Enhancing Patient Safety by Disrupting the Lifecycle of the Urinary Catheter

Enhancing Patient Safety by Disrupting the Lifecycle of the Urinary Catheter Sanjay Saint, MD, MPH George Dock Professor of Internal Medicine University of Michigan Medical School Ann Arbor VA Medical Center NY State Partnership for Patients September 2013

Patient Safety Movement Has highlighted the importance of systems solutions to preventing adverse events Rather than rely solely on education, utilize components of the system to enhance safety

Outline Infection Prevention Trigger Points Conclusions

Healthcare-Associated Infection (HAI) At least 20% of episodes are preventable; perhaps as much as ~70% (Harbath et al. J Hosp Infect 2003; Pronovost et al. NEJM 2006; Berenholtz et al. ICHE 2011) Medicare no longer reimburses U.S. hospitals for the additional costs of certain infections Preventive practices are variably used Infection prevention is a model for understanding implementation both successes and failures

Catheter-Associated Urinary Tract Infection (CAUTI) UTI is a leading cause of hospitalacquired infections Largely due to urinary catheters ~20% of inpatients are catheterized Leads to increased morbidity and healthcare costs www.catheterout.org

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)

Indwelling Urinary Catheters: A One-Point Restraint? Sanjay Saint, MD, MPH Benjamin A. Lipsky, MD Susan Dorr Goold, MD, MHSA, MA 16 July 2002

Disrupting the Lifecycle of the Urinary Catheter 1. Preventing Unnecessary and Improper Placement 1 4. Preventing Catheter Replacement 4 2 2. Maintaining Awareness & Proper Care of Catheters (Meddings. Clin Infect Dis 2011) 3 3. Prompting Catheter Removal

How Can We Implement Changes to Reduce CAUTI?

Implementation Technical Socio- adaptive

The Most Common Venue for Foley Placement?

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)

Indwelling Urinary Catheters Inserted in the Emergency Department (ED) The ED is a very important factor in efforts to reduce the use of indwelling urinary catheters! The charge nurses [on the floor] say, You know, they keep putting them in down in the ER and they come up to the floor, we don t even have a Foley order...they re just in because the patient was incontinent or confused [in the ER]. (Krein et al. JAMA Intern Med 2013)

Work with ED Leadership on Education and Monitoring Hospitals succeeded in reducing catheter use with support from the head physician & nurse manager in the ED: The Emergency Department was basically looking at it [like] We re very busy, we really don t have time to deal with all this toileting, but when the physician medical director made it a priority, it changed the tone...we did see good improvement there too.

2009 Prevention of CAUTI HICPAC Guidelines (Gould et al, Infect Control Hosp Epidemiol 2010; 31: 319-326) 16

Alternatives to Consider 1) Accurate daily weights 2) Urinal/commode/bedpan 3) Condom catheters 4) Intermittent catheterization with bladder scanning

Avoiding Indwelling Catheter Insertion in the ED 2 studies have intervened in the ED to reduce insertion: 1) Gokula et al. ER staff education and use of a urinary catheter indication sheet improves appropriate use of Foley catheters. Am J Infect Control. 2007: 75% fewer indwelling catheters inserted after the intervention 2) Fakih et al. Effect of establishing guidelines on appropriate urinary catheter placement. Acad Emerg Med. 2010: Physicians ordered 40% fewer insertions after the intervention

But if the patient really, really needs a Foley Ensure proper aseptic technique is used during insertion

Use 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, 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

Proper Maintenance Keep the urinary system closed Make sure flow is unobstructed: No kinking of the catheter Drainage bag should be lower than the bladder Regularly empty the bag

Hospital Outcomes Program of Excellence (HOPE) (http://va-hope.org) Systems redesign grant to Ann Arbor VAMC Behavioral lab for interventions to improve quality of care, and enhance nurse-doctor communication CAUTI prevention one of many initiatives: nurseinitiated reminder

Our Experience: Nursing Template

Nursing Template for Maintenance

Percent of Catheterized Patients Indication for Catheter Placement 35% Patients with Inappropriate Indication for Foley 30% 25% 20% 15% 10% 5% 0% Sept '10 Oct '10 Dec '10 Mar '11 Jun '11 Oct '11 Mar '12 June '12

CAUTI Rate per 10,000 Patient Days Significant Reduction in CAUTIs (Miller B et al. ICHE 2013) Average CAUTI Rate Before and After Implementation of CAUTI Initiative 14.0 13.1 12.0 10.0 8.0 39% decrease in CAUTI Rate; P=.04 8.0 6.0 4.0 2.0 0.0 Pre-Initiative Post-Initiative

A Systems (and Technical) Solution: Timely Removal of Indwelling Catheters 14 studies have evaluated urinary catheter reminders and stop-orders (written, computerized, nurse-initiated) Significant reduction in catheter use (~2.5 days) Significant reduction in infection (~50%) No evidence of harm (ie, re-insertion) (Meddings J et al. Clin Infect Dis 2010)

Regularly Using to Prevent CAUTI: 2005 vs. 2009 U.S. National Data (Krein et al. J Gen Intern Med 2012) 100 90 80 2005 70 60 2009 % 50 40 30 20 10 9% 21% 0 Urinary catheter reminder or stop-order

Implementing Change Across Michigan

Preventing CAUTI: A Statewide Effort Evaluated the effect of the Keystone Center s CAUTI Initiative in Michigan: Bladder Bundle Study Period: 2007 to 2010 163 units in 71 participating Michigan hospitals

Foley Use & CAUTI Rates in Michigan ~25% relative decrease ~30% relative increase (Fakih et al. Arch Intern Med 2012) CAUTI by 6% in non-michigan hospitals (95% CI: 4 to 8% ) CAUTI by 25% in Michigan hospitals (95% CI: 13 to 37% ) (Saint et al. JAMA Intern Med 2013)

Infection Prevention Trigger Points Conclusions Outline

What about the ICU?

NHSN Data: Intensive Care vs. General Wards (Edwards, Am J Infect Control 2009; Dudeck, Am J Infect Control. 2011) Urinary Catheter Use: ICU > General Units Unit 2006-8 Urinary Catheter Utilization Ratio 2009 Urinary Catheter Utilization Ratio ICU (med-surg) 0.79 0.72 General Wards (med-surg) 0.22 0.19 (Slide courtesy of M. Fakih)

Just because a patient is in the ICU does NOT mean that the patient needs a Foley The Key Question is this: Are hourly assessments of urine output required?

Trigger Point: ICU To Floor ICUs have very high urinary catheter use Utilization may be reduced hospital-wide if patients transferred out of the ICU are evaluated for catheter necessity at time of transfer ICU Transfer from ICU (Slide courtesy of M. Fakih) Floor

Trigger Point: OR To Floor Operating Rooms have very high urinary catheter use Utilization may be reduced hospital-wide if patients transferred out of the PACU are evaluated for catheter necessity at time of transfer PACU Transfer from PACU Floor

Outline Infection Prevention Trigger Points Conclusions

Conclusions Foley catheters lead to important infectious and noninfectious complications CAUTI is a common patient safety problem Preventing CAUTI requires both the technical and socio-adaptive aspects of implementation Several practices appear to decrease CAUTI But most importantly

Thank you! www.catheterout.org