patient’s with epidurals

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• Make sure the catheter is indicated

Adhere to general infection control principles (e.g., aseptic insertion, proper maintenance, hand hygiene, education, feedback)

• Remove the catheter as soon as possible

• Consider other methods of prevention

Prevention of Catheter- Associated UTI

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CAUTI Prevention: HICPAC Recommendations, CA-UTI

II. Proper Techniques for Urinary Catheter Insertion – Perform hand hygiene immediately before and after insertion or any

manipulation of the catheter device or site . (Cat. IB) [see also:Ehrenkranz NJ ICHE 1991;12:654-62 - alcohol handrub much more effective than handwash]

– Ensure that only properly trained persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Cat.IC)

– Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (Cat.IC)

• NEJM Videos in Clinical Medicine:

– Male Urethral CatheterizationT. W. Thomsen and G. S. Setnik - 25 May, 2006

– Female Urethral CatheterizationR. Ortega, L. Ng, P. Sekhar, and M. Song - 3 Apr, 2008

• Goal is to avoid contamination of the sterile catheter during the insertion process

• Should not assume that the healthcare workers inserting urinary catheters know how to do so

Use Proper Aseptic Technique for Catheter Insertion

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• Make sure the catheter is indicated

• Adhere to general infection control principles (eg, aseptic insertion, proper maintenance, hand hygiene, education, feedback)

Remove the catheter as soon as possible

• Consider other methods of prevention

Prevention of Catheter-Associated UTI

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Early Removal of Indwelling Catheters: Summary of the Evidence

• 14 studies have evaluated urinary catheter reminders and stop-orders (written, computerized, nurse-initiated)

– Significant reduction in catheter use

– Significant reduction in infection

– No evidence of harm (ie, re-insertion)(Meddings J et al. Clin Infect Dis 2010)

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Nurse-Initiated Removal of

Unnecessary Urinary

Catheters Program

Baseline: Collect urinary catheter prevalence with evaluation for indications (15 days).

Implementation: nursing staff education, daily assessment of urinary catheters and evaluation for indications, and discussion with nursing staff about removal of non-indicated catheters. Rationale given to obtain order to discontinue unnecessary urinary catheters with nursing (10 days).

After Implementation: urinary catheter prevalence and indications, one day a week for 6 weeks (6 days). Patient’s nurse to daily assess need for catheter.

Weeks 1 - 3

Weeks 5 & 6

Weeks 7 - 12

QuarterlySustainability: urinary catheter prevalence and indications, 1 week quarterly (5 consecutive days) for 5 quarters. Patient’s nurse to daily assess need for catheter.

Data review and unit feedback

Week 4 Prepare for implementation.

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QUESTION ???

How many people have or are considering a nurse driven protocol for urinary catheter removal??

If so—what barriers are you anticipating?

• Make sure the catheter is indicated

• Adhere to general infection control principles (eg, aseptic insertion, proper maintenance, hand hygiene, education, feedback)

• Remove the catheter as soon as possible

Consider other methods of prevention

Prevention of Catheter-Associated UTI

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• Alternatives to the indwelling catheter

–Bladder ultrasound

–Intermittent catheterization

–Condom catheter

Other Methods for Preventing CAUTI

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• Nurse driven protocols

• Decision algorithm

• Reminders/flags

• Reviewed daily on rounds

• Daily screening

Execute: What do we need to do?

Microsoft Word 97 - 2003 Document

C:\Users\Pat\Desktop\Kansas City and Miss

Pocket Card

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Remove that Urinary Catheter!

Foley catheters can cause:

Infections

Length of Stay Cost Patient Discomfort Antibiotic Use

Urinary Catheters confine patients to bed, making them more immobile and thus increasing their risk for skin breakdown.

PREVENTION IS KEY.

OBTAIN ORDERS TO DISCONTINUE UNNECESSARY URINARY

CATHETER!

Remove that Urinary Catheter!

Foley Catheters are indicated for:

Acute urinary retention or obstructionPerioperative use in selected surgeriesAssist healing of perineal and sacral wounds in incontinent patientsHospice/comfort/ palliative careRequired immobilization for trauma or surgeryChronic indwelling urinary catheter on admissionAccurate measurement of urinary output in the critically ill patients (intensive care)

Foley Catheters are not indicated for:Urine output monitoring OUTSIDE intensive careIncontinence (place on toileting routine, change frequently)Prolonged postoperative usePatients transferred from intensive care to general unitsMorbid obesityImmobility (turn patient q 2 hours, up in chair)Confusion or dementiaPatient request

Evaluate: How will we know we made a difference?

Outcome Measures:•UTI rate/1000 patient days•UTIs / 1000 catheter days

Process Measures:•UC days/ 1000 patient days•Percent appropriate catheters/total number of catheters

CUSP & CAUTI Interventions

1. Educate on the science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from Defects

5. Implement teamwork & communication tools

CUSP CAUTI

1. Care and Removal Intervention

Removal of unnecessary catheters

Proper care for appropriate catheters

2. Placement Intervention

Determination of appropriateness

Sterile placement of catheter

The Michigan Keystone ICU Project saved over 1,500 lives and $200 million by reducing health care

associated infections.

Office of Health Reform, Department of Health and Human Services

“Needs Improvement” Statewide Michigan CUSP ICU Results

• Less than 60% of respondents reporting good safety climate = “needs improvement”• Statewide in 2004 84%

needed improvement, in 2007 23%

• Non-teaching and Faith-based ICUs improved the most

• Safety Climate item that drives improvement: “I am encouraged by my colleagues to report any patient safety concerns I may have” 37

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No BSI 21%No BSI 21% No BSI 44%No BSI 44% No BSI 31% No BSI 31%

No BSI = 5 months or more w/ zero

The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care

Health Services Research, 2006;41(4 Part II):1599.

Can we change practice through Can we change practice through process improvement alone?process improvement alone?

Can we change practice through Can we change practice through process improvement alone?process improvement alone?

or

Will successful change require Will successful change require an altering of the value structure an altering of the value structure

within the unit?within the unit?

Will successful change require Will successful change require an altering of the value structure an altering of the value structure

within the unit?within the unit?

How to Get Successful Results

• Both nurses and physicians should evaluate the indications for urinary catheter utilization

• Physicians should promptly discontinue catheters when no longer needed

• Nurses evaluating catheters and finding no indication should contact the physician to promptly discontinue the catheter

• Partner with different disciplines (e.g., case management, nursing, infection prevention) to successfully achieve your goals

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How to Sustain Your Success• After implementing the program, identify unit champions to

promote the need to evaluate the appropriateness of urinary catheter use

• Incorporate the following questions during nursing rounds:– Does the patient have a urinary catheter? – What is the reason for use?

• Provide feedback on performance to nurse managers related to prevalence of utilization

• If no improvement in utilization is seen, evaluate appropriateness of utilization (indications vs. non-indications)

• The long term goal is for the patient care nurses to own the process of evaluation of urinary catheter need

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• Leadership support is crucial• Define barriers to implementation• Obtain physician and nursing buy-in• Provide alternatives to the “Foley” catheter• Look closely at the emergency department and

intensive care units. Both areas utilize a high number of urinary catheters

• Learn from defects and continue to improve process

Additional Areas to Address

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QUESTIONS???