1. AHRQ Safety Program for Long-term Care: HAIs/CAUTI Evidence-Based Practices to Prevent HAIs/CAUTI and Improve Resident Safety

2. Upon completion of this module, participants will be able to: Describe the goals and benefits of the national long-term care (LTC) collaborative to reduce HAIs/CAUTI and improve safety culture; Review the evidence-based practices in HAI/CAUTI prevention; and Highlight the role of the prescriber in promoting evidence- based practices in HAI/CAUTI prevention. 2 Objectives

3. Leading cause of mortality, morbidity, resulting in 388,000 deaths 1.6-3.8 million HAIs 1 26-50% due to infections $673 million-$2 billion for hospitalizations 2 150,000-300,000 hospital admissions UTI’s most commonly treated infection (32%) 3 Up to 75% of antibiotics prescribed incorrectly 4 $38-137 million on antimicrobial therapy 2 Up to 70% of residents receive an antibiotic 4 88% placed in LTC or non-acute care settings 5 99% of catheterized residents have asymptomatic bacteriuria within 30 days 7 7-10% of all LTC residents have a urinary catheter 6 3 Annual Impact of HAIs in LTC Setting

4. LTC Project Goals Primary Goals—reduce HAIs/CAUTI and improve safety culture Develop/adapt evidence-based CAUTI elimination and safety practices and resources for LTCFs Reduce CAUTIs and HAIs Improve safety culture Secondary Goals—support expanded infection prevention efforts for C. diff, UTI, MDROs, etc. by providing education to: Improve hygiene practices (hand, environmental) Promote antibiotic stewardship Promote catheter stewardship Reduce re-hospitalizations

5. Benefits of the LTC Program Improve the Nursing Home Compare Quality Measures Enhance data collection skills and prepare for mandatory reporting of infection data (NHSN) Benchmark against other LTC facilities (project-level and nationally) Improve communication and relationships with referring hospitals that may results in reduced readmissions Improve compliance with survey requirements related to quality of care, infection control, etc.

6. 6 The Important Role of the Clinician

7. 7 Actively Engage Staff Using T.E.A.M.S. and C.A.U.T.I. C.A.U.T.I. Infographic: http://www.hret.org/ltc_safety/resources/Infographics/CAUTI%20Mnemonic%20Poster.pdfhttp://www.hret.org/ltc_safety/resources/Infographics/CAUTI%20Mnemonic%20Poster.pdf T.E.A.M.S. Infographic:http://www.hret.org/ltc_safety/resources/Infographics/LTC_T.E.A.M.S._FINAL.pnghttp://www.hret.org/ltc_safety/resources/Infographics/LTC_T.E.A.M.S._FINAL.png

8. Assessing Catheter Necessity Catheters in newly admitted and re- admitted residents should be assessed for necessity Every resident, when clinically possible, deserves a chance to be “catheter-free” Remember, a resident cannot develop a CAUTI if they do not have a catheter NHSN CAUTI definition does NOT include suprapubic, straight nor condom catheters 8 8

9. CAUTI Surveillance Criteria CAUTI Criteria - NHSN Definitions Pocket Card 9 View Onboarding 2 materials on the NHSN definition for CAUTI here: http://www.ltcsafety.org/webinars/resources/Onboarding%20Training%20Materials.shtml http://www.ltcsafety.org/webinars/resources/Onboarding%20Training%20Materials.shtml

10. Chronically-catheterized patients have bacteriuria 99% of the time Bacteriuria can be symptomatic or asymptomatic Urine cultures, dip sticks and the presence of pyuria cannot be used to distinguish between CAUTI and asymptomatic bacteriuria (ASB) Non-Specific Bacteriuria Signs Urine color Urine smell Urine sediment Cloudy urine 10 Avoid Unnecessary Urine Cultures Nicolle L.E., Bradley S., Colgan, R., et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults.Clin Inf Dis 2005; 40:643-54. ASB CAUTI

11. 11 Ordering Unnecessary Urine Cultures Can Lead to Resident Harms Urinary catheter present Cloudy, odorous urine, sediments Inappropriate use of urine culture Over-inflated CAUTI rates Inappropriate Treatment and Antibiotic Overuse Miss the correct diagnosis More resistant organisms, Clostridium difficile, increased cost, further health complications Resident Harms

12. Reduce unnecessary urine cultures Review urine culture data Assess whether s/s present to collect urine cultures Reduce the overuse of antibiotics Review antibiotic use data 1 Confirm s/s and positive urine culture Determine if appropriate antibiotic prescription was given Identify clinical situations driving antibiotic use (e.g., asymptomatic bacteriuria, UTI prophylaxis) 12 Strategies to Reduce Unnecessary Urine Cultures and Overuse of Antibiotics Communicate with nurse, staff, residents and families the harms of starting antibiotics not clinically indicated Creating a Culture to Improve Antibiotic Use in Nursing HomesCreating a Culture to Improve Antibiotic Use in Nursing Homes. CDC’s The Core Elements for Antibiotic Stewardship in Nursing Homes.

13. Effective and clear communication between multidisciplinary teams and nurses and providers leads to better: – Recognition of acute change of condition (ACOC) – Timely intervention – Improve treatment decision-making – Overarching ACOC management 13 Communication is Critical and TeamSTEPPS Can Help! TeamSTEPPS for Long-term Care version: http://www.ahrq.gov/professionals/education/curriculum- tools/teamstepps/longtermcare/index.htmlhttp://www.ahrq.gov/professionals/education/curriculum- tools/teamstepps/longtermcare/index.html

14. Be familiar with the NHSN CAUTI Surveillance definition Avoid obtaining unnecessary urine cultures Initiate care plan discussions with staff, residents and families to review ways to prevent CAUTI and harms together Document clinical indications for the catheter Document signs and symptoms of CAUTI Prescribe antibiotics only when appropriate 14 How You Can Help

15. Stay Updated with Useful Resources 1.AHRQ Safety Program for Long-term Care: HAIs/CAUTI Project WebsiteAHRQ Safety Program for Long-term Care: HAIs/CAUTI Project Website Login information Username: ltcsafety Password: ltcsafety 2.TeamSTEPPS ® for Long-term CareTeamSTEPPS ® for Long-term Care 15 3.LTC Safety ToolkitLTC Safety Toolkit 4.NHSN CAUTI Definition Pocket CardsNHSN CAUTI Definition Pocket Cards 5.Antibiotic Stewardship BrochureAntibiotic Stewardship Brochure 6.Letter to LTC physicians re: clinical interventions to reduce CAUTI from Dr. Lona ModyLetter to LTC physicians re: clinical interventions to reduce CAUTI from Dr. Lona Mody 7.C.A.U.T.I InfographicC.A.U.T.I Infographic 8.T.E.A.M.S. InfographicT.E.A.M.S. Infographic

16. References Module 1: Improving Communication and Decisions about Antibiotic Use in Nursing Homes. June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module1/index.htmlhttp://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module1/index.html Al Qas-Hanna, Am J Infect Control 2013;41 (12): 1173-77 Centers for Medicare and Medicaid Services, Long Term Care Minimum Data Set, Resident profile table as of 05/02/2005. Baltimore. MD. Centers for Disease Control and Prevention (CDC). (2015). Infographic: Antibiotic Stewardship in Nursing Homes. Accessed on 09/23/15 at http://www.cdc.gov/longtermcare/pdfs/infographic-antibiotic-stewardship-nursing-homes.pdf. http://www.cdc.gov/longtermcare/pdfs/infographic-antibiotic-stewardship-nursing-homes.pdf CDC. (2014). Antibiotic Use in Nursing Homes. Accessed on 06/23/15 at http://www.cdc.gov/getsmart/week/downloads/gsw-factsheet-nursinghomes.pdf.http://www.cdc.gov/getsmart/week/downloads/gsw-factsheet-nursinghomes.pdf CDC. Healthcare Infection Control Practices Advisory Committee (HICPAC) approved guidelines for the Prevention of catheter-associated urinary tract infections, 2009. Available at http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf CDC. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance (online). Accessible at: http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf. http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf CDC, National Center for Health statistics, 1999 National Nursing Home Survey. Nursing Home Residents, number, percent distribution, and rate per 10,000, by age at interview, according to sex, race, and region: United States, 1999. Loeb, M et.al. Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med 2001; 16: 376-383. National Healthcare Safety Network (NHSN). Long-term Care Facility (LTCF) Component Healthcare Associated Infection Surveillance Module: UTI Event Reporting [online].Long-term Care Facility (LTCF) Component Healthcare Associated Infection Surveillance Module: UTI Event Reporting [online] Mody L, Bradley SF, Galecki A, et al. Conceptual model for reducing infections and antimicrobial resistance in skilled nursing facilities: focus on residents with indwelling devices. Clin Infect Dis. 2011;52:654-61. PMID: 21292670. Nicolle L.E., Bradley S., Colgan, R., et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults.Clin Inf Dis 2005; 40:643-54. Richards CL. Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel. J Am Geriatr Soc 2002;50:570-6. Smith PW, Bennett G, Bradley SF, et al. SHEA/APIC Guideline: Infection prevention and control in the long-term care facility. Infect Control Hosp Epidemiol 2008; 29:785–814. PMID: 18786461. Stone ND, Ashraf MS, Calder J. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol 2012;33(10):965-977. Trautner, B. (2014). Demystifying CAUTI: When to Culture and When to Treat. AHRQ Safety Program for Long-term Care: HAIs/CAUTI. http://www.ltcsafety.org/webinars/resources/September%202014%20Content%20Webinar.shtml http://www.ltcsafety.org/webinars/resources/September%202014%20Content%20Webinar.shtml Wagner, LM., Roup, B.J., Castle, NG. Impact of infection preventionists on Centers for Medicare and Medicaid quality measures in Maryland nursing homes. Am J Infect Control 2014; Jan 42(1): 2-6. 16