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Utilization of National Surgical Quality Improvement Data and Surgical Care

Improvement Protocols to Improve the Rate of Catheter Association Urinary

Tract Infection

Robert E. Glasgow, MD

Department of SurgeryUniversity of UtahSalt Lake City, UT

Background• Catheter-Associated Urinary Tract Infection (CA-UTI) is a

major cause of healthcare associated morbidity in the United States

• Over 80% of patients undergoing major operations have periprocedural urinary catheterization

• Prolonged urinary catheterization is significantly associated with increased risk of UTI and 30 day operative mortality

• CA-UTI costs the healthcare system approximately $758 per infection and over $330 million annually

*Anderson DJ. Infect Control Hosp Epidemiol. 2007 Jul;28(7):767-73Scott RD. “The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention.” Centers for Disease Control and Prevention. March, 2009

NSQIP and the University of Utah• ACS NSQIP is a data-driven, risk-adjusted, outcomes-based

surgical quality improvement program.

– 258 participating hospitals in 2010

• Benefits of participation:

– Identifying QI targets

– Improving patient care

– Decreasing institutional costs

• University of Utah joined in 2001

June 2009 NSQIP Report Urinary Tract Infection

Goal

Observed Rate: 2.46%

Expected Rate: 1.33%

O/E Ratio: 1.85

Status: Needs Improvement

June 2009 NSQIP Report

Our Hospital O/E Thru June 2009

SCIP Core Measure: Catheter Associated-UTI (CA-UTI)

SCIP Core MeasuresSCIP ComplianceNovember 2009

Urinary catheter removed on POD 1 or POD 2 49.2%

N = 61

Timeline

June 09’

University of UtahHigh Outlier

June 09’

University of UtahHigh Outlier

Aug 09’

UTI: Performance Excellence Team

Created

Timeline

Performance Performance Excellence Excellence

TeamTeam Clinical Clinical Staff Staff

EducatioEducationn

QualityQuality

Internal Internal MedicineMedicine

AnesthesAnesthesiaia

UrologyUrology

NursingNursing

General General SurgerySurgery

June 09’

University of UtahHigh Outlier

Aug 09’

UTI-Performance Excellence Team

Created

Sept 09’

Define-Research-Analyze-Improve-Control

Timeline

Define: The Problem• Strict definition of UTI (NSQIP definition)

–Patient had indwelling urinary catheter at diagnosis or within 48 hours before onset of the event

–Positive urine culture of 100,000 CFU/ml with no polymicrobia

• Identify patient-related variables

–Gender, age, type of surgery, history of urinary retention (males) and/or UTIs (females), bacteriuria

• Identify healthcare provider-related variables

Define: Ask the right questions

4 Key Questions

1. Are the right patients getting UC?

2. Are UC in place for right duration?

3. Are we inserting UC properly?

4. Are we performing proper peri-care?

Define: The Goals• Lower the rate of UTI to 1.4% or better and O/E

status to non-outlier

• SCIP Core Measure compliance

–Urinary catheter removed on POD 1 or POD 2

–Greater than 90% compliance in non-excluded patients

• Sustained quality improvement

Research: The Standard

• Define evidence-based practices in patient and urinary catheter management

–Management of urinary retention, catheters in setting of regional anesthesia

• Study of nursing training and current practice in catheter care

Review of 48 general surgery patients who

developed UTI <30 days following surgery

•Foley catheter left in place >48h in 85% of

patients

•Average duration of foley catheter placement at

6 days

Research - Current practice (2009)

Timeline

June 09’

University of UtahHigh Outlier

Aug 09’

Performance Excellence Team

Created

Sept 09’

Define - Research - Analyze - Remedy - Implement Strategy

Oct 09’

Action and Results

Remedy - “The Bladder Bundle”

Remedy - “The Bladder Bundle”NEED– Use indwelling catheters only when necessary

PLACEMENT– Foley placement only by trained personnel

DURATION– Remove in the O.R. when possible

– Document reasoning if use > 24 hours

CARE

– Contained-single unit catheter systems now in place

– Catheter is well-secured and insertion site is clean at all times

– Keep the drainage bag lower than the bladder to prevent backflow

Bladder BundlePrompting Care Givers: Physicians, Nurses, Midlevels

• Education and media blitz targeting physicians & nurses:

• Mid-level, nursing, physician champions

• Visual cue on patient board

• EMR: “DC or Justify”

• Foley a daily part of patient rounding: RN and MD.

• Epidural order sets modified

• Data tracked and reported

– Foley insertion/removal compliance (NSQIP, SCIP), UTI rates

* Includes General and Vascular Surgery Cases

Observed Rate: 1.39%

Expected Rate: 1.25%

Odds Ratio: 1.10

Status: Non-Outlier

December 2010 NSQIP Report Urinary Tract Infection

June 2009 NSQIP Report Our Hospital O/E Ratio over Time

“Bladder Bundle Initiative”

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Results: SCIP Compliance

• SCIP Compliance

– Goal: • Urinary catheter removal on POD 1 or POD 2

– Result:

• Greater than 90% compliance in General and Vascular Surgery since implementation of “Bladder Bundle” protocol

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With reference to healthcare cost?

• Annual savings

–Reduced our UTI incidence by 86 occurrences per year

–Approximate annual cost savings–$65,188 per year

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Conclusion

• NSQIP is a powerful tool for identifying institutional morbidity and setting quality targets to improve healthcare delivery while reducing cost.

• An evidence based approach to management of peri-operative urinary tract infections can reduce the incidence of UTIs

• Physician led quality improvement projects can result in sustained improvement in patient care and reduced cost