On the CUSP: Stop CAUTI

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Content Call #5 :Prevention of CAUTI: The View from the Bedside

Cohort 2May 3, 2011: 1 ET/12 CT/11 MT/10 PT

Russ Olmsted, MPH, CICDirector, Infection Prevention & Control ServicesSaint Joseph Mercy Health System, Ann Arbor, MI

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CUSP/CAUTI Content Call #2 - The Science of SafetyModerator – Sam Watson; Speaker – Sean Berenholtz03/22/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.CUSP/CAUTI Content Call #3 - Care and Removal InterventionModerator – Sam Watson; Speaker – Mohamad Fakih04/05/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.CUSP/CAUTI Content Call #4 - Data CollectionModerator – Sam Watson; Speaker – Sam Watson04/19/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.CUSP/CAUTI Content Call #5 - The View from the BedsideModerator – Sam Watson; Speaker – Russ Olmsted05/03/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.CUSP/CAUTI Content Call #6 - Implementation in a Community HospitalModerator – Sam Watson; Speaker – Mary Jo Skiba05/17/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.

CUSP/CAUTI Content Call #1 – CUSP Moderator – Sam Watson; Speaker – Sean Berenholtz03/07/11 2 ET/1 CT/12 MT/11 PT Attendee: (866) 256-9295 60 Min.

CAUTI Content Call Schedule

Overview of Today’s Call

• Overview of External Factors Impacting Prevention of

CAUTI

• How are we doing with CAUTI Prevention Intervention?

A National Survey

• From the Bedside: One Infection Preventionist’s

Experience with CAUTI Prevention Collaborative

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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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Pathogenesis of CA-UTI• Source: colonic or perineal flora Source: colonic or perineal flora

or hands of personnelor hands of personnel• Microbes enter the bladder via Microbes enter the bladder via

extraluminal {around the extraluminal {around the external surface} (proportion = external surface} (proportion = 2/3) or intraluminal {inside the 2/3) or intraluminal {inside the catheter} (1/3)catheter} (1/3)

• Daily risk of Daily risk of bacteriuriabacteriuria with with catheterization is 3% to 10%; by catheterization is 3% to 10%; by day 30 = 100%day 30 = 100%

– Maki DG EID 2001Maki DG EID 2001

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Facts & Figures on CAUTI According to Rodney…”these just don’t get any respect!”

• Increased morbidity, mortality (attributable mortality

= 2.3%), hospital cost, and length of stay• 15% - 25% of hospitalized patients may receive

short-term indwelling urinary catheters• 17% to 69% of CAUTI may be preventable with

recommended infection prevention measures– Up to 380,000 infections and 9000 deaths related

to CAUTI per year could be prevented • Gould CV, et al. Guideline for prevention of CAUTIs, 2009

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Snapshot of Relative Distribution of Health Care-Associated Infections (HAIs) in U.S.

hospitals, 2002

HRN = high risk newbornsWBN -= well-baby nurseries

ICU = intensive care unitSSI = surgical site infectionsBSI – bloodstream infections

UTI = urinary infectionsPNEU = pneumonia

SSI20%

BSI11%

UTI36%

PNEU11%

Other22%

133,368

424,060

263,810

129,519

274,098

-967

-21

-28,725

244,385

TOTAL

HRN

WBN

Non-newborn ICU

= SSI

Klevens, et al. Pub Health Rep 2007;122:160-6

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American Recovery and Reinvestment Act (ARRA), 2009.Public Law 111-5

Action Plan to Prevent HAIs, June 2009

http://www.hhs.gov/ophs/initiatives/hai/draft-hai-plan-01062009.pdf

Tier 1: See Targets/Metrics

Tier 2: Ambulatory Surgery Clinics, Dialysis Centers, Influenza vaccine for Healthcare Personnel

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Health & Human Services HAI Prevention Plan 5 yr. Targets; Progress Report, 09/23-24/10

TOPIC METRIC & TARGET Progress Report

Central line-assoc. bloodstream infection (CLABSI)

CLABSI Std Infection Ratio (SIR);

50% reduction18% drop in 2009 – on target!

CLABSI Insert. Bundle Proportion of insertions using bundle; 100% adherence

Sample of Hospitals = 92% - on target

C. difficile Infection (CDI) Rate/1000 discharges; 30% reduction

8.9 in 2009; 9.4 in 2010 – not likely to meet target

Catheter-assoc. UTI (CAUTI) CAUTI rate ; 25% reduction Estimate in ’08 = 5% reduction but new def. in ’09 - unsure

MRSA Rate invasive MRSA/100k pop.; 50% reduction

22.72 in 2009 = 13.4% drop compared to ’07-’08 – on target

SSI SIR; 25% reduction 5% fewer SSIs in 2009 – on target

SSI Proportion SCIP measures; 95% adherence

> 92% in 2009 – on target

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National Patient Safety Goals (NPSG), Hospital, 2010

• NPSG.07.01.01: Hand Hygiene• NPSG.07.03.01: Prevent HAIs caused by multidrug-

resistant organisms (MDROs)• NPSG.07.04.01: CLABSI prevention • NPSG.07.05.01: SSI prevention ===============================New Goals for 2011; CAUTI & VAP – in press

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• Proposed NPSG.07.07.01: Proposed NPSG.07.07.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI)– Insertion:

• Limiting use and duration to situations necessary for patient care

• Use aseptic techniques

– Maintenance:• Secure

• Maintain closed system

– Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes

Field Review Comments Were Due: January 27, 2011Field Review Comments Were Due: January 27, 2011Final version and elements are in pressFinal version and elements are in press

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UTIs Also Represent Significant Reservoir of MDROs

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New Respect for UTIs? Emerging Reservoir of MDROs*

New Delhi metallo-beta-lactamase (NDM-1): Transmissible genetic element Enterobacteriaceae [Klebsiella, E. coli, etc.] Inactivates beta lactam antibiotics [penicillin, cephalosporins, carbapenem First identified in 2008 in India – now found in US, Canada, Israel, Turkey, China, Australia, France, Japan, Kenya, Singapore, Taiwan, Sweden, & the UK

Epidemiology of Cases in the U.S.: 3 different patients residing in 3 different states in the U.S.; prior history of Health care in India All were causing urinary tract infection

N Engl J Med 2010 December 16, 2010* Multidrug-resistant organisms

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CAUTI Prevention AHRQ Report (2001); APIC (2008); SHEA/IDSA (2008); CDC/HICPAC (2009)

• Appropriate urinary catheter use– Insert only for appropriate reasons

– Remove when no longer needed (reminders/stop orders)

• Avoid catheter use– Portable bladder ultrasound

• Consider use of alternatives– Condom catheters, intermittent catheterization

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CAUTI Prevention (cont.)

• Use of proper insertion technique

– Aseptic technique in acute care settings

• Proper urinary catheter maintenance

• If the CAUTI rate is not decreasing after implementing other prevention strategies, consider using antimicrobial catheters

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Which method of hand hygiene is best for personnel caring for urinary

catheters? Poor Better Best

Plain Soap Antimicrobial soap

Alcohol-based handrub

Catheter bacterial contamination study: hand hygiene followed by contact with urinary catheter; findings:

Soap + water failed to prevent transfer to cath. in 11/12 (92%) instances

Alcohol-based handrub: 2/12 (17%) (p < 0.001) Source: Ehrenkranz NJ ICHE 1991;12:654-62

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Ann Arbor VA Health Services Research & Development (HSRD) & U of M Patient Safety

Enhancement Program [PSEP]• Mixed Methods Research Project: Drs. Sarah Krein &

Sanjay Saint – Principal Investigators – Practice Survey– Qualitative Interviews– Site Visits

• Collaboration with MI Keystone Center for Patient Safety & Quality

• Survey Distributed March 2009: – Note of thanks to Infection Preventionists who completed survey and

have participated in interviews & ongoing site visits– Results in press

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Methods

•National survey of infection preventionists

•Stratified random sample of U.S. hospitals

–Non-federal general medical/surgical hospitals with 50 or more hospital beds and intensive care unit beds

–Randomly selected 300 with 50-250 beds and 300 with > 250 beds

–Oversample of hospitals in Michigan

•Initial survey in March 2005 and repeated in March 2009

•Response rate of ~ 70% (national) / ~ 80% (MI)18

Hospital Characteristics

2005(national)*

2009(national)*

2009(MI)

Number of hospital beds mean (95% CI)

229 (219 - 239)

226 (215 - 237)

238(187 – 289)

Have hospitalists 57% 75% 76%

Number of full-time equivalent infection preventionists (IP) mean (95% CI)

1.3 (1.2 – 1.4)

1.5 (1.4 – 1.7)

1.7(1.2 – 2.1)

Lead IP certified in infection control

57% 59% 58%

Participate in a collaborative effort to reduce HAI

42% 68% 99%

*Weighted estimates19

Report almost always or always using to prevent CAUTI

National Sample

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Efficacy of Enhancing Catheter Awareness; Meddings J, et al. Clin Infect Dis 2010;51:550-60

Rate of CAUTIcan be reducedby half with useof catheter reminder or stop order.

Process vs. Outcome

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CAUTI Prevention Initiative: A Simple Approach

• Physician Reminder System Implemented, 473 bed community, teaching hospital– Appropriate use of urinary catheters at 3 months (57% vs

73%; p=0.007) and 6 months (57% vs 86%; P <0.001). – Significant reduction in rate of CA-UTI after 3 months (7.02

vs 2.08; P <0.001) and 6 months (7.02 vs 2.72; p <0.001)

Bruminhent J, et al. Am J Infect Control2010;38:689-93.

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Report almost always or always using to prevent CAUTI

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System for monitoringduration and/or discontinuation of urinary catheters

74 73

3959

19 1434 28

0%10%20%30%40%50%60%70%80%90%

100%

2005 MI 2005National

2009 MI 2009National

facility wide

unit specific

none

2005 MI 2005 Nation 2009 MI 2009 Nation

%

0

100

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Managing Expectations: Catheter-Associated Urinary Tract Infection and the Medicare Rule Changes [Saint S, et al. Ann Intern Med 2009;877-84]

• Recommendations for Providers:– Develop or adopt existing protocols that emphasize

appropriate use, care and maintenance of urethral catheters

– Develop systems that promote removal of catheters once no longer needed

– Clinician education: use, interpretation, and response to urinalysis & urine cultures

– Avoid use of urinalysis or culture to detect “present on admission” (POA)

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CLABSI

Use of infection prevention practices 2009: Minding the Gap

VAP CAUTI

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Nurse-Led Multidisciplinary Rounds on Reducing Unnecessary Catheter UtilizationProportion of urinary catheters indicated = 54.8%

Nurse-led intervention was associated with discontinuationof 45% of those catheters that did not meet Indications.

Fakih M, et al. Infect Control Hosp Epidemiol 2008;29:815-9

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Focus on Processes of Care

Acknowledgement: Images courtesy of St. Alphonsus Regional Medical Center, Boise, IA

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Process vs Outcome Metrics Related to CAUTI Prevention

• Progressive Care & Observation Units, 60 beds

• Urinary catheter use decreased by 42% and the incidence of CAUTIs decreased by 57%.

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At the Bedside: CAUTI PreventionCollaborative, St. Joseph Mercy Hospital, Ann Arbor

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CAUTI Prevention Team Members

• Katy Hoffman, Nurse Manager, 3 East – Chair & Chief Executive Champion

• Alvira Galbraith, Nurse Manager, Older Adult Unit• Pilot Units [3E, 9E] Staff: RNs, MDs, Pt Care Assistants• Pam Ceo, Nurse Practitioner - Urology• Pam Willoughby, Education Coordinator, 3 East• Linda Bloom, Manager, SJM-Saline Comm. Hosp, Med-Surg• Gail Siedlaczak & Russ Olmsted, Infection Prevention &

Control• Lakshmi Halasyamani, MD – VP, Quality, Patient Safety &

Systems Improvement

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At the Bedside - Baseline data, SJMH

One Day Point Prevalence Study: All inpatient units, 4/20/2009• Total Patients: 340• Total With Indwelling Urinary Catheters (IUC) = 101• Prevalence = 29.7%

Keystone Bladder Bundle: Two Pilot Units • 76.2% of IUC’s had a physician order• 67.9% met HICPAC indications

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CAUTI Prevention At the Bedside, SJMH

1. Ensure the catheter is indicated. • Revision of Hospital Policy • Improve consistency of Provider orders• Education:

• CDC indications and non-indications for Indwelling Urinary Catheters• Poster Presentations• Online education module for personnel • Patient/Family Handouts

• Collaboration with the Emergency Dept. to decrease insertion of unnecessary IUC’s

• Consider alternatives to IUC’s (condom catheters, scheduled toileting, etc.)

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CAUTI Prevention At the Bedside, (cont)

2. Insert and Maintain IUC using proper technique

• Adherence with Revised IUC Policy • Utilization of Stat-lock or other securing

devices (Dale elastic leg strap, tape)• Location of tubing and dependent drainage

bag• Improve documentation of Insertion, including

date/time

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Urinary Cath. alert to RN (with task and order)

Supporting Improvement through the Electronic Health Record

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CAUTI Prevention At the Bedside, SJMH,cont.

3. Remove catheters when no longer appropriate

• Daily screening tool• Nurse driven process for discontinuation• Portable Bladder Ultrasound Scanning

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Results of Bladder Bundle: Before & After EHR Implementation, SJMH-AA, 2009

CAUTI Quarterly Data

0

10

20

30

40

50

60

70

80

90

100

April June September December

Prevalence Percentage of IUC's with Physician Order

Percentage of IUC's Clinically Appropriate

New EHR System

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Summary CAUTI Data, SJMH

0

10

2030

40

50

60

70

8090

09-Nov 10-Feb

Prevalence

Indications-Meet CDCcriteriaOrders

%

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Distribution for Indication for Urinary Catheterization, SJMH-AA, November 2009, Med-Surg Unit A

Urinary Retention-10%U.O. Critically Ill-5%Immobilization-45%No Orders-40%

45%

5%10%

40%

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Distribution for Indication for Urinary Catheterization, SJMH-AA, February 2010, Med-Surg Unit A

Urinary Retention-55%U.O. Critically Ill-15%Immobilization-12%No Orders-18%

18%

12%55%

15%

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Surveillance for CAUTI, NHSN

• Urinary tract infections (UTI) are defined:– Symptomatic urinary tract infection (SUTI) or

Asymptomatic Bacteremic UTI (ABUTI)

• CAUTIs = catheter-associated (i.e. patient had an indwelling urinary catheter at the time of or within 48 hours before onset of the UTI)– NOTE: There is no minimum period of time that the

catheter must be in place in order for the UTI to be considered catheter-associated

http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf

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Surveillance for CAUTI, NHSNApplication

• CAUTI:– Day 1: Patient admitted

through the ED where a urinary catheter is inserted and admitted to Unit A. Day 3 of hospitalization:

• Catheter remains in place• Fever (>38°C),• Urine culture = ≥105

colony-forming units (CFU)/ml of E. coli

– Meets NHSN criteria for symptomatic urinary tract infection (SUTI) + has catheter

• Not CAUTI:– Day 1: Patient has an

indwelling urinary catheter in place on an inpatient unit B.

– Day 2: Catheter is discontinued

– Day 6: • fever (>38°C), urgency, &

frequency• Urine culture = ≥105 CFU/ml

Proteus mirabilis – Patient has a SUTI BUT is not

a CAUTI because the time since discontinuation of the catheter is > 48 hours

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CAUTI Surveillance Flow Chart

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CAUTI Surveillance Flow Chart

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ABUTI Flow Chart

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Calculation of CAUTI Rate

• Numerator: # CAUTIs for May 2011, Unit A• Denominator: Tot. number of catheter days for Unit

A in May 2011

• RATE: The CAUTI rate per 1000 urinary catheter days is calculated by dividing the number of CAUTIs by the number of catheter days and multiplying the result by 1000– Example: 1 CAUTI, Unit A, 05/11______

250 urin.cath.days,Unit A, 05/11 X 1,000 = 4.0

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NHSN Summary Data Report

Edwards JR, et al. Am J Infect Control 2009;37:783-805.

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• Nurse, and ideally, Physician Champion(s) in the Clinical Care Area Are Critical Element of Success– We were fortunate to have engagement of clinical leadership of our

CAUTI Prevention Team• Infection Preventionist – key stakeholder and subject matter

expertise, but not necessarily Team Leader or Unit-based Champion. – [Note: this was the model from Keystone ICU involving prevention of

VAP & CLABSI]• A member of Infection Prevention & Control Services at SJMH

does collect ongoing, periodic, unit-based data on processes of care involving IUCs.

• Ongoing monitoring to sustain gains is important; aka keeping your eye on the ball [Meaningful Use of Surveillance]

Perspectives on Role of the Infection Preventionist on CAUTI Prevention Teams

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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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Saint S, et al ICHE 2010 50

A Model For Implementation Science

Parting Thoughts

• Prevention of CAUTI is supported by several external organizations and initiatives

• National surveys continue to identify significant gaps between CAUTI prevention evidence in the literature and care of the patient at the bedside

• Use the 4 “Es”: engage, educate, execute, & evaluate for your CAUTI prevention teams

• The IP is a key member of this team but does not necessarily have to lead – clinical champions can provide this leadership

• Use a variety of measures with emphasis on processes aimed at urinary catheter stewardship

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Your Feedback is Important

http://www.surveymonkey.com/s/FN9BJKB

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Questions

• Content – Russ Olmsted, SJMHS–Olmstedr@trinity-health.org

• Participation– Your State Lead