1. Preventing Catheter-Associated Urinary Tract Infections: Planning and Implementing the Effort
Mohamad Fakih, MD, MPH
Associate Professor of Medicine
Wayne State University School of Medicine
St John Hospital and Medical Center, Detroit, MI
9/14/12

2. An 82-year-old woman was admitted for congestive heart failure…
She had a urinary catheter (UC) placed and was started on diuretics. She appeared frail. Her physician and nurses felt that keeping the catheter in place would make her more comfortable.
On the 5th day of admission, she started complaining of chills, had a fever of 102°F, and her BP dropped to 90 systolic. Blood cultures and urine cultures grew Escherichia coli. She was diagnosed with symptomatic CAUTI and had to be treated with intravenous antibiotics.
The following three slides present actual scenarios wherein unnecessary urinary catheter placement led to poor patient outcomes.
The first case involves an 82-year-old woman admitted for congestive heart failure. She was started on diuretics and had a urinary catheter placed. Because she appeared frail, her physician and nurses decided to keep the catheter in place, hoping to improve her overall comfort. On the fifth day of admission, she complained of chills. Her temperature was 102°F and her systolic blood pressure dropped to 90. Both blood and urine cultures grew Escherichia coli. The patient was diagnosed with symptomatic catheter-associated urinary tract infection, necessitating intravenous antibiotics.

3. A 78-year-old nursing home resident was admitted for a gastrostomy tube change…
The ED nurse noted that he was incontinent. The male patient was confused because of long-standing dementia. Although a bladder scan did not show any urinary retention, the nurse spoke to the ED physician about placing a catheter. Several hours after the catheter was placed, the patient pulled it out, leading to a urethral injury and hematuria.
This required a urology evaluation.
The second case scenario involves a 78-year-old nursing home resident admitted for a gastrostomy tube replacement. The emergency department nurse noted the man’s incontinence. He also was confused, due to long-standing dementia. Although the bladder scan did not reveal urinary retention, the nurse asked the ED physician for an order to place a urinary catheter. Several hours after placement, the patient pulled his catheter out, leading to urethral injury and hematuria. A urology evaluation was required.

4. Objectives Epidemiology of UC use and CAUTI
How to reduce the risk of CAUTI
Proper insertion/ maintenance
Prompt removal of no longer needed catheters
Limit use to indications
Where to intervene
How to sustain improvements
Engaging nurses and physicians
Measuring improvements (process, outcome)
Our goal is to assist healthcare facilities in preventing catheter-associated urinary tract infections (CAUTIs). We will describe urinary catheter use and the epidemiology of catheter-associated urinary tract infections. We will explain the steps that CMS (Center for Medicare and Medicaid Services) and HHS (Health and Human Services) have taken to reduce CAUTIs in the hospital setting.
We will also review how to reduce the risk of CAUTIs (for example, proper insertion techniques and appropriate use), discuss how to sustain your facility’s improvement (how to keep catheter utilization and CAUTI rates down), provide tools for avoiding unnecessary urinary catheter placement and metrics to calculate utilization rates.

5. Epidemiology
Urinary catheters are frequently used in the hospital setting.
The presence of the indwelling urinary catheter increases the risk of urinary tract infections.
Urinary catheters are commonplace in today’s healthcare setting. Unfortunately, as we will demonstrate, the presence of an indwelling urinary catheter greatly increases the risk of urinary tract infections.

6. Urinary Catheter Utilization
About % of patients will have a urinary catheter placed during their hospitalization.
Many are placed either in the intensive care unit, emergency department or the operating room.
Please read slide.

7. Mean Use of UCs (NHSN): ICU > General Wards (Edwards, Am J Infect Control 2009; 37: , Dudeck, Am J Infect Control. 2011;39(5): ; Am J Infect Control 2011;39(10): )
Unit
Urinary Catheter Utilization Ratio
2009 Urinary Catheter Utilization Ratio
2010 Urinary Catheter Utilization Ratio
ICU (med-surg, major teaching)
0.78
0.73
ICU (med-surg, >15 beds)
0.79
0.72
0.71
General Wards (med-surg)
0.22
0.19
Data from the CDC’s National Healthcare Safety Network (NHSN) reveals that urinary catheter utilization is nearly four times greater in an intensive care unit than on a general, “med-surg” unit. A small decrease in use is seen when we compare to , but no change between 2009 and 2010.

8. Inappropriate Use
40% - 50% of patients from non-intensive medical and surgical units may not have a valid indication for urinary catheter placement.
This can occur:
At the time of placement
With continued use
It is estimated that 40% to 50% of patients in non-intensive medical-surgical units do not have a valid indication for urinary catheter placement. Some urinary catheters are not indicated at the time of placement, while others are needed for a certain period, but are not removed when no longer indicated.

9. Inappropriate Use in non-ICU: Michigan Experience (Fakih et al, Arch Intern Med 2012;172: )
Baseline % of all patients with catheters (57.6%)
% of patients with catheters without appropriate indications*
Non-obstructive renal insufficiency
2.2
3.8
Transferred from intensive care
4.2
7.3
Patient request
1.5
2.6
Confusion
4.6
8.0
Incontinence
6.5
11.3
Other or no clear reasons
38.6
67.0
*Based on the 1983 CDC recommendations
In data collected by Michigan Hospital Association (MHA) between 2007 and 2010, 57.6% of patients did not have an appropriate indication for urinary catheter use (as defined in the 1983 CDC recommendations). Of those who did not have an acceptable indication, two-thirds did not have a clear reason for why the catheter was being used. (May read the different reasons for use that were not compliant with 1983 CDC recommendations).

10. Very Elderly Women Are at High Risk for Unnecessary Utilization (Fakih et al, Am J Infect Control 2010;38:683-8)
Evaluated urinary catheter (UC) placement for all admissions from the emergency department (ED).
532 (11.8%) of 4521 patients had a UC placed. Of those, 69.7% were indicated, and 58.6% had a physician order documented.
Inappropriate placement: older (mean age 71.3 vs. those with indication 60.0 years, p<0.0001, and patients with no UC placed 56.2, p<0.0001).
Half of women ≥80 years with a UC placed did not have an indication.
Independent factors: women were twice more likely than men, and very elderly (≥80 years) were 3 times more likely than those 50 or younger, to have UC placed without indication.
A study performed at St John Hospital & Medical Center in Detroit, Michigan evaluated urinary catheter placement for all admissions from the emergency department. Of the 4,521 patients, 532 (11.8%) had a urinary catheter placed. Of those, nearly 70% were appropriately indicated, but only 60% had a physician order documented. Inappropriate placement was higher in the elderly population, and half of the women aged 80-years-old or greater who had catheters placed did not have an appropriate indication.

11. Urinary Catheter Harm CAUTI Falls?
Part of the HEN work
Urinary Catheter Harm
CAUTI
Increased Length of Stay
Patient discomfort
Trauma
Immobility
Pressure ulcers
Venous thrombo-embolism?
We want to stress that urinary catheters are not harmless devices. They may lead to urinary tract infections and cause mechanical trauma to the urethra and bladder. They also immobilize patients—increasing the likelihood of pressure ulcers, falls and prolonged inpatient stays. Dr. Saint has described this eloquently in 2002 as a “one point restraint” affecting patient rights, comfort, and dignity.
Falls?
Isn’t this a patient safety issue, not just CAUTI?

12. Catheter-Associated UTIs (CAUTIs) (Tambyah, Infect Control Hosp Epidemiol 2002;23:27-31; Saint S, Am J Infect Control 2000;28:68-75 ; Dudeck, Am J Infect Control. 2011;39(5): )
Hospital-acquired bacteriuria and candiduria in 25% of those with urinary catheters placed for a week
Risk of bacteriuria: about 5% per day
Symptomatic UTI: 16-32% of those bacteriuric
Several studies discovered hospital-acquired bacteriuria and candiduria in 25% of patients who had a urinary catheter in place for a week. This risk of bacteriurua increases by 5% every day the catheter remains in place.

13. Mean CAUTI Rates: Changes with New Definition (Edwards, Am J Infect Control 2009; 37: , Dudeck, Am J Infect Control. 2011;39(5): ; Am J Infect Control 2011;39(10): )
Unit
NHSN CAUTI Rate* (per 1,000 catheter days)
2009 NHSN S-CAUTI Rate (per 1,000 catheter days)
2010 NHSN S-CAUTI Rate (per 1,000 catheter days)
ICU (med-surg, major teaching)
4.7
2.3
2.2
ICU (med-surg, >15 beds)
3.1
1.2
1.3
General wards (med-surg)
5.9
1.6
1.5
The CAUTI rates reported by NHSN have significantly dropped after NHSN changed the definition of CAUTI to “symptomatic CAUTI.” This led to a reduction in the rate by about two thirds in many non-intensive care units, and some of the ICUs. A significant drop of more than 50% was also seen in major teaching ICUs when the definition was changed.
Note that the NHSN CAUTI rate in the intensive care units used to be lower than the non-intensive care setting prior to the new definition of CAUTI. This may be in part related to more antibiotic use in intensive care units (antibiotics are associated with a reduction in bacteriuria).
*Prior to the new SUTI definition

14. Limit catheter use to indications (Avoid placing the catheter unless appropriately indicated)
Limit catheter use to indications (promptly remove those that are no longer necessary)
Appropriate Care of the Catheter
Proper Insertion Technique
Reduce urinary catheter days leading to a reduction in days at risk for CAUTI
Reducing Risk of CAUTI
Reduce risk of introducing organisms to the bladder leading to a reduction of risk of CAUTI when catheter in place
How do we reduce the risk of CAUTI? Please read the slide.

15. Proper Insertion Technique
Perform hand hygiene before and after placement.
Maintain aseptic technique and use of sterile equipment.
Use sterile gloves, drape, an antiseptic solution for periurethral cleaning, and a single packet of lubricant for insertion.
Use the appropriate catheter size.
Please read slide.

16. Maintenance of Urinary Catheters
Keep a closed system for the urinary drainage system.
Make sure urinary flow is not obstructed:
No kinks in the catheter.
Urinary bag should always be lower than the bladder.
Regular emptying of urinary bag.
Please read slide.

17. Limit Use to Indications
Avoid use unless appropriate indication
Promptly remove of catheter when no longer indicated
Reduction in Inappropriate Urinary Catheter Use
Limiting the use to indications is addressed in 2 ways: If a patient has a urinary catheter in place, it should be assessed daily for necessity, and promptly removed if there is no continued need. In addition, we should avoid placing a catheter unless there is an appropriate indication for use.
Clear Identification of what is considered an appropriate indication

18. Removal of No-Longer Indicated Catheters
Nurse-driven removal of no longer needed catheters
Pilot study: 45% reduction in unnecessary catheter utilization (Fakih et al, Infect Control Hosp Epidemiol 2008; 29: 815-9)
Identify appropriate indications based on HICPAC guidelines (Gould et al, Infect Control Hosp Epidemiol 2010; 31: ).
Daily evaluation of catheters for presence and need is important in reducing inappropriate use. A pilot study at St. John Hospital & Medical Center (Detroit, MI) focused on encouraging the nurses to evaluate the catheter for necessity and to trigger the process of removal of urinary catheters if they were no longer indicated. As a result, there was a 45% reduction in unnecessary catheter utilization. The HICPAC guidelines are used to help facilities clarify the appropriate indications for catheter use.

19. 2009 Prevention of CAUTI HICPAC Guidelines (Gould et al, Infect Control Hosp Epidemiol 2010; 31: )
The following table lists the HICPAC list of appropriate and inappropriate uses of urinary catheters (review indications with audience).

20. HICPAC Guidelines vs. Other Acceptable Institutional Indications
2009 CAUTI HICPAC guidelines: based on expert consensus, not randomized controlled or quasi-experimental trials.
Institutions may opt to have additional limited number of reasons for placing the urinary catheter which they may consider acceptable.
Also, note that the 2009 CAUTI HICPAC acceptable indications are based on expert consensus, rather than randomized controlled or quasi-experimental trials. We, however, understand that each institution may have certain additional acceptable reasons for catheter use. We encourage each facility to clearly identify its own acceptable indications. Keep in mind, however, that additional acceptable indications should be carefully decided.

21. Nurse Driven UC Removal Program
Education of nurses on:
Appropriate indications.
Ways to avoid urinary catheter placement.
Evaluation of urinary catheter use and compliance with appropriate indications.
Sustainability: nurses own the process of evaluating for catheter appropriateness of use daily.
The CAUTI prevention program consists of three main elements. The first is the education of nurses on the appropriate institutional indications and the ways to avoid unnecessary urinary catheter placement. Secondly, the program evaluates urinary catheter use and compliance with appropriate indications over time. Lastly, the program looks at sustaining the improvements by giving nurses ownership of the process.

22. Two Important Items
Train nurses to drive the process of daily urinary catheter evaluation (regardless of whether data is collected or not).
Provide periodic feedback to the units on their urinary catheter use and compliance with appropriate indications.
Please read slide.

23. Tools Used with Intervention
Lecture for nurses
Pocket cards, posters
During our intervention, we created colorful posters, handouts and laminated pockets cards to reemphasize appropriate urinary catheter uses. Posters were hung in break rooms and common areas, and the pocket cards were distributed after each educational session. 23

24. Main Education is Performed During Nursing Rounds
Does the patient have a urinary catheter?
Reason for catheter use?
If no appropriate indication, the patient nurse will contact the physician to discontinue the urinary catheter.
This process will be continued after implementation with the patient’s nurse owning the process.
We suggest incorporating the main education in nursing rounds. A decision-making algorithm is another useful tool to post and distribute. Here, the nurse-driven approach is outlined. If an appropriate indication is not identified, the nurse will contact the physician for an order to promptly remove the catheter. 24

25. Urinary Catheter Removal
Prompt removal should not be interpreted as an increased workload for either the nurse or nurse aide.
Promote alternatives to the urinary catheter.
Highlight risks associated with having the urinary catheter.
The nurse-owned process of removing unnecessary urinary catheters should be promoted as an empowering, positive endeavor—not as an increase in workload or another added task. Focus on the importance of patient safety and prevention of associated risks. Promoting alternatives to the urinary catheter may help more nurses to support the effort.

26. Following Implementation
Evaluation of catheter need is incorporated into the patient’s nurse daily assessment.
A champion from the unit will promote appropriate urinary catheter utilization on the unit; this will be encouraged through daily nursing rounds.
Units involved will receive feedback on the results of program implementation.
To successfully sustain the program, catheter evaluations must be incorporated into the nurses’ daily assessments of patients. Consider identifying a unit champion who will promote appropriate urinary catheter utilization from within his or her own team. Continue to provide feedback to participating units, so unit members will be able to identify the results of their work.

27. Success with Implementation: Michigan Experience (Fakih et al, Arch Intern Med 2012;172:255-260)
The implementation included 163 inpatient units in 71 participating Michigan hospitals.
Urinary catheter use dropped from 18.1% at baseline to 13.8% at 2 years.
Appropriate urinary catheter use (based on the 1983 CDC guidelines) improved from 44.3% at baseline to 57.6% at 2 years.
Please read slide.

28. Success with Implementation: Michigan Experience (Fakih et al, Arch Intern Med 2012;172:255-260)
30% relative increase
25% relative decrease
The figure depicts the reduction in catheter use over time (about 25% relative decrease) and the improvement in the appropriate indications for catheter use (a 30% relative increase).

29. Partnering with Residents, PAs, NPs
Resident physicians are responsible for a large number of patients in teaching hospitals and may have a significant effect on utilization if engaged.
PAs and NPs are responsible for a substantial part of the care rendered in some hospitals.
Residents, PAs, and NPs may help in 2 ways:
Evaluate the need for the catheter and discontinue if no longer needed.
Serve as an easier access to nurses to obtain order for discontinuation of no longer needed catheters.
Broaden the scope of your program by including resident physicians, physician assistants and nurse practitioners in your educational endeavors. These healthcare providers render a substantial part of care in many hospitals, and can assist in evaluating and discontinuing catheters. In addition, they are usually more available than practicing physicians, thus easier to contact for discontinuation of catheters.

30. Physicians Physicians should evaluate the need for the catheter daily.
High volume physicians (hospitalists) may be selected to champion the effort.
Physicians who are considered leaders and whose practice is followed by others (e.g., cardiology, nephrology) may also be instrumental in changing behaviors and monitoring of urine output in non-ICU.
Please read slide.

31. Avoiding Inappropriate Placement
Avoiding inappropriate placement may have a substantial effect on utilization.
Consider areas of high placement (e.g., emergency department) to focus your efforts.
In addition to promptly removing unnecessary catheters, avoiding inappropriate catheter placement will reduce overall catheter use. Consider interventions in areas with high placement rates (for example, emergency departments).

32. Established institutional guidelines for UC placement in ED
ED Compliance with Institutional Guidelines (Fakih et al, Acad Emerg Med 2010; 17:337–340)
Established institutional guidelines for UC placement in ED
Compared the rate of placement before and after guidelines
ED physician champion involved
Institutional guidelines were established for an emergency department, this was with the help of an ED champion and the Infection Prevention team. ED attending staff agreed on adopting the institutional guidelines for urinary catheter placement. Urinary catheter use and the compliance with appropriate indications were evaluated before and after the implementation of the institutional guidelines.

33. Physician Intervention in the ED (Fakih et al, Acad Emerg Med, 2010; 17:337–340)
UC utilization dropped significantly after starting the physician intervention from 212 of 1421 (14.9%) pre-intervention to 110 of 1041 (10.6%) post-intervention (p = 0.002).
Physicians ordered fewer UCs post-intervention (45 of 1041, 4.3%), compared to pre-intervention (106 of 1421, 7.5%), (p = 0.002).
Only 151 of 322 (47.0%) of UCs initially placed in the ED had a physician order documented.
Please read slide.

34. Avoiding Urinary Catheter Placement: Emergency Department-Specific
Addressing both nurses and physicians is important.
Consider agreed-upon institutional guidelines for urinary catheter placement in the emergency department (ED).
Identify nurse and physician champions for the ED.
Similar work has been recently implemented in Michigan (through MHA) and Ascension Health hospitals with successful results
In the ED, both physician and nurse support of the process are important. Having clarity regarding the acceptable indications for urinary catheter use will help both physicians and nurses when they evaluate whether a patient needs to have a catheter in. Finally, identify nurse and physician champions who are enthusiastic, passionate, patient safety advocates to gain peer support.

35. How to Sustain Improvement
Make sure that the process is part of the daily nursing assessment.
Provide feedback on urinary catheter use over time to the units involved.
Evaluating compliance with appropriate urinary catheter use may be helpful if no significant drop in utilization occurs.
To sustain improvements, urinary catheter evaluations must remain part of nurses’ daily assessments. Continue to collect prevalence rates and feed the information back to nursing units. If an overall improvement has not been achieved, evaluate compliance with appropriate indications. In doing so, you can easily identify problem areas.

36. Does the Effect Persist? (Fakih, Am J Infect Control, in press)
Nurse-driven removal of unnecessary catheters
Incorporating the evaluation of catheter need during nursing rounds, and collecting urinary catheter prevalence twice weekly since 2007
Establishing institutional guidelines for the ED and education
Urinary Catheter Prevalence (%)
Must all good things come to an end? How do we sustain low urinary catheter prevalence permanently? Nurses must incorporate urinary catheter evaluations into their daily assessments. Data collection and feedback help sustaining the improvement. At St. John Hospital & Medical Center, urinary catheter use data continue to be collected biweekly, thanks to a collaborative effort among Infection Prevention, Quality and Case Management teams. Prevalence results are periodically fed back to the units.
SJHMC, Detroit, MI

37. What Did We Do to Keep the Rates Down?
Provided knowledge on appropriate indications.
Linked the target (appropriate utilization) to certain stakeholders’ interests (case management), regarding LOS and complications.
Intervened in the ED to reduce inappropriate placement from the 1st step reaching the hospital.
Built a structure to evaluate the catheters at least twice weekly.
Provided periodic feedback of rates.
Our team utilized a multifaceted approach. We educated healthcare workers on appropriate indications. We linked our goals with other stakeholder’s interests, increasing the likelihood of our success. By identifying the area with the highest placement rates, we successfully decreased overall utilization. Once an evaluation process was created, we ensured that the process was maintained by continuing to collect the data. Finally, we reported the rates back to the involved units.

38. Alternatives to Indwelling Urinary Catheterization
Bladder scanners may be used in cases where urinary retention is suspected, or when the patient did not have any witnessed urine output and the clinician needs to evaluate for obstruction. Consider having bladder scanners available.
Condom catheters may be considered in men that require fluid monitoring. Their use reduces the risk of urethral trauma (compared to indwelling urinary catheter). Condom catheters are not used in cases of urinary retention.
Please read slide.

39. Alternatives to Indwelling Urinary Catheterization
Intermittent catheterization may be considered in patients with non-obstructive urinary retention (e.g., patients with neurogenic bladder).
Please read slide.

40. Engaging Physicians and Nurses

41. Physicians
Play a significant role in shaping care in the hospital setting.
Most are very autonomous and may not be employed by the hospital.
Many are interested in treating illness, but not trained to focus on improving safety and preventing harm.
Many are unaware of the efforts being implemented to promote safety in the hospital.
Many may have a limited amount of time to volunteer for supporting the quality agenda.

42. Physicians as Partners
Physicians are leaders of safety efforts.
Make safety a “home-grown” product, not imposed on physicians, but owned by all of the stakeholders.
Move physicians from reactive to proactive role (get involved in decision making related to safety, rather than reacting to a plan being implemented).
Physicians responsible for safety: “could I have prevented a CAUTI with bacteremia if I removed the catheter a few days earlier?”

43. Physician Champions
Identify motivated physicians who want to be engaged, want to help improve safety, excited to have the opportunity of making a change, and appreciate the recognition associated with their role.
Physicians that have an interest in reducing the harm related to the catheter are more likely to be engaged in the effort to reduce unnecessary urinary catheter use.
Physician champions should be engaged from the start and should be visible to both staff and other physicians.

44. Role of Physician Champions
Educate physicians on the guidelines for urinary catheter use and risks of the catheter (lectures, providing educational materials).
Encourage physicians to comply with the guidelines.
Support the work of the team to resolve any barriers to implementation.
Provide technical expertise for the team.
Provide feedback to other physicians about the progress of the project; share the results.

45. Physician Champions and Other Physicians
Spread the word to physicians about the effort to reduce CAUTI and unnecessary utilization and the importance of physician support (may need to present the project to multiple disciplines in the hospital).
Clarify with other physicians their concerns about any reasons for use that are not considered appropriate and work with physicians to gain their support (use EBM to help).
Address physicians in training and midlevel providers to obtain their support.

46. Physician Champion and Indications
The HICPAC guidelines identify the appropriate uses of the urinary catheter.
Some hospitals may consider having a limited number of additional institutionally based acceptable indications for urinary catheter use.
Physician champion to obtain consensus on the additional locally acceptable indications from key physician leaders; this will likely provide you with support during the implementation.

47. The Physician Champion…and Physician Supporters
CAUTI Physician Champion
Infectious Diseases specialists/ Hospital Epidemiologist
Urologists
Hospitalists
Geriatricians
Rehabilitation Medicine specialists
Surgeons
Intensivists
Emergency Medicine Physicians

48. Physician Supporters: Reasons for Them to Support the Champion
Infectious Disease Specialists
Urologists
Reduce CAUTI.
Reduce antibiotic use.
Reduce potential of increased resistance and Clostridium difficile disease.
Reduce trauma (mechanical complications):
Meatal and urethral injury
Hematuria
Hospitalists
Geriatricians
Infectious and mechanical complications.
Potential catheter complications prolonging length of stay.
Hospitalists care for a large number of patients. Their support may help significantly improve the appropriate use of the urinary catheter.
Many elderly are frail.
Urinary catheters are placed more commonly in elderly inappropriately.
Urinary catheters increase immobility and deconditioning risk, in addition to infection and trauma.

49. Physician Supporters: Reasons for them to Support the Champion
Rehabilitation Specialists
Surgeons
The urinary catheter reduces mobility in patients: one point restraint.
Rapid recovery (improvement in ambulation) may be hampered by the catheter (in addition to the other associated risks).
Surgical Care Improvement Project: Remove catheters by postop day 1 or 2.
Inappropriate urinary catheter use postoperatively will negatively affect the surgeon’s profile.
Risk of infection and trauma related to the catheter.
Intensivists
Emergency Medicine physicians
A significant opportunity is present upon transfer from the ICU to discontinue no longer needed devices, including urinary catheters.
Intensivists can support the evaluation of catheter need before transfer out of the unit and may significantly impact use.
Up to half of the patients are admitted through the emergency department (ED).
Inappropriate urinary catheter placement is common in the ED.
Promoting appropriate placement of urinary catheters in the ED will reduce inappropriate use hospital-wide.

50. Physician Champions and the Team
Meet with the other CAUTI team members regularly to discuss the progress of the work (keep meetings efficient and productive).
Address the team’s concerns about any physician barriers to implementation and work as a facilitator between the team and the physicians.
Relay physicians concerns to the CAUTI team to address any barriers to implementation.

51. Physician Champions and Their Leaders
Physician leaders should identify physician champions with passion for improving safety and support them to promote a safer environment.
Physician leaders should support the physician champion to achieve the goals of the project.
The physician champions are at risk of having challenges in their efforts to reduce inappropriate catheter use.
Physician champions need to be empowered to be able to succeed.

52. Nurse Champions
Responsible for the education of other nurses, and the one who will trigger the process of assessment for the presence and indication for use of the catheter during implementation.
May be a technical expert for peers.
May be the nurse manager, a unit nurse leader, or a bedside nurse who is well respected by peers.

53. Nurse Champion: Making the Case
Adverse outcomes associated with the catheter
Preventability
Urgency for the change (patient safety)
Not having the urinary catheter ≠ more work (examples: bundling turning and skin care with addressing incontinence)

54. Transition of Bedside Nurse to Champion
Initially, a nurse champion will support the effort
The ultimate goal is to have the bedside nurse be the champion for every patient, assessing device need as part of the daily work

55. The Bedside Nurse…and Supporters
Nurse (Bedside)Champion
Infection Preventionists
Case Managers
Nurse Manager
Physical Therapists
Intensive Care Nurses
Wound Care Nurses
Emergency Medicine Nurses
Post-operative, Recovery Nurses
Physician

56. Nurse Supporters: Reasons for Them to Support the Champion
Infection preventionists
Case managers
Reduce CAUTI.
Reduce antibiotic use.
Reduce potential of increased resistance and Clostridium difficile disease.
Less complications (mechanical or infectious)= lower cost
Early removal of catheter may reduce length of stay
Nurse manager
Physical therapists
Leader and supporter to the bedside nurse (empowers the nurse)
Makes the appropriate urinary catheter use a priority and a safety issue
Addresses any barriers encountered by the bedside nurse
The urinary catheter reduces mobility in patients: one point restraint.
Rapid recovery (improvement in ambulation) may be hampered by the catheter (in addition to the other associated risks).

57. Nurse Supporters: Reasons for Them to Support the Champion
Intensive care unit (ICU) nurses
Wound care nurses
A significant opportunity is present upon transfer from the ICU to discontinue no longer needed urinary catheters.
ICU nurse transferring the patient may evaluate catheter need before transfer out of the unit and discontinue unnecessary catheters.
Urinary catheter use increases immobility, which in turn results in an increased risk of pressure ulcers.
Wound care nurses may help in advising the bedside nurse on methods to reduce skin breakdown in patients with incontinence without using urinary catheters
Emergency medicine (ED) nurse
Post-operative recovery nurses
Up to half of the patients are admitted through the emergency department (ED).
Inappropriate urinary catheter placement is common in the ED.
Promoting appropriate placement of urinary catheters in the ED will reduce inappropriate use hospital-wide.
Urinary catheters are commonly placed preoperatively for fluid management during the surgery.
Post-operative recovery nurses evaluate the catheter for continued need and promptly remove no longer catheters.

58. Metrics to Evaluate Improvement
Process
Outcome
What metrics would we use to evaluate improvement? Process measures reflect the changes in utilization of the catheter, and the outcome measures reflect the changes in CAUTIs.

59. Process Measures
Urinary catheter utilization (number of urinary catheters/ number of patients)
Compliance with appropriateness of use (number of appropriately used catheters/ total number of catheters used)
Utilization is easy to measure; reporting appropriateness is more challenging
Please read slide.

60. Outcome Measures
Number of CAUTIs (collected by infection preventionists)
NHSN CAUTI rate (requires accurate collection of catheter-days): important to measure risk with insertion and maintenance
Population CAUTI rate (uses patient-days in the denominator-easier to calculate): provides important assessment of improvement over time
Outcome measure are more labor intensive, requiring case review by experienced infection preventionists. The number of CAUTIs must be first be collected to determine your overall CAUTI rate. We use the National Healthcare Safety Network (NHSN) definition for CAUTI. The NHSN CAUTI rate evaluates the risk of infection with insertion and maintenance and requires accurate collection of total catheter-days. An easier calculation is using a population CAUTI rate, which uses patient-days (may be provided from hospital administrative database) as a denominator. A population CAUTI rate will assess a facility’s improvement over time.

61. Summary
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.
Nurses and physicians must be accountable for urinary catheter appropriateness. Physicians are responsible for promptly discontinuing catheters when no longer needed. Likewise, we need daily nursing assessments to identify unnecessary catheters as soon as possible. Remember to broaden the scope of your initiative and partner with different disciplines. Look to case management, infection prevention, and nursing support services to achieve your goals. Remember to include physician assistants, nurse practitioners and resident physicians in your initiative!

62. Summary
A continued reduction in urinary catheter utilization may be a marker of the program’s success.
If no significant improvement is noted after implementation, you may need to reexamine the process for barriers or problems in implementation.
Please read slide.