On the CUSP: Stop CAUTI

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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)

• Project overview and data requirements

– Expected outcomes

– What it requires

• What are the next steps

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Project Goals

• Reduce CAUTI rates in participating units by 25%– Appropriate placement– Appropriate continuance– Appropriate utilization

• Improve patient safety culture on participating units

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Project Overview

Hospitals or Hospital Systems

State Hospital Associations

National Project Team

Project Management

Clinical Faculty & Data Management CUSP Faculty

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National Project Team

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Partner Team Members

Michigan Health & Hospital AssociationKeystone Center for Patient Safety & Quality

Sam Watson, MSA; Chris George, RN, MS

Health Research & Educational Trust Steve Hines, PhDDeborah Bohr, MPHMarchelle Djordjevic, MBA

Centers for Disease Control & Prevention Katherine Allen-Bridson, RN, BSN, CICCarolyn Gould, MD, MSCR

Johns Hopkins Quality Safety Research Group Sean Berenholtz, MDChris Goeschel, MPA, MPS, ScD, RN

Ann Arbor VA Medical CenterUniversity of Michigan Medical School

Sanjay Saint, MD, MPHSarah Krein, RN, PhD

St. John Hospital & Medical Center Mohamad Fakih, MD, MPH

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

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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

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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

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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)

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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

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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

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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)

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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

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

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Intraluminal Extraluminal

Detrusor spasm Shedding of cells Bacteremia

Leakage Obstruction Fever (+) UA Hypotension

Bladder infection with inflammation

Urinary Catheter-Related Infection: Pathophysiology

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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)

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• Background

• Prevention

Catheter-Associated Urinary Tract Infection

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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

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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)

0

10

20

30

40

50

Initi

al

Pt D

ays

Percent unjustified

Unjustified

(Jain. Arch Int Med 95)

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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)

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One Reason Catheters Are Used Inappropriately

Level Proportion Unaware of the Catheter

Medical students 18%

House officers 25%

Attending physicians

38%

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

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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)

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• 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

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• 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

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• 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

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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)

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• 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

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• Alternatives to the indwelling catheter

–Bladder ultrasound

–Intermittent catheterization

–Condom catheter

Other Methods for Preventing CAUTI

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On the CUSP: Stop CAUTI

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Recent Guidelines on CAUTI Prevention

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

On the CUSP: Stop CAUTI

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Modified HICPAC Categorization Scheme

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

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Core Prevention Strategies: (All Category IB)

Catheter Use

InsertionMaintenance

• Insert catheters only for appropriate indications• Leave catheters in place only as long as needed

• Ensure that only properly trained persons insert and maintain catheters

• Insert catheters using aseptic technique and sterile equipment (acute care setting)

• Following aseptic insertion, maintain a closed drainage system

• Maintain unobstructed urine flow

Hand Hygiene

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

Quality Improvement Programs

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Comprehensive Unit-based Safety Program (CUSP)

On the CUSP: Stop CAUTI

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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

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“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

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

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Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture

1. Educate staff on science of safety http://www.onthecuspstophai.org

2. Identify defects

3. Assign executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

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

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Teamwork Tools

• Daily Goals

• AM briefing

• Shadowing

• Culture check up

• TEAMSTepps

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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

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

CUSP CAUTI

1. Care and Removal Intervention

Removal of unnecessary catheters

Proper care for appropriate catheters

2. Placement Intervention

Determination of appropriateness

Sterile placement of catheter

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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

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Expected Benefits

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

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What Participation Requires Data Submission

Intervention Measure Frequency Suggested Collector

CUSP

Readiness Assessment Baseline Project Lead

HSOPS Baseline and post intervention All staff on unit

Team Check-up Tool Quarterly Project team

Care and Removal

Process Prevalence & Appropriateness

Weekly within Protocol Unit staff

Outcome Monthly within Protocol

Infection Prevention - UTI Rate / Device Days

- UTI Rate / Patient Days Monthly within Protocol

Insertion TBD TBD TBD43

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Data Collection Schedule

MEASURE DATA COLLECTION SCHEDULE DATES

CAUTI Rates (Outcome)1.Number of Symptomatic CAUTI’s attributable to your unit for that month2.Number of urinary catheter days per month (number of patients with urinary catheter device is collected daily at the same time each day and the total is summed for the month)3.Number of patient days per month

Collect monthly for 5 months beginning in June and quarterly thereafter (June-August will be considered baseline)

2011: June 1-30 July 1-31 August 1-31 September 1-30 October 1-312012: January 1-31April 1-30July 1-31October 1-31

Prevalence & Appropriateness (Process)1.Assess each patient on the unit for the presence of a urinary catheter2.Record the reason for the catheter

Baseline: Mon-Fri for 3 weeks Baseline: August 1-5, 8-12, 15-19, 2011

Prospective: Mon-Fri for 2 weeks, 1 day per week for 6 weeks then one week per quarter thereafter

Prospective: September 5-9, 12-16, 20 & 27October 4, 11, 18, 252012:January 9-13April 9-13July 9-13October 15-19

What are the Next Steps

Timeline at a glance

March 2 Unit attends first immersion call

March -May Unit attends Kick Off Meeting and begins participating in national content/coaching calls

March - May - Participate in content and coaching calls - Collect and report quarterly data to monitor change

June Unit begins base line data collection and culture survey

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Questions

• Content – Sam Watson, MHA Keystone–swatson@mha.org

• Participation–Kristina Davis, HRET–kdavis@aha.org