System Performance Improvement Leader St. Joseph Mercy Health System On the CUSP: Stop CAUTI Implementing CUSP to Eliminate Catheter-Associated Urinary Tract Infections (CAUTI) Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System Ann Arbor, MI patposa@gmail.com Good afternoon and thank you Kimberly for the opportunity to update the Missouri teams on the national CAUTI project. This project is still in development, with plans to launch this fall. My name is Marchelle Djordjevic, I am a program manager at HRET- the research affiliate of the American Hospital Association. My primary responsibility is overall national project management for the CUSP projects. I have several years project management experience working in healthcare research and quality where most recently I was the program manager at the American College of Surgeons for the ACS NSQIP. I started with HRET at the beginning of this year. I work closely with Deb Bohr, who is also a Program Manager for the CUSP projects at HRET. Deb manages state recruitment and is here to help address any questions you may have about state and hospital recruitment.

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? Here is the agenda for this presentation. Basically, I want to cover why the project is important, who is involved, and what we hope to accomplish… then leave a little time for questions.

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 Care and Removal Intervention Removal of unnecessary catheters Proper care for appropriate catheters 2. Placement Intervention Determination of appropriateness Sterile placement of catheter This slides summarizes the interventions of this effort: The 5 elements of the Comprehensive Unit-based Safety Program or CUSP Care and Removal Removal of unnecessary indwelling catheters based on HICPAC recommendations Proper care for appropriate indwelling catheters 3) Placement Intervention Determination of appropriateness of indwelling catheter based on HICPAC recommendations Sterile placement of indwelling catheter

Project Goals Reduce CAUTI rates in participating units by 25% Appropriate placement Appropriate continuance Appropriate utilization Improve patient safety culture on participating units This project has two primary goals To reduce CAUTIs in participating units by 25% by using education & reinforcing appropriate management of urinary incontinence (using the New CDC guideline that has a emphasis on appropriate use of the catheter- outlines specific criteria); and by promoting the appropriate UC utilization in hospitals The second goals is to improve patient safety culture through the implementation of CUSP

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

Adult, Peds, and Neonatal ICUs Healthcare Facility HAI Reporting to CMS via NHSN – Current and Future Requirements HAI Event Facility Type Reporting Start Date CLABSI Acute Care Hospitals Adult, Peds, and Neonatal ICUs January 2011 CAUTI Adult and Pediatric ICUs January 2012 SSI Colon and abdominal hysterectomy Long Term Care Hospitals * October 2012 Inpatient Rehabilitation Facilities MRSA Bacteremia Lab ID Acute Care Hospitals – facility wide January 2013 C. difficile LabID Event HCW Influenza Vaccination * Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN CMS 2012 IPPS final rule released; August 2011 Federal Register 6 6

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.

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)

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

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

Urinary Catheter-Related Infection: Pathophysiology Intraluminal Extraluminal Detrusor spasm Shedding of cells Bacteremia Leakage Obstruction Fever (+) UA Hypotension Bladder infection with inflammation

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)

A Model For Implementation Science Saint S, et al ICHE 2010 13

Core Prevention Strategies:(All Category IB) Educate: How will we accomplish this? Catheter Use Insert catheters only for appropriate indications Leave catheters in place only as long as needed Insertion Maintenance Following aseptic insertion, maintain a closed drainage system Maintain unobstructed urine flow Ensure that only properly trained persons insert and maintain catheters Insert catheters using aseptic technique and sterile equipment (acute care setting) Hand Hygiene Quality Improvement Programs http://www.cdc.gov/hicpac/cauti/001_cauti.html

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

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) 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.

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)

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) 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.

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

Prevention of Catheter- Associated UTI 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

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)

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.

Nurse-Initiated Removal of Unnecessary Urinary Catheters Program Baseline: Collect urinary catheter prevalence with evaluation for indications (15 days). Weeks 1 - 3 Nurse-Initiated Removal of Unnecessary Urinary Catheters Program Week 4 Prepare for implementation. 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). Weeks 5 & 6 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 7 - 12 Data review and unit feedback Sustainability: urinary catheter prevalence and indications, 1 week quarterly (5 consecutive days) for 5 quarters. Patient’s nurse to daily assess need for catheter. Quarterly

QUESTION ??? How many people have or are considering a nurse driven protocol for urinary catheter removal?? If so—what barriers are you anticipating?

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 CAUTI Alternatives to the indwelling catheter Bladder ultrasound Intermittent catheterization Condom catheter

Execute: What do we need to do? Nurse driven protocols Decision algorithm Reminders/flags Reviewed daily on rounds Daily screening

Remove that Urinary Catheter! Remove that Urinary Catheter! Pocket Card 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 obstruction Perioperative use in selected surgeries Assist healing of perineal and sacral wounds in incontinent patients Hospice/comfort/ palliative care Required immobilization for trauma or surgery Chronic indwelling urinary catheter on admission Accurate measurement of urinary output in the critically ill patients (intensive care) Foley Catheters are not indicated for: Urine output monitoring OUTSIDE intensive care Incontinence (place on toileting routine, change frequently) Prolonged postoperative use Patients transferred from intensive care to general units Morbid obesity Immobility (turn patient q 2 hours, up in chair) Confusion or dementia Patient 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 Care and Removal Intervention Removal of unnecessary catheters Proper care for appropriate catheters 2. Placement Intervention Determination of appropriateness Sterile placement of catheter This slides summarizes the interventions of this effort: The 5 elements of the Comprehensive Unit-based Safety Program or CUSP Care and Removal Removal of unnecessary indwelling catheters based on HICPAC recommendations Proper care for appropriate indwelling catheters 3) Placement Intervention Determination of appropriateness of indwelling catheter based on HICPAC recommendations Sterile placement of indwelling 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”

Teamwork Climate Across Michigan ICUs The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care % of respondents within an ICU reporting good teamwork climate   No BSI 21% No BSI 44% No BSI 31% No BSI = 5 months or more w/ zero Health Services Research, 2006;41(4 Part II):1599.

or Can we change practice through process improvement alone? Will successful change require an altering of the value structure 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

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

Additional Areas to Address 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

QUESTIONS???