1. Improving patient outcomes using a collaborative, inter-professional approach to Catheter Associated Urinary Tract Infection prevention in the ICU. Jo Ritchie, MSN, RN, CNL Denise White, BSN, MHA, RN, CCRN, NEA-BC

2. Highlight the dynamic changes in today’s U.S. healthcare environment as it relates to Catheter Associated Urinary Tract Infection prevention. Focus on the tenets of infection prevention in the Intensive Care Unit using a collaborative, interprofessional team approach.

3. 328 bed; average daily census (ADC) - 200 Not for profit, acute care, community teaching Serves 272,000 in SW Connecticut 1 hour 20 min train ride from NYC http://norwalkhospital.org/about-us/

4. 16 bed, mixed Medical/Surgical/Cardiac ADC = 12 patients Top Diagnosis Related Grouping (DRG): – Sepsis – Acute Respiratory Failure – Acute Myocardial Infarction – GI bleed – Drug Overdose

5. Nursing Leadership Team Nursing Staff – Engaged Unit Based Shared Governance – 79% BSN – 14 % MSN – 31% Board Certified

6. Institute of Medicine (IOM) To Err is Human (2000) Crossing the Quality Chasm (2001) HITECH act (2009) Meaningful Use (2011 – 2016)

7. Patient Protection and Affordable Care Act (March 2010) Models of Care: – Accountable Care Organizations – Patient Centered Medical Homes Payment models: – Bundled Payments – Pay for Performance

8. In 2008: Eight preventable HAC In 2014: ↑ 14 preventable HAC https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

9. Urinary Tract Infections (UTI) tied with Pneumonia UTIs account for >15% of infections Healthcare associated UTI caused by instrumentation Catheter Associated Urinary Tract Infections (CAUTI) can be prevented http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

10. A UTI where an indwelling urinary catheter was in place for more than two calendar days, with the day of placement considered day one. Two specific types: SUTI (Symptomatic UTI) ABUTI (Asymptomatic Bacteremic UTI) http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

11. 1.Indwelling urinary catheter in place for more than two calendar days. 2.At least one of the following signs or symptoms: fever (>38.0°C) suprapubic tenderness costovertebral angle pain or tenderness 3. Positive urine culture no more than two species of organisms http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

12.  risk of bacteriuria by 5% for each day of catheterization Risk of bacteremia is 1 – 4% of patients with a CAUTI  hospital stay Added complications Added cost Mortality CAUTI rates are publicly reported hospitalcompare.gov

13. Dudeck et at, 2013 Start of CAUTI prevention team

14. Dudeck et at, 2013 Start of CAUTI prevention team

15. Mission, Vision and Values of the Organization – Annual Five pillars – Care Coordination – Operational Efficiency – Growth and Market Development – Community Health – Workplace of Choice – Quality, Safety and Patient Satisfaction

16. A. Endorse an Interprofessional approach B. Research Evidence Based Practices (Review of the Literature) C. Implement recommended practices D. Monitor trends and outcomes E. Engage all key stake holders Remain Patient Centered

18. Background Best practices Plus/Delta (What works well; Opportunities) Next steps

19. http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf HAIs are reported to National Healthcare Safety Network (NHSN). Healthcare Infection Control Practices Advisory committee (HICPAC) Qualidigm (CT) Excellent Resources

20. Evidence Based Interventions for CAUTI Prevention Insert only when appropriate Bladder scan Aseptic technique Daily assessment and documentation of insertion Trained staff Insertion and maintenance Hand Hygiene Closed Systems and Unobstructed flow Early removal Clinical Decision Support Documentation of discontinuation Nurse Driven Protocol

21. Proactive Rounding “CAUTI Audi” ICU interdisciplinary goals sheet Staff engagement RCA for all CAUTIs Dashboards Transparency External Benchmarks Change of Shift Hand-offs Visual Cues Catheter Use Education RN & PA Competency Validation(insertion) Technician education (maintenance) Transport Physical Therapy

22. Equipment ($) Bladder Scanner External Urinary Devices with stabilization device Indwelling Urinary Kits Intermittent Catheter trays Mannequins Skin Care products (Peri-care) Information Technology Foley Indication Nurse Driven Foley Removal Protocol Policy Bladder Scanner Algorithm (Inpatient and Emergency Dept) Urine Culture Practice Nurse Driven Protocol

24. Physician Leaders Nurse leaders Nursing Shared Governance

25. All of us! W hy T he F oley? Core team - Algorithms Nurse champions Senior Leadership

26. Benchmark (Pooled Mean): National Healthcare Safety Network Report, 2012 Dudeck et at, 2013 Start of CAUTI prevention team

27. Benchmark (Pooled Mean): National Healthcare Safety Network Report, 2012 Dudeck et at, 2013 Start of CAUTI prevention team

28. Engage the frontline Create a diverse, energetic team You need a “CAUTI Audi” Know your stakeholders Data, Data, Data – Be transparent Share your success story

30. Centers for Disease Control and Prevention. (2014). Data and Statistics: HAI Prevalence Survey. Retrieved from http://www.cdc.gov/HAI/surveillance/index.html http://www.cdc.gov/HAI/surveillance/index.html Centers for Disease Control and Prevention. (2014). National and State Healthcare Associated Infections Progress Reports. Retrieved from: http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdfhttp://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf Centers for Medicare and Medicaid Services. (2014). Hospital-Acquired Conditions and Present on Admission Indicator Reporting Provision. Retrieved from: http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/downloads/wPOAFactSheet.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/downloads/wPOAFactSheet.pdf Dudeck, M.A., Weiner, L.M., Allen-Birdson, K., Malpiedi, P.J., Peterson, K.D., Pollock, D.A., Sievert, D.M. and Edwards, J.R. (2013). National Healthcare Safety Network (NHSN) report, data summary for 2012, Device- associated module. American Journal of Infection Control, 41 (2013), 1148 – 1166. Fink, R., Gilmartin, H., Richard, A., Capezuti, E., Boltz, M. and Wald, M. (2012). Indwelling urinary catheter management and catheter associated urinary tract infection prevention practices in nurses improving care for health system elders’ hospitals. American Journal of Infection Control, 1-6. Gorman, D. (2011). Reducing the incidence of catheter-associated urinary tract infections in the acute care setting using evidence-based guidelines. P. Tenke (Ed.), Urinary Tract Infections (pp. 133-152). Available from: http://www.intechopen.com/books/urinary-tract-infections/reducing-the-incidence-of-catheter-associated- urinary-tract-infections-in-the-acute-care-setting-usi.

31. Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., Pegues, D.A. and the Healthcare Infection Control Practices Advisory Committee. (2010). Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Infection control and Hospital Epidemiology, 31(4), 319-326. Hughes, R.G. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. In R.G.Hughes (Ed.), Tools and Strategies for quality Improvement and Patient Safety (pp. 1 – 39). Rockville, Maryland: Agency for Healthcare Research and Quality Lo, E., Nicolle, L.E., Coffin, S.E., Gould, C., Maragakis, L., Meddings, J., Pegues, D., Pettis, A.M., Saint, Sanjay and Yokoe, D.S. (2014) Strategies to Prevent Catheter – Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology, 35(5), 464-479. Mikel, G. (2010). Reducing catheter - associated urinary tract infection in the Critical Care Unit. Advanced Critical Care, 21(3), 247-57. Oman, K.S., Flynn, M.B., Fink, R., Schrader, N., Hulett, t., Keech, T. and Wald, H. (2012). Nurse-directed interventions to reduce catheter - associated urinary tract infections. American Journal of Infection Control, 40, 548-553.