Welcome to the. TMIT High Performer Webinar: Catheter-Associated Urinary Tract Infection: No One Owns It We ALL Pay for It!

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1 Welcome to the TMIT High Performer Webinar: Catheter-Associated Urinary Tract Infection: No One Owns It We ALL Pay for It! (SP 25) Hosted by TMIT For resource downloads go to: TMIT 1

2 Welcome Charles Denham, MD Chairman, TMIT Co-chairman, NQF Safe Practices Consensus Committee Chairman, Leapfrog Safe Practices Program TMIT High Performer Webinar August 19, TMIT 2

3 With regard to webinar sound volume, please check the WebEx volume (see example above in red box), computer volume, and external speaker (if any) volume. If you are still having difficulty hearing the webinar, please click on Request Phone button to receive a toll dial-in number (see example on right-hand side in red box) TMIT 3

4 The following panelists certify: Disclosure Statement that unless otherwise noted below, each presenter provided full disclosure information, does not intend to discuss an unapproved/investigative use of a commercial product/device, and has no significant financial relationship(s) to disclose. If unapproved uses of products are discussed, presenters are expected to disclose this to participants. Charles Denham: Chairman, TMIT; education grant (CareFusion) and co-production with Discovery Channel Carolyn Gould: Employed by Centers for Disease Control and Prevention Sanjay Saint: Employed by Ann Arbor VA Medical Center and the University of Michigan Jeanette Harris: Employed by MultiCare Health System Denise Graham: Employed by Association for Professionals in Infection Control and Epidemiology Patti O Regan has no relevant financial interests in this presentation 2010 TMIT 4

5 Roundtable Panelists Charles Denham Carolyn Gould Sanjay Saint Jeanette Harris Image not available Denise Graham Patti O Regan 2010 TMIT 5

6 Introduction Patti O Regan, DNP, ARNP, ANP-C, PMHNP-BC Nurse practitioner, Port Richey, FL Founding member, TMIT Patient Advocate Panel TMIT High Performer Webinar August 19, TMIT 6

7 Safe Practice Overview Charles Denham, MD Chairman, TMIT Co-chairman, NQF Safe Practices Consensus Committee Chairman, Leapfrog Safe Practices Program TMIT High Performer Webinar August 19, TMIT 7

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10 TMIT Mission Accelerate performance solutions that save lives, save money, and build value in the communities we serve and ventures we undertake TMIT 10

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13 Extraordinary impact through ordinary things Chasing Zero is the first in a series of documentaries produced by TMIT that targets consumers, caregivers, and healthcare leaders. The goal is to inspire them to act now to prevent healthcare harm. The war on healthcare harm is not targeting bad people, but bad systems. These support systems no longer protect caregivers and patients as healthcare has become more complex and fragmented. Healthcare harm has risen from the 8th leading cause of death to the 3rd leading cause of death when we include infections we have given patients during care. 20 jumbo jets are crashing every week in American healthcare The documentary was shot in multiple locations around the world. Interviews of World Health Organization leaders were undertaken in Geneva and London. Dennis Quaid was filmed on the movie set of Soul Surfer on Oahu, Hawaii. Caregivers were shot in action at their hospitals including the Brigham and Women s Hospital, the Mayo Clinic, the Cleveland Clinic, Johns Hopkins, and the Vanderbilt University Medical Center. Zero is the number Now is the time Narrator Dennis Quaid Our goal is to reinforce role models of great caregivers and healthcare leaders, and to open dialogue among governance and leadership teams at America s hospitals and healthcare organizations so our care will be safer and more reliable. DVD Contents and Bonus Features Chasing Zero documentary feature 53-minute run time Medical articles for background reading and continuing education: Chasing Zero: Can Reality Meet the Rhetoric? by Charles Denham, Peter Angood, Donald Berwick, Leah Binder, Carolyn Clancy, Janet Corrigan, and David Hunt The Chasing Zero Department: Making Idealized Design a Reality by Charles Denham, Peter Angood, Donald Berwick, Leah Binder, Carolyn Clancy, Janet Corrigan, and David Hunt Story Power by Dennis Quaid, Julie Thao, and Charles Denham The No Outcome - No Income Tsunami is Here: Are You a Surfer, Swimmer, or Sinker? by Charles Denham Web links to receive free assets, such as the National Quality Forum 2010 Safe Practices for Better Healthcare, in return for survey responses to safe practices adoption. Messages from funding organization leaders. Web links to view other resource materials from Discovery Channel, AORN, CareFusion, TMIT, and other patient safety organizations. Stories of great healthcare leaders and caregiver role models communicate the actions that we can take to save lives, save money, and deliver value to the communities we serve. Visit DiscoveryChannelCME.com Chasing Zero online at Chasing Zero is a trademark of CareFusion Corporation This program was produced with educational grants funding from CareFusion, AORN, and TMIT.

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17 Culture 2010 NQF Report Consent & Disclosure Consent and Disclosure Workforce Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- & Site-Specific Practices 2010 TMIT 17

18 The CDC Guideline for Prevention of CAUTI Carolyn Gould, MD, MSCR Medical Epidemiologist, Division of Healthcare Quality Promotion (DHQP), Centers for Disease Control and Prevention (CDC) TMIT High Performer Webinar August 19, TMIT 18

19 Outline Background Review of new guideline Core Strategies Supplemental Strategies Measurement There are no financial disclosures The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention 19

20 Impact of CAUTI Most common type of HAI > 30% of infections reported to NHSN > 560,000 nosocomial UTIs annually Increased morbidity & mortality Estimated 13,000 attributable deaths annually Leading cause of secondary BSI with ~10% mortality Excess length of stay 2-4 days Increased cost $ billion per year nationally Unnecessary antimicrobial use a third of use may be inappropriate (treatment of ASB) Hidron AI et al. ICHE 2008;29: Klevens RM et al. Pub Health Rep 2007;122:160-6 Weinstein MP et al. Clin Infect Dis 1997;24: Cope M et al. Clin Infect Dis 2009;48: Givens CD, Wenzel RP. J Urol 1980;124:646-8 Green MS et al. J Infect Dis 1982;145: Foxman B. Am J Med 2002;113:5S-13S Saint S. Am J Infect Control 2000;28:68-75

21 Urinary Catheter Use 15-25% of hospitalized patients 5-10% (75, ,000) NH residents Often placed for inappropriate indications Physicians frequently unaware In a recent survey of U.S. hospitals: > 50% did not monitor which patients catheterized 75% did not monitor duration and/or discontinuation Weinstein JW et al. ICHE 1999;20:543-8 Warren JW et al. Arch Intern Med 1989;149: Benoit SR et al. J Am Geriatr Soc 2008;56: Rogers MA et al. J Am Geriatr Soc 2008;56: Munasinghe RL et al. ICHE 2001;22:647-9 Saint S et al. Am J Med 2000;109: Jain P et al. Arch Intern Med 1995;155: Saint S et al. Clin Infect Dis 2008;46:

22 Pathogenesis of CAUTI * Source of microorganisms may be endogenous (meatal, rectal, or vaginal colonization) or exogenous, usually via contaminated hands of healthcare personnel during catheter insertion or manipulation of the collecting system Figure from: Maki DG, Tambyah PA. Emerg Infect Dis 2001;7:1-6 22

23 Biofilm Formation Formation of biofilms by urinary pathogens common on the surfaces of catheters and collecting systems Bacteria within biofilms resistant to antimicrobials and host defenses Some novel strategies in CAUTI prevention have targeted biofilms Scanning electron micrograph of S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm Photograph from CDC Public Health Image Library: 23

24 HHS Metrics and Prevention Targets Metric Measurement System National 5-year Prevention Target Rate of BSI secondary to UTI / 1,000 patient days NHSN 50-75% reduction # of symptomatic UTI / 1,000 urinary catheter days NHSN 25% reduction (Urinary catheter days / patient days)*100 NHSN 50% reduction HHS Action Plan to Prevent Healthcare-Associated Infections: 24

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27 Modified HICPAC Categorization Scheme All Category I recommendations carry same strength; levels A and B represent the quality of the evidence underlying the recommendation 27

28 Prevention Strategies for Implementation Core Strategies Supplemental Strategies High levels of Some scientific scientific evidence Demonstrated feasibility evidence Variable levels of feasibility 28

29 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 Ensure that only properly Following aseptic trained persons insert and maintain catheters Insert catheters using aseptic technique and sterile equipment (acute care setting) Hand Hygiene and Standard Precautions insertion, maintain a closed drainage system Maintain unobstructed urine flow Quality Improvement Programs 29

30 Core Prevention Strategies: Specific recommendations (IB) Insert catheters only for appropriate indications *Table primarily based on expert consensus 30

31 Core Prevention Strategies: Specific recommendations (IB) Insert catheters only for appropriate indications Minimize use in all patients, particularly those at higher risk of CAUTI and mortality (women, elderly, impaired immunity) Avoid use for management of incontinence Use catheters in operative patients only as necessary 31

32 Core Prevention Strategies: Specific recommendations (IB) Leave catheters in place only as long as needed Remove catheters ASAP postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use 32

33 Core Prevention Strategies: Specific recommendations (IB) Insert catheters using aseptic technique and sterile equipment (acute care setting) Perform hand hygiene before and after insertion Use sterile gloves, drape, sponges, antiseptic or sterile solution for periurethral cleaning, single-use packet of lubricant jelly Antiseptic lubricant is not necessary (II) Properly secure catheters 33

34 Core Prevention Strategies: Specific recommendations (IB) Following aseptic insertion, maintain a closed drainage system If breaks in aseptic technique, disconnection, or leakage occur, replace catheter and collecting system using aseptic technique and sterile equipment Consider systems with preconnected, sealed catheter-tubing junctions (II) Obtain urine samples aseptically 34

35 Core Prevention Strategies: Specific recommendations (IB) Maintain unobstructed urine flow Keep catheter and collecting tube free from kinking Keep collecting bag below level of bladder at all times (do not rest bag on floor) Empty collecting bag regularly using a separate, clean container for each patient. Ensure drainage spigot does not contact nonsterile container 35

36 Core Prevention Strategies: Specific recommendations (IB) Implement quality improvement programs to enhance appropriate use of indwelling catheters and reduce risk of CAUTI Examples: Alerts or reminders Stop orders Protocols for nurse-directed removal of unnecessary catheters Guidelines/algorithms for appropriate perioperative catheter management 36

37 Reductions in CAUTI with Quality Improvement Programs % Reductions CAUTI rate * (baseline) DUR (baseline) Mean duration of catheterization (baseline, days) Author, Year Intervention Apisarnthanarak, 2007 RN-generated daily reminders 76% (21.5) Topal, 2005 Computerized feedback, RNdirected protocol/scanners 73% (36.0) Stephan, 2006 Guidelines for ortho patients 59% (45.8) Misset, 2004 IC program in ICU 43% (22.0) Rosenthal, 2004 Education and feedback in ICUs 42% (21.3) Jain, 2006 Collaboration with IHI initiative 37% (3.8) Reilly, 2006 Checklist and algorithm for use 33% (?) 37% (5) Huang, 2004 Daily reminders in ICU 28% (11.5) 34% (7) Verdier, 2006 IC program in ICU 23% (15.9) Fakih, 2008 RN-led rounds to review need CPOE-generated reminders Cornia, 2003 *No. of CAUTIs/1000 catheter-days 73% (11) 81% (16) 22% (5) 0 (73) 20% (20) 37% (8) No. of catheter-days/no. of patient-days x

38 Supplemental Strategies: (Examples) Catheter Use Alternatives to indwelling urinary catheterization (II) Portable ultrasound devices (II) Maintenance Insertion Core Strategies Antimicrobial/ antisepticimpregnated catheters (IB, tiered) 38

39 Supplemental Prevention Strategies: Alternatives to Indwelling Catheters Consider intermittent catheterization for: Patients requiring chronic urinary drainage for neurogenic bladder (e.g., spinal cord injury, myelomeningocele) Postoperative patients with urinary retention May be used in combination with bladder ultrasound scanners Consider external catheters for: Cooperative male patients without obstruction or urinary retention 39

40 Supplemental Prevention Strategies: Bladder Ultrasounds To reduce unnecessary catheterizations Data for adults with neurogenic bladder undergoing intermittent catheterization in rehab centers Two underpowered studies found fewer catheterizations but no differences in UTI Indirect evidence from QI program involving RNdirected protocols and bladder scanners Polliak T et al. Spinal Cord 2005;43:615-9 Topal J et al. Am J Med Qual 2005;20:121-6 Anton HA et al. Arch Phys Med Rehab 1998;79:

41 Supplemental Prevention Strategies: Antimicrobial/ Antiseptic-Impregnated Catheters Considered using if CAUTI rates not decreasing after implementing a comprehensive strategy First implement core recommendations for use, insertion, and maintenance Ensure compliance with core recommendations 41

42 Summary of Data on Antimicrobial/Antiseptic-coated Catheters Decreased risk of bacteriuria (not demonstrated for SUTI or other clinical outcomes) Effects greater for patients catheterized < 1 week and in earlier studies Mixed results in observational studies in hospitalized patients Control catheters might make a difference 42

43 Strategies NOT recommended for CAUTI prevention Complex urinary drainage systems (e.g., antiseptic releasing cartridges in drain port) Changing catheters or drainage bags at routine, fixed intervals Routine antimicrobial prophylaxis Cleaning of periurethral area with antiseptics while catheter is in place Irrigation of bladder with antimicrobials Instillation of antiseptic or antimicrobial solutions into drainage bags Routine screening for ASB 43

44 Measurement: Recommended Outcome Measures Recommended metrics: Number of CAUTI per 1000 catheter-days Number of BSI secondary to CAUTI per 1000 catheter-days Catheter utilization ratio (urinary catheterdays/patient-days) x 100 CDC/NHSN definitions for numerator data (SUTI): 44

45 Measurement: NHSN Deviceassociated Module 45

46 Are Additional Metrics Needed? If primary intervention reduces catheter days, will CAUTI rates go up? Smaller denominator Limiting to a sicker population? Alternative denominator examples: Numbers of catheters used (not typically collected) Patient-days (not specific to population at risk) 46

47 Summary, Metrics CAUTI rates should be presented in the context of urinary catheter utilization More information needed on whether rates should be stratified by utilization ratios Additional metrics may be used in conjunction with standard metrics to demonstrate impact 47

48 HAI-specific toolkits and questionnaires 48

49 Additional Resources APIC CAUTI Elimination Guide IHI Program to Prevent CAUTI National Quality Forum (NQF) Safe Practices for Better Healthcare IDSA Guidelines (Clin Infect Dis 2010;50:625-63) SHEA/IDSA Compendium (ICHE 2008;29:S41-S50) CDC/Medscape collaboration 49

50 Translating Catheter-Associated Urinary Tract Infection Research into Practice Sanjay Saint, MD, MPH Director, Patient Safety Enhancement Program, Ann Arbor VA Medical Center & University of Michigan Health System Professor of Internal Medicine, Dept. of Internal Medicine, Division of General Medicine, University of Michigan Health System TMIT High Performer Webinar August 19, TMIT 50

51 Healthcare-Associated Infection (HAI) At least 20% of episodes are preventable (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 Infection control is a good model for understanding translation both successes and failures 51

52 Overview Preventing CAUTI Translating Research into Practice Conclusions 52

53 Preventing 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 53

54 UTI Prevention Rule #1: Make Sure the Patient Really Needs the Catheter Appropriate indications Percent unjustified Bladder outlet obstruction 50 Incontinence and sacral wound 40 Urine output monitored (Wong and Hooton - CDC 1983) 54 Pt Days During or just after surgery 10 Initial Patient s request (end-of-life) Unjustified (Jain. Arch Int Med 1995)

55 One Reason Catheters Are Used Inappropriately Level Proportion Unaware of the Catheter Medical students 18% House officers 25% Attending physicians 38% 55 (Am J Med 2000)

56 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 56

57 Use Proper Aseptic Technique for Catheter Insertion NEJM Videos in Clinical Medicine: Male Urethral Catheterization T. W. Thomsen and G. S. Setnik 25 May 2006 Female Urethral Catheterization R. Ortega, L. Ng, P. Sekhar, and M. Song 3 Apr Goal is to avoid contamination of the sterile catheter during the insertion process Educating and perhaps re-training those who insert catheters can be useful 57

58 Prevention of CatheterAssociated 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 58

59 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 (i.e., re-insertion) (Meddings J. et al. Clin Infect Dis 2010) 59

60 ** URINARY CATHETER REMINDER ** Date: / / This patient has had an indwelling urethral catheter since / /. Please indicate below EITHER (1) that the catheter should be removed OR (2) that the catheter should be retained. If the catheter should be retained, please state ALL of the reasons that apply. Please discontinue indwelling urethral catheter; OR Please continue indwelling urethral catheter because patient requires indwelling catheterization for the following reasons (please check all that apply): Urinary retention Very close monitoring of urine output and patient unable to use urinal or bedpan Open wound in sacral or perineal area and patient has urinary incontinence Patient too ill or fatigued to use any other type of urinary collection strategy Patient had recent surgery Management of urinary incontinence on patient s request Other - please specify: Physician s Signature 60 Doctor Number

61 Prevention of CatheterAssociated 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 61

62 Other Methods for Preventing CA-UTI Alternatives to the indwelling catheter Bladder ultrasound Intermittent catheterization Condom catheter Antimicrobial catheters 62

63 Recent Guidelines on CAUTI Prevention 63

64 10 pages 64

65 Linda Greene, RN, MS, CIC James Marx, RN, MS, CIC Shannon Oriola, RN, CIC, COHN 41 pages 65

66 38 pages 66

67 ***BOOTLEG VERSION*** Total number of pages of all 4 documents = 414 pages 325 pages 67

68 CA-UTI Prevention: Concise Summary of Recommendations Adherence to infection control principles (e.g., aseptic insertion, proper maintenance, education) is important Bladder ultrasound may avoid indwelling catheterization Condom or intermittent catheterization in appropriate pts Do not use the indwelling catheter unless you must! Early removal of the catheter using reminders or stoporders appears warranted 68

69 ABCDE Adherence to infection control principles (e.g., aseptic insertion, proper maintenance, education) is important Bladder ultrasound may avoid indwelling catheterization Condom or intermittent catheterization in appropriate pts Do not use the indwelling catheter unless you must! Early removal of the catheter using reminders or stoporders appears warranted 69 (Jt Comm J Qual Patient Saf 2009)

70 ABCDE Adherence to infection control principles (e.g., aseptic insertion, proper maintenance, education) is important Bladder ultrasound may avoid indwelling catheterization Condom or intermittent catheterization in appropriate pts Do not use the indwelling catheter unless you must! Early removal of the catheter using reminders or stoporders appears warranted 70

71 Overview Catheter-Associated UTI Translating Research Into Practice Conclusions 71

72 What are Hospitals Using to Prevent CA-UTI? National survey of U.S. hospitals (focused on device-related infection) 719 hospitals surveyed (Spring 2005) Lead Infection Control Professional filled out the survey 72% response rate (Clin Infect Dis 2008) 72

73 Urinary Catheter-Related Infection Prevention Practices Practice Bladder ultrasound scanner Regularly using 30% Antimicrobial catheters 30% Condom catheters in men 14% Urinary catheter reminder 9% Antimicrobials in the drainage bag 3% 73 (Clin Infect Dis 2008)

74 Translating Research Into Practice No common strategy used in hospitals to prevent UTI Less than 10% of U.S. hospitals using catheter reminders or stop-orders Next Step: Evaluate why interventions are used in some hospitals but not in others 74

75 Sequential Mixed-Methods Explanatory Study Quantitative phase Part 1 Surveyed infection control personnel at 719 U.S. hospitals Qualitative phase Part 2 Phone interviews with key informants at 14 hospitals 75 Part 3 Site visits at 6 hospitals (Krein et al. Am J Infect Control 2006)

76 Why Use Qualitative Methods? Quantitative methods help us answer the question of what is happening Qualitative methods help us answer why 76 (Forman et al. Am J Infect Control 2008)

77 Main UTI Qualitative Theme Urinary catheter-related infection is a low priority, but timely removal of catheters considered important 77 (Infect Control Hosp Epidemiol 2008)

78 Urinary catheter-related infection is a low priority A hospital epidemiologist: I [nor] anyone else has really been able to get ourselves that excited about trying to prevent bladder colonization. But.I think that we probably should try to be more proactive about getting the catheters out. 78

79 but timely catheter removal considered important Hospitals using reminders highlighted noninfectious reasons for catheter removal: patient dignity & mobility, and length of stay Some pushback from nurses A nurse: [C]onvenience unfortunately is a high priority especially with urinary catheters the workload will be increased if you have to take [patients] to the bathroom or you have to change their bed a little more often 79

80 but timely catheter removal considered important Nurse buy-in critical A physician administrator: Because the nurses on the geriatrics unit wanted to have their patients regain mobility they viewed ambulation and mobility as a very important goal versus the other units where the nurses didn t necessarily feel that was a real goal in the patient s plan for that day. Partnering with a nurse leader is key 80

81 Urinary Catheters Often Placed in the Emergency Department Avoiding insertion also important 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... Initiatives to avoid insertion should include emergency department personnel (same for aseptic insertion) 81

82 Qualitative UTI Themes 1) Urinary catheter-related infection is a low priority, but timely removal of catheters considered important 2) Identifying a committed champion facilitated prevention activities in several sites 3) Small hospital-specific pilot studies are important in deciding whether or not to use antimicrobial catheters 82 (Infect Control Hosp Epidemiol 2008)

83 Barriers and Facilitators Interested in overarching qualitative themes These themes spanned the hospital-acquired infections studied (UTI, CRBSI, VAP) Specifically interested in identifying barriers to and facilitators of the use of preventive practices Marked variability of practices observed 83

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85 If not for the great variability among individuals, medicine might as well be a science and not an art. Sir William Osler (1892) 85

86 Findings: Key Barriers Active Resisters: people who prefer doing things the way they have always done them 86

87 Findings: Key Barriers Active Resisters: people who prefer doing things the way they have always done them Organizational Constipators: passive-aggressives who undermine change without active resistance 87

88 Findings: Key Barriers Active Resisters: people who prefer doing things the way they have always done them Organizational Constipators: passive-aggressives who undermine change without active resistance (Jt Comm J Qual Patient Saf 2009) Culture of Mediocrity (rather than Excellence) 88

89 Findings: Key Barriers Active Resisters: people who prefer doing things the way they have always done them Organizational Constipators: passive-aggressives who undermine change without active resistance (Saint et al. Jt Comm J Qual Patient Saf 2009) Culture of Mediocrity (rather than Excellence) 89

90 What is a Culture of Excellence? Hospital wants to be superb Employees are rewarded for exemplary work Employees describe their hospital as the best and enjoy working there Clear goals that can be achieved 90

91 Culture of Mediocrity Happy to be average Constipators are prevalent Leadership is considered ineffective Over-performers are rewarded by Underperformers are not held accountable 91

92 Key Facilitators 92

93 The Importance of Effective Leadership Applies not only to the CEO Getting the right people on the bus and in the right seats: identify and support champions Works well with other disciplines Examples: IPs, hospital epidemiologists, CMOs, etc. 93

94 Key Behaviors of Effective Infection Prevention Leaders Cultivated a culture of clinical excellence Developed a clear vision Successfully conveyed that to staff Inspired staff Motivated and energized followers Some, not all, were charismatic 94 (Infect Control Hosp Epidemiol 2010)

95 Key Behaviors of Effective Infection Prevention Leaders Solution-oriented Focused on overcoming barriers rather than complaining Dealt directly with resistant staff Thought strategically while acting locally Planned ahead leaving little to chance; politicked before crucial issues came up for a vote in committees Kept their eyes on the prize: improving patient care 95 (Infect Control Hosp Epidemiol 2010)

96 Another Key Facilitator: Collaboratives Collaboratives: align clinical silos and goals Examples: 100K Lives Campaign, Keystone 96

97 Key Facilitator: Collaboratives Tools used by collaboratives: CEO buy-in Spotlighting an issue Identifying a champion within the organization Using off-the-shelf solutions that have already been developed 97

98 Overview Catheter-Associated UTI Translating Research into Practice Conclusions 98

99 Future Directions & Conclusions Collaborative efforts to prevent CA-UTI in Michigan, North Carolina, and elsewhere Improve the evidence base through observational, interventional, and economic studies Understand the implementation process and tailor as appropriate 99

100 Conclusion Preventing CatheterAssociated UTI is a Team Sport! 100

101 CAUTI Reduction Using Rapid-Cycle Improvement Jeanette Harris, MS, MSM, MT (ASCP), CIC Infection Prevention and Control, MultiCare Health System TMIT High Performer Webinar August 19, 2010 [Acknowledgments: Slides courtesy of Marcia Patrick, RN, MSN, CIC, MultiCare Health System] 2010 TMIT 101

102 Who, What, Where, Why, How MultiCare Health System 4 hospitals and 200+ ambulatory sites UTI Most numerous HAI (>35% of all HAIs) Non-reimbursement 10/1/2008 CMS, others MHS UTI cost: $7,700 each, 6.9 extra days UTI Reduction Program began 9/1/2007 UTI Bundle developed Unintended consequences: Other infections went down, too! 102

103 Step 1: Identify the Problem July-August 2007: a spike in UTIs on all acute care units TIME to DO 103 SOMETHING!

104 Plan Based on Analysis 40% of UTIs likely POA but not recognized Convenience Foleys being used Catheters left in, forgotten (some post-op) Staff not following aseptic insertion practices Staff, pts not following proper maintenance Bags above level of bladder or on floor Pericare non-existent Urines for culture not sent promptly to lab 104

105 Step 2: Performance Improvement Use electronic surveillance: tracking, reporting Use PDSA (Six Sigma) for rapid implementation Plan Pick ONE trial unit, plan attack Do UTI Bundle get bedside staff involved Study How is it working? Act Change what doesn t work, enhance what does COMMUNICATE! 105

106 The UTI Bundle Check for signs and symptoms of UTI on admit Proceed only for patients with + signs, symptoms Not EVERY patient gets a culture Collect urine (mid-stream/cath), does it look +UTI? Inform physician, order UA, Culture if Indicated Send to lab in gray top urine tube (preservative) Foley ONLY placed for medical reasons Hemodynamic: Critically ill or post-op patients who need accurate measurement of urine output Obstruction: Anatomic or physiologic obstruction Retention: Surgical, postpartum Neurological: Debilitated, paralyzed, comatose pts 106

107 UTI Bundle, continued Hand hygiene, gloves for access Aseptic insertion/maintenance technique Maintain urine drainage bag below the bladder, off the floor, and no dependent loops in the tubing Peri-care every shift (soap and water) Use a securing device to prevent movement of the catheter Daily assessment for catheter removal 107

108 Intervention #1 Education of unit management, then staff Current rates unacceptable data! Asked for and outlined identified gaps Enlisted help of CNS and unit educator Computer program review aseptic insertion Learning lab demonstration Review of daily maintenance, hand hygiene 108

109 Step 3: ATTACK PDSA #1 109

110 Step 4: 5J Confounding Variables 110

111 Step 5: Refine Communication is the KEY! 111 Gray urine tubes started

112 5J 2008 UTI DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC PT DAYS UTI House-wide hand hygiene program in place

113 Significant Results* First 8 month results (6 units) Pre-intervention, there were 77 UTIs/40,274 patient days (pd), for a rate of 1.91 per 1000 pd over a period of nine months in two units, and six months in two other units. Post-intervention identified 31 UTIs over 44,329 patient days, for a rate of.70 per 1000 patient days over the same time-frame. A 273% improvement! (p= ) 113

114 Current Results 3 Hospitals (Sept 2007-June 2010)* Current # Units monitored = 23 All Tacoma General inpatient units + EDs (13) All Allenmore inpatient units + EDs (5) All Mary Bridge inpatient units + EDs (5) UTIs avoided (23 units) = 1080 Approximate cost avoided = 1080 UTIs x $7,700 = $8,316,000 Million 114

115 Other Important Rewards Culture of care improvement, awareness Several awards Qualis, VHA, MedMined Poster at SHEA conference 2008 MHS President s Award 5J Innovative Unit RWJ grant Improved patient satisfaction scores Improved staff morale 115

116 Lessons Learned If you don t measure it, you can t fix it Management/administrative buy-in, support Start small and build on successes, celebrate Rates may not be meaningful, use raw numbers Patient stories impact of UTI Encourage staff input, feedback, problems, etc. Calculate the savings, present to administration 116

117 APIC Support Denise Graham Executive Vice President, Association for Professionals in Infection Control and Epidemiology (APIC) TMIT High Performer Webinar August 19, TMIT 117

118 IP Program Evaluation Tool Guide to the Elimination of CAUTI APIC Text For more information, visit or go to APICEliminationGuides/APIC_Elimination_Gui.htm 118

119 The Role of the Patient Advocate Patti O Regan, DNP, ARNP, ANP-C, PMHNP-BC Nurse practitioner, Port Richey, FL Founding member, TMIT Patient Advocate Panel TMIT High Performer Webinar August 19, TMIT 119

120 Roundtable Q & A Charles Denham Carolyn Gould Sanjay Saint Image not available Jeanette Harris 2010 TMIT Denise Graham 120 Patti O Regan