Project Initiation Call On the CUSP: Stop CAUTI Implementing CUSP to Eliminate Catheter-Associated Urinary Tract Infections (CAUTI) Project Initiation Call 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 of Today’s Call Welcome and introductions Why this initiative is important: Overview of CAUTI Comprehensive Unit-Based Safety Program (CUSP) Project overview and data requirements Expected outcomes What it requires What are the next steps 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.

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

Project Overview Hospitals or Hospital Systems State Hospital Associations National Project Team Project Management Clinical Faculty & Data Management CUSP Faculty The On the CUSP: Stop CAUTI project is an AHRQ funded demonstration project to reduce Catheter associated urinary tract infections in 10 states nation wide. This is a collaborative initiative between several entities, with the work being lead by expert faculty out of MHA Keystone. Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center . AND Mohamad Fakih Infectious Diseases Faculty, St John Hospital and Medical Center, also in Michigan are leading the development of the project interventions with MHA Keystone. JHU will provide expert faculty on CUSP and HRET is responsible for project management.

National Project Team Partner Team Members Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality Sam Watson, MSA; Chris George, RN, MS Health Research & Educational Trust Steve Hines, PhD Deborah Bohr, MPH Marchelle Djordjevic, MBA Centers for Disease Control & Prevention Katherine Allen-Bridson, RN, BSN, CIC Carolyn Gould, MD, MSCR Johns Hopkins Quality Safety Research Group Sean Berenholtz, MD Chris Goeschel, MPA, MPS, ScD, RN Ann Arbor VA Medical Center University of Michigan Medical School Sanjay Saint, MD, MPH Sarah Krein, RN, PhD St. John Hospital & Medical Center Mohamad Fakih, MD, MPH

Healthcare-Associated Infections (HAI’s) 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 The most common HAI is urinary tract infection

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.

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

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)

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

Cost Implications of CMS Rule Change University of Michigan patient with pneumonia: Without complication or comorbidity (CC): $6899 With CA-UTI (CC): $8495 (~$1600 more) University of Colorado patient with acute MI: Without CC: $5436 With CA-UTI (CC): $6721 (~$1300 more) (Wald and Kramer. JAMA 12/19/07)

Urinary Catheter-Related Infection: Pathophysiology Organisms enter the bladder by 3 ways: 1) At time of catheter insertion 2) Through the catheter lumen (from a colonized drainage bag) 3) Along external surface of the catheter (migrate along the catheter-mucosal interface) (Tambyah, Halvorson, Maki. Mayo Clin Proc 1999)

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)

Catheter-Associated Urinary Tract Infection Background Prevention

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)

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.

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

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

Recent Guidelines on CAUTI Prevention On the CUSP: Stop CAUTI Recent Guidelines on CAUTI Prevention 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.

On the CUSP: Stop CAUTI http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf

Modified HICPAC Categorization Scheme IB: Even though there may be low to very low quality evidence directly supporting the benefits of the intervention, the theoretical benefits are clear, and the theoretical risks are marginal. All Category I recommendations carry same strength; levels A and B represent the quality of the evidence underlying the recommendation

Core Prevention Strategies: (All Category IB) 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

Comprehensive Unit-based Safety Program (CUSP) On the CUSP: Stop CAUTI Comprehensive Unit-based Safety Program (CUSP)

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”

Pre CUSP Work Create an CUSP/CAUTI team Nurse, physician, administrator, infection control, others Assign a team leader Measure Culture in your clinical unit (discuss with hospital association leader) Work with hospital quality leader to have a senior executive assigned to your unit based team

Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture Educate staff on science of safety http://www.onthecuspstophai.org Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Timmel J, et al. Jt Comm J Qual Patient Saf 2010;36:252-260.

Teamwork Tools Daily Goals AM briefing Shadowing Culture check up TEAMSTepps

CUSP Lessons Learned Culture is local Implement in a few units, adapt and spread Include frontline staff on improvement team Not linear process Iterative cycles Takes time to improve culture Couple with clinical focus No success improving culture alone CUSP alone viewed as ‘soft’ Lubricant for clinical change

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

Expected Benefits Increased awareness of appropriate indications for indwelling urinary catheter use Reduced use of indwelling urinary catheters Improved caregiver accountability to assess need and trigger UC discontinuation when UC no longer necessary Reduced risk of urethral trauma with reduction in utilization Reduced patient discomfort The expected short-term outcomes are: Increased awareness of appropriate use for catheter Reduced use of urinary catheters Improved ability to assess the need or discontinuation of a catheter Reduced patient discomfort Improved patient “dignity”

Expected Benefits Reduction in bacteriuria Reduction in symptomatic UTIs Shortened Length of Stay Decreased Cost per stay Improved sensitivity to “patient dignity”

What Participation Requires Data Submission Intervention Measure Frequency Suggested Collector CUSP   Readiness Assessment Baseline Project Lead HSOPS Baseline and post intervention All staff on unit Team Check-up Tool Quarterly Project team Care and Removal Process Prevalence & Appropriateness Weekly within Protocol Unit staff Outcome Monthly within Protocol Infection Prevention - UTI Rate / Device Days - UTI Rate / Patient Days Insertion TBD

Baseline Data Collected 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18   Cohort 2 PROCESS Cohort 2 OUTCOME S M T W F BASELINE PERIOD No Data Collected JUN 2011 Baseline Data Collected 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29  30 JUL 2011 29 31 AUG 2011 IMPLEMENTATION Intervention Data Collected SEPT 2011 SUSTAINABILITY PERIOD 1 OCT 2011

Post-Intervention Data Collected SUSTAINABILITY PERIOD 2 No Data Collected NOV 2011   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 DEC 2011 31 Post-Intervention Data Collected JAN 2012

Data Collection Schedule MEASURE DATA COLLECTION SCHEDULE DATES CAUTI Rates (Outcome) Number of Symptomatic CAUTI’s attributable to your unit for that month Number of urinary catheter days per month (number of patients with urinary catheter device is collected daily at the same time each day and the total is summed for the month) Number of patient days per month Collect monthly for 5 months beginning in June and quarterly thereafter (June-August will be considered baseline) 2011: June 1-30 July 1-31 August 1-31 September 1-30 October 1-31 2012: January 1-31 April 1-30 Prevalence & Appropriateness (Process) Assess each patient on the unit for the presence of a urinary catheter Record the reason for the catheter Baseline: Mon-Fri for 3 weeks Baseline: August 1-5, 8-12, 15-19, 2011 Prospective: Mon-Fri for 2 weeks, 1 day per week for 6 weeks then one week per quarter thereafter Prospective: September 5-9, 12-16, 20 & 27 October 4, 11, 18, 25 January 9-13 April 9-13 July 9-13 October 15-19

What are the Next Steps Timeline at a glance March 2 Unit attends first immersion call March -May Unit attends Kick Off Meeting and begins participating in national content/coaching calls March - May - Participate in content and coaching calls - Collect and report quarterly data to monitor change June Unit begins base line data collection and culture survey

Questions Content – Sam Watson, MHA Keystone swatson@mha.org Participation–Kristina Davis, HRET kdavis@aha.org