Pat Posa RN, BSN, MSA System Performance Improvement Leader St. Joseph Mercy Health System

1. 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 patposa@gmail.com

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?

3. CUSP & CAUTI Interventions CUSP CAUTI • Care and Removal Intervention • Removal of unnecessary catheters • Proper care for appropriate catheters • 2. Placement Intervention • Determination of appropriateness • Sterile placement of catheter 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

4. Project Goals • Reduce CAUTI rates in participating units by 25% • Appropriate placement • Appropriate continuance • Appropriate utilization • Improve patient safety culture on participating units

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. Healthcare Facility HAI Reporting to CMS via NHSN – Current and Future Requirements CMS 2012 IPPS final rule released; August 2011 Federal Register

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

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 http://www.cdc.gov/hicpac/cauti/001_cauti.html

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

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)

19. One Reason Catheters Are Used Inappropriately (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)

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;12:654-62 - 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 CatheterizationT. W. Thomsen and G. S. Setnik - 25 May, 2006 • Female Urethral CatheterizationR. 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)

28. 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 7 - 12 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. 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 CUSP CAUTI • Care and Removal Intervention • Removal of unnecessary catheters • Proper care for appropriate catheters • 2. Placement Intervention • Determination of appropriateness • Sterile placement of catheter 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

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 2004 84% needed improvement, in 2007 23% • 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. No BSI = 5 months or more w/ zero No BSI 21% No BSI 44% No BSI 31% 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 Health Services Research, 2006;41(4 Part II):1599.

39. Can we change practice through process improvement alone? or 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???