Evidence- based Catheter Associated Urinary Tract Infec8on CAUTI Preven8on. Effec%ve CAUTI Preven%on Saves Lives, Prevents Harm, and Reduces Costs

Transcription

1 Evidence- based Catheter Associated Urinary Tract Infec8on CAUTI Preven8on Effec%ve CAUTI Preven%on Saves Lives, Prevents Harm, and Reduces Costs Maureen Dailey, PhD, RN, CWOCN

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3 CMS Leadership to Reduce Hospital Acquired Condi8ons (HACs) Na%onal Quality Strategy (NQS) Tri- part Aim o BeLer Care, Healthier Popula%ons, & Reduced Cost Center for Medicare and Medicaid Services Innova%on s (CMMI) Partnership for Pa%ents (PfP) o hlp://wwwpartnershipforpa%ents.cms.gov/ o PfP Goals Reduc%on of HACs by 40% Reduc%on of Readmissions by 20%

4 HACs Addressed Adverse Drug Events Catheter- Associated Urinary Tract Infec8ons Central Line Associated Blood Stream Infec%ons Injuries from Falls and Immobility Obstetrical Adverse Events Pressure Ulcers Surgical Site Infec%ons Venous Thromboembolism Ven%lator- Associated Pneumonia Readmissions Addi%onal HACs addressed by LEAPT HENs (PfP 1.0)

5 PfP 1.0 Structure/Strategies 27 Hospital Engagement Networks (HENs) o Evidence- based Strategies o Resources/Support o Measure Progress Employed Mul%ple NQS Levers o Innova%on and Diffusion o Workforce Development o Measurement and Feedback Three PfP Care Engines

6 PfP Three Care Engines to Achieve Results (PfP, 2014)

7 ANA s Ac8ve Partnership with PfP 1.0 Provided Na%onal Data from Na%onal Database of Nursing Quality Indicators (NDNQI ) o Falls, Pressure Ulcers and Ven%lator Associated Pneumonia (VAP) ANA Took Leadership Role in Pressure Ulcers and Fall Reduc%on in 2011 Disseminated Evidence- Based prac%ce (E- B) Bundles from NDNQI Research (pressure ulcers and falls) o Par%cipated in HEN webinars o Engaged nurses in PfP via ANA listservs and publica%ons o Engaged the ANA- convened Nursing Alliance for Quality Care (NAQC) Members

8 ANA Ac8ve Partnership Con8nued Tapped ANA s Organiza%onal Affiliates o Nursing Specialty Organiza%ons as Co- Partners with PfP o AORN, ARN, WOCN, AMSN Streamlined Infec%on Repor%ng to Reduce Burden o Center for Disease Control and Preven%on (CDC) Infec%on Repor%ng Took a leadership role in CAUTI Preven%on 2014 and 2015

9 Success and Challenges Reduc%on of pressure ulcers, falls, CLABSI, and VAP and other HACs CAUTI Presented a Challenge o Rates were Rising (up 6% in CDC, 2015) o Mul%factorial (complex) o Strategies Successful to Reduce CLABSI Less Effec%ve for CAUTI Mul%ple Interprofessional Organiza%ons Laid Groundwork for Improvement

10 Progress on Key HAIs 2013 results CLABSI 2013 goal against baseline 2013 actual progress CAUTI - 50% - 46% - 25% +6% SIS Abdominal Hysterectomy SIS Colon Surgery - 25% - 14% - 25% - 8% MRSA - 30% - 8% C. difficile - 25% - 10% Source: Centers for Disease Control and Prevention

11 ANA Iden8fies Cri8cal Gap ANA and Mul%ple OA Met with Interprofessional Organiza%ons and AHRQ Contractors Working on CAUTI o ID Strategies Already Employed o ID Gaps ANA Iden%fied Gap in Universally- accepted Stream- lined E- B Tool o Diffuse Evidence into Prac%ce Seminal Infec%on Control Research Confirmed this Gap (Stone et al., 2014).

12 ANA Leads Innova8ve Tool Development ANA Convenes Technical Expert Panel (TEP) Common Understanding for CAUTI Preven%on Nursing Sensi%ve Problem Nurse Driven Solu%ons Needed (e.g., nurse driven protocol) Mul%disciplinary Teamwork is Important TEP Develops Streamlined Evidence- based Tool - User Friendly/Effec%ve One Page back/front Clinical Algorithms» Achieve CDC Iden%fied Goals» Cue EB Assessments for Bladder Emptying and Incon%nence Checklist for Inser%on & Key EB Clinical Cues

13 Tool Tes8ng/Revision, Engagement, & Implementa8on 2014 HEN Pilots o Nurse Feedback o TEP Revised Tool Implementa%on First Quarter 2015 o Dissemina%on and Nurse Engagement ANA 2015 Quality Conference Kick Off ANA s Cons%tuent State Nurses Associa%ons (C/SNAs) and OAs Federal Agencies/Other Organiza%ons Dissemina%on/Engagement of Nurses/Other Clinicians o Innova%ve Nurse Driven Strategies for Tool Implementa%on Structural Supports: Nursing Structures of Care, Health Informa%on Technology. CUSP & Culture of Safety Processes

14 CAUTI Preven8on Tool - Algorithm Criteria for Appropriate Indwelling Urinary Catheter (IUC) Use* Acute urinary reten8on (sudden and painful inability to urinate (SUNA, 2008)) or bladder outlet obstruc8on To improve comfort for end- of- life care if needed Cri8cally ill and need for accurate measurements of I&O Selected surgical procedures (GU surgery/colorectal surgery) To assist in healing open sacral/perineal wound in incon%nent pa%ent Need for intraopera8ve monitoring of urinary output during surgery or large volumes of fluid or diure%cs an%cipated Prolonged immobiliza8on (poten%ally unstable thoracic or lumbar spine, mul%ple trauma%c injuries, e.g., pelvic fractures) *CDC (2009) Criteria for Indwelling Urinary Catheter (IUC) Inser%on

15 CAUTI Preven8on Tool - Algorithm Evalua8ng 8mely removal of IUC Yes Does patient meet CDC Criteria? Insert IUC per Tool Checklist (See page 2) Assess daily for meeting CDC Criteria for IUC (Follow nurse-driven removal protocol, if approved by the facility) Prevent CAUTI after IUC Insertion (See CDC IUC Maintenance Bullets, page 2) Assess for/report signs/symptoms of CAUTI (See facility protocol/procedure) Does patient meet CDC (2009) Criteria for IUC? No Remove IUC, assess bladder emptying (See A and B below) Yes Prevent CAUTI (See bottom of page 2)

16 CAUTI Preven8on Tool - Algorithm Assessment of bladder emptying and incon8nence Does patient meet CDC Criteria? Do Not Insert IUC Assess urina%on and bladder emptying No No Has patient urinated? Yes (Inability to control urine flow) (See A and B below) No Yes Develop individualized toile%ng plan with interdisciplinary input (e.g., prompted voiding use of commode, use of gender- specific urinals) to regain con%nence. Prompt patient to urinate and evaluate results (See B below) Assess bladder emptying (See A below) Use gender- appropriate collec%on device (e.g., external catheter, penile pouch/sheath (male) or urinary pouch (female) or absorbent products) to manage incon%nence and maintain skin integrity.

17 Assess for Adequate Bladder Emptying A.If Pa8ent HAS urinated (voided) within 4-6 hours follow these guidelines: If minimum urinated volume 180 ml in 4-6 hours or urinary incon8nence present, confirm bladder emptying. Prompt pa%ent to urinate/check for spontaneous urina%on within 2 hours if post- void residual (PVR) < ml o Recheck PVR within 2 hours.* * Perform bladder scan (CDC, 2009) to determine PVR. If no scanner available, perform straight catheteriza%on.

18 Assess for Adequate Bladder Emptying Con8nued B.If Pa8ent HAS NOT urinated within 4-6 hours and/or complains of bladder fullness, then determine presence of incomplete bladder emptying.* o Prompt pa%ent to urinate. If urina%on volume 180 ml, perform bladder scan.* * Perform bladder scan (CDC, 2009) to determine PVR. If no scanner available, perform straight catheteriza%on.

19 CAUTI Preven8on Tool - IUC Inser8on Checklist Before IUC Inser8on : 1) Determine if IUC is appropriate per the CDC Guidelines (CDC, 2009) (See page 1, Box 1). 2) Select smallest appropriate IUC (14 Fr., 5ml or 10 ml balloon is usually appropriate unless ordered otherwise). 3) Obtain assistance PRN (e.g., 2- person inser%on, mechanical aids) to facilitate appropriate visualiza%on/inser%on. 4) Perform hand hygiene Yes Yes with Reminder Comments

20 CAUTI Preven8on Tool - IUC Inser8on Checklist Pa8ent Prepara8on/Inser8on of IUC: 1) Perform peri- care, then, re- perform hand hygiene. 2) Maintain strict asep%c technique throughout the actual IUC inser%on procedure, re- perform hand hygiene upon comple%on. Use sterile gloves and equipment Do not pre- inflate the balloon to test it 3) Insert IUC to appropriate length and check urine flow before balloon infla%on to prevent urethral trauma. In males, insert fully to the IUC y connec%on, or in females, advance ~1 inch or 2.5 cm beyond point of urine flow. 4) Inflate IUC balloon correctly: Inflate to 10 ml for catheters labeled 5 ml or 10 ml per manufacturer.

21 CAUTI Preven8on Tool - IUC Inser8on Checklist A`er IUC inser8on comple8on: 1) Perform Triple Ac8on for IUC/Drainage System: Secure IUC to prevent urethral irrita%on Posi%on drainage bag below the bladder (but not res%ng on the floor) Check system for closed connec%ons and no obstruc%ons/kinks Yes Yes with Reminder Comments

22 CAUTI Preven%on Tool Maintenance of IUC/Drainage System and Other Pa8ent Care to Prevent CAUTI (CDC 2009) Maintain appropriate catheter securement per facility protocol/ procedure and the drainage bag below the level of the bladder at all %mes (but not on the floor, even when emptying). Empty the drainage bag regularly using a separate, clean collec%ng container for each pa%ent; avoid splashing, and prevent contact of the drainage spout. Maintain unobstructed urine flow by keeping the catheter and tube free from kinking. Maintain a closed drainage system.

23 CAUTI Preven%on Tool Maintenance of IUC/Drainage System and Other Pa8ent Care to Prevent CAUTI (CDC 2009) Con8nued If breaks in the closed system are noted (e.g., disconnec%on, cracked tubing), replace the catheter and collec%ng system following above IUC inser%on checklist. Perform perineal hygiene at a minimum, daily per facility protocol/procedure and PRN. Use %mely fecal containment device when appropriate for fecal incon%nence. Teach nursing assistants and pa%ent/family IUC maintenance.

24 Updated CAUTI Outcomes AHRQ Reported Reduced CAUTI Rates first quarter 2015 (AHRQ, 2015) AHRQ Updated Longitudinal HAC Report 10/2015 Final HAC Rates o Cumula%vely, approximately 1.3 million fewer incidents of harm occurred in 2011, 2012, and 2013 (compared to 2010), with most of the improvement occurring in 2012 and About 40 percent of this reduc%on is from ADEs, about 20 percent is from pressure ulcers, and about 14 percent from catheter- associated urinary tract infec%ons (CAUTIs) p. 7 o PfP Measured HACs per 1,000 Discharges = 8.8

25 Key Points Nurse/Team Driven CAUTI Preven8on Consistent Use of ANA s CAUTI Preven%on Tool Link: hlp://nursingworld.org/ana- CAUTI- Preven%on- Tool E- B Reduc%on of IUC Use and Catheter Days Comprehensive Bladder Emptying and Incon%nence Assessment & Interven%ons E- B Inser%on E- B Timely Removal E- B IUC Maintenance Ensure Key Structural Supports

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