1. HAI Affinity Group The Essentials of CAUTI Prevention March 13, 2013 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice President, Infection Prevention/Staff Engagement

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 2 Objectives Describe the harm associated with catheter-associated urinary tract infections (CAUTI). Outline the essential elements necessary to prevent CAUTI in the hospital setting. Discuss methods to involve patients/families in preventing CAUTI. 2

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3 Where We Are 3

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 4 CAUTI Harm Not a simple infection Harm – Pain – Antibiotic exposure – Sepsis Increase length of stay for infection or failure to d/c catheter Non payment for HAC higher cc DRG Potential for falls and decreased ambulation with catheter 4

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 5 Prevention of CAUTI – A Challenge Perception not serious Easy to use catheters, easy to lose track Professional convenience…what we have always done Patient and family requests 5

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6 The Essentials – A Broad Approach Eliminating CAUTI Harm Evidence Based Practices Prevention Culture Patient/Family Engagement Teamwork 6

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 7 Starts with a Vision and Goal Focus on patient harm – the why Decrease rate by 40% Decrease catheter utilization – Begins with insertion necessity including ED and OR – Daily assessment Target zero Share current state and future state Tell a story 7

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 8 8 Obtain leadership support: 1. Senior Executive Champion 2. Nursing 3. Physician Identify champions: Physician leaders - Physician with interest in improving safety/ quality (for example, an Infectious Diseases specialist, urologist, or hospitalist) Nursing leaders - Potential candidates include nursing director, or a very effective nurse manager/charge nurse Garner Support

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 9 9 Partner with nursing, case management, infection prevention, and physicians Evaluate unit(s) with high prevalence and/ or unit(s) with increased non-indicated urinary catheter use Start with one general medical/surgical unit Choose a unit with an effective unit manager (complete support of the unit leader is usually needed to be successful) and committed staff Will use as a pilot to develop reliable process then spread Start with One Unit

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 10 Develop Your Team Team leader Nurse manager Staff – nurses and techs Physician Infection Preventionist Quality professional Case manager or others Executive champion 10

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 11 Communicate Goals and Process Improvement The why – reduce patient harm related to CAUTI Provide the data Develop a reliable process to implement evidence based practices Standardize and spread 11

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 12 Use the Evidence to Formulate Process Identify Evidence based practices – Criteria for Appropriate Use – Daily assessment of necessity – Nurse driven protocol for removal – Insertion/maintenance standards – Patient/ Family Engagement – Rounding and White Boards – Bedside Report 12

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 13 Assess and Identify Variables Assess current practice – ask 5 people Identify variables – Urinary catheter presence – Urinary catheter reason for use Indications vs. non-indications for urinary catheter use are based on the 2009 HICPAC guidelines

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 14 Acceptable Indications for Catheter Use Acceptable Indications 1 Acute urinary retention or obstruction 2 Perioperative use in selected surgeries 3 Assist healing of perineal and sacral wounds in incontinent patients 4 Hospice/comfort/ palliative care 5 Required immobilization for trauma or surgery 6 Chronic indwelling urinary catheter on admission 7 Accurate measurement of urinary output in the critically ill patients 14

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 15 1. Acute Urinary Retention or Obstruction Outflow obstruction: examples include prostatic hypertrophy with obstruction, urethral obstruction related to severe anasarca, urinary blood clots with obstruction Acute urinary retention: may be medication- induced, medical (neurogenic bladder) or related to trauma to spinal cord 15

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 16 2. Perioperative Use in Selected Surgeries Anticipated prolonged duration of surgery, large volume infusions during surgery, or need for intraoperative urinary output monitoring Urologic surgery or other surgery on contiguous structures of the genitourinary tract Spinal or epidural anesthesia may lead to urinary retention (prompt discontinuation of this type of anesthesia should prevent need for urinary catheter placement) 16

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 17 3. Assist Healing of Perineal and Sacral Wounds in Incontinent Patients This is an indication when there is concern that urinary incontinence is leading to worsening skin integrity in areas where there is skin breakdown 17

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 18 4. Hospice/Comfort Care/Palliative Care Patient comfort at end-of-life 18

19. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 19 5. Required Immobilization for Trauma or Surgery Including: 1. Unstable thoracic or lumbar spine 2. Multiple traumatic injuries, such as pelvic fractures 3. Acute hip fracture with risk of displacement with movement 19

20. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 20 7. Accurate measurement of urinary output in the critically ill patients Applies to patients in the intensive care setting Assess opportunity for alternative measurement 20

21. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 21 Unacceptable Indications 21 1 Accurate measurement of urinary output in the noncritically ill patients 2 Incontinence without a sacral or perineal pressure sore 3 Prolonged postoperative use 4 Other: Transfers from ICU Morbid obesity Immobility Confusion or dementia Patient request

22. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 22 1. Urine Output Monitoring OUTSIDE Intensive Care Monitoring of urine output in patients with congestive heart failure receiving diuretics is not an indication for urinary catheter placement 22

23. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 23 2. Incontinence without a Sacral or Perineal Pressure Sore Incontinence should not be a reason for urinary catheter placement. Patients admitted from home or from extended care facilities with incontinence managed their incontinence without problems prior to admission. Mechanisms to keep the skin intact need to be in place. Avoid urinary catheter placement in these patients 23

24. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 24 3. Prolonged Postoperative Use Prompt discontinuation of the urinary catheter (within 24 hours of surgery) is recommended unless other indications are present 24

25. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 25 4. Other Non-Indicated Reasons Including: 1.Patients transferred from intensive care to floor 2.Morbid obesity 3.Immobility 4.Confusion or dementia 5.Patient request 25

26. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 26 Morbid Obesity and Immobility Morbid obesity should not be a trigger for urinary catheter placement. 26

27. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 27 Confusion or Dementia Patients with confusion or dementia should not have a urinary catheter placed unless there is an indication for placement 27

28. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 28 Patient/Family Request Patient request should not be the reason for placement of unnecessary urinary catheters. Explain to the patients the risk of infection, trauma, and immobility related to the use of the urinary catheter. The only exception is in patients that are receiving end-of-life or palliative care 28

29. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 29 Nurse Request Convenience not an indication Need to change perception about necessity and harm 29

30. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 30 Create Reliable Processes Identify first priority, cause for variation Use small tests of change to refine process until reliable – Remember to assess resources/supplies needed 30

31. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 31 Recommendations for Implementation Define and educate nursing staff on appropriate urinary catheter utilization Define and ensure competency of insertion and catheter maintenance procedures Develop Nurse driven protocol for removal Provide printed educational material, lectures, posters, pocket cards 31

32. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 32 Rounding and Use of White Boards Hourly rounding to assist with toileting Reminder to patient, family regarding catheter use and reason for use/nonuse, catheter care A healthcare worker champion (usually a nurse, alternatively an infection preventionist, or quality improvement healthcare worker who is knowledgeable of indications for urinary catheter utilization) participates in daily nursing rounds to assess catheter necessity Use white board to remind catheter days

33. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 33 Bedside Shift Report Discuss necessity at each shift report. If there are no valid indications for the urinary catheter, the nurse is asked to contact the physician to discontinue the urinary catheter or initiate nurse driven removal protocol Necessity included in nurse assessment Key Factor for Success: a nurse manager who supports this initiative and holds the nursing staff accountable for removing non-indicated urinary catheter

34. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 34 Create final policy/procedure Educate and assess competency of staff Provide feedback on success – Transparent – Public Hold each other and everyone accountable – Create safe environment for speaking up – Coach on inappropriate use Standardize, Spread, Sustain

35. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 35 Important Issues A continued reduction in urinary catheter utilization can indicate a program’s success If no significant improvement is noted after implementation, reexamine whether or not compliance with indications has decreased and why The risk of urinary tract infection increases the longer the urinary catheter is present. A single patient who has a urinary catheter placed without indication for a prolonged period of time may affect your effort significantly

36. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 36 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, OR and intensive care units. These areas utilize a high number of urinary catheters – many are unnecessary Critical Areas to Address

37. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 37 Remember… It can be a long journey to zero but… Decreasing the use and length of time od catheter placement will decrease patient harm 37

38. Learn. Act. Improve. Spread. Keep the Drum Beat Going. CONTACT INFORMATION Denise Flook dflook@gha.orgdflook@gha.org. 770-249-4518