Catheter Associated Urinary Tract Infections Palmetto Health Baptist 1501 Sumter St Columbia, SC Catheter Associated Urinary Tract Infections Lendon Thomas, BS, CIC

Background Catheter Associated Urinary Tract Infections are an ongoing issue in health care Recent changes in the landscape of CAUTI prevention Growing interest by many stakeholders

Disclosure I am an employee of C.R. Bard, Inc., Bard Medical Division. Any discussion regarding Bard products during my presentation is limited to information that is consistent with Bard labeling for those products.

Broad Stroke Objectives Review/update the problem of CAUTI Outline many newer events within the last five years Discuss the latest concepts in prevention strategy From literature and published guidelines Locally at Palmetto Health System

Problem 100 million indwelling urethral catheters sold worldwide anually 24 million in the U.S. 25% of hospitalized patients exposed to catheters during their stay UTI = up to 40% of all HAI Vast majority of UTI are catheter related Not without increased cost and morbidity Saint S, Kaufman S, Thompson M, Rogers M, Chenoweth C. A Reminder Reduces Urinary Catheterization in Hospitalized Patients. Journal on Quality and Patient Safety. 2005 August. (31)8; 455-62

Problem CAUTI accounts for 36% of all HAI Incidence of catheter associated bacteriuria is 26% in patients with indwelling catheter for 2 to 10 days 24% of those acquiring bacteriuria will advance to CAUTI Approximately 3% will develop bacteremia of urinary origin Greene L, Marks J, Oriola S. Association for Professionals in Infection Control. Guide to The Elimination of Catheter Associated Urinary Tract Infections (CAUTIs). 2008, p. 5.

Stakeholders CAUTI Federal Agencies/Mandates State Involvement CMS SCIP Public Reporting of HAI CAUTI HICPAC Michigan Keystone CDC AHRQ Organizations APIC SHEA JCAHO Private Websites CatheterOut.org Workingtowardzero IDSA Consumer Groups

Federal Original CDC Guidelines for CAUTI prevention, 1981 HICPAC (Healthcare Infection Control Practices Advisory Committee) Revised the Guidelines for Prevention of CAUTI in 2008 DHHS Document from CDC = 321 pages Abbreviated guidelines issued 2009 Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Guideline for Prevention of Catheter Associated Urinary Tract Infections 2008, DHHS, Centers for Disease Control and Prevention

Federal HICPAC/CDC Guidelines Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS, Centers for Disease Control and Prevention, 2009

Centers for Medicare & Medicaid Services (CMS) Rule Changes: 1 October 2008 CMS now holds U.S. hospitals accountable for not preventing certain hospital-acquired complications CMS required to choose at least 2 conditions that: are high cost and/or high volume; and could reasonably have been prevented through the application of evidence-based guidelines Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides] CatheterOut.org website, University of Michigan. CR5499 Instruction on the CMS web site at http://www.com.hhs.gov/Transmittals/downloads/R 1240CP.pdf

CMS Chose More Than 2 Conditions Catheter-associated UTI Vascular catheter-associated infection Retained object during surgery Air embolism Blood incompatibility Pressure ulcers Surgical Site Infections after certain surgical procedures Falls and Trauma Manifestations of Poor Glycemic Control DVT or PE following certain orthopedic surgeries 42 CFR Parts 411, 412, 413, and 489; August 2007 Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides] CatheterOut.org website, University of Michigan.

Why Urinary Tract Infections? DHHS: Med-Par Data, 2006: 42 CFR Parts 411, 412, 413, and 489; August 2007

SCIP Surgical Care Improvement Project1 11 SCIP Performance Measures Reported publically on CMS “Hospital Compare” website SCIP-INF-9: Urinary catheter removed on post-operative day 1 or post-operative day 2 with day of surgery being day 0. PHB showed 96% on Hospital Compare. (Site qualified by saying small sample, less than a quarter).2 1Hospitals.tmf.org [Internet]. TMF Health Quality Institute. SCIP Quality Indicators. Available from http:/hospitals.tmf.org/SCIP/SCIPQuality Indicators/tabid/678/Default.aspx 2HHS.gov [Internet]. Medicare Hospital Compare Process of Care Measures. Surgical Care Improvement Project Process of Care Measure. Available from http://www.hospitalcompare.hhs.gov

Public Reporting As of last year, 2010: 27 states require public reporting of selected HAI 2 states report “confidentially” to state agencies 3 states have “voluntary” public reporting 5 states made laws to study the issue of public reporting 13 states and DC have no public reporting laws. RID—Committee to Reduce Infection Deaths. State Legislation and Initiatives on Healthcare-Associated Infections, [Updated March 2010, cited 2011 Aug 13]. Available from http://hospitalinfection.org/legislation.shtml

Organizations Infectious Disease Society of America (IDSA) Hooton T, Bradley S, Cardenas D, Colgan R, Geerlings S, Rice J, Saint S et. al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Disease Society of America. CID 2010:50 (1 March) 000

Organizations Association for Professionals in Infection Control Greene L, Marks J, Oriola S. Association for Professionals in Infection Control. Guide to The Elimination of Catheter Associated Urinary Tract Infections (CAUTIs). 2008

Organizations Society for Healthcare Epidemiology of America (SHEA) Lo E, Nicolle L, Classen D, Arias K, Podgorny K, Anderson D, Burstin, H et. al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:S41-S50

Organizations JCAHO New National Patient Safety Goal (NPSG.07.06.01)—May 9, 2011 “Implement evidence based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI)” 2012 = Get Ready Year January 2013—in surveys. Dings included. JCAHO. 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-Publication Version. DivSSM, May 9, 2011.

CAUTI Prevention All these guidelines/mandates, etc, point to the same direction Care Process Strategies Change in the culture of the organization Medical Staff Patient Care Staff Administrative/Management Staff

Process Measures in Brief Make sure the catheter is indicated Adhere to general infection control principles (aseptic insertion, proper maintenance, hand hygiene, properly trained staff, feedback to care providers) Remove the catheter as soon as possible Consider alternatives to indwelling catheters Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides] CatheterOut.org website, University of Michigan.

Appropriate Indications for Catheters Acute urinary retention or bladder outlet obstruction Critical output monitoring in critically ill patients (hourly output measurement) Peri-operatively in selected surgical procedures GU tract or its contiguous structures Long procedures (remove the catheter in PACU) Large volume infusions or diuretics during surgery Intra-operative urinary output monitoring Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS, Centers for Disease Control and Prevention, 2009

Appropriate Indications for Catheters Assist healing of open sacral or perineal wounds in incontinent patients Prolonged immobilization [further defined as] Unstable thoracic or lumbar spine Multiple traumatic injuries Improve comfort for end of life care Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS, Centers for Disease Control and Prevention, 2009

Examples of Inappropriate Catheter Use Incontinence1 Obtaining urine for culture or diagnostic test (when the patient can void)1 Prolonged post-operative duration (more than 1 or 2 days)2 1Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS, Centers for Disease Control and Prevention, 2009 2CMS. Measure ID# SCIP-Inf-9. Specifications Manual for National Hospital Inpatient Quality Measures, 2009.

How Many Catheters are Inappropriate? Munasinghe et. al, looked at 836 medical admissions over a 1 month period 10% of the admissions had indwelling catheter placed within 24 hours of admission 38% had no justifiable indication Munasinge RL, Yazdani H, Siddique M, Hafeez W. Appropriateness of use of Indwelling Urinary Catheters in Patients Admitted to the Medical Service. Infection Control and Hospital Epidemiology. 2001 October 22(10), 617

How Many Catheters are Inappropriate? Gardam, et. al, in a similar study reported: 20% indwelling catheter rate Only 50% of the catheters justifiable Jain, et. al, reported 34% unjustified catheters Gardam Ma, Amihod B, Orienstein P, Consolacion N, Miller MA. Overutilization of indwelling catheters and the development of nosocomial urinary tract infections. Clinical Performance and Quality Healthcare. 1998, (6) 99-102 Jain P, Parada JP, David A, Smith LG. Overuse of indwelling urinary tract catheter in hospitalized medical patgients. Arch. Intern. Med. 1995; 155:1425-1429

Why Inappropriate Catheters? Caretakers forget to assess the risk Maki DG, Tambyah PA. CDC. Engineering Out the Risk of Infection with Urinary Catheters. Emerging Infectious Diseases. 2001 Mar-Apr; 7(2): 1-12.

Why Inappropriate Catheters? Risk Awareness In patients with indwelling catheters: Risk of bacteriuria increases by 5% every day the catheter remains indwelling 10% of those becoming bacteruric advance to symptomatic CAUTI. Around 3% will develop urinary associated bacteremia Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides] CatheterOut.org website, University of Michigan.

Why Inappropriate Catheters? Forget the catheter is in place Survey of 288 physicians (attending, house staff, interns and medical students). 469 patients in their care—25% with catheters by observation Saint S, Wiese J, Amory JK, Bernstein MI, Patel UD, Zemencut JK, et. al. Are physicians aware of which of their patients have indwelling urinary catheters? Am. J. Med, 2000 Oct 15; 109 (6): 476-80

Why Inappropriate Catheters? Survey Findings Percent UNAWARE their patient had catheter 31% of the catheters were inappropriate Medical Students 21% Interns 22% Residents 27% Attendings 38% Saint S, Wiese J, Amory JK, Bernstein MI, Patel UD, Zemencut JK, et. al. Are physicians aware of which of their patients have indwelling urinary catheters? Am. J. Med, 2000 Oct 15; 109 (6): 476-80

Popular Interventions Appropriateness and Duration Insertion checklists Removal reminder systems Automatic stop orders

Example of Checklist and Flags C.R. Bard, Inc. Bard ADVANCE Foley Tray System [component], 2010

Data on Reminder Systems Recent Study, Meddings et. al, 2010 Systematic review and meta-analysis Reviewed published interventional studies that used reminders to physicians or nurses that urinary catheter in use or stop orders to prompt catheter removal in hospitalized patients Meddings J, Rogers MA, Macy M, Saint S. Systematic Review and meta-analysis: reminder systems to reduce catheter associated urinary tract infections and urinary catheter use in hospitalized patients. Clin. Infect. Dis. 2010 Sept 1; 51(5): 550-60

Data on Reminder Systems Results: CAUTI rate reduced by 52% (p = <0.001) with the use of reminder or stop order Foley duration decreased by 37% (2.6 fewer days per patient Stop orders were more effective than reminders Need for re-catheterization not different, control vs. intervention Meddings J, Rogers MA, Macy M, Saint S. Systematic Review and meta-analysis: reminder systems to reduce catheter associated urinary tract infections and urinary catheter use in hospitalized patients. Clin. Infect. Dis. 2010 Sept 1; 51(5): 550-60

Alternatives to Indwelling Catheters Use of portable bladder scanners Straight catheterization vs. indwelling Condom catheters in male patients Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing Hospital-Acquired Urinary Tract Infections in the United States: A National Study. Clinical Infectious Diseases 2008; 46: 243-50

Bladder Scan Accurate for urine volume Reduce the number of intermittent catheterizations One group found that use of bladder scan decreased catheter related UTI from 87% to 38% in one nursing unit and from 81% to 50% in another unit over a 12 month period. Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing Hospital-Acquired Urinary Tract Infections in the United States: A National Study. Clinical Infectious Diseases 2008; 46: 243-50

Condom Catheters for Men Randomized controlled trial published in 2006 found: Condom catheters instead of indwelling catheters lowered the incidence of bacteriuria in men [without dementia] Men reported condom catheters more comfortable than indwelling catheters Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing Hospital-Acquired Urinary Tract Infections in the United States: A National Study. Clinical Infectious Diseases 2008; 46: 243-50

Before New Pressures, Guidelines and Mandates National survey of prevention strategies Survey data collected during 2005 Random sample of non-federal hospitals (n = 600) All VA Hospitals (n = 119) 72% response rate Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing Hospital-Acquired Urinary Tract Infections in the United States: A National Study. Clinical Infectious Diseases 2008; 46: 243-50

National Survey Findings, 2005 Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing Hospital-Acquired Urinary Tract Infections in the United States: A National Study. Clinical Infectious Diseases 2008; 46: 243-50

National Survey Findings, 2005 Concluded: Despite the strong link between urinary catheters and CAUTI, we found no strategy to be widely used to prevent HA-UTI. The most commonly used practices (bladder ultrasound and antimicrobial catheters) were each used in fewer than one-third of hospitals Urinary catheter reminders, which have proven benefits were used in <10% of U.S. hospitals. Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing Hospital-Acquired Urinary Tract Infections in the United States: A National Study. Clinical Infectious Diseases 2008; 46: 243-50

Back to JCAHO: NSPG.07.06.01 Elements of performance (insertion and use) Insert indwelling urinary catheters according to established evidence based guidelines that address the following: Limiting use and duration to situations necessary for patient care Using aseptic techniques for site prep, equipment and supplies JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, May 9, 2011.

Back to JCAHO: NSPG.07.06.01 Elements of Performance (catheter management) Manage indwelling urinary catheters according to established evidence based guidelines Securing catheters Maintaining sterility of collection system Replacement when required Asepsis in urine sample collection JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, May 9, 2011.

Back to JCAHO: NSPG.07.06.01 Measure and monitor the processes and outcomes Select measures based on evidence based guidelines or best practices Monitor compliance (ongoing audit or point prevalence) Evaluate effectiveness UTI Surveillance Decreased indwelling catheter days Decreased inappropriate use Improved nursing care practices JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, May 9, 2011.

Example: Appropriateness Audit Tool Association for Professionals in Infection Control. Guide to the Elimination of Catheter-Associated Urinary Tract Infections, 2008. Washington DC.

Example: Nursing Process Monitoring Tool Unit Number of Observations Securement = Yes % Securement Compliant *TES Intact = Yes % TES Compliant Dependent Loop Compliant % Loop Compliance Below Bladder Level Compliant % Bladder Level Compliant Not Touching Floor Compliant % No Touch Floor Compliant Not Over-filled Compliant % No Overfill Compliant MSU 10 2 20.0 100.0 5 50.0 9 90.0 SCU 8 1 12.5 3 37.5 4 7 87.5 6 75.0 JSC 0.0 GSU 16.7 5N 25.0 Overall 30 25 83.3 15 26 86.7 27 Ref: Bard Medical Division: Foley Catheter Observation Survey. Compliance Document # 1007-02, 7-14-10 Lo E, Nicolle L, Classen D, Arias K, Podgorny K, Anderson D, Burstin, H et. al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:S41-S50

Local Prevention Activities at Palmetto Health Active CAUTI Prevention Team Developed successful implementation bundles: Indwelling catheter insertion bundle Catheter care and maintenance bundle CAUTI prevention education Nurses Physicians Palmetto Health Baptist Catheter-Associated Urinary Tract Infection (CAUTI) Team. AIM Statement, 2011.

Palmetto Health—Next Up Measures Foley Removal Protocols Tested in several critical care units at Palmetto Richland Reduced catheter days Reduced CAUTI Currently in pilot at PHB in PCU and ICU Target date, full implementation: Oct. 1, 2011 Palmetto Health Baptist Catheter-Associated Urinary Tract Infection (CAUTI) Team. AIM Statement, 2011.

Palmetto Health—Also Coming in the Future Stop order pop-up reminders in the electronic medical record EHR enhancements will allow Physician to: Utilize a Foley removal guideline OR Require Physician to justify in record why continuing catheter If catheter continued, must provide justification in the record. Palmetto Health Baptist Catheter-Associated Urinary Tract Infection (CAUTI) Team. AIM Statement, 2011.

Palmetto Health—How Can Physicians Help at PH? Realize this is a common initiative in hospitals throughout the U.S.—not just at PH. It is evidence based medicine. Participate Be supportive Think about these measures as a way to reduce patient risks and improve patient care/outcomes Be a part of the success story when it happens.