1. System Performance Improvement Leader St. Joseph Mercy Health System
On the CUSP: Stop CAUTI
Implementing CUSP to Eliminate Catheter-Associated Urinary Tract Infections (CAUTI)
Pat Posa RN, BSN, MSA
System Performance Improvement Leader
St. Joseph Mercy Health System
Ann Arbor, MI
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.

2. Overview Overview of CAUTI
Comprehensive Unit-Based Safety Program (CUSP) to eliminate CAUTI
4E’s to CAUTI
Engage: How does this make the world a better place?
Educate: How will we accomplish this?
Execute: What do we need to do?
Evaluate: How will we know we made a difference?
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.

3. 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
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

4. 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

5. Healthcare-Associated Infections (HAI’s) ENGAGE: Why should we do this?
CAUTI are the most common HAI, accounting for 35% of all HAI’s
At least 20% of episodes are preventable; perhaps as much as 70%
(Harbath et al. J Hosp Infect 2003)
Preventive practices are variably used
Medicare no longer reimburses U.S. hospitals for the additional costs of certain infections
CAUTI prevention is part of the 2012 National Patient Safety Goal

6. Adult, Peds, and Neonatal ICUs
Healthcare Facility HAI Reporting to CMS via NHSN – Current and Future Requirements
HAI Event
Facility Type
Reporting Start Date
CLABSI
Acute Care Hospitals
Adult, Peds, and Neonatal ICUs
January 2011
CAUTI
Adult and Pediatric ICUs
January 2012
SSI
Colon and abdominal hysterectomy
Long Term Care Hospitals *
October 2012
Inpatient Rehabilitation Facilities
MRSA Bacteremia Lab ID
Acute Care Hospitals – facility wide
January 2013
C. difficile LabID Event
HCW Influenza Vaccination
* Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN
CMS 2012 IPPS final rule released; August 2011 Federal Register 6 6

7. 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.

8. 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)

9. 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

10. Pathogenesis of CAUTI
Source: colonic or perineal flora on hands of personnel
Microbes enter the bladder via extraluminal {around the external surface} (proportion = 2/3) or intraluminal {inside the catheter} (1/3)
Daily risk of bacteriuria with catheterization is 3% to 10%; by day 30 = 100%
Maki DG EID 2001

11. Urinary Catheter-Related Infection: Pathophysiology
Intraluminal Extraluminal
Detrusor spasm Shedding of cells Bacteremia
Leakage Obstruction Fever
(+) UA Hypotension
Bladder infection with inflammation

12. 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)

13. A Model For Implementation Science
Saint S, et al ICHE 2010 13

15. Core Prevention Strategies:(All Category IB) Educate: How will we accomplish this?
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

16. 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

17. Table. 2 Appropriate indications for indwelling urethral catheter use
Patient has acute urinary retention or obstruction
Need for accurate measurements of urinary output in critically ill patients
Perioperative use for selected surgical procedures:
Patients undergoing surgery or other surgery on contiguous structures of the GU tract
Anticipated prolonged duration of surgery (these should be removed in PACU)
Patients anticipated to receive large-volume infusions or diuretics during surgery
Operative patients with urinary incontinence
Need for intraoperative monitoring of urinary output
To assist in healing of open sacral or perineal wounds in incontinent patients
Patient requires prolonged immobilization (e.g. potentially unstable thoracic or lumbar spine)
To improve comfort for end of life care if needed
Indwelling catheters should not be used:
As a substitute for nursing care of the patient or resident with incontinence
As a means of obtaining urine for culture or other diagnostics when the patient can voluntarily void
Prolonged post-operative duration without appropriate indications
Routinely for patients receiving epidural anaesthesia/analgesia

18. 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.

19. 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)

20. 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.

21. QUESTION ???
What barriers are you facing—or anticipate to face related to these indications?
In the ICU?
In the ED?
With specific patient populations?
IE: patient’s with epidurals

22. 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

23. CAUTI Prevention: HICPAC Recommendations, CA-UTI
II. Proper Techniques for Urinary Catheter Insertion
Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site . (Cat. IB) [see also:Ehrenkranz NJ ICHE 1991;12: alcohol handrub much more effective than handwash]
Ensure that only properly trained persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Cat.IC)
Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (Cat.IC)

24. 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

25. 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

26. 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.

28. Nurse-Initiated Removal of Unnecessary Urinary Catheters Program
Baseline: Collect urinary catheter prevalence with evaluation for indications (15 days).
Weeks 1 - 3
Nurse-Initiated Removal of Unnecessary Urinary Catheters Program
Week 4
Prepare for implementation.
Implementation: nursing staff education, daily assessment of urinary catheters and evaluation for indications, and discussion with nursing staff about removal of non-indicated catheters. Rationale given to obtain order to discontinue unnecessary urinary catheters with nursing (10 days).
Weeks 5 & 6
After Implementation: urinary catheter prevalence and indications, one day a week for 6 weeks (6 days). Patient’s nurse to daily assess need for catheter.
Weeks
Data review and unit feedback
Sustainability: urinary catheter prevalence and indications, 1 week quarterly (5 consecutive days) for 5 quarters. Patient’s nurse to daily assess need for catheter.
Quarterly

29. QUESTION ???
How many people have or are considering a nurse driven protocol for urinary catheter removal?? If so—what barriers are you anticipating?

30. 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

31. Other Methods for Preventing CAUTI
Alternatives to the indwelling catheter
Bladder ultrasound
Intermittent catheterization
Condom catheter

32. Execute: What do we need to do?
Nurse driven protocols
Decision algorithm
Reminders/flags
Reviewed daily on rounds
Daily screening

33. Remove that Urinary Catheter! Remove that Urinary Catheter!
Pocket Card
Remove that Urinary Catheter!
Foley catheters can cause:
 Infections
 Length of Stay
 Cost
 Patient Discomfort
 Antibiotic Use
Urinary Catheters confine patients to bed, making them more immobile and thus increasing their risk for skin breakdown.
PREVENTION IS KEY.
OBTAIN ORDERS TO
DISCONTINUE UNNECESSARY URINARY CATHETER!
Remove that Urinary Catheter!
Foley Catheters are indicated for:
Acute urinary retention or obstruction
Perioperative use in selected surgeries
Assist healing of perineal and sacral wounds in incontinent patients
Hospice/comfort/ palliative care
Required immobilization for trauma or surgery
Chronic indwelling urinary catheter on admission
Accurate measurement of urinary output in the critically ill patients (intensive care)
Foley Catheters are not indicated for:
Urine output monitoring OUTSIDE intensive care
Incontinence (place on toileting routine, change frequently)
Prolonged postoperative use
Patients transferred from intensive care to general units
Morbid obesity
Immobility (turn patient q 2 hours, up in chair)
Confusion or dementia
Patient request

34. Evaluate: How will we know we made a difference?
Outcome Measures:
UTI rate/1000 patient days
UTIs / 1000 catheter days
Process Measures:
UC days/ 1000 patient days
Percent appropriate catheters/total number of catheters

35. 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
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

36. 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

37. “Needs Improvement” Statewide Michigan CUSP ICU Results
Less than 60% of respondents reporting good safety climate = “needs improvement”
Statewide in % needed improvement, in %
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”

38. Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence:
caregivers feel comfortable speaking up if they perceive a problem with patient care
% of respondents within an ICU reporting good teamwork climate
No BSI 21%
No BSI 44%
No BSI 31%
No BSI = 5 months or more w/ zero
Health Services Research, 2006;41(4 Part II):1599.

39. or Can we change practice through process improvement alone?
Will successful change require
an altering of the value structure
within the unit?

40. How to Get Successful Results
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

41. How to Sustain Your Success
After implementing the program, identify unit champions to promote the need to evaluate the appropriateness of urinary catheter use
Incorporate the following questions during nursing rounds:
Does the patient have a urinary catheter?
What is the reason for use?
Provide feedback on performance to nurse managers related to prevalence of utilization
If no improvement in utilization is seen, evaluate appropriateness of utilization (indications vs. non-indications)
The long term goal is for the patient care nurses to own the process of evaluation of urinary catheter need

42. Additional Areas to Address
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 and intensive care units. Both areas utilize a high number of urinary catheters
Learn from defects and continue to improve process

43. QUESTIONS???