Urinary Catheters Do Not Have to Be Removed if They Were Never Placed

Urinary Catheters Do Not Have to Be Removed if They Were Never Placed A formal performance improvement project to decrease utilization of urinary catheters in surgical patients A. D. Yang 1,2,3, M. W. Wandling 1,2,3, N. F. Siparsky 1,3, R. D. Kennedy 1,3, K. J. Nelis 1, W. Wilson 1, C. M. Gonzalez 1,4, K. Schelling 1, C. Perry 1, K. Y. Bilimoria 1,2,3 1 Northwestern Memorial Hospital, Chicago, IL, USA; 2 Northwestern University, Surgical Outcomes And Quality Improvement Center, Chicago, IL, USA; 3 Northwestern University Feinberg School Of Medicine, Department Of Surgery, Chicago, IL, USA; 4 Northwestern Memorial Hospital, Department Of Urology, Chicago, IL, USA Abstract Session Quality Improvement II NSQIP National Convention July 26, 2015 Anthony D. Yang, MD Assistant Professor of Surgery Division of Surgical Oncology / Dept. of Surgery Northwestern Univ. Feinberg School of Medicine

Catheter-Associated Urinary Tract Infection (CAUTI) UTI = #1 Hospital-Acquired Infection (40% of HAI) 75% of UTI associated with indwelling catheters Accounts for > 500,000 nosocomial infections/year > 10,000 deaths annually Leading cause of secondary bloodstream infection Costs $400-500 million annually 2

CAUTI at Northwestern Catheter Associated Urinary Tract Infection (ICU) NMH is seventh among 9in US News honor roll ** NMH is seventh among 9 Chicago comparators ** NMH ranks80 th among 87 UHC academic medical centers* NMH FY15 Quality Metrics FY2014 FY2015YTD Target Variance From Target Central Line Infections (all inpatient units) 81 < 41 0 Catheter Associated Urinary Tract Infections (all inpt units) 86 < 43 0 Long Range Goal 30-Day All-Cause All-Payer Readmissions (source: UHC) 15.1% < 14.4% < 11.3% VTE Prophylaxis (SCIP-1) 91% > 95% 100% Preventable Serious Adverse Events 1 0 0 Note slightly varying comparison group sizes due to missing data * most current data ** 2012-2013 data

Defining the problem Urinary Catheter Utilization in NMH Operating Rooms FY2014 Total Catheters Overall 11390 n Total n % Total Catheters < 3 hours 7587 67% Removed Postop: Case Duration 0-1 hour 953 1777 46% Case Duration 1-2 hour 3074 3388 9% Case Duration 2-3 hour 2249 2422 7%

Sometimes the problem is defined for you

Building a Team Team Leader: A. Yang PI Coach: Chris Perry (Surgeon) (Process Improvement) Team Members: R. Kennedy (Surgical Critical Care Fellow / SICU) D. Liwanag (Manager, Feinberg/Prentice/Olson/259 OR) A. Mikolajczak (Infection Preventionist, NMH Infection Prevention) K. Nelis (Clinical Quality Leader, Surgery) K. Schelling (Infection Preventionist, NMH Infection Prevention) E. Slade-Smith (Manager, Surgical Services) N. Siparsky (Surgical Critical Care Fellow / SICU) S. Thill (Manager, Preop/Postop/Preop Clinic) M. Wandling (Surgical Resident) P. Yeo (Manager, OR & Pre/Post Recovery) Executive Sponsor: K. Bilimoria Clinical Sponsor: Wendy Willson (Surgeon, Vice Chair for Quality) (Director of Nursing, Surgical Services) 6

Charter Decrease Surgical CAUTI at NMH Project Overview Linkage to Strategic Plan: Provide the highest quality, most effective and safest care. Problem Statement: Catheter-associated urinary tract infection (CAUTI) is a major, preventable source of hospital-acquired infection at Northwestern Memorial Hospital. NMH has exhibited consistently poor performance in regard to CAUTI rate, particularly in surgical patients. NMH is currently in the bottom 10-20% of hospitals for CAUTI risk among general surgery patients in the ACS NSQIP database. The rate of CAUTI at NMH is a publicly reported quality measure that is increasingly being used to define the quality of care given at NMH and other hospitals, and also to determine the level of reimbursement from payers. Little attention has been paid to measures to decrease rates of CAUTI in surgical patients outside of nursing-based interventions, particularly in regard to catheters placed in the operating room. In FY14, ~11,000 urinary catheters were placed in surgical patients, 67% of which were in patients undergoing procedures < 3 hours. Goal/Benefit: Decrease the number of urinary catheters placed in the NMH operating rooms by 5%. Decrease the number of catheters left in patients undergoing procedures < 3 hours by 5%, with particular focus on removal of the catheters in the operating room/pacu. Ensure correct sterile technique utilized and documented 95% of the time when inserting catheters in the operating room, and that catheter status is documented as discussed with the attending surgeon 95% of the time. Help to achieve hospital goal of decreasing CAUTI rate at NMH by 50% in 1 year (< 42 CAUTI). Scope: All surgical service lines in the operating rooms at NMH over 6 months. System Capabilities / Deliverables: Align with hospital-wide efforts to decrease CAUTI 50% in 1 year. Resources Required: Support of Surgical Services Leadership (particularly nursing). Materials for training nurses/residents/students correct catheter insertion technique. Data support from NMH EDW. Support from IT for changes to EMR. Key Metrics Milestones Last Update: 3-10-15 Process Metric(s): Metric #1: Adherence to two-person sterile technique for OR catheter placement (Goal: 95% documentation compliance) Metric #2: Adherence to sign out protocol for urinary catheters (Goal: 95% documentation compliance) Outcome Metric(s): Metric #1: # of urinary catheters placed in Feinberg ORs (Goal: decrease utilization by 5%) Metric #2: # of urinary catheters removed in postsurgical patients prior to transfer to ward (Goal: increase removals by 5%) Metric #3: Absolute number of CAUTI at NMH in 1 year (Goal: decrease 50%) Description Problem Statement Completion Approve Project Charter Present Plan to Surgery Oversight & Quality Committee Establish Baseline Identify Key Drivers of Error Approve Improvement Plan Implement Improvements Establish Control Plan Date Oct. 23, 2014 Oct. 2014 Oct. 21, 2014 Oct.-Nov. 2014 Nov. 2014 Nov. 2014 Dec. 2014 Apr. 2014 Executive/Clinical Sponsor: Karl Bilimoria Improvement Leader: Anthony Yang Clinical Sponsor: Wendy Wilson Process Owner(s): Dow Liwanag, Erin Slade-Smith, Steve Thill, Tricia Yeo 7

Define and Measure High-Level Process Map Preop Holding OR Check-In Foley Inserted OR Pre- Incision Timeout OR Attending Debrief PACU Surgeon Preference Cards / Preop Setup

Define and Measure High-Level Process Map Decision for No Catheter Decision to Remove Catheter Preop Holding OR Check-In Foley Inserted OR Pre- Incision Timeout OR Attending Debrief PACU Surgeon Preference Cards / Preop Setup Sterile Technique Goals: 1) Decrease number of catheters placed in OR 2) Increase number of catheters removed prior to transfer to floor 3) Decrease CAUTI

Areas of Intervention High-Level Process Map Decision for No Catheter Decision to Remove Catheter Preop Holding OR Check-In Foley Inserted OR Pre- Incision Timeout OR Attending Debrief PACU All patients to void on-call to OR Surgeon Preference Cards / Preop Setup Develop criteria for catheter insertion in short cases Routinely address catheter necessity = Tracked 2-person team catheter insertion Goals: Routinely address catheter necessity with attending surgeon 1) Decrease number of catheters placed in OR 2) Increase number of catheters removed prior to transfer to floor 3) Change culture regarding catheter necessity 4) Decrease CAUTI

Ensuring Sterile Technique In-service all nurses, residents, students in proper sterile technique with new Foley catheter kits Two-person team insertion to identify breaks in sterile technique

Promoting Decreased Utilization of Urinary Catheters Documentation in surgical EMR 12

Tracking performance Creation of customized EMR report

Catheters Inserted in the OR by Case Duration Number of Catheters Inserted in OR by Month and Time for Cases < 3 hours 500 450 400 350 300 Total = 434 156 Total = 412 161 Total = 465 168 Total = 391 152 Total = 348 127 Total = 427 Total = 409 Total = 387 Total = 382 161 181 145 145 250 200 150 191 175 167 161 150 162 160 171 179 100 50 0 130 87 76 78 71 66 82 67 87 Oct Nov Dec Jan Feb Mar Apr May Jun 0-59 minutes 60-119 minutes 120-180 minutes Baseline Average Utilization: 437 // Unadjusted Average Post-Intervention: 391 (-11%)

Catheters Inserted in the OR in Short Cases -Adjusted 20 # Catheters per Day in Cases < 3 Hrs 19 18 Baseline Mean: 14.2 Post-Intervention Mean: 12.9 # Catheters per day 17 16 15 14 13 14.0 13.7 15.0 12.6 12.4 13.2 12.9 12.4 14.2 12 11 10 Oct Nov Dec Jan Feb Mar Apr May Jun Goal: Decrease utilization by 5% // Actual = 9.1% Decrease

Overall Utilization of Catheters in Shorter Cases % of Cases < 3 hrs with Catheter 40 35 % Cases < 3 hrs with Catheter Baseline: 23.7% Post-Intervention Mean: 20.9% 30 25 23.7 21.5 21.5 21.2 19.8 19.7 20 15 10 5 22.1 0 Dec Jan Feb Mar Apr May Jun Goal: Decrease utilization by 5% // Actual = 11.8% Decrease

Catheters Removed Postoperatively % of Catheters Discontinued Postop in Cases < 3 hours 70 60 Baseline: 18.3% Post-Intervention Mean: 21% 50 40 30 20 16.4 16.7 21.7 19.7 25.6 20.3 16.8 19.9 23.7 10 0 Oct Nov Dec Jan Feb Mar Apr May Jun Goal: Decrease utilization by 5% // Actual = 14.8% Increase

Discussed at Signout 100 % of Cases in Which Catheter Status Was Discussed with Attending Surgeon at Signout 95 90 85 80 75 70 65 60 Dec Jan Feb Mar Apr May

Other Parameters Monitored % of Catheters Discontinued Postop in OR Monthly by Case Duration 100 90 80 70 60 50 40 30 20 30.6 21.7 17.3 33.3 17.4 15.1 36.6 27.3 17.3 30.3 25.6 22.8 22.4 22.8 22.9 22.3 21.7 14.4 14.4 14.5 15.3 10 0 Dec Jan Feb Mar Apr May Jun % Discontinued < 1 hr % Discontinued 1-2 hr % Discontinued 2-3 hr 100 95 90 85 80 75 70 65 60 % 2-Person Insertion Jan Feb Mar Apr May Jun

CAUTI in Patients with Catheters Inserted in the OR Baseline Mean: 2.75 CAUTI/Month 14 12 Post-Intervention Mean: 0.3 CAUTI/Month 10 # CAUTI 8 2 7 8 4 OUT OF 6 MONTHS = ZERO CAUTI 6 2 4 2 0 5 5 2 1 2 2 2 2 2 1 1 5 1 1 1 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Catheter Inserted in OR Catheter In-Place Preop No Surgery Goal: Decrease CAUTI by 5% // Actual = 89% Decrease for Catheters Inserted in OR 2 2 1 2

Conclusions Our multidisciplinary team was able to identify a novel area of intervention to decrease CAUTI at our institution Process improvement methodology (DMAIC) was vital in facilitating a data-driven, rigorous, impactful, approach to QI Improved adherence to best practice process measures can lead to improvements in outcomes Culture change is as valuable as improving outcomes in leading to durable changes in practice patterns 21

Future Steps Continue feedback of performance data Service line and individual surgeon utilization feedback Develop consensus criteria for catheter insertion for short cases based on CDC indications for catheter insertion Culture change at NMH = ongoing 22

Last Update: 1-7-15 Analyze and Improve Root Cause Solution Solution Lead Process Metric Culture of choosing to maintain urinary catheters in surgical patients postoperatively over removal leads to preventable CAUTIs. 1 Address necessity of catheter insertion in all patients undergoing surgery at check-in procedure in the OR. Goals: 1) Decrease catheter utilization, 2) focus on changing culture of catheter usage among residents. 2 Circulating nurse asks attending surgeon directly if catheter can be removed immediately postoperatively. Goals: 1) Remove as many catheters as possible in the immediate postoperative period, prior to transfer to the surgical ward, 2) focus on changing culture of catheter usage among attending surgeons. 3 Have all patients undergoing short (<2-3 hour) procedures void in preoperative holding area prior to transfer to OR. Goal: Remove barriers to decreased catheter utilization in OR Yang Yang Thill Not formally tracked (observation) Documentation in SurgiNet Documentation in surgical record. 4 Develop consensus criteria for catheter insertion in short cases. Address in surgeon procedure preference cards. Breaks in sterile technique in catheters inserted in the OR leads to preventable CAUTI. 5 Formal training for all personnel (nurses, residents, students) placing catheters in patients in the OR using new, user-friendly catheter kits being utilized hospital-wide. 6 Two person team technique for insertion. Yang, Willson. Yang, Willson Not formally tracked; will need to be addressed in control plan Documentation in SurgiNet Implementation Timeline Nov 2 5 1 3 5 4 Dec 6 Jan Feb Mar Apr May Planned Completed On Hold 24