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On the CUSP: Stop CAUTI. Implementing CUSP to Eliminate Catheter-Associated Urinary Tract Infections (CAUTI) Project Initiation Call. Overview of Today’s Call. Welcome and introductions Why this initiative is important: Overview of CAUTI Comprehensive Unit-Based Safety Program (CUSP)

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slide1

On the CUSP: Stop CAUTI

Implementing CUSP to Eliminate Catheter-Associated Urinary Tract Infections(CAUTI)

Project Initiation Call

overview of today s call
Overview of Today’s Call
  • Welcome and introductions
  • Why this initiative is important: Overview of CAUTI
  • Comprehensive Unit-Based Safety Program (CUSP)
  • Project overview and data requirements
    • Expected outcomes
    • What it requires
  • What are the next steps
project goals
Project Goals
  • Reduce CAUTI rates in participating units by 25%
    • Appropriate placement
    • Appropriate continuance
    • Appropriate utilization
  • Improve patient safety culture on participating units
healthcare associated infections hai s
Healthcare-Associated Infections (HAI’s)
  • At least 20% of episodes are preventable; perhaps as much as 70%

(Harbath et al. J Hosp Infect 2003)

  • Medicare no longer reimburses U.S. hospitals for the additional costs of certain infections
  • Preventive practices are variably used
  • The most common HAI is urinary tract infection
urinary catheter related infection background
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
slide8

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
slide9

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)
slide10

Centers for Medicare & Medicaid Services (CMS) Rule Changes: 1 October 2008

  • CMS now holds U.S. hospitals accountable for not preventing certain hospital-acquired complications
  • CMS required to choose at least 2 conditions that:
    • are high cost and/or high volume; and
    • could reasonably have been prevented through the application of evidence-based guidelines
slide11

CMS Chose More Than 2 Conditions

  • Catheter-associated UTI
  • Vascular catheter-associated infection
  • Retained object during surgery
  • Air embolism
  • Blood incompatibility
  • Pressure ulcers
  • Surgical Site Infections after certain surgical procedures
  • Falls and Trauma
  • Manifestations of poor glycemic control
  • DVT or PE following certain orthopedic surgeries
slide12

Cost Implications of CMS Rule Change

  • University of Michigan patient with pneumonia:
  • Without complication or comorbidity (CC): $6899
  • With CA-UTI (CC): $8495 (~$1600 more)
  • University of Colorado patient with acute MI:
  • Without CC: $5436
  • With CA-UTI (CC): $6721 (~$1300 more)
  • (Wald and Kramer. JAMA 12/19/07)
urinary catheter related infection pathophysiology
Urinary Catheter-Related Infection: Pathophysiology

Organisms enter the bladder by 3 ways:

1) At time of catheter insertion

2) Through the catheter lumen (from a colonized drainage bag)

3) Along external surface of the catheter (migrate along the catheter-mucosal interface)

(Tambyah, Halvorson, Maki. Mayo Clin Proc 1999)

urinary catheter related infection pathophysiology14
Urinary Catheter-Related Infection: Pathophysiology

Intraluminal Extraluminal

Detrusor spasm Shedding of cells Bacteremia

Leakage Obstruction Fever

(+) UA Hypotension

Bladder infection with inflammation

slide15

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)
prevention of catheter associated uti
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
uti prevention rule 1 make sure the patient really needs the catheter
UTI Prevention Rule #1: Make Sure the Patient Really Needs the Catheter

Appropriate indications

  • Bladder outlet obstruction
  • Incontinence and sacral wound
  • Urine output monitored
  • Patient’s request (end-of-life)
  • During or just after surgery

(Wong and Hooton - CDC 1983)

(Jain. Arch Int Med 95)

why are catheters used inappropriately
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)

one reason catheters are used inappropriately
One Reason Catheters Are Used Inappropriately

(Saint S, Wiese J, Amory J, et al. Am J Med 2000)

slide21

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)
prevention of catheter associated uti22
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
use proper aseptic technique for catheter insertion
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
prevention of catheter associated uti24
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
early removal of indwelling catheters summary of the evidence
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)

prevention of catheter associated uti26
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
other methods for preventing cauti
Other Methods for Preventing CAUTI
  • Alternatives to the indwelling catheter
    • Bladder ultrasound
    • Intermittent catheterization
    • Condom catheter
slide28

On the CUSP: Stop CAUTI

Recent Guidelines on CAUTI Prevention

slide30

On the CUSP: Stop CAUTI

http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf

modified hicpac categorization scheme
Modified HICPAC Categorization Scheme

All Category I recommendations carry same strength; levels A and B represent the quality of the evidence underlying the recommendation

core prevention strategies all category ib
Core Prevention Strategies: (All Category IB)

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

slide34

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

needs improvement statewide michigan cusp icu results
“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”
pre cusp work
Pre CUSP Work
  • Create an CUSP/CAUTI team
    • Nurse, physician, administrator, infection control, others
    • Assign a team leader
  • Measure Culture in your clinical unit(discuss with hospital association leader)
  • Work with hospital quality leader to have a senior executive assigned to your unit based team
slide37
Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture
  • Educate staff on science of safety http://www.onthecuspstophai.org
  • Identify defects
  • Assign executive to adopt unit
  • Learn from one defect per quarter
  • Implement teamwork tools

Timmel J, et al. JtComm J Qual Patient Saf 2010;36:252-260.

teamwork tools
Teamwork Tools
  • Daily Goals
  • AM briefing
  • Shadowing
  • Culture check up
  • TEAMSTepps
cusp lessons learned
CUSP Lessons Learned
  • Culture is local
    • Implement in a few units, adapt and spread
    • Include frontline staff on improvement team
  • Not linear process
    • Iterative cycles
    • Takes time to improve culture
  • Couple with clinical focus
    • No success improving culture alone
    • CUSP alone viewed as ‘soft’
    • Lubricant for clinical change
cusp cauti interventions
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

expected benefits
Expected Benefits

Increased awareness of appropriate indications for indwelling urinary catheter use

Reduced use of indwelling urinary catheters

Improved caregiver accountability to assess need and trigger UC discontinuation when UC no longer necessary

Reduced risk of urethral trauma with reduction in utilization

Reduced patient discomfort

expected benefits42
Expected Benefits

Reduction in bacteriuria

Reduction in symptomatic UTIs

Shortened Length of Stay

Decreased Cost per stay

Improved sensitivity to “patient dignity”

questions
Questions
  • Content – Sam Watson, MHA Keystone
    • swatson@mha.org
  • Participation–Kristina Davis, HRET
    • kdavis@aha.org