1. CAUTI Care and Removal Program Preventing Catheter-Associated Urinary Tract Infections: What You Need to Know Mohamad Fakih, MD, MPH Associate Professor of Medicine Wayne State University School of Medicine St John Hospital and Medical Center, Detroit, MI 1

2. An 82-year-old woman was admitted for congestive heart failure… She had a urinary catheter 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 5 th 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. 2

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. 3

4. Objectives Describe urinary catheter use and the epidemiology of CAUTI. Explain what CMS and HHS have done. Review how to reduce CAUTI risk (proper insertion technique, appropriate use). Address the CAUTI Emergency Department Improvement Intervention. Discuss how to sustain improvements. Address metrics. 4

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. 5

6. Urinary Catheter Utilization About 15 - 25% 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. 6

7. Mean Use of UCs (NHSN): ICU > General Wards Unit2006-8 Urinary Catheter Utilization Ratio 2009 Urinary Catheter Utilization Ratio 2010 Urinary Catheter Utilization Ratio ICU (med-surg, major teaching) 0.780.73 ICU (med-surg, >15 beds) 0.790.720.71 General Wards (med-surg) 0.220.19 (Edwards, Am J Infect Control 2009; 37:783-805, Dudeck, Am J Infect Control. 2011;39(5):349-367; Am J Infect Control 2011;39(10):798-816 ) 7

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: 1.At the time of placement 2.With continued use 8

9. Inappropriate Use in non-ICU: Michigan Experience 2007-10 (Fakih et al, Arch Intern Med 2012;172:255-260) 9

10. Very Elderly Women Are at High Risk for Unnecessary Utilization One center; evaluated urinary catheter (UC) placement for all admissions from the emergency department over 12 weeks. 532 (11.8%) of 4521 patients had a UC placed. 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: no appropriate indication. UC placed without indication: women 2 times more than men, and very elderly (≥80 years) were 3 times more than those 50 or younger. (Fakih et al, Am J Infect Control 2010;38:683-8) 10

11. Isn’t this a patient safety issue, not just CAUTI? Falls Partnership for Patients Venous thrombo- embolism Adverse drug events 11

12. Catheter-Associated UTIs (CAUTIs) 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 (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):349-367) 12

13. Mean CAUTI Rates: Changes with New Definition Unit2006-8 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) 4.72.32.2 ICU (med-surg, >15 beds) 3.11.21.3 General wards (med-surg) 5.91.61.5 *Prior to the new SUTI definition (Edwards, Am J Infect Control 2009; 37:783-805, Dudeck, Am J Infect Control. 2011;39(5):349-367; Am J Infect Control 2011;39(10):798-816 ) 13

14. CMS and Hospital-Acquired Conditions High cost, high volume or both Result in the assignment of a case to an MS-DRG that has a higher payment when present as a secondary diagnosis Could reasonably have been prevented through the application of evidence-based guidelines http://www.cms.hhs.gov/HospitalAcqCond/ 14

15. Ten Non-Reimbursable Selected Conditions by CMS (October 2008) 1.Foreign Object Retained After Surgery 2.Air Embolism 3.Blood Incompatibility 4.Stage III and IV Pressure Ulcers 5.Falls and Trauma 6.Manifestations of poor glycemic control 7.Catheter-Associated Urinary Tract Infection 8.Vascular Catheter-Associated Infection 9.Surgical Site Infection-Mediastinitis, bariatric, some ortho 10.DVT/ PE post orthopedic cases http://www.cms.hhs.gov/HospitalAcqCond/ More falls with UCs? More pressure ulcers with immobility? 15

16. Health and Human Services Targets Metrics and National 5-Year Prevention Targets Metric Label MetricMeasurement System National 5-Year Prevention Target CAUTI # of symptomatic UTI / 1,000 urinary catheter days CDC NHSN25% reduction in the number of symptomatic UTI / 1,000 urinary catheter days CAUTI[Number of UTIs (ICD- 9-CM +not present on admission) / (# major surgery ICD-9-CM + urinary catheter ICD- 9CM)]*100 discharges Administrative discharge data 25% reduction in the [Number of UTIs (ICD- 9-CM+not present on admission) / (# major surgery ICD-9-CM + urinary catheter ICD-9- CM)]*100 discharges (http://www.hhs.gov/ash/initiatives/hai/prevtargets.html ) 16

17. What Is Our Goal? Reduce the number of CAUTIs. Provide tools for hospitals to reduce the risk for CAUTI. 17

18. Reducing Risk of CAUTI Reduce urinary catheter days leading to a reduction in days at risk for CAUTI Reduce risk of introducing organisms to the bladder leading to a reduction of risk of CAUTI when catheter in place 18

19. 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. 19

20. Simplified Insertion Checklist for Urinary Catheter 20

21. Maintenance of Urinary Catheters Keep a closed system for the urinary drainage system. Make sure urinary flow is not obstructed: 1.No kinks in the catheter. 2.Urinary bag should always be lower than the bladder. 3.Regular emptying of urinary bag. 21

22. Limit Use to Indications Clear Identification of what is considered an appropriate indication 22

23. 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) –Michigan collaborative: 25% reduction in use for 163 units (Fakih et al, Arch Intern Med 2012;172:255-260) Most of the units involved were non-intensive care 23

24. 2009 Prevention of CAUTI HICPAC Guidelines (Gould et al, Infect Control Hosp Epidemiol 2010; 31: 319-326) 24

25. 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. 25

26. Main Elements of Program Education of nurses on: 1.Appropriate indications. 2.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. 26

27. The Periods 27

28. 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. 28

29. Tools Used with Intervention Lecture for nurses Pocket cards, posters 29

30. 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 for an order to discontinue the urinary catheter. This process will be continued after implementation with the patient’s nurse owning the process. 30

31. 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: 1.Evaluate the need for the catheter and discontinue if no longer needed. 2.Serve as an easier access to nurses to obtain order for discontinuation of no longer needed catheters. 31

32. 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. 32

33. 33 Urinary Catheter Removal Prompt removal should not be interpreted as an increased workload for either the nurse or nurse aide. Highlight risks associated with having the urinary catheter. Promote alternatives to the urinary catheter.

34. 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. 34

35. Alternatives to Indwelling Urinary Catheterization Intermittent catheterization may be considered in patients with non-obstructive urinary retention (e.g., patients with neurogenic bladder). 35

36. Following Implementation Evaluation of catheter need is incorporated into the patient’s nurse daily assessment. Physicians continue to evaluate daily catheter need. 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. 36

37. Success with Implementation: Michigan Experience 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. (Fakih et al, Arch Intern Med 2012;172:255-260) 37

38. Success with Implementation: Michigan Experience 25% relative decrease 30% relative increase (Fakih et al, Arch Intern Med 2012; 2012;172:255-260 38

39. 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. 39

40. From Higher to Lower Use Areas Non-ICU Evaluate need on admission Evaluate for continued need PACU/OR Remove promptly after surgery before transfer out ICU Evaluate for continued need Discontinue no longer needed before transfer out ED Avoid initial placement Reevaluate for continued need after patient stabilizes 40

41. ICU Intervention ICUs have a high prevalence of urinary catheter utilization. Utilization may be significantly reduced in the non-ICU if patients transferred out of the intensive care units are evaluated for catheter necessity. Transfer from ICU Non-ICU ICU 41

42. ED Improvement Intervention Addressing CAUTI reduction outside the in-patient units… 42

43. Intervening in ED The emergency department is an area where a large number of urinary catheters are placed. ED All hospital units Urinary catheters placed 43

44. Intervening in ED Addressing the appropriateness of placement of urinary catheters in the ED may also help reduce unnecessary urinary catheter use. ED ED: Prevent inappropriate urinary catheter placement All hospital units 44

45. Early Efforts in the ED One center: institutional guidelines in ED, intervention with physicians; UC use dropped about a third with intervention, with physicians ordering fewer UCs post-intervention (Fakih et al, Acad Emerg Med, 2010; 17:337–340). Pilot work recently implemented in >30 EDs in Michigan (through MHA) and Ascension Health with successful results; key was engaging nurses and physicians using champions 45

46. ED Improvement Intervention Expand the reach of the On the CUSP: STOP CAUTI national collaborative Engage national societies to support the work American College of Emergency Physicians (ACEP) Emergency Nurses Association (ENA) Goals: improve appropriateness of catheter placement, and proper insertion technique Focus on the technical and adaptive (including teamwork and CUSP) 46

47. ED Improvement Intervention Resources National project support includes: Comprehensive ED Tool Kit with customizable resources Educational events: National expert presentations Coaching support by the National Project Team In-person training opportunities Data collection and analysis: Number of admits from the ED, including observation patients Number of admits from the ED, including observation patients with a newly placed indwelling catheter 47

48. How to Get Involved To get involved please contact: Keesha Mwangangi, Research Specialist at kmwangangi@aha.org or (312) 422-2654 kmwangangi@aha.org See the project website for more information: http://www.onthecuspstophai.org/on- the-cuspstop-cauti/toolkits-and-resources/emergency- department-improvement-intervention/ http://www.onthecuspstophai.org/on- the-cuspstop-cauti/toolkits-and-resources/emergency- department-improvement-intervention/ 48

49. How to Sustain Improvements 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. Example: SJHMC, Detroit: 5 years of the intervention, the prevalence of UC utilization on inpatient wards is 12-13% (down from 17.3%). 49

50. Does the Effect Persist? Nurse-driven removal of unnecessary catheters Establishing institutional guidelines for the ED and education Incorporating the evaluation of catheter need during nursing rounds, and collecting urinary catheter prevalence twice weekly since 2007 Urinary Catheter Prevalence (%) SJHMC, Detroit, MI (Fakih et al, Am J Infect Control 2013; 41: 236-9) 50

51. What Did We Do to Keep the Rates Down? Provided knowledge on appropriate indications. Linked the target (appropriate utilization) to certain stakeholders’ interests to increase support and build capacity. Intervened in the ED to reduce inappropriate placement from the 1 st step reaching the hospital. Built a structure to evaluate the catheters at least twice weekly. Provided periodic feedback on rates of catheter use. 51

52. Metrics to Evaluate Improvement Process Outcome 52

53. Process Measures 1.Urinary catheter utilization (number of urinary catheters/ number of patients) 2.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 53

54. Outcome Measures 1.Number of CAUTIs (collected by infection preventionists) 2.NHSN CAUTI rate (requires accurate collection of catheter-days): important to measure risk with insertion and maintenance 3.Population CAUTI rate (uses patient-days in the denominator-easier to calculate): provides important assessment of improvement over time 54

55. 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. 55

56. Tying Everything Together Leadership support –Administration –Nursing –Physician Units involved –Safety culture –Program-supportive unit manager Plan to have a process to sustain your success! 56

57. Thank you! 57