Kimberlee J Souhrada MM, BSN, CLNC Clinical Specialist, Rochester Medical Corporation One Rochester Medical Drive Stewartville, MN 55976 [email protected]

Kimberlee J Souhrada MM, BSN, CLNC Clinical Specialist, Rochester Medical Corporation One Rochester Medical Drive Stewartville, MN 55976 [email protected] Office: 800-615-2364 x609; 507-533-9609 Mobile: 651.319.2714

At her weekly book club meeting, Donna is again embarrassed by the inability to control her bladder.

Author affiliation: Rochester Medical Corporation Memberships: APIC, SUNA, NLN, AACN, AORN, NACLNC This program has been approved by the American Association of Critical-Care Nurses (AACN) for 1.0 CERPs, Synergy CERP Category B, File Number 00017795

1. Identify and describe the risks and complications associated with CAUTI 2. Review and assess the complexity of Consumer Awareness and Healthcare Reform as they relate to CAUTI 3. Review NHSN hospital reporting system as it pertains to symptomatic UTIs 4. Assess TJC and the 2012 National Patient Safety Goal 5. Analyze the common goals and objectives of agency guides for CAUTI reduction initiatives

Catheter Fever

To relieve painful retention of urine since time immemorial Ancient materials from 3000 BC!!! Straw Rolled up palm leaves Dried leaves of allium, gold, silver, copper, brass and lead 11 th Century Development of malleable catheters with bored holes 19 th and early 20 th Century Coude catheter Self-catheterization for urinary retention - Catheter Fever 1930s - The Foley Dr. Frederic E.B.Foley; St. Cloud, MN Catheter To let or send down

Indwelling Urinary Catheters (IUC) are inserted in >5 million patients per year One out of four hospitalized patients will have an IUC 40 50% do not have a valid indication for use In a recent study >50% of physicians did not know which patients were catheterized or for how long ~ 40% of all HAI most common site of Hospital Acquired Infection (HAI) UTIs account for more than 8 million doctor visits per year 8% prevalence in the home care setting Leading cause of secondary bloodstream infection Most are asymptomatic 900,000 patients with nosocomial bacteriuria in US hospitals each year

Discomfort Daily Risk for UTI from an IUC 3%-7% Prolong hospital stay Secondary bacteremia/sepsis Acute pyelonephritis Increased use of antimicrobial drug therapy Urethral stricture Increased mortality 5% of all deaths from HAI are associated with urinary catheters MDRO Infection Increased cost Adds $500 to $3800 to hospitalization cost/ $400M to >$1B annually The CMS no longer reimburses hospitals for the costs associated with the development of HAIs CAUTI

PRIMARYSECONDARY Female Age >50 Diabetes Urethral colonization Debilitated health Incomplete bladder emptying Fecal incontinence Dehydration Sickle-cell anemia Immobility Concurrent infections History of UTI Colonization with MDROs Poor personal hygiene

Lack of hand hygiene prior to catheter manipulation Drainage spigot contamination No catheter securement Catheters in place too long Poor insertion technique Breaks in the closed system or non-use of a closed system Drainage bag raised above the level of the bladder Lack of use of methods to control incontinence No sample port on closed system

Historical Timeline of Key Events

Pioneered the principle of accountability for the results of medical practice Campaigned to improve health standards with measurable outcomes supported by undeniable data It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.

1985 First reporting of hospital data to a state agency Maryland Quality Indicator Project (surgical morbidity) 1991 NYS inadvertent publication of cardiac surgeons mortality rates Note - with public awareness came a drop in mortality from 4.2% to 1.6% in ~ 10 years Additional states and new conditions have been added to state reporting as legislation continues to change

Consumer Awareness is born! Consumer Awareness is born! Plaintiffs turned Protesters

To Err is Human (1999) 98,000 deaths annually (3 full jumbo jets/qod) Medical error total cost is estimated at $17 - $29B It is not acceptable for patients to be harmed by the health care system The IOM recommended Four Tiered Strategy for Improvement 1. Establish a national focus 2. Identify and learn from errors through nationwide public reporting 3. Raise performance standards and expectations 4. Implement safety systems in HealthCare Organizations

Centers for Medicare & Medicaid Services (CMS)

Hello, incontinence helpline can you hold?

Family Tree 18 US Dept of Health & Human Services (HHS) And 21 more! Centers for Medicare & Medicaid Services (CMS) Agency for Healthcare Research & Quality (AHRQ) Centers for Outcomes & Evidence Center for Quality Improvement and Patient Safety Food & Drug Administration (FDA) Centers for Disease Control & Prevention (CDC) Office of Infectious Diseases Natl Ctr for Emerging & Zoonotic Infectious Diseases National Health Safety Network (NHSN)HICPAC National Institute for Occupational Safety & Health National Institutes of Health (NIH)

CMS has transformed from a passive payer of services into an active purchaser of higher quality, affordable care. Now rewards providers by linking the payment to the quality and efficiency of care provided *The CMS main goal: to foster joint clinical and financial accountability in the healthcare system. *The CMS main goal: to foster joint clinical and financial accountability in the healthcare system.

Inpatient and Home Healthcare: Pay-for-Reporting Reduction of payment for hospitals and Home Health Agencies not submitting data regarding specified quality measures Medicare Home Health Compare and Hospital Compare Medicare Home Health Compare and Hospital Compare www.medicare.gov www.medicare.gov Resource link More measures continue to be added

Improve clinical quality, patient safety and efficiency of care Reduce adverse events Encourage patient-centered care Avoid unnecessary costs Stimulate investment in systems to improve quality and efficiency Make performance results transparent and understandable for consumer empowerment

National Health Safety Network (NHSN)

State reporting to CDC initially was voluntary, and not standardized 2005 - NHSN Reporting System was launched Standard in HAI surveillance Open enrollment to all types of healthcare facilities in the US 2008 CMS disallows payment for certain Hospital Acquired Conditions (HAC) such as: CAUTI Staph Aureaus bloodstream infections Serious bedsores, objects left in pt, blood incompatibility, and air embolism Surgical Site Infections (SSI)

Patient Safety Component *Reporting will be publically accessible through www.hospitalcompare.hhs.gov Patient Safety Component Device Associated Model - DA Central Line Associated BSI - CLABSI Ventilator Associated Pneumonia - VAP Catheter Associated UTI - CAUTI Dialysis Incident - DI Procedure Associated Model - PA Surgical Site Infection - SSI Post-procedure Pneumonia - PPP Medication Associated Model - MA Antibiotic Use and Resistance - AUR

The NHSN uses the information reported to produce comprehensive rates used for hospital comparison. It is very important that the data is collected using exactly the same definitions each time. It is very important that the data is collected using exactly the same definitions each time.

CAUTI: CAUTI: UTI that occurs in a patient who had an indwelling urethral catheter in place within 48 hours prior to specimen collection. Transfer Rule: Transfer Rule: If the UTI develops in a patient within 48 hours of discharge from a location, the discharging location is indicated NHSN definitions: NHSN definitions: Reportable CAUTI http://www.cdc.gov/nhsn/index.html Six specific definitions Four are associated with the patient that had an indwelling urinary catheter at the time of specimen collection, removed within 48 hours prior to specimen collection, and the patient who did not have an IUC Two definitions for patients < 1 year of age

The new 2012 National Patient Safety Goal (NPSG)

Founded in 1951 it is the oldest and largest standards- setting and accrediting body in healthcare Evaluates and accredits >19,000 health care organizations and programs in the US Governed by a Board of Commissioners Accreditation Earned by an entire health care organization Certification Earned by programs or services based within or associated with an accredited health care organization i.e. diabetes, heart disease, cancer, and more

2002 Established to help organizations address specific areas of patient safety concerns Patient Safety Advisory Group determines the highest priority safety issues and how to address them Elements of Performance 2004 - Aligned with the CDC and endorsed by CMS to standardize common measures www.qualitycheck.org Public website www.qualitycheck.org

Approval of one new NPSG NPSG.07.06.01 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI) Evidence-based guidelines 2008 SHEA Compendium of Strategies 2009 HICPAC/CDC Guideline Phase-in period TJC Survey will ensure planning and preparation for full implementation in 2013 This goal is not applicable to This goal is not applicable to pediatric populations pediatric populations

Prevention Interventions and Control Practices

APIC Association for Professionals in Infection Control and Epidemiology 2008 Guide to the Elimination of CAUTIs SHEA Society for Healthcare Epidemiology of America 2008 Strategies to Prevent HAI in Acute Care Hospitals CDC/HICPAC Healthcare Infection Control Practices Advisory Committee 2009 Guideline for the Prevention of Catheter-associated Urinary Tract Infections IDSA Infectious Diseases Society of America 2009 Strategies to Reduce the Risk of CAUTI IHI Institute for Healthcare Improvement 2011 How-to Guide: Prevent Catheter-associated Urinary Tract Infections

1. Identify the Problem of CAUTI Prevalence and Burden 2. Risk Assessment Baseline data to determine patients at highest risk 3. Surveillance Monitoring and data collection 4. Strategies to Prevent CAUTI Policies, procedures, education, and feedback 5. Implementation of Best Practices ABC Bundle, protocols, and techniques

1. Basic Infection Prevention and Antimicrobial Stewardship Programs, Policies and Protocols Systems and Strategies 2. Prevalence of Urinary Tract Infections Risk factors Bacteriuria 3. Urinary Catheter Use in Healthcare settings 4. Complications of IUCs 5. UTI Pathogens Endogenous pathogens Contaminated equipment Environmental Long-term IUC 6. Pathogenesis Extraluminal Intraluminal Biofilms 7. Diagnosis of CAUTI Specimen collection

1. Existing organizational program What systems are in place? 2. Population at risk Point prevalence survey 3. Baseline outcome data Examine CAUTI utilizing pathology reports Assess location, frequency and prevalence Use NHSN definitions 4. Financial impact 5. Multidisciplinary Team

Surveillance for CAUTI is a dynamic and essential way to turn data into useful information to drive interventions! Elements of Surveillance 1. Assessment of the population 2. Identification of those at greatest risk 3. Determination of observation time period 4. Choice of surveillance methodology 5. Monitoring for outcomes 6. Collection of data 7. Analysis of data 8. Display and distribution of findings

Clear and Consistent Document UTIs, assess risk factors, and monitor procedures and practices Device utilization ratio (NHSN) Numerator number of events Denominator number or event-related catheter days or patient days Monthly assessment Incidence new cases in a given time period Prevalence number of cases at a particular point in time divided by the total population being studied

Plan: Monthly rate of CAUTI in MICU for one year Criteria: NHSN criteria for CAUTI Data collection: Active surveillance of MICU patients Numerator: Number of new CAUTI per month Denominator: number of IUC days in MICU Calculation of Incidence rate: CAUTI RATE = Number of new CAUTI X 1000 Number of catheter days 2 UTI/702 catheter days =.002847 X 1000 = 2.8 per 1000 IUC days

*As of 02/2012 - Zero CAUTI

A. Appropriate Infrastructure 1. Written guidelines for UC use, insertion and maintenance 2. Only trained, dedicated personnel insert UCs 3. Necessary supplies for aseptic technique 4. Documentation system 5. Resources to support surveillance B. Surveillance 1. Risk assessment and identification of patient units 2. Standardized criteria 3. Appropriate and valid C. Education and Training * Adherence to a sterile, continually closed system has been the cornerstone of CAUTI prevention

D.Appropriate Technique for IUC Insertion Indications for insertion Alternatives Hand hygiene Aseptic technique and sterile equipment/kit Smallest size catheter E.Appropriate Management of IUCs Proper securement Sterile closed system Appropriate sample collection Unobstructed urine flow Empty the bag regularly Keep the bag below the level of the bladder Routine perineal hygiene after insertion F.Accountability Executive level support Management Direct healthcare providers

1. Remove Unnecessary IUCs Assess the need for an IUC daily Physician reminder systems EMR, written, daily rounds reminder 2. Automatic stop orders Requires renewal of the order for continuation 3. Nurse-driven protocols May be part of an algorithm Independent of a physician order 4. Surgical patients SCIP 9 Core Measure Indicator 5. Bladder scanners 6. Anti-microbial coated catheters * Postoperative Urinary Catheter removed on POD 1 or POD 2

A A septic insertion and proper maintenance B B ladder ultrasound may avoid IUC C C ondom or intermittent catheterization in appropriate patients D D o not use IUC unless necessary E E arly removal of catheters using reminders or stop orders Create your own acronym for a Bundle that would work in your organization

Culture of Patient Safety Information and education Foundation for surveillance Involvement can make a difference Assemble a Team Oversee the process Be the driving force Partner with nursing, case management, infection prevention, and physicians Implement Teamwork and Communication Use tools for improvement Identify opportunities and barriers If you only have a hammer, you tend to see every problem as a nail. -- A. Maslow

Identify and Learn for Defects What happened and why What can be done to reduce risk Engage Senior Executive Bridge the gap Help remove barriers Implement improvement efforts Everyone is accountable for efforts to reduce risks to patients

No of CAUTI/Patient Days*1000No of CAUTI/Month 43.3% Reduction

Catheter bundle implemented with a decrease in CAUTI > 83% in 5 years St. Joseph Regional Medical Center, Lewiston, ID In one month # of CAUTI dropped from 8 to 2 As of 1/30/12 no UTIs for 403 days Intervention provided a 98.87% decrease in UTI over 4 years Tacoma General, Mary Bridge Childrens, Allenmore and Good Samaritan Hospitals, Tacoma, WA

Bringing about cultural change is difficult but achievable CAUTI rates can be reduced by a multidisciplinary approach Review evidence-based resources Implement recommended practices Ensure that evidence-based practices are adhered to and embraced by all members of the team Continuous education and feedback will bring success Evaluate and re-evaluate your own facility Do NOT give up the fight to Aim for Zero on CAUTI reduction!!

Finally, the other catheter is getting the attention it deserves!

1. APIC 2008 Guide to the elimination of Catheter-associated Urinary Tract Infections 2. A Brief History of Report Cards by John Steen 3. Centers for Medicare and Medicaid Services, Roadmap for Implementing Value Driven Healthcare in the traditional Medicare Fee-for-Service Program www.cms.hhs.gov 4. The CMS. www.cms.hhs.gov ww.extendingthecure.org 5. Healthcare Associated Infections: States and Public Reporting. ww.extendingthecure.org 6. Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of Catheter-associated Urinary Tract Infections 2009. 7. Infection control and Hospital Epidemiology. SHEA Position Paper 2008. Strategies to Prevent Catheter-associated Urinary Tract Infections in Acute Care Hospitals 8. Infectious Disease Society of America 2009 International Clinical Practice Guidelines. Diagnosis, Prevention, and Treatment of Catheter-associated Urinary Tract Infection in Adults 9. Institute of Medicine. To Err is Human Series: Building a Safer Health System & toDelay is Deadly. 10. Jeffers, T.W., The GOAL: Elimination of Catheter Associated Urinary Tract Infections. Online webinar slide retrieval. August 2011 www.jointcommission.org. 11. The Joint Commission. www.jointcommission.org. 2012 Hospital National Patient Safety Goals 12. Mourad,M., Auerbach,A., Improving Use of the Other Catheter. Archive of Internal Medicine. Vol 172 (no. 3) Feb. 13,2012. Whitehouse.gov/Recovery 13. The Recovery Act. Whitehouse.gov/Recovery 14. Responsible Reform for the Middle Class. The Patient Protection and Affordable Care Act www.cdc.gov/nhsn 15. The Center for Disease Control and Prevention. www.cdc.gov/nhsn

Documents

Kimberlee J Souhrada MM, BSN, CLNC Clinical Specialist, Rochester Medical Corporation One Rochester Medical Drive Stewartville, MN 55976 [email protected]