1. 1 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. 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. 2 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.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. Project Goals Reduce CAUTI rates in participating units by 25% Appropriate placement Appropriate continuance Appropriate utilization Improve patient safety culture on participating units 3 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 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

4.  4 The On the CUSP: Stop CAUTI project is an AHRQ funded demonstration project to reduce Catheter associated urinary tract infections in 10 states nation wide. This is a collaborative initiative between several entities, with the work being lead by expert faculty out of MHA Keystone. Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center . AND Mohamad Fakih Infectious Diseases Faculty, St John Hospital and Medical Center, also in Michigan are leading the development of the project interventions with MHA Keystone. JHU will provide expert faculty on CUSP and HRET is responsible for project management. The On the CUSP: Stop CAUTI project is an AHRQ funded demonstration project to reduce Catheter associated urinary tract infections in 10 states nation wide. This is a collaborative initiative between several entities, with the work being lead by expert faculty out of MHA Keystone. Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center . AND Mohamad Fakih Infectious Diseases Faculty, St John Hospital and Medical Center, also in Michigan are leading the development of the project interventions with MHA Keystone. JHU will provide expert faculty on CUSP and HRET is responsible for project management.

5. National Project Team 5

6. 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 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 7 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.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.

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13. 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) Urinary Catheter-Related Infection: Pathophysiology 13

14. Intraluminal Extraluminal Detrusor spasm Shedding of cells Bacteremia Leakage Obstruction Fever (+) UA Hypotension Urinary Catheter-Related Infection: Pathophysiology 14

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16. Background Prevention Catheter-Associated Urinary Tract Infection 16

17. 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 Prevention of Catheter- Associated UTI 17

18. 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) 18

19. 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 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.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.

20. One Reason Catheters Are Used Inappropriately 20 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.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.

21. 21 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. 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.

22. 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 Prevention of Catheter- Associated UTI 22

23. 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 Use Proper Aseptic Technique for Catheter Insertion 23

24. 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 Prevention of Catheter-Associated UTI 24

25. 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) 25 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.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.

26. 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 Prevention of Catheter-Associated UTI 26

27. Alternatives to the indwelling catheter Bladder ultrasound Intermittent catheterization Condom catheter Other Methods for Preventing CAUTI 27

28. 28 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. 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.

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31. Modified HICPAC Categorization Scheme 31 IB: Even though there may be low to very low quality evidence directly supporting the benefits of the intervention, the theoretical benefits are clear, and the theoretical risks are marginal.IB: Even though there may be low to very low quality evidence directly supporting the benefits of the intervention, the theoretical benefits are clear, and the theoretical risks are marginal.

32. Core Prevention Strategies: (All Category IB) 32

33. Comprehensive Unit-based Safety Program (CUSP) 33

34. 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 34

35. “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” 35

36. Pre CUSP Work Create an ICU 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 36

37. Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture Educate staff on science of safety http://www.safercare.net Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools 37

38. Teamwork Tools Call list Daily Goals AM briefing Shadowing Culture check up TEAMSTepps 38

39. 39 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

40. 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 40 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 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

41. 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 41 The expected short-term outcomes are: Increased awareness of appropriate use for catheter Reduced use of urinary catheters Improved ability to assess the need or discontinuation of a catheter Reduced patient discomfort Improved patient “dignity” The expected short-term outcomes are: Increased awareness of appropriate use for catheter Reduced use of urinary catheters Improved ability to assess the need or discontinuation of a catheter Reduced patient discomfort Improved patient “dignity”

42. Expected Benefits Reduction in bacteriuria Reduction in symptomatic UTIs Shortened Length of Stay Decreased Cost per stay Improved sensitivity to “patient dignity” 42

43. What Participation Requires Data Submission 43

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46. Next Steps: Cohort 1 46

47. Next Steps: Cohort 2 47

48. 48 Questions Content – Sam Watson, MHA Keystone swatson@mha.org Participation–Marchelle Djordjevic, HRET mdjordjevic@aha.org