Implementing Change: The Technical & Socio-Adaptive Aspects of Preventing CAUTI Sanjay Saint, MD, MPH Professor of Medicine Ann Arbor VA Medical Center University of Michigan Medical School I would like to begin by acknowledging my collaborators.

Consistently Using Evidence-Based Practices Remains a Challenge…

Hand Hygiene Compliance in Healthcare Workers (Erasmus et al Hand Hygiene Compliance in Healthcare Workers (Erasmus et al. Infect Control Hosp Epidemiol March 2010) Systematic review of 96 studies Overall median compliance of 40% Lower rates in physicians (32%) than nurses (48%) Lower rates “before” (21%) patient contact rather than “after” (47%)

Given this Gap Between What Should Be Done and What Is Done… Focus on “implementation science” “The scientific study of methods to promote the systematic uptake of research findings into routine practice” (Eccles & Mittman. Implementation Science. Feb 2006) Synonyms: “T3” translation Theory-practice gap Knowledge transfer Knowledge utilization

How can we better implement evidence-based practices in infection prevention?

Implementation Science: Conceptual Model In the last 6 decades, “knowledge utilization” field dominated by one person: Everett Rogers, PhD (Estabrooks et al. Implementation Science. Nov 2008) Rogers’ “Diffusion of Innovation” Model is the canonical model since World War 2 Originally developed for the study of agriculture

“Diffusion of Innovation” Model of Everett Rogers, PhD Definitions: Diffusion = spread Innovation = a new practice A “descriptive” model – not a “prescriptive” one Describes what is occurring rather than what to do

4E’s Model of Implementation (Pronovost et al. BMJ 2008) Needs Assessment: measure baseline performance, identify local barriers, select interventions to implement Engage (discuss importance of intervention) Educate (share specifics of the intervention) Execute (provide an intervention toolkit) Evaluate (intended and unintended consequences)

Several Challenges for Implementation Researchers Ensuring Sustainability Understanding Context

The Importance of Context (Davidoff JAMA Dec 2009; Greenhalgh et al The Importance of Context (Davidoff JAMA Dec 2009; Greenhalgh et al. Milbank Q 2004) Implementation within healthcare is “context” specific: dependent on the setting, hospital leadership and followership, & organizational culture (and micro-culture) Healthcare settings are unpredictable and generally non-linear: if ‘A’ then ‘B’ or ‘C’ or ‘X’… Implementation is both a clinical and a social discipline: has both “technical” components and “adaptive” ones Use tools from social science – such as “qualitative research” – to better understand the context I have divided these overarching themes into barriers and facilitators. First the barriers: One of the important barriers we discovered [HIT RETURN FOR NEXT BULLET] was the presence of organizational “constipators” who we define as passive-aggressive types who undermine change without active resistance. These individuals appear to be supportive of change but end up ‘gumming’ up the system, thereby requiring others to erect work-arounds to get by them. [HIT RETURN FOR NEXT BULLET] Another important barrier was the presence of silos. These were either “Clinical/work-unit silos”: in which everyone is in their own little world; And “Economic silos” in which the cost of the practice comes from a different bucket than where the benefits flow

What is Qualitative Research? A method of inquiry used in many different disciplines Increasingly being used in biomedical research Used to obtain an in-depth understanding of human behavior and the reasons for such behavior Investigates the why and how Information is gathered using open-ended data collection: interviews, focus groups, and direct observation Organizing the data in the words and categories of participants (“themes”) can be compelling JANE Artistic = Intuitive and non-linear thinking Interpreting the meaning of e.g., “size" (Johnson & Onwuegbuzie. Educ Researcher 2004; Forman et al. AJIC 2008) 11

Implementation Science The Technical and Socio-Adaptive Aspects of Preventing CAUTI

Healthcare-Associated Infection (HAI) At least 20% of episodes are preventable; perhaps as much as 70% (Harbath et al. J Hosp Infect 2003) Medicare no longer reimburses U.S. hospitals for the additional costs of certain infections Preventive practices are variably used Infection control is a good model for understanding implementation – both successes and failures

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 Urinary tract infection causes over 40% of hospital-acquired infections, making it the most common nosocomial infection. Most of these infections are due to urinary catheters. 25% of inpatients are catheterized at some time during their hospital stay. Nosocomial UTI leads to increased morbidity and increased costs.

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

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

Prevention of Catheter-Associated UTI 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

UTI Prevention Rule #1: Make Sure the Patient Really Needs the Catheter Appropriate indications Bladder outlet obstruction Incontinence and sacral wound Urine output monitored Patient’s request (end-of-life) During or just after surgery (Wong and Hooton - CDC 1983) (Jain. Arch Int Med 95)

One Reason Catheters Are Used Inappropriately As seen in this table, 18% of medical students, 22% of interns, 28% of residents, and 35% of attending physicians were unaware that the patients that they were responsible for had an indwelling catheter. (Saint S, Wiese J, Amory J, et al. Am J Med 2000)

Prevention of Catheter-Associated UTI 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

Use Proper Aseptic Technique for Catheter Insertion NEJM Videos in Clinical Medicine: Male Urethral Catheterization T. W. Thomsen and G. S. Setnik - 25 May, 2006 Female Urethral Catheterization R. 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

Prevention of Catheter-Associated UTI 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

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) Because of these increased morbidity and costs, several preventive strategies have been attempted. Silver-coated catheters are one such intervention used to prevent catheter-related infection. The rationale for using silver is that this substance has in vitro antibacterial activity and is commonly used to prevent infection in burn patients. The efficacy of silver alloy catheters in preventing urinary tract infection was shown in a recent meta-analysis of randomized trials that we performed.

Prevention of Catheter-Associated UTI 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

Other Methods for Preventing CA-UTI Antimicrobial catheters Alternatives to the indwelling catheter Bladder ultrasound Intermittent catheterization Condom catheter

Recent Guidelines on CAUTI Prevention

CA-UTI Prevention: Concise Summary of Recommendations Adherence to infection control principles (eg, aseptic insertion, proper maintenance, education) is important Bladder ultrasound may avoid indwelling catheterization Condom or intermittent catheterization in appropriate pts Do not use the indwelling catheter unless you must ! Early removal of the catheter using reminders or stop-orders appears warranted (Saint et al. Jt Comm J Qual Saf 2009)

What are Hospitals Using to Prevent CA-UTI? National survey of U.S. hospitals (focused on device-related infection) 719 hospitals surveyed (Spring 2005) Lead Infection Control Professional filled out the survey 72% response rate (Saint et al. Clin Infect Dis 2008)

Urinary Catheter-Related Infection Prevention Practices Regularly using Antimicrobial catheters 30% Bladder ultrasound scanner 29% Condom catheters in men 12% Urinary catheter reminder 9% Antimicrobials in the drainage bag 3% (Saint et al. Clin Infect Dis 2008)

Translating Research Into Practice No common strategy used in hospitals to prevent UTI Less than 10% of U.S. hospitals using catheter reminders or stop-orders Next Step: Evaluate why interventions are used in some hospitals but not in others

Why Are Some Hospitals Better than Others in Preventing Infection? Quantitative Qualitative phase phase Part 1 Part 2 Part 3 Surveyed infection control personnel at 719 U.S. hospitals Phone interviews with key informants at 14 hospitals Site visits at 6 hospitals across the U.S. (2006-2007) (Krein et al. Am J Infect Cont 2006)

Qualitative UTI Themes: 2006-07 1) Urinary catheter-related infection is a low priority, but timely removal of catheters considered important 2) Identifying a committed “champion” facilitated prevention activities in several sites (Saint et al. Infect Cont Hosp Epid 2008)

But a lot has changed in the last 3 years… Since qualitative research focuses on discovering underlying “themes”, I will discuss one of these themes, Namely… Urinary catheter-related infection is a low priority, but timely removal of the catheters was considered important I provide illustrative quotes to explain this theme on the next few slides.

Current Sequential Mixed-Methods Study Quantitative Qualitative Part 1 Survey of infection control personnel 2005 & 2009 All MI hospitals (~130) Stratified random sample U.S. hospitals (~600) Response rates 70%/80% Part 2 Purposeful sample 12 hospitals in MI Phone interviews with key informants (n = 18) Site visits at 3 hospitals in MI Part 3 Facilitated implementation intervention Study is using a sequential mixed methods approach. Started with a survey The survey response rate was70%/80% in MI Next we moved to the qualitative phase of the study focusing only on hospitals in Michigan to better understand some of the complexities in practice use and implementation, which often can’t be quantified. Survey responses were used to implement a purposeful sampling strategy, resulting in the selection of 12 hospitals. Selection was based on participation in the Keystone Bladder Bundle initiative (already implemented vs. just starting), reported ease of implementation, geographic location, facility-wide vs. unit specific implementation, hospital size. Interviewed 18 individuals, 1-3/hospital 3 of the12 hospitals have been selected for site visits, which provided an opportunity to gather more information about issues emerging from our data analysis and obtain perspectives from a wider variety of staff The third part of the study is the intervention component but as that is still under development I will only be sharing preliminary results from parts 1 and 2.

Hospital Characteristics 2005 (national)* 2009 (MI) Number of hospital beds mean (95% CI) 229 (219 - 239) 226 (215 - 237) 238 (187 – 289) Have hospitalists 57% 75% 76% Number of full-time equivalent infection preventionists (IP) 1.3 (1.2 – 1.4) 1.5 (1.4 – 1.7) 1.7 (1.2 – 2.1) Lead IP certified in infection control 59% 58% Participate in a collaborative effort to reduce HAI 42% 68% 99% Point out percent with hospitalists and the percent participating in a collaborative effort (IHI, Keystone, other regional or state base initiatives) *Weighted estimates

Report Regularly Using to Prevent CAUTI: National Sample In the interest of time I will just be focusing on a few practices and on practices that we asked about in both 2005 and 2009.

Report Regularly Using to Prevent CAUTI: Comparing Michigan with U.S. MI in maize and blue

Summary of Quantitative Findings Increase in the percentage of U.S. hospitals (in Michigan and across the U.S.) using several practices to prevent CAUTI Notable differences in the types of practices used; Michigan hospitals focusing more on reducing unnecessary catheter use Our data show

Qualitative UTI Themes from Michigan’s CAUTI Experience: 2009-2010 Where Do We Go From Here? Qualitative UTI Themes from Michigan’s CAUTI Experience: 2009-2010 Tailoring Workflow Leadership

The Importance of Tailoring May need to tailor (ie, modify) your approach to CAUTI given your specific context and circumstances We saw different solutions at different hospitals; different solutions within different units at the same hospital Examples: Educating nurses about urinary catheters Who assesses for catheter appropriateness Modifying the indications for catheter use (slightly) Focus on insertion or early removal or both?  

The Challenge: How to Make Urinary Catheter Removal Part of the Workflow The intervention(s) should become part of the workflow: both removal (floor) and insertion (ED) Nursing workload was a big issue - since Foleys can be easier for the nurses, this may be a disincentive to remove

The Challenge: How to Make Urinary Catheter Removal Part of the Workflow The intervention(s) should become part of the workflow: both removal (floor) and insertion (ED) Nursing workload was a big issue - since Foleys can be easier for the nurses, this may be a disincentive to remove For insertion, ED is paramount Foleys put in for specimen collection and left in ED nurses may think they’re doing floor nurses a favor Nursing aides often insert Foleys in the ED with improper technique

The Importance of Leadership Leadership at various levels appears to be important, especially at the nurse manager level Physicians often play an important role Behind-the-scenes (getting buy-in from medical executive committees and other physicians) Front-line (eg, hospitalists, hospital epidemiologists)

The Importance of Leadership Leadership at various levels appears to be important, especially at the nurse manager level Physicians often play an important role Behind-the-scenes (getting buy-in from medical executive committees and other physicians) Front-line (eg, hospitalists, hospital epidemiologists) The type of champion that is needed depends on organizational culture Not a one-size-fits-all strategy Nurse manager or charge nurse may be best option

Qualitative UTI Themes from Michigan’s CAUTI Experience: 2009-2010 Tailoring Workflow Leadership