Portneuf Medical Center CAUTI Prevention Plan Evidence-Based Guidelines Utilizing a Nurse Driven Catheter Protocol

Background Indwelling catheters are one of the main causes of hospital acquired conditions CAUTIs increase morbidity & mortality CAUTIs account for $340-450 million in additional healthcare costs annually CAUTIs are relatively preventable CMS does not reimburse for CAUTIs CDC

CAUTI & VBP CAUTI are part of Value Based Purchasing in the Patient Safety Domain - up to 2% of Medicare payments are at risk

Efforts to Reduce CAUTI Implementation of the Foley Bundle: Insert using sterile technique Hand hygiene before/after contact Secure catheter to thigh at all times Keep catheter below level of bladder Avoid dependent loops Maintain a sterile, continuously closed system Peri care daily and after incontinent stool Discontinue as soon as not required

Emphasis Has Been Care & Discontinuing as Early as Possible Bacteria is a function of time with a Foley catheter: Single event = risk for UTI < 1% 4 days = risk for UTI = 30% 30 days = risk for UTI = 95-100%

CAUTI Rates at PMC Despite our efforts we have not decreased CAUTI to zero

Why The Need For Change? Despite our efforts we have not deceased our CAUTI rate further Evidence shows that a Nurse Driven Catheter Use Protocol can reduce catheter use and catheter days = reduced CAUTI risk/rates Studies show that up to 50% of indwelling catheters are not medically necessary Often physicians do not know their patients have catheters that were placed in the OR or ED

Recommendations by CDC & ANA CDC – Centers for Disease Control; ANA – American Nurses Association Medical necessity Insertion guidelines Catheter maintenance Quality Improvement plan Administrative infrastructure Surveillance strategies How will we meet these recommendations?

Medical Necessity Acute urinary retention or bladder outlet obstruction Need for accurate measurements of output in critically ill patients Perioperative use for selected surgical patients Assist in healing of open sacral or perineal wounds in incontinent patients Patients that require prolonged immobilization To improve comfort for end of life care

Selected Surgical Patients Urologic surgery or other surgery on contiguous structures of the GU tract Anticipated prolonged duration of surgery (remove in PACU) Anticipated to receive large-volume infusions or diuretics during surgery Need for intraoperative monitoring of urinary output

Alternatives External catheters in male patients without urinary retention or bladder outlet obstruction Intermittent catheterization with bladder scanning in patients with spinal cord injuries or neurogenic bladder

Insertion Guidelines Implementation of BARD Foley Kits to assist with compliance of insertion – based on Lean process Use smallest bore catheter possible unless ordered otherwise by physician Hand hygiene before and after insertion Aseptic technique with sterile supplies National average compliance for hand hygiene in hospitals is 40-50%!

Catheter Maintenance Continue to utilize the Foley Bundle Avoid irrigation unless obstruction is anticipated – requires a physician’s order Use soap and water for routine pericare – avoid antiseptics in the periurethral area

Quality Improvement Plan All patients that need or may need indwelling catheters will have Nurse Driven Catheter Protocol orders CPOE order sets for Nurse Driven Catheter Protocol unless patient is excluded Exclusions will require LIP documentation CAUTI Prevention Team to assess compliance with protocol & Foley Bundle

Administrative Infrastructure Nurses will demonstrate annual competencies for insertion and care/maintenance CAUTI Prevention Team will monitor compliance and provide immediate education for variances in protocol and bundle Catheters will be removed if medical necessity is not met, unless excluded by physician

Surveillance All patients that receive indwelling catheterization will be monitored by the team Urinary tract infections are defined using National Health Safety Network criteria Date of event (DOE) is the date when the first element used to meet UTI criteria occurred Location of attribution is the location where the patient was assigned on the date of the UTI event (see transfer rule)

Surveillance (continued) CAUTI is defined as a UTI where an indwelling urinary catheter was in place for > 2 calendar days on the date of event (UTI), with day of device placement being Day 1 and an indwelling urinary catheter was in place on the date of event or the day before i.e. if a patient is diagnosed with a UTI the day after catheter is placed, this is NOT a CAUTI

Surveillance (continued) Transfer rule: if the date of event for the CAUTI is within 2 days of transfer or discharge, the infection is attributed to the transferring or discharging location In instances where a patient has been transferred to more than one location on the date of a UTI, or the day before, attribute the UTI to the first location in which the patient was housed the day before the UTI’s date of event

CAUTI Criterion (Symptomatic) OR (seen next slide)

CAUTI Criterion (Symptomatic)

CAUTI Criterion (Asymptomatic)

CDC/ANA Evidence-Based RN Tool

CDC/ANA Evidence-Based RN Tool

CDC/ANA Evidence-Based RN Tool Bottom of Page 2:

CDC/ANA Evidence-Based RN Tool

Conclusion A practice change needs to occur to further drive down our CAUTI risk/rate Nurses spend an entire shift with patients, physicians see them for a short window each day – nurses can assess better the need for catheter placement and continuation unless patient is excluded by physician It takes a team to reduce hospital acquired conditions