1 © 2010 TMIT NQF-Endorsed ® Safe Practices for Better Healthcare Safe Practice 25 Catheter-Associated Urinary Tract Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections

© 2006 HCC, Inc. CD XX 2 © 2010 TMIT Slide Deck Overview Slide Set Includes:  Section 1: NQF-Endorsed ® Safe Practices for Better Healthcare Overview  Section 2: Harmonization Partners  Section 3:The Problem  Section 4: Practice Specifications  Section 5: Example Implementation Approaches  Section 6: Front-line Resources

3 © 2010 TMIT NQF-Endorsed ® Safe Practices for Better Healthcare Overview Safe Practice 25 Catheter-Associated Urinary Tract Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections

4 © 2010 TMIT 34 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness 2010 NQF Safe Practices for Better Healthcare: A Consensus Report

5 © 2010 TMIT Culture SP NQF Report

CHAPTER 7: Healthcare-Associated Infections Hand Hygiene Influenza Prevention Central Line-Associated Blood Stream Infection Prevention Surgical-Site Infection Prevention Daily Care of the Ventilated Patient MDRO Prevention Catheter-Associated UTI Prevention Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- and Site-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Press. Ulcer Prevention VTE Prevention Anticoag. Therapy VAP Prevention Central Line-Assoc. BSI Prevention Sx-Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Leadership Structures and Systems Med. Recon. Culture CPOE Read-Back & Abbrev. Discharge Systems Patient Care Info. Labeling Diag. Studies Culture Meas., FB., and Interv. Structures and Systems Risk and Hazards Team Training and Skill Bldg. Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 2: Creating and Sustaining a Culture of Safety (Separated into Practices]  Culture of Safety Leadership Structures and Systems  Culture Measurement, Feedback, and Intervention  Teamwork Training and Skill Building  Risks and Hazards CHAPTER 5: Information Management and Continuity of Care  Patient Care Information  Order Read-Back and Abbreviations  Labeling Diagnostic Studies  Discharge Systems  Safe Adoption of Computerized Prescriber Order Entry CHAPTER 6: Medication Management  Medication Reconciliation  Pharmacist Leadership Structures and Systems CHAPTER 8: Condition- and Site-Specific Practices Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention Pressure Ulcer Prevention VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Organ Donation Glycemic Control Falls Prevention Pediatric Imaging Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 3: Consent and Disclosure Informed Consent Life-Sustaining Treatment Disclosure Care of the Caregiver Consent and Disclosure Care of Caregiver MDRO Prevention UTI Prevention Falls Prevention Organ Donation Glycemic Control Pediatric Imaging

7 © 2010 TMIT Harmonization Partners Safe Practice 25 Catheter-Associated Urinary Tract Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections

8 © 2010 TMIT Harmonization – The Quality Choir

9 © 2010 TMIT The Patient – Our Conductor

© 2006 HCC, Inc. CD XX 10 © 2010 TMIT The Objective Catheter-Associated Urinary Tract Infection Prevention  Prevent healthcare-acquired catheter-associated urinary tract infections (CAUTIs)

11 © 2010 TMIT The Problem Safe Practice 25 Catheter-Associated Urinary Tract Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections

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© 2006 HCC, Inc. CD XX 14 © 2010 TMIT The Problem

© 2006 HCC, Inc. CD XX 15 © 2010 TMIT The Problem Frequency  CAUTIs are the most frequent HAIs in acute care hospitals  80% are attributable to an indwelling urethral catheter  CAUTIs are associated with increased morbidity, mortality, hospital cost, and length of stay [Saint, Infect Control Hosp Epidemiol 2000 Jun;21(6):375-80; Saint, Infect Dis Clin North Am 2003 Jun;17(2):411-32]

© 2006 HCC, Inc. CD XX 16 © 2010 TMIT The Problem Severity  Between 15%-25% of hospitalized patients may receive short-term indwelling urinary catheters  In 2002, the Centers for Disease Control and Prevention estimated that 561,667 CAUTIs occurred in the United States, contributing to 13,088 deaths [Warren, Int J Antimicrob Agents 2001 Apr;17(4): ; Weinstein, Infect Control Hosp Epidemiol 1999 Aug;20(8):543-8; Klevens, Public Health Rep 2007 Mar-Apr;122(2):160-6]

© 2006 HCC, Inc. CD XX 17 © 2010 TMIT The Problem Preventability  Estimated to be 17%-69% with recommended infection control measures  380,000 preventable infections and 9,000 preventable deaths related to CAUTI annually  Limiting catheter use and minimizing the duration the catheter remains in situ are principal strategies for CAUTI prevention  Use of an antimicrobial or silver alloy-coated catheter reduces risk of CAUTIs [Saint, Infect Dis Clin North Am 2003 Jun;17(2):411-32; Kanouff, Crit Care Nurs Q 2008 Oct-Dec;31(4):302-8; Ciavarella, Infect Control Hosp Epidemiol 2009 Apr;30(4):404-5; author reply 405-6; Parker, J Wound Ostomy Continence Nurs 2009 Jan-Feb;36(1):23-34]

© 2006 HCC, Inc. CD XX 18 © 2010 TMIT The Problem Cost Impact  The annual direct medical cost of CAUTI is estimated to be $565 million in the United States [Scott, The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention, 2009]

19 © 2010 TMIT Practice Specifications Safe Practice 25 Catheter-Associated Urinary Tract Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections

© 2006 HCC, Inc. CD XX 20 © 2010 TMIT Additional Specifications

© 2006 HCC, Inc. CD XX 21 © 2010 TMIT Safe Practice Statement CAUTI Prevention  Take actions to prevent catheter-associated urinary tract infection by implementing evidence- based intervention practices [Lo, Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S41-50; Gould, Guideline for prevention of catheter-associated urinary tract infections, 2008; Gould, Guideline for prevention of catheter-associated urinary tract infections, 2009]

© 2006 HCC, Inc. CD XX 22 © 2010 TMIT Additional Specifications  Document the education of personnel—involved in catheter insertion, care, management, and removal— on CAUTI prevention  Education should occur upon hire and annually thereafter  Prior to insertion, educate the patient and family members about CAUTI prevention  Identify the patient groups or units on which surveillance should be conducted, considering frequency of catheter use and potential risk  Implement policies and practices to reduce the risk of CAUTI [Willson, J Wound Ostomy Continence Nurs 2009 Mar-Apr;36(2):137-54; Kanouff, Crit Care Nurs Q 2008 Oct-Dec;31(4):302-8; Smith, Am J Infect Control 2008 Sep;36(7):504-35]

© 2006 HCC, Inc. CD XX 23 © 2010 TMIT Additional Specifications  Evidence-based practices include, but are not limited to, the following:  Perform hand hygiene immediately before and after catheter insertion  Ensure that the supplies necessary are readily available  Insert catheters following an aseptic technique and using sterile equipment  Leave urinary catheters in place only as long as indications remain  Obtain a urine culture before initiating antimicrobial therapy [Greene, Guide to the Elimination of Catheter-Associated Urinary Tract Infections, 2008; Institute for Healthcare Improvement, Catheter-Associated Urinary Tract Infection (CA UTI) Prevention, IHI Improvement Map, 2009; Joint Commission Resources, Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, National Patient Safety Goals, 2010; Barford, BJU Int 2008 Jul;102(1):67-74]

© 2006 HCC, Inc. CD XX 24 © 2010 TMIT Additional Specifications  Measure compliance with best practices, evaluating the effectiveness of prevention efforts  Provide CAUTI surveillance data, including process and outcome measures, to key stakeholders within the organization

25 © 2010 TMIT Example Implementation Approaches Safe Practice 25 Catheter-Associated Urinary Tract Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections

© 2006 HCC, Inc. CD XX 26 © 2010 TMIT Example Implementation Approaches

© 2006 HCC, Inc. CD XX 27 © 2010 TMIT Example Implementation Approaches  Implement a system for documenting the following in the patient record:  indications for catheter insertion  date and time of catheter insertion  individual who inserted catheter  date and time of catheter removal  Develop and implement facility criteria for acceptable indications for indwelling urinary catheter use [Gokula, Am J Infect Control 2004 Jun;32(4):196-9; Marklew, Nurs Crit Care 2004 Jan-Feb;9(1):21-7]

© 2006 HCC, Inc. CD XX 28 © 2010 TMIT Example Implementation Approaches  Suggested indications for indwelling urethral catheter use include:  Perioperative use for selected surgical procedures  Accurate measurement of urine output in critically ill patients  Management of acute urinary retention and urinary obstruction  To assist in pressure ulcer healing for incontinent residents  As an exception, at patient request to improve comfort  Relief of bladder outlet obstruction or congenital urologic abnormalities

© 2006 HCC, Inc. CD XX 29 © 2010 TMIT Example Implementation Approaches  Following aseptic insertion of the urinary catheter, maintain a closed drainage system  Maintain unobstructed urine flow  Implement an organization-wide program to identify and remove catheters no longer necessary; method examples include:  Automatic stop orders  Standardized reminders placed into patient record  Implementation of daily ward rounds to review all patients with urinary catheters [Gould, Guideline for prevention of catheter-associated urinary tract infections, 2009]

© 2006 HCC, Inc. CD XX 30 © 2010 TMIT Example Implementation Approaches Strategies of Progressive Organizations  High-performing organizations have protocols for the management of post-operative urinary retention  Innovations include direct visualization of the urethra during insertion of catheters  Implement a system for analyzing and reporting data on catheter use, including adverse events [Chapple, 2004 June;93(9) ; Fenton, Urology 2005 Jun;65(6):1055-8; Agency for Healthcare Research and Quality, National Healthcare Disparities Report 2008, 2009; Agency for Healthcare Research and Quality, National Healthcare Quality Report 2008, 2009]

31 © 2010 TMIT Front-line Resources Safe Practice 25 Catheter-Associated Urinary Tract Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections

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35 © 2010 TMIT [ Poster available in Spanish

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© 2006 HCC, Inc. CD XX 37 © 2010 TMIT TMIT National Webinar Series Catheter-Associated Urinary Tract Infection: No One Owns It... We ALL Pay for It! (SP 25)  Carolyn Gould, MD, MSCR – Topic: The CDC Guideline for Prevention of CAUTI  Sanjay Saint, MD, MPH – Topic: CAUTI Prevention: The Bladder Bundle  Marcia Patrick, RN, MSN, CIC – Topic: CAUTI Reduction Using Rapid-Cycle Improvement  Denise Graham – Topic: APIC Support  Patti O'Regan, DNP, ARNP, ANP-C, PMHNP-BC – Topic: The Role of the Patient Advocate  Go to: (August 19, 2010)

© 2006 HCC, Inc. CD XX 38 © 2010 TMIT TMIT National Webinar Series Healthcare-Associated Infection and You: Cleaner, Safer Care (SPs 19-25)  Kathy Warye – Topic: Perspective on the Development of the Implementation Examples of the NQF Safe Practices  Peter Angood, MD – Topic: HAI National Attention and Harmonization  David Classen, MD – Topic: HAI Compendium Harmonization with the Safe Practices  Julianne Morath, RN – Topic: Implementation  Jennifer Dingman – Topic: Call to Action  Go to: (May 14, 2009)