Preventing CAUTI: Engaging Clinicians and Senior Leadership to Implement Change

1. Preventing CAUTI: Engaging Clinicians and Senior Leadership to Implement Change Sanjay Saint, MD, MPH M. Todd Greene, MPH, PhD University of Michigan Medical School Ann Arbor VA Medical Center

2. Learning Objectives • Describe the methods to engage clinicians in CAUTI prevention • Describe methods to engage leadership in CAUTI prevention • Employ the CAUTI cost calculator • Identify future directions for implementing change

3. Healthcare-Associated Infection • At least 20% of episodes are preventable; perhaps up to 70% (Harbath et al. J Hosp Infect 2003; Umscheid et al. ICHE 2011 ) • Preventive practices are variably used • Infections due to devices are especially common and preventable • Implementing change within hospitals and within specific units is often challenging

4. “The hospital is the most complex human organization ever devised…” - Peter Drucker

5. Hand Hygiene Compliance in Healthcare Workers • Systematic review of 96 studies • Overall median compliance of 40% • Lower rates in physicians (32%) than nurses (48%) • Lower rates “before” (21%) patient contact rather than “after” (47%) (Erasmus et al. Infect Control HospEpidemiol March 2010)

6. Given this Gap Between What Should Be Done and What Is Done… • Focus on “implementation science” • “The scientific study of methods to promote the systematic uptake of research findings into routine practice” (Eccles & Mittman. ImplemetationScience. Feb 2006)

7. Implementation TechnicalSocio- adaptive

8. Catheter-Associated Urinary Tract Infection (CAUTI) • UTI is a common cause of hospital-acquired infection • Most due to urinary catheters • Up to 25% of inpatients are catheterized • Leads to increased morbidity and healthcare costs www.catheterout.org

9. The Indwelling Urinary Catheter:A “1-Point” Restraint? 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)

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

11. 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)

12. Regularly Using to Prevent CAUTI: 2005 vs. 2009(Krein et al. J Gen Intern Med. 2012)

13. Implementing Change At HomeAcross the State of Michigan

14. Hospital Outcomes Program of Excellence (HOPE)(http://va-hope.org) • Systems redesign grant to Ann Arbor VAMC • Behavioral lab for interventions to improve quality and efficiency of care • CAUTI prevention one of many initiatives: nurse-initiated reminder • Focus: enhancing nurse-physician communication

15. Nursing Template for Maintenance

16. Patients with Inappropriate Indication for Foley

17. CAUTI Rate (Miller et al. Infect ContHospEpid 2013 – in press) 39% decrease in CAUTI Rate; P=.04

18. Implementing Change At HomeAcross the State of Michigan

19. Reducing Inappropriate Urinary Catheter Use: A Statewide Effort • Evaluate 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 • Nurse-led catheter discontinuation protocol

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

21. Catheter-Associated UTIs(Slide courtesy of Scott Fridkin, CDC) 24 facilities 34 facilities 981 facilities

22. A key ingredient for success is figuring out how to engage the clinicians in the hospital.

23. Learning Objectives • Describe the methods to engage clinicians in CAUTI prevention • Describe methods to engage leadership in CAUTI prevention • Employ the CAUTI cost calculator • Identify future directions for implementing change

24. Start with a Plan • Form a CAUTI prevention team that consists of various key people, with one person identified as the team leader • Develop a CAUTI policy for the institution; the basics should be covered (e.g., condom catheters, bladder scanners) • Pick a unit where to begin, usually where there are the most number of catheters

25. Start with a Plan • Anticipate barriers – nurse resistance, physician resistance, patient/family requests for a catheter • Track performance (both processes and outcomes) and then escalate the intervention as necessary • Once successful, spread to other places (either units or other hospitals)

26. Key Roles and Responsibilities (Modified from www.catheterout.org)

27. Physicians…(Following slides courtesy of Dr. Fakih) • Play a significant role in shaping care in the hospital • Tend to be fairly autonomous; may not be employed by the hospital • Primarily interested in treating illness – typically not trained to focus on improving safety and preventing harm • Likely unaware of safety efforts in the hospital; most have limited time to volunteer for supporting the safety agenda • Change may not be readily embraced

28. How to Engage Physicians?(James Reinertsen, IHI innovation Series White Paper, 2007) • Develop a common purpose (patient safety, efficiency) • View physicians as partners (not barriers) • Identify physician champions early • Standardize evidence-based processes • Provide support from leadership for the efforts of the physician champion

29. Overcoming Resistance: Finding a Member of the Tribe • A chief of staff (and a surgeon): “...surgeons are very tribal so what you need to do if you have something that you think is a best practice at your hospital…you need to get…either the chair of surgery or some reasonable surgeon…If you come in and you’re an internist …into a group of surgeons …the first thing we’re going to do is we’re going to say, ‘Look, you’re not one of us’…the way to get buy-in from surgeons is you got to have a surgeon on your team.” (Saint et al. Joint Comm Journal Qual Safety 2009)

30. The Physician Champion & Physician Supporters

31. CAUTI Physician Champion: Reasons for Them to Support the Champion (or Become One…)

32. CAUTI Physician Champion: Reasons for Them to Support the Champion (or Become One…)

33. How to Engage Nurses? • Develop a common purpose (patient safety) • View nurses as partners (not barriers) • Identify nurse champions early • Standardize evidence-based processes (and make the right thing to do, the easy thing to do) • Provide support from leadership for the efforts of the nurse champion

34. Attention to Urinary Catheters: Workload • Nursing workload can be an issue … • A nurse: “…convenience unfortunately is a high priority …especially with urinary catheters…the workload will be increased if you have to take [patients] to the bathroom or you have to change their bed a little more often ….” (Saint et al. Infect ContHospEpid 2008)

35. Overcoming Barriers • Nurse buy-in is key to success • A physician administrator: “Because the nurses on the geriatrics unit wanted to have their patients regain mobility…they viewed mobility as very important …versus the other units where the nurses didn’t necessarily feel that was a real goal..” • A nurse champion is critically important!

36. Identifying the “Champion” • 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)

37. Learning Objectives • Describe the methods to engage clinicians in CAUTI prevention • Describe methods to engage leadership in CAUTI prevention • Employ the CAUTI cost calculator • Identify future directions for implementing change

38. Leadership Engagement Can Help • The key senior leaders in preventing CAUTI are the CNO and CMO • But other leaders are important… • Unit managers/chiefs, service-line chiefs, hospital epidemiologist, infection preventionist

39. 4 Key Behaviors of Effective Prevention Leaders(Saint et al. Infect Cont Hosp Epid. Sept 2010) • Cultivated a culture of clinical excellence • Developed a clear vision • Successfully conveyed that to staff • Inspired staff • Motivated and energized followers • Some, not all, were charismatic

40. 4 Key Behaviors of Effective Prevention Leaders(Saint et al. Infect Cont HospEpid. Sept 2010) • Solution-oriented • Focused on overcoming barriers rather than complaining • Dealt directly with resistant staff • Thought strategically while acting locally • Planned ahead leaving little to chance; politicked before crucial issues came up for a vote in committees

41. One way to engage the leaders at your hospital is by showing them that you have a good plan.

42. Start with a Plan… • Form a CAUTI prevention team that consists of various key people, with one person identified as the team leader • Develop a CAUTI policy for the institution; the basics should be covered (e.g., condom catheters, bladder scanners) • Pick a unit where to begin, usually where there are the most number of catheters • Anticipate barriers – nurse resistance, physician resistance, patient/family requests for a catheter • Track performance (both processes and outcomes) and then escalate the intervention as necessary • Once successful, spread to other places (either units or other hospitals)

43. Another way to engage the leaders at your hospital is by showing them that you have a good plan B.

45. A third way to engage the leaders at your hospital is by considering sustainability at the outset.

46. Acknowledgements… MohamadFakih, MD, MPH Medical Director, Infection Prevention and Control St. John Hospital and Medical Center Sarah Krein, PhD, RN Research Associate Professor, Division of General Medicine University of Michigan, Ann Arbor

47. What is Sustainability? • Desired health benefits are maintained or improved • The innovation – CAUTI prevention/reducing catheter use or CLABSI prevention – loses its separate identity and becomes part of the regular activities of the unit or hospital (“institutionalization”)

48. Factors that Influence Sustainability • Integration with existing programs/services (“institutionalization”) • Program champions • Periodic evaluation and feedback

49. 1) Institutionalization • The initiative becomes part of the “standard of care” in the hospital (or unit) • Only place the urinary catheter based on appropriate indications • Comply with proper insertion and maintenance • Evaluate daily for need; remove if unnecessary • With time, modifications of the program may occur based on new evidence (e.g., appropriate indications)

50. 1) Institutionalization • Routinization and Integration • Align with the organization’s goals (e.g., promoting safety) • Regular education and competencies • Nursing daily routine • Use of electronic reminders/nursing templates • Identify how this work might be synergistic with other initiatives