Bronson Healthcare Group

2. Bronson Healthcare Group A regional, tertiary not-for-profit health system providing services in southwest Michigan since 1900 Serves a population of one million Employs over 5,000 full- and part-time employees

3. Bronson�s Service Area

4. Bronson Methodist Hospital Flagship of Bronson Healthcare Group 380-bed tertiary hospital 24,000 inpatient discharges annually 80,000 Emergency Department visits annually (2008) 780 Medical Staff in virtually every specialty Teaching hospital Level I Trauma Center Area�s first accredited Chest Pain Center

5. Bronson Methodist Hospital One of four Children�s Hospitals in Michigan, including PICU Level III NICU Leading birthplace and high-risk pregnancy center in southwest Michigan Regional Perinatal Center Joint Commission certified Primary Stroke Center General Medical, Surgical, Cardiac, Ortho Surgical, Neurovascular, and Three Adult Critical Care Units

6. Achievements And, over time, we have recorded a number of impressive achievements in quality and service that demonstrate the many ways in which Bronson is a national leader. Our commitment to excellence has been validated by many outside organizations who have recognized us for clinical excellence, for being a great place to work, for our commitment to the environment � for many reasons. And, over time, we have recorded a number of impressive achievements in quality and service that demonstrate the many ways in which Bronson is a national leader. Our commitment to excellence has been validated by many outside organizations who have recognized us for clinical excellence, for being a great place to work, for our commitment to the environment � for many reasons.

7. Strategic Plan

8. Keystone HAI Bronson Methodist Hospital�s Adult Medical Unit participates in the Keystone HAI Collaborative starting in 2007. Hand Hygiene (HH)-beginning of 2007 CAUTI bundle in July 2007 The Keystone HAI program chose catheter-associated urinary tract infections and hand hygiene as their first two projects for improving patient safety in the non-ICU patient The Keystone initiative employs sets of steps or processes called bundles to implement a set of best practices all in one step Why did we choose HH and CAUTI The Keystone HAI program chose catheter-associated urinary tract infections and hand hygiene as their first two projects for improving patient safety in the non-ICU patient The Keystone initiative employs sets of steps or processes called bundles to implement a set of best practices all in one step Why did we choose HH and CAUTI

9. CAUTI Bundle Team Catheter Utilization Indications Team-nurse manager, unit coordinator, staff RN, COI, Dir. Of inf. Control-PhD epidemiologist, worked with nurse educator on initiatives Utilization-pulled from comp. Doc. System-purchasing not accurate-most coming from ED-would not indication our utilization on the unit level Focus on removing inappropriate caths Indications-Palliative/Hospice care, Neurogenic bladder, Urinary tract obstruction, urologic surgery, sacral decub III or IV, accurate monitoring of I&O on a critically ill patientTeam-nurse manager, unit coordinator, staff RN, COI, Dir. Of inf. Control-PhD epidemiologist, worked with nurse educator on initiatives Utilization-pulled from comp. Doc. System-purchasing not accurate-most coming from ED-would not indication our utilization on the unit level Focus on removing inappropriate caths Indications-Palliative/Hospice care, Neurogenic bladder, Urinary tract obstruction, urologic surgery, sacral decub III or IV, accurate monitoring of I&O on a critically ill patient

10. Catheter-Associated Urinary Tract Infections The most common type of hospital-associated infection More than 40% of all reported Almost all are caused by indwelling urinary catheters Complications Bronson is a member of the National Healthcare Safety Network (NHSN) of the CDC, and we use CDC definitions for catheter utilization and urinary tract infection. What follows are the national NHSN definitions. Complications: Discomfort Prolonged hospital stay Increased cost Increased antibiotic utilization Risk of urosepsis Risk factors: acuity, age, diabetes, female (AMU�s patients!) Bronson is a member of the National Healthcare Safety Network (NHSN) of the CDC, and we use CDC definitions for catheter utilization and urinary tract infection. What follows are the national NHSN definitions. Complications: Discomfort Prolonged hospital stay Increased cost Increased antibiotic utilization Risk of urosepsis Risk factors: acuity, age, diabetes, female (AMU�s patients!)

11. Definition: CAUTI A urinary tract infection that occurs in a patient who had an indwelling urethral urinary catheterin place within the 7-day period before the onset of infection If the UTI develops in a patient within 48 hours of transfer from a location, indicate the unit of origin on the infection report, not the current location of the patient

12. Definition: Indwelling Catheter A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system (Foley catheter) Does not include straight in and out catheters or urinary catheters that are not placed in the urethra (for example, suprapubic, or condom catheters)

13. Definition: Symptomatic UTI Patient has at least one of the following signs or symptoms with no other recognized cause: fever (>38�C), urgency, frequency, dysuria, or suprapubic tenderness And patient has a positive urine culture, that is 105 microorganisms per cc of urine with no more than two species of microorganisms 100,000 Keep in mind that the Elderly may present with atypical symptoms such as confusion, falls, or functional impairment Capezuti, E., Awicker, D., Mexey, M., Fulmer, T., Gray-Miceli, D., Kluger, M. 2008. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: NY: Springer Publishing Co.100,000 Keep in mind that the Elderly may present with atypical symptoms such as confusion, falls, or functional impairment Capezuti, E., Awicker, D., Mexey, M., Fulmer, T., Gray-Miceli, D., Kluger, M. 2008. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: NY: Springer Publishing Co.

14. Definition: Symptomatic UTI Or, if no positive culture, one of the following: Positive dipstick Pyuria Organisms seen on Gram stain At least two urine cultures with repeated isolation of the same uropathogen with =102 colonies/ml =105 colonies/ml of a single uropathogen in a patient being treated for a UTI Physician diagnosis of a UTI Physician institutes therapy for UTI

15. Relationship between catheterization and infection Graph shows how risk of CAUTI increases as catheter days increase 5% for each day. There is a significant increase in UTI�s when a cath is removed greater that 48 hours and a reduction in hosp LOS when it�s removed 24-48 hours Capezuti, E., Awicker, D., Mexey, M., Fulmer, T., Gray-Miceli, D., Kluger, M. 2008. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: NY: Springer Publishing Co.  Graph shows how risk of CAUTI increases as catheter days increase 5% for each day. There is a significant increase in UTI�s when a cath is removed greater that 48 hours and a reduction in hosp LOS when it�s removed 24-48 hours Capezuti, E., Awicker, D., Mexey, M., Fulmer, T., Gray-Miceli, D., Kluger, M. 2008. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: NY: Springer Publishing Co.

16. Reducing the risk of CAUTI Many healthcare settings use indwelling urinary catheters when they are not indicated Since infection is directly related to catheter use, the first way to address infection risk is to reduce unnecessary catheter use Do not insert without appropriate indications Remove the device as soon as it is no longer needed Measure total utilization and appropriate utilization Total utilization is measured as a ratio of catheter days (number of days patients in the unit had a catheter divided by the total number of patient days). Catheter days are typically measured either through the documentation entered by the nurse into the electronic medical record or by a direct count each day. Partial days count as full days, although some electronic systems count once per day, for example at midnight. Note that catheter utilization does not measure appropriate utilization; high utilization may all be appropriate if all patients meet the criteria stated in the policy. Appropriate utilization measures whether a patient with a catheter meets the criteria stated in the policy. Up to 50% of indwelling caths used are inappropriate Capezuti, E., Awicker, D., Mexey, M., Fulmer, T., Gray-Miceli, D., Kluger, M. 2008. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: NY: Springer Publishing Co. Total utilization is measured as a ratio of catheter days (number of days patients in the unit had a catheter divided by the total number of patient days). Catheter days are typically measured either through the documentation entered by the nurse into the electronic medical record or by a direct count each day. Partial days count as full days, although some electronic systems count once per day, for example at midnight. Note that catheter utilization does not measure appropriate utilization; high utilization may all be appropriate if all patients meet the criteria stated in the policy. Appropriate utilization measures whether a patient with a catheter meets the criteria stated in the policy. Up to 50% of indwelling caths used are inappropriate Capezuti, E., Awicker, D., Mexey, M., Fulmer, T., Gray-Miceli, D., Kluger, M. 2008. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: NY: Springer Publishing Co.

17. CAUTI project timeline July 2007 Planning for data collection to begin in September 2007 Policies were reviewed and revised using CDC Guidelines August 2007 Emergency Department Hospitalist physician Executive champion Seven policies regarding catheterization were incorporated into one. Ensured Foley removal protocol had corresponding indications Most physicians seeing patients on AMU are Bronson-employed hospitalists. Some patients are seen by outside primary care physicians. Emergency Department staff partners-key to decreasing utilization Maybe talk about how our EOS as an organization showed opportunity for teamwork, and the organizational focus we have put on that to improve safety? Seven policies regarding catheterization were incorporated into one. Ensured Foley removal protocol had corresponding indications Most physicians seeing patients on AMU are Bronson-employed hospitalists. Some patients are seen by outside primary care physicians. Emergency Department staff partners-key to decreasing utilization Maybe talk about how our EOS as an organization showed opportunity for teamwork, and the organizational focus we have put on that to improve safety?

18. CAUTI project timeline September 2007 Data Collection December 2007 Emergency Department follow up Baseline data collection for 4 wks starting in August, intervention week 5 and 6 (September), and post was week 7-10 (wanted more data) ED performance improvement council representatives educated Hospitalists Champions identified and given informational resource documents September 2007-pre intervention and intervention-staff education in �huddles�, re-introducing Foley removal protocol with rationale Dec 2007-Follow up meeting with ED leadership (manager, director, physician leaders)-Education providedBaseline data collection for 4 wks starting in August, intervention week 5 and 6 (September), and post was week 7-10 (wanted more data) ED performance improvement council representatives educated Hospitalists Champions identified and given informational resource documents September 2007-pre intervention and intervention-staff education in �huddles�, re-introducing Foley removal protocol with rationale Dec 2007-Follow up meeting with ED leadership (manager, director, physician leaders)-Education provided

19. Staff Education Huddles Foley Removal Protocol Continuing Education Yearly skills validation Multidisciplinary Rounds Nursing and Physician For the last several years, the PCAs have had to do a revalidation of foley insertion as part of their yearly low frequency/high risk skills housewide. Each year it is up for discussion and so far the consensus has been it continues to be low frequency/high risk although not necessarily problem prone. After successful completion of unit orientation, PCAs are signed up for foley insertion class. The class covers principles of aseptic technique, gloving technique, pertinent male/female anatomy, procedure for foley insertion male and female. Attendees perform two observed insertions on a mannequin as part of the class. They must then be observed and validated on the unit by an RN for a minimum of four actual catheter insertions. Observations 1 & 2 the RN observer may provide them with cues or suggestions. They must perform two additional insertions perfectly without cues or suggestions to complete the sign offs. During class it is strongly recommended that even after completing their unit sign off that they never perform a catheter insertion without another RN or PCA in the room to provide assistance to the patient with positioning and to act as a "spotter" for sterile technique. RNs receive no training on catheter insertions. It is considered part of their basic RN education. For AMU, the last two years I have validated their ability to don sterile gloves, maintain aseptic technique during a procedure in the yearly LFHR. That has been with trach care. Both RNs and PCAs receive updates either via special emails or as part of the PNMC monthly update email as the procedures are revised. Education of staff RN�s is key, empowerment, assertiveness For the last several years, the PCAs have had to do a revalidation of foley insertion as part of their yearly low frequency/high risk skills housewide. Each year it is up for discussion and so far the consensus has been it continues to be low frequency/high risk although not necessarily problem prone. After successful completion of unit orientation, PCAs are signed up for foley insertion class. The class covers principles of aseptic technique, gloving technique, pertinent male/female anatomy, procedure for foley insertion male and female. Attendees perform two observed insertions on a mannequin as part of the class. They must then be observed and validated on the unit by an RN for a minimum of four actual catheter insertions. Observations 1 & 2 the RN observer may provide them with cues or suggestions. They must perform two additional insertions perfectly without cues or suggestions to complete the sign offs. During class it is strongly recommended that even after completing their unit sign off that they never perform a catheter insertion without another RN or PCA in the room to provide assistance to the patient with positioning and to act as a "spotter" for sterile technique. RNs receive no training on catheter insertions. It is considered part of their basic RN education. For AMU, the last two years I have validated their ability to don sterile gloves, maintain aseptic technique during a procedure in the yearly LFHR. That has been with trach care. Both RNs and PCAs receive updates either via special emails or as part of the PNMC monthly update email as the procedures are revised. Education of staff RN�s is key, empowerment, assertiveness

20. Foley Removal Protocol RN�s can initiate independent of a physician orderRN�s can initiate independent of a physician order

21. Additional Tactics Use of Bladder Scanner Multidisciplinary Rounds Nurse Manager or CNS lead Executive safety rounds Employee Patient Note: Frequency of scan and amt to st cath for. Bladder scan if no void in 6 hours>300cc=st cath � Mills, E. J. (2006) Lippincott Manual of Nursing Practice, Eighth edition Lippincott, St. Louis, MO. A 2005 study from Yale-New Haven Hospital demonstrated that a multidisciplinary approach encouraging timely removal reduced catheter utilization by 81% and CAUTI�s by 73% Capezuti, E., Awicker, D., Mexey, M., Fulmer, T., Gray-Miceli, D., Kluger, M. 2008. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: NY: Springer Publishing Co. Note: Frequency of scan and amt to st cath for. Bladder scan if no void in 6 hours>300cc=st cath � Mills, E. J. (2006) Lippincott Manual of Nursing Practice, Eighth edition Lippincott, St. Louis, MO. A 2005 study from Yale-New Haven Hospital demonstrated that a multidisciplinary approach encouraging timely removal reduced catheter utilization by 81% and CAUTI�s by 73% Capezuti, E., Awicker, D., Mexey, M., Fulmer, T., Gray-Miceli, D., Kluger, M. 2008. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: NY: Springer Publishing Co.

22. Foley Catheter Indicator RatesBronson Healthcare Group, Inc. 1/1/2007-12/31/2008 Other category contains other �non indicators� not listed Other category contains other �non indicators� not listed

23. Foley Catheter Prevalence Bronson Healthcare Group, Inc. 1/1/2007-12/31/2008 Reporting units from 95 pre down to 36 post 3Reporting units from 95 pre down to 36 post 3

24. AMU Foley Days per Patient Day Catheter utilization declined from 0.21 in 2007 to 0.15 in 2008, a 29% reduction.Catheter utilization declined from 0.21 in 2007 to 0.15 in 2008, a 29% reduction.

25. Results Catheter utilization declined as a result of the Keystone HAI initiative AMU catheter utilization in 2008 was 0.15 AMU CAUTI rate was 0.7 NHSN publishes percentile rankings of hospitals in their database for catheter utilization and urinary tract infection incidence. AMU catheter utilization in 2008 was 0.15 CDC hospital mean was 0.23, placing Bronson in the top 25th percentile CDC hospital mean was 3.7, placing Bronson in the top 25th percentile AMU operated 16 months without a CAUTI AMU CAUTI rate was 0.7 (1 infection in 9529 catheter days) Proteus mirabilis and E. coli, so those are two of the most common organisms.� Nothing surprising there. NHSN publishes percentile rankings of hospitals in their database for catheter utilization and urinary tract infection incidence. AMU catheter utilization in 2008 was 0.15 CDC hospital mean was 0.23, placing Bronson in the top 25th percentile CDC hospital mean was 3.7, placing Bronson in the top 25th percentile AMU operated 16 months without a CAUTI AMU CAUTI rate was 0.7 (1 infection in 9529 catheter days) Proteus mirabilis and E. coli, so those are two of the most common organisms.� Nothing surprising there.

26. Uropathogens from AMU patients There were a total of 122 positive urine cultures in AMU patients in 2006 and 89 in 2008. The distribution of pathogens was the essentially same, with E. coli representing the predominant species, although E. coli the distribution of pathogens was diverse, with 15 different microorganisms recovered. The wide diversity of microbial pathogens in the AMU population confirms that cultures should be done on these patients to guide antibiotic therapy. There were a total of 122 positive urine cultures in AMU patients in 2006 and 89 in 2008. The distribution of pathogens was the essentially same, with E. coli representing the predominant species, although E. coli the distribution of pathogens was diverse, with 15 different microorganisms recovered. The wide diversity of microbial pathogens in the AMU population confirms that cultures should be done on these patients to guide antibiotic therapy.

27. Next steps Continue tracking catheter utilization Appropriate versus total utilization Continue work with sending departments (ED, ICU) Document indication with order Begin tracking appropriate (meets established criteria) versus total utilization Improve physician documentation of the reason for the catheter Begin tracking appropriate (meets established criteria) versus total utilization Improve physician documentation of the reason for the catheter

28. Next steps cont�d Utilization rates being distributed to all inpatient areas Incorporate indication for foley into electronic nursing documentation If no indication, initiate foley removal protocol

29. Questions?

30. Thank You