ON THE CUSP: STOP CAUTI Cohort 8 - Getting Started April 25, 2014 2-3:30 pm ET

1. ON THE CUSP: STOP CAUTI Cohort 8 - Getting StartedApril 25, 20142-3:30 pm ET

2. Agenda • Why Work on CUSP/CAUTI • On the CUSP/Stop CAUTI Overview • Cohort 8 • CUSP • CAUTI Prevention • Data Reporting • Getting Started- Next Steps • Resources • FHA CAUTI Cohort 8 Work Plan - Monthly Key Activities • Calls, Webinars, Website, etc.

3. Introductions • Introduce yourself (name, hospital, unit) • Describe your unit (e.g. specialty, size, etc.) • Why do you want to participate • What do you hope to gain from participation • Boca Raton Regional Medical Center • CVICU, MICU, SICU • Tampa General Hospital • 2D 1 & 2 • University of Miami Hospital • Penthouse North

4. ON THE CUSP: STOP CAUTIWHY PARTICIPATE • Healthcare Associated Infections • Affect 2 Million hospitalized patients each year in the U.S. • 32% develop UTIs each year • 15% develop pneumonia • 14% develop bloodstream infections • Annual cost of catheter-associated UTI (CAUTI) is $450 Million • Up to 380,000 infections and 9000 deaths related to CAUTI per year could be prevented

5. ON THE CUSP: STOP CAUTIWHY PARTICIPATE • Opportunity to implement a proven, effective culture change model • Hospitals can use the CUSP framework for other process improvement projects • Opportunity to network and learn from other hospitals • Access to expert faculty • Data collection and monitoring support • Many free resources to support improvement efforts • www.onthecuspstophai.org • www.catheterout.org

6. ON THE CUSP: STOP CAUTIGOALS & EXPECTED OUTCOMES • GOALS: • Reduce mean CAUTI rates in participating clinical units by 25 percent, and • Improve safety culture by disseminating CUSP methodology as evidenced by improved teamwork and communication • EXPECTED OUTCOMES • Increased awareness of appropriate urinary catheter (UC) use • Reduced use of indwelling UCs • Empower staff to discontinue UC when appropriate • Reduced patient discomfort • Reduced incidence of bacteriuria • Reduced rates of symptomatic UTIs • Shortened LOS and decreased cost per stay • Share lessons with others • Specialized support is available for emergency departments

7. ON THE CUSP: STOP CAUTIProgram Overview • Program Requirements: • Work with your hospital team to reduce CAUTI using the evidence based practice • Collect & Submit Data as scheduled • Outcome data: CAUTI rates • Process Data: Catheter Prevalence • Implement the CUSP Program Using the CUSP tools: • Unit Readiness tool • Staff Safety Assessment • Hospital Safety Culture Survey (HSOPS) • Learning from Defects • Team Check Up Tool • Improve CAUTI rates in your hospital • Develop & implement a Sustainability Plan

8. ON THE CUSP: STOP CAUTIREQUIREMENTS • Program Requirements: • Hospital inpatient units need to participate in the program for 18 months • Learn and implement CUSP and CAUTI prevention interventions • Meet regularly as a team to review data and monitor performance improvement • Have at least one or more team members participate in national content and monthly coaching calls • Share lessons with others • Collaboration is one of the keys to rapid improvement

9. ON THE CUSP: STOP CAUTI RESOURCES

10. CUSP CUSP is an intervention to reduce mistakes and improve teamwork and communication CUSP is a good approach to use whenever there is a gap between evidence based practice and current practice on your unit.

11. Why Is CUSP Important? Culture has been linked to clinical and operational outcomes in healthcare*: • Wrong site surgeries • Decubitus ulcers • Bloodstream infections • Post-op infections • RN Turnover • VAP *data provided by Bryan Sexton

12. Pre CUSP Work • Create an CUSP CAUTI team • Nurse, physician, administrator, infection control, others • Assign a team leader • Measure culture in your clinical unit (HSOPS or other valid process ~discuss with hospital association leader) • Work with hospital quality leader to have a senior executive assigned to your unit based team

13. Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture • Educate staff on science of safety • Staff Safety Assessment ~Identify defects • Assign executive to adopt unit • Learn from one defect per quarter • Implement teamwork tools Timmel J, et al. Jt Comm J Qual Patient Saf 2010;36:252-260.

14. Science of Safety • Understand the system determines performance • Use strategies to improve system performance • Standardize • Create independent checks for key process • Learn from mistakes • Apply strategies to both technical work and team work • Recognize teams make wise decisions with diverse and independent input

15. Identify Defects • Ask staff how will the next patient be harmed (Does not need to be related to CUSP/CAUTI) • Ask how they think that harm could be mitigated

16. Prioritize Defects • List all defects • Discuss with staff what are the three greatest risks • Work with executive and CUSP CAUTI team to eliminate risks and learn from mistakes

17. Executive Partnership • Executives should become a member of the CUSP CAUTI team • Executives should meet monthly with the CUSP CAUTI team • Executives should review defects, ensure the CUSP CAUTI team has resources to reduce risks, and hold team accountable for improving risks and catheter associated urinary tract infections

18. Learning from Mistakes • What happened? • Why did it happen (system lenses)? • What could you do to reduce risk? • How do you know risk was reduced? • Create policy / process / procedure • Ensure staff know policy • Evaluate if policy is used correctly Pronovost 2005 JCJQI

19. To Evaluate Whether Risks were Reduced • Did you create a policy or procedure? • Do staff know about the policy? • Are staff using it as intended? • Do staff believe risks have been reduced?

20. Teamwork Tools • Daily Goals Checklist • Morning briefing • Shadowing • Culture debriefing • TeamSTEPPS

21. Shadowing • Follow another type of clinician doing their job for between 2 to 4 hours • Have that person discuss with staff what they will do differently now that they walked in another person’s shoes

22. CUSP Lessons Learned • Culture is local • Implement in a few units, adapt and spread • Include frontline staff on improvement team • Not linear process • Iterative cycles • Takes time to improve culture • Couple with clinical focus (eg CUSP CAUTI) • No success improving culture alone • CUSP alone viewed as ‘soft’ • Lubricant for clinical change

23. CUSP is a Continuous Journey • Add science of safety education to orientation • Learn from one defect per month, share or post lessons (answers to the 4 questions) with others • Implement teamwork tools that best meet your teams needs • Details are in the CUSP CAUTI manual

25. CUSP & CAUTI Interventions CUSP CAUTI • Care and Removal Intervention • Removal of unnecessary catheters • Proper care for appropriate catheters • 2. Placement Intervention • Determination of appropriateness • Sterile placement of catheter 1. Educate on the science of safety 2. Staff Safety Assessment ~Identify defects 3. Executive adopts the unit 4. Learn from Defects 5. Implement teamwork & communication tools

26. Core Prevention Strategies Catheter Use • Insert catheters only for appropriate indications • Leave catheters in place only as long as needed Insertion Maintenance • Ensure that only properly trained persons insert and maintain catheters • Insert catheters using aseptic technique and sterile equipment (acute care setting) • Maintain a closed drainage system • Maintain unobstructed urine flow Hand Hygiene Quality Improvement Programs http://www.cdc.gov/hicpac/cauti/001_cauti.html

27. CAUTI Prevention #1: Make Sure the Patient Really Needs the Catheter Appropriate indications • Bladder outlet obstruction • Incontinence and sacral wound • Urine output monitored • Patient’s request (end-of-life) • During or just after surgery (Wong and Hooton - CDC 1983) Jain. Arch Int Med 95

28. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf

29. Indications2009 Prevention of CAUTI HICPAC Guidelines(Gould et al, Infect Control Hosp Epidemiol 2010; 31: 319-326)

30. Appropriate Indications forCatheter Use Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

31. Inappropriate Indications for Indwelling Urinary Catheter Use Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

32. Other Reasons and Risk of Urinary Catheters Perceived Short term benefits • Real cumulative risks: • LOS • Cost • Mortality • Other Reasons • Urine output monitoring outside the ICU • Incontinence without skin breakdown/decubitus • Prolonged post-operative use beyond 24 hours • Transfer from ICU to floor • Morbid obesity or immobility • Confusion or dementia • Patient request • Other Risks • Secondary bacteremia, sepsis, metastatic infection • “One-point restraint” = decreased mobility • DVT/PE, pressure ulcers • Fall risk by tripping over catheter • Deconditioning • Patient discomfort, need to retrain bladder 32

33. CAUTI Prevention #2: Proper Placement and Use of Aseptic Insertion Technique • Use smallest catheter size effective for patient (14 or 16F) • Ensure that only properly trained persons insert catheters • Insert using aseptic technique • Goal is to avoid contamination of the sterile catheter during the insertion process

34. CAUTI Prevention #3: Maintenance • Maintain a closed drainage system • Maintain unobstructed urine flow • Free of kinks • Collecting bag below the bladder • Empty the bag regularly • Use routine hygiene, i.e., do not clean the periurethral area with antiseptics

35. CAUTI Prevention #3: Maintenance

36. CAUTI Prevention #4: Consider Other Methods for Preventing CAUTI • Alternatives to the indwelling catheter • Bladder ultrasound • Intermittent catheterization • Condom catheter • Antimicrobial urinary catheters (?)

37. Program Goals • Reduce placement of unnecessary indwelling urinary catheters • Increase prompt removal of indwelling urinary catheters that are no longer needed • Ensure the use of proper insertion technique for indwelling urinary catheters that are appropriately indicated Decrease the risk of hospital-acquired catheter-associated urinary tract infections

38. How Do We Achieve These Goals? • Engagement • Education about the appropriate use and insertion of urinary catheters • Execution and Evaluation • Monitoring and Feedback (aka Data collection)

39. Consistently Using Evidence-Based Practices Remains a Challenge…

40. Prevailing Themes 1) Prioritization 2) Champions 3) Tailoring 4) Workload and Workflow 5) Leadership (Saint et al. Infect Cont Hosp Epid 2008)

41. Catheter-associated urinary-tract infection is a low priority “I would say there’s a general perception in the field that urinary tract infections don’t cause a lot of morbidity and mortality compared to the quote, sexy topic such as blood stream infection or surgical site infection or VAP.”(Saint et al. Infect Cont Hosp Epid 2008) From an Infection Preventionist: The main urologist “who everybody knows and loves thinks the whole Bladder Bundle is just stupid. There is no one who is passionate about getting Foley catheters out of our patients.”

42. But . . .timely removal of catheters considered important by some A physician administrator from a large private hospital explained, “the nurses on the geriatrics unit wanted to have their patients regain mobility or maintain their mobility at all costs and having a catheter . . . was one other reason why they never had to get out of bed . . .the catheters are always removed on the geriatrics unit but it’s a fight on the other units to have those catheters taken out because there’s always an excuse. Like, ‘well, they’re really big or it’s hard for them to get out of bed or it’s a two person assist’...”

43. Identifying a committed “champion” can facilitate prevention activities successful champions tend to be intrinsically motivated and enthusiastic about the practices they promote “I have a certain stature in this hospital…People know that I’m very passionate about patient care so…I get positive reinforcement from them…they’re happy to see me…because …they know that I’m thinking about what’s best for the patient…” (Damschroder et al., Qual and Safety in Healthcare 2009)

44. The Importance of Tailoring • May need to tailor (i.e. modify or adapt) your approach to CAUTI given your specific context and circumstances • We saw different solutions at different hospitals; different solutions within different units at the same hospital • Examples: • Educating nurses about urinary catheters • Who assesses for catheter appropriateness • Focus on insertion or timely removal or both?

45. Attention to Urinary Catheters: Workflow and Workload • The intervention(s) should become part of the workflow: both removal (floor) and insertion (ED) • For insertion, ED is paramount • Foleys put in for specimen collection and left in • ED nurses may think they’re doing floor nurses a favor • Nursing workload was a big issue - since Foleys can be easier for the nurses, this may be a disincentive to remove

46. The Importance of Leadership • Leadership at various levels appears to be important, especially at the nurse manager level • Project leader to help ‘manage’ the process can be very useful • Physician leadership • Behind-the-scenes (getting buy-in from medical executive committees and other physicians) • Front-line (eg, hospitalists, hospital epidemiologists)

47. Teamwork: Key Roles and Responsibilities

48. Conclusions Many reasons to prevent CAUTI Implementing change is not easy Preventing CAUTI requires understanding both the “technical” components and the “socio-adaptive” aspects Preventing CAUTI is a Team Sport The ultimate objective is to ensure we provide the safest and most effective care for patients

49. Data Reporting Understand Why Data is Crucial to the Project Understand the Project’s Data Elements: ---What Data Do We Collect? ---When Is It Due? ---What Infrastructure Do Teams Need to Accomplish This?

50. Why is Data Crucial to the Project? Project’s data elements will help you: Track adoption of technical work and CUSP interventions Measure progress of CAUTI reduction Identify barriers to teams’ progress Keep you on course to achieve BOTH project goals