Overcoming Challenges to Reduce CAUTI and Improve Safety Culture National Content Series for All Staff Welcome to today’s content webinar on Overcoming Challenges to Reduce Catheter Associated Urinary Tract Infections, or CAUTI, and Improving Safety Culture for the residents and families we serve. This webinar is part of the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-Term Care that addresses Healthcare Associated Infections (or HAIs) and Catheter Associated Urinary Tract Infections (or CAUTI). We have designed this education session specifically for any staff member who works in a long-term care facility. Every team member is important in helping make your long-term care facility a safe place to live and work! Current as of August 2015

Learning Objectives Upon completion of this training, participants will be able to: Describe common challenges to implementing the clinical and cultural interventions that reduce HAIs/CAUTIs and improve safety culture in LTC facilities Identify strategies and tools to address challenges in your LTC facility Review how you can help achieve success in the program goals During today’s webinar, we will take time to describe some of the common challenges that many long-term care facilities have reported as they strive to implement the clinical and cultural interventions that have been proven to reduce CAUTI infections and improve safety culture. We will also identify the strategies and tools to help you successfully address these opportunities for improvement. These strategies and tools have been used by other LTC facilities and we hope this information will help you achieve success in the program goals.

Reducing CAUTI and Improving Safety Culture: Challenges CLINICAL CULTURAL Physician buy-in Antibiotic stewardship Knowledge and skills (e.g., remove catheters as soon as clinically indicated, not routinely changing catheters) Prioritization (time management) Lack of champions Workload and workflow Understanding CAUTI definition Lack of leadership Data collection Poor communication Reduce unnecessary urine culture orders Staff turnover So let’s start by reviewing a list of some of the common challenges reported by other LTC facilities. We know that change is a hard process and it doesn’t happen overnight! Throughout this program many facilities have struggled with making the necessary changes in clinical practices as a result of many of the challenges listed on this slide. Physician buy-in has been reported as an area that has a strong impact on whether or not staff feel they are supported to make the changes that are based on evidence. It is critical that physicians and the facility administrators are included in the program education and that they understand the importance of the need to adopt practices proven to reduce infections. Physicians, as well as all staff, need to have the knowledge and skills to understand when to remove catheters as soon as clinically indicated and to not routinely change catheters. It becomes a challenge when only a few staff have the knowledge of when catheters are medically necessary and when to take them out. Some facilities have policies in place to change indwelling urinary catheters on regular intervals. However, this is against practice guidelines. This tends to be a clinical practice that many facilities change early in the program, but this can become a challenge if physicians are not supportive of stopping this practice. Another area many facilities feel is a big challenge is simply understanding the CAUTI definition. Because so many facilities struggle with this area, it is important to highlight the criteria for defining CAUTI in a variety of ways throughout the program. Reducing unnecessary urine culture orders is another practice that has been shown to have a major impact on false-positive CAUTI diagnosis and, therefore, the unnecessary use of antibiotics. Many facilities have had long-standing practices that residents are cultured if their urine is smelly or cloudy, when in fact, the research has shown this is not a best practice. In fact, unnecessary urine cultures have been tied to inappropriate antibiotic use and can contribute to the development of antibiotic-resistant germs. It is important to understand the challenges your facility is facing so you can take steps to reduce any barriers to change or improve staff support for the appropriate practices. Many of the clinical challenges are related to the culture at your facility. For example, the way in which your facility prioritizes work and manages projects can affect how much time and support staff have to address the program goals. Generally, programs need champions and leaders who are respected by the staff and who help guide the work. Having clear priorities and leaders can also help manage workload and workflow, especially when your facility experiences staff turnover. If any of these areas are not addressed, it can become very difficult for the staff to implement change, including new skills. So leaders in long-term care must be committed to explaining CAUTI risks and prevention strategies and to involve all team members in the work. The most successful facilities have incorporated changes into their daily workflow. One of the most important cultural challenges that can affect any project is poor communication. Improving communication plays a key role in addressing all of the challenges listed here. In fact, it is so important we want to review several communication strategies that have been shown to help improve how facilities are able to overcome numerous challenges.

TeamSTEPPS Communication Strategies SBAR CUS Check-Back TeamSTEPPS is an evidence-based framework designed to help teams work together and communicate to improve safety and quality. There are several communication and mutual support tools that have been shown to help team members clearly and accurately exchange information. Let’s look at a few of these tools.

SBAR Situation Background Assessment Recommendation Explain the current situation Background Brief history with only the important information Assessment Summarize the facts and what you think is going on Recommendation Explain what actions you think should take place SBAR is a tool that team members can use to reinforce important information that needs immediate attention and action concerning a resident’s situation. It can be a helpful tool for staff to use to organize their conversations about indwelling urinary catheter use or antibiotic orders. When all staff members use this approach to share information about residents, the staff will be more consistent and organized in sharing essential information and highlighting the recommendations that address best practices. When practicing this, staff should first explain the Situation; what is the current state of the resident and the issue the family is concerned about? Next have them share some Background information about the resident and why it can be unsafe for the resident to receive unnecessary urinary catheters, urine cultures or antibiotics. Staff will then provide other staff or concerned family members with an Assessment of the situation, such as other factors that might be influencing the resident’s health and why this might not be a CAUTI. Finally, share your alternative Recommendation for the resident’s care. It is helpful to have staff emphasize that they are recommending a different course of action out of concern for the safety of the resident so that the team will follow approved care practices to prevent CAUTI.

Please use CUS Words but only when appropriate! The TeamSTEPPS CUS tool is another method to improve communication between long-term care facility staff and physicians. Your facility may already be using a communication strategy and you want to discuss your strategy at this point in the All Staff training. If a strategy is not already in place at your facility, we strongly encourage you to consider using CUS. CUS utilizes signal words to provide a framework for conflict resolution, advocacy and mutual support. Many staff members may already be familiar with this tool so ask them to help others learn how to apply this approach. The trigger words for the CUS system are concerned, uncomfortable and safety. These words are meant to catch an individual’s attention and act as a signal when they are spoken. They allow all team members to clearly understand that there is an important issue that needs to be addressed. When practicing this, staff should first state their concern. Then state why they are uncomfortable. And if the conflict is not resolved, state that there is a safety issue. For more information about implementing CUS at your facility, please check out the TeamSTEPPS for Long-term Care website linked at the end of this presentation. Additional Facilitators Notes TeamSTEPPS for Long-term Care: http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/longtermcare/

Check-Back is… Check-Back is another communication tool that helps you make sure the information you shared is understood by the receiver as intended. This methods starts with the sender sending the message. Once the information is shared, the receiver accepts the information and then provides feedback to confirm the message was heard and understood. The sender then verifies the message was indeed received. This approach makes sure any misunderstandings are addressed immediately and provides an opportunity to clarify or ask more questions to be sure everyone is on the same page. Now that we’ve reviewed these communication strategies, think about any communication challenges you have faced in your facility. Discuss how one or more of these tools might help you improve your communication.

TeamSTEPPS: Using SBAR Mr. Belding is an 82-year-old resident of your facility. He has an indwelling catheter due to acute urinary retention. Yesterday his urine was clear and yellow. Today he is more tired than normal and his urine is definitely pink and smells bad. You need to communicate what you’ve observed with a nurse or prescribing clinician. Situation—What is happening? Background—What is the background? Assessment—What do I think the problem is? Recommendation—What would I recommend? PAUSE FOR DISCUSSION Example of what the messaging might be Situation—What is happening? Mr. Belding has cloudy, smelly urine today. Background—What is the background? He has an indwelling urinary catheter due to acute urinary retention, which is a clinical indication for a catheter. Assessment—What do I think the problem is? He had a busy day yesterday, but does not have a fever, confusion or any symptoms of a CAUTI. Recommendation—What would I recommend? I do not think he needs a urine culture now, but would like to document this in his chart and watch him more closely.

CAUTI Definitions and Data Collection Resources Definition check-lists Pocket Cards Four Questions to Identify a CAUTI Question 1 Question 2 Question 3 Question 4 Does the resident have an indwelling urinary catheter connected to a drainage device? Does the resident have one or more CAUTI symptoms? There is no other explanation for this resident’s symptoms? Does the resident have a urine culture that fits the criteria? We mentioned earlier in today’s program that understanding CAUTI definitions was a huge challenge for many facilities. We have developed a number of different tools to help you understand the signs and symptoms and other criteria for a CAUTI. These tools include a check-list and pocket cards that you can carry with you and use as a reference.

Four Questions to Identify a CAUTI then the resident has a CAUTI! NHSN CAUTI Criteria Four Questions to Identify a CAUTI Question 1 Question 2 Question 3 Question 4 Does the resident have an indwelling urinary catheter connected to a drainage device? Does the resident have one or more CAUTI symptoms? There is no other explanation for this resident’s symptoms? Does the resident have a urine culture that fits the criteria? If you suspect that your resident has a CAUTI, ask yourself: Does the resident have an indwelling urinary catheter connected to a drainage device? Does the resident have one or more CAUTI symptoms? Is there no other explanation for this resident’s symptoms? Does the resident have a urine culture that fits the CAUTI criteria? If you answered “YES” to all of these questions, then your resident does indeed have a CAUTI. Which of these questions do you feel the most challenged by answering or are the most difficult to understand? YES YES YES YES then the resident has a CAUTI!

What are the Signs and Symptoms of CAUTI? ONE or MORE of the following: CAUTI Sign or Symptom Fever Rigors (chills and sweats) New confusion or functional decline (with NO alternative diagnosis AND leukocytosis) New suprapubic pain or costovertebral angle pain or tenderness New onset hypotension (with no alternate site of infection) Acute pain, swelling or tenderness of the testes, epididymis or prostate Purulent (pus) discharge from around the catheter Often times, staff struggle with remembering the signs and symptoms that fit the CAUTI criteria based on the NHSN definition. As a reminder, the following are signs and symptoms associated with a CAUTI: Fever Rigors New onset confusion or functional decline New onset of suprapubic pain or costovertebral angle pain or tenderness New onset hypotension Acute pain, swelling or tenderness of the testes, epididymis or prostate gland Purulent discharge or pus from around the catheter If a resident with an indwelling catheter (or one removed in the last 2 days) has just one of these symptoms and a positive urine culture meeting CDC criteria, it will then count as a CAUTI All levels of staff involved in direct resident care should be familiar with these symptoms and understand how to observe, report and document them. If you’re still unclear or want more details about these signs and symptoms, you can ask to review Onboarding #2 and obtain a pocket cards to guide you in your observations. See Onboarding 2: CAUTI Definitions and Reporting video for all LTC staff for further details

Antibiotic Stewardship: The Challenge Antibiotic overuse is common in LTCFs as a result of : Positive urine dipstick Positive urine culture Lack of communication among all team members can result in antibiotic overuse Antibiotic stewardship is another common challenge that facilities face for a variety of reasons. Antibiotic resistance has become a national problem because it impacts all health care settings and communities. So as part of this program, we focus on antibiotic stewardship, or making sure antibiotics are being used for the right purpose, at the right time and for the right reasons. It is important for staff to understand that a positive urine dipstick or positive urine culture does not automatically mean the resident has a urinary tract infection! A positive urine culture is sometimes treated with antibiotics even when there are no signs and symptoms of a UTI. Staff receive education in this program concerning how to report signs and symptoms to clinicians in order to reduce unnecessary urine cultures and unnecessary antibiotic use. Communication among all team members is so important in preventing antibiotic overuse. We focus on all of these elements to not only reduce false-positive CAUTI identification, but to also reduce unnecessary testing and treatment. ______________ Facilitator Notes There are many common situations in which antibiotics are overused. Be aware of overuse in these situations that are common in long-term care facilities: Positive urine dipstick Positive urine culture Viral respiratory symptoms Chronically red feet or legs Link to Office of the Press Secretary Fact Sheet: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant The White House Office of the Press Secretary FACT SHEET: Obama Administration Releases National Action Plan to Combat Antibiotic-Resistant Bacteria March 27, 2015

Antibiotic Stewardship: Solutions Educate all team members, including residents and families Ask staff and residents /family to look for signs and symptoms Explain the appropriate use of an indwelling catheter, urine culture or antibiotics Promote shared decision-making And remember, it is important to communicate with residents and families on indications for a catheter, infection prevention strategies and when antibiotics may not be indicated. Proactive education is important to help residents and families be part of the team regarding all the efforts to prevent CAUTI. Resident and family engagement can also promote a culture of safety by supporting shared decision-making among all team members, especially the resident and their family.

Overcoming Challenges Identify the challenge Recognize and engage champion(s) Use teams to tackle the challenge Collect data and communicate progress Empower staff to be part of the solutions Celebrate success We addressed only three common challenges LTC facilities face everyday in their efforts to prevent HAIs and improve safety culture. Take time to think about what challenges you have at your facility. Identify a champion – someone who is willing to work with all staff to help them overcome these challenges. Use teams of staff from different departments to tackle the challenge together. Use data to help your team understand not only what you need to improve, but how much you are improving over time. Remember to use your communication skills to engage everyone in the plan to improve. Everyone needs to feel they are empowered to be part of the solutions to any challenges. And don’t forget to recognize staff who are modeling the improvement strategies you identified and celebrate the team’s success! These steps and the communication strategies discussed earlier can also be useful to address other types of long-term care facility concerns, such as fall prevention or readmissions. Remember: Every team member is important in helping make your long-term care facility a safe place to live and work!

Stay Updated with Useful Resources NHSN Criteria—CAUTI Definition Pocket Cards Antibiotic Stewardship Brochure As we wrap up today’s discussion, I’d like to thank you for viewing this presentation. We need all staff’s input to reduce HAIs and CAUTIs in long-term care facilities. The following resources are available to you as participants in the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project. Resources: The first resource is a link to the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project website. On the website you will find a variety of tools to help you prevent CAUTIs and improve your facility’s culture of safety. The second resource is a link to the TeamStepps for Long-term Care web page. TeamStepps is a communication and teamwork system that offers solutions to improving collaboration and communication within health care facilities. The resources on this page are specifically designed for the long-term care environment. The third resource is a link to NHSN Criteria CAUTI Definition Pocket Cards. The final resource is a link to the Antibiotic Stewardship Brochure. We hope that these resources will be helpful on your journey to reduce CAUTIs and HAIs and improve your facility’s culture of safety.