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On the CUSP: Stop CAUTI

On the CUSP: Stop CAUTI. Content Call #5 : Prevention of CAUTI: The View from the Bedside Cohort 2 May 3, 2011: 1 ET/12 CT/11 MT/10 PT Russ Olmsted, MPH, CIC Director, Infection Prevention & Control Services Saint Joseph Mercy Health System, Ann Arbor, MI. CAUTI Content Call Schedule.

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On the CUSP: Stop CAUTI

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  1. On the CUSP: Stop CAUTI Content Call #5 : Prevention of CAUTI: The View from the Bedside Cohort 2 May 3, 2011: 1 ET/12 CT/11 MT/10 PT Russ Olmsted, MPH, CIC Director, Infection Prevention & Control Services Saint Joseph Mercy Health System, Ann Arbor, MI

  2. CAUTI Content Call Schedule

  3. Overview of Today’s Call • Overview of External Factors Impacting Prevention of CAUTI • How are we doing with CAUTI Prevention Intervention? A National Survey • From the Bedside: One Infection Preventionist’s Experience with CAUTI Prevention Collaborative

  4. Project Goals • Reduce CAUTI rates in participating units by 25% • Appropriate placement • Appropriate continuance • Appropriate utilization • Improve patient safety culture on participating units

  5. Pathogenesis of CA-UTI Source: colonic or perineal flora or hands of personnel Microbes enter the bladder via extraluminal {around the external surface} (proportion = 2/3) or intraluminal {inside the catheter} (1/3) Daily risk of bacteriuria with catheterization is 3% to 10%; by day 30 = 100% Maki DG EID 2001

  6. Facts & Figures on CAUTI According to Rodney…”these just don’t get any respect!” Increased morbidity, mortality (attributable mortality = 2.3%), hospital cost, and length of stay 15% - 25% of hospitalized patients may receive short-term indwelling urinary catheters 17% to 69% of CAUTI may be preventable with recommended infection prevention measures Up to 380,000 infections and 9000 deaths related to CAUTI per year could be prevented Gould CV, et al. Guideline for prevention of CAUTIs, 2009

  7. Snapshot of Relative Distribution of Health Care-Associated Infections (HAIs) in U.S. hospitals, 2002 263,810 274,098 -967 -21 -28,725 244,385 TOTAL HRN WBN Non-newborn ICU = SSI 133,368 Other BSI 22% 11% SSI 20% UTI PNEU 36% 11% 424,060 129,519 HRN = high risk newbornsWBN -= well-baby nurseriesICU = intensive care unitSSI = surgical site infectionsBSI – bloodstream infectionsUTI = urinary infectionsPNEU = pneumonia Klevens, et al. Pub Health Rep 2007;122:160-6 7

  8. Action Plan to Prevent HAIs, June 2009 http://www.hhs.gov/ophs/initiatives/hai/draft-hai-plan-01062009.pdf Tier 1: See Targets/Metrics Tier 2: Ambulatory Surgery Clinics, Dialysis Centers, Influenza vaccine for Healthcare Personnel American Recovery and Reinvestment Act (ARRA), 2009. Public Law 111-5

  9. Health & Human Services HAI Prevention Plan 5 yr. Targets; Progress Report, 09/23-24/10

  10. National Patient Safety Goals (NPSG), Hospital, 2010 NPSG.07.01.01: Hand Hygiene NPSG.07.03.01: Prevent HAIs caused by multidrug-resistant organisms (MDROs) NPSG.07.04.01: CLABSI prevention NPSG.07.05.01: SSI prevention =============================== New Goals for 2011; CAUTI & VAP – in press

  11. Proposed NPSG.07.07.01: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI) Insertion: Limiting use and duration to situations necessary for patient care Use aseptic techniques Maintenance: Secure Maintain closed system Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes Field Review Comments Were Due: January 27, 2011 Final version and elements are in press

  12. UTIs Also Represent Significant Reservoir of MDROs 12

  13. New Respect for UTIs? Emerging Reservoir of MDROs* • New Delhi metallo-beta-lactamase (NDM-1): • Transmissible genetic element Enterobacteriaceae [Klebsiella, E. coli, etc.] • Inactivates beta lactam antibiotics [penicillin, cephalosporins, carbapenem • First identified in 2008 in India – now found in US, Canada, Israel, Turkey, China, Australia, France, Japan, Kenya, Singapore, Taiwan, Sweden, & the UK • Epidemiology of Cases in the U.S.: • 3 different patients residing in 3 different states in the U.S.; prior history of Health care in India • All were causing urinary tract infection N Engl J Med 2010 December 16, 2010 * Multidrug-resistant organisms

  14. CAUTI PreventionAHRQ Report (2001); APIC (2008); SHEA/IDSA (2008); CDC/HICPAC (2009) Appropriate urinary catheter use Insert only for appropriate reasons Remove when no longer needed (reminders/stop orders) Avoid catheter use Portable bladder ultrasound Consider use of alternatives Condom catheters, intermittent catheterization

  15. CAUTI Prevention (cont.) Use of proper insertion technique Aseptic technique in acute care settings Proper urinary catheter maintenance If the CAUTI rate is not decreasing after implementing other prevention strategies, consider using antimicrobial catheters

  16. Which method of hand hygiene is best for personnel caring for urinary catheters? Poor Better Best Alcohol-based handrub Antimicrobial soap Plain Soap Catheter bacterial contamination study: hand hygiene followed by contact with urinary catheter; findings: Soap + water failed to prevent transfer to cath. in 11/12 (92%) instances Alcohol-based handrub: 2/12 (17%) (p < 0.001) Source: Ehrenkranz NJ ICHE 1991;12:654-62

  17. Ann Arbor VA Health Services Research & Development (HSRD) & U of M Patient Safety Enhancement Program [PSEP] Mixed Methods Research Project: Drs. Sarah Krein & Sanjay Saint – Principal Investigators Practice Survey Qualitative Interviews Site Visits Collaboration with MI Keystone Center for Patient Safety & Quality Survey Distributed March 2009: Note of thanks to Infection Preventionists who completed survey and have participated in interviews & ongoing site visits Results in press 17

  18. Methods • National survey of infection preventionists • Stratified random sample of U.S. hospitals • Non-federal general medical/surgical hospitals with 50 or more hospital beds and intensive care unit beds • Randomly selected 300 with 50-250 beds and 300 with > 250 beds • Oversample of hospitals in Michigan • Initial survey in March 2005 and repeated in March 2009 • Response rate of ~ 70% (national) / ~ 80% (MI) 18

  19. Hospital Characteristics *Weighted estimates 19

  20. Report almost always or always using to prevent CAUTI National Sample 20

  21. Efficacy of Enhancing Catheter Awareness; Meddings J, et al. Clin Infect Dis 2010;51:550-60 Rate of CAUTI can be reduced by half with use of catheter reminder or stop order. Process vs. Outcome 21

  22. CAUTI Prevention Initiative: A Simple Approach Physician Reminder System Implemented, 473 bed community, teaching hospital Appropriate use of urinary catheters at 3 months (57% vs 73%; p=0.007) and 6 months (57% vs 86%; P <0.001). Significant reduction in rate of CA-UTI after 3 months (7.02 vs 2.08; P <0.001) and 6 months (7.02 vs 2.72; p <0.001) Bruminhent J, et al. Am J Infect Control 2010;38:689-93. 22

  23. Report almost always or always using to prevent CAUTI 23

  24. System for monitoringduration and/or discontinuation of urinary catheters 100 % 0 2009 MI 2005 Nation 2009 Nation 2005 MI 24

  25. Managing Expectations: Catheter-Associated Urinary Tract Infection and the Medicare Rule Changes [Saint S, et al. Ann Intern Med 2009;877-84] Recommendations for Providers: Develop or adopt existing protocols that emphasize appropriate use, care and maintenance of urethral catheters Develop systems that promote removal of catheters once no longer needed Clinician education: use, interpretation, and response to urinalysis & urine cultures Avoid use of urinalysis or culture to detect “present on admission” (POA) 25

  26. Use of infection prevention practices 2009: Minding the Gap CLABSI VAP CAUTI 26

  27. Nurse-Led Multidisciplinary Rounds on Reducing Unnecessary Catheter Utilization Proportion of urinary catheters indicated = 54.8% Nurse-led intervention was associated with discontinuation of 45% of those catheters that did not meet Indications. Fakih M, et al. Infect Control Hosp Epidemiol 2008;29:815-9 27

  28. Focus on Processes of Care Acknowledgement: Images courtesy of St. Alphonsus Regional Medical Center, Boise, IA 28

  29. Process vs Outcome Metrics Related to CAUTI Prevention Progressive Care & Observation Units, 60 beds Urinary catheter use decreased by 42% and the incidence of CAUTIs decreased by 57%. 29

  30. At the Bedside: CAUTI Prevention Collaborative, St. Joseph Mercy Hospital, Ann Arbor 30

  31. CAUTI Prevention Team Members Katy Hoffman, Nurse Manager, 3 East – Chair & Chief Executive Champion Alvira Galbraith, Nurse Manager, Older Adult Unit Pilot Units [3E, 9E] Staff: RNs, MDs, Pt Care Assistants Pam Ceo, Nurse Practitioner - Urology Pam Willoughby, Education Coordinator, 3 East Linda Bloom, Manager, SJM-Saline Comm. Hosp, Med-Surg Gail Siedlaczak & Russ Olmsted, Infection Prevention & Control Lakshmi Halasyamani, MD – VP, Quality, Patient Safety & Systems Improvement 31

  32. At the Bedside - Baseline data, SJMH One Day Point Prevalence Study: All inpatient units, 4/20/2009 Total Patients: 340 Total With Indwelling Urinary Catheters (IUC) = 101 Prevalence = 29.7% Keystone Bladder Bundle: Two Pilot Units 76.2% of IUC’s had a physician order 67.9% met HICPAC indications 32

  33. CAUTI Prevention At the Bedside, SJMH Ensure the catheter is indicated. Revision of Hospital Policy Improve consistency of Provider orders Education: CDC indications and non-indications for Indwelling Urinary Catheters Poster Presentations Online education module for personnel Patient/Family Handouts Collaboration with the Emergency Dept. to decrease insertion of unnecessary IUC’s Consider alternatives to IUC’s (condom catheters, scheduled toileting, etc.) 33

  34. CAUTI Prevention At the Bedside, (cont) Insert and Maintain IUC using proper technique Adherence with Revised IUC Policy Utilization of Stat-lock or other securing devices (Dale elastic leg strap, tape) Location of tubing and dependent drainage bag Improve documentation of Insertion, including date/time 34

  35. Supporting Improvement through the Electronic Health Record Urinary Cath. alert to RN (with task and order) 35

  36. CAUTI Prevention At the Bedside, SJMH,cont. 3. Remove catheters when no longer appropriate Daily screening tool Nurse driven process for discontinuation Portable Bladder Ultrasound Scanning 36

  37. Results of Bladder Bundle: Before & After EHR Implementation,SJMH-AA, 2009 New EHR System 37

  38. Summary CAUTI Data, SJMH % 38

  39. Distribution for Indication for Urinary Catheterization, SJMH-AA, November 2009, Med-Surg Unit A 10% 5% 40% 45% 39

  40. Distribution for Indication for Urinary Catheterization, SJMH-AA, February 2010, Med-Surg Unit A 18% 55% 12% 15% 40

  41. Surveillance for CAUTI, NHSN Urinary tract infections (UTI) are defined: Symptomatic urinary tract infection (SUTI) or Asymptomatic Bacteremic UTI (ABUTI) CAUTIs = catheter-associated (i.e. patient had an indwelling urinary catheter at the time of or within 48 hours before onset of the UTI) NOTE: There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf 41

  42. Surveillance for CAUTI, NHSNApplication CAUTI: Day 1: Patient admitted through the ED where a urinary catheter is inserted and admitted to Unit A. Day 3 of hospitalization: Catheter remains in place Fever (>38°C), Urine culture = ≥105 colony-forming units (CFU)/ml of E. coli Meets NHSN criteria for symptomatic urinary tract infection (SUTI) + has catheter Not CAUTI: Day 1: Patient has an indwelling urinary catheter in place on an inpatient unit B. Day 2: Catheter is discontinued Day 6: fever (>38°C), urgency, & frequency Urine culture = ≥105 CFU/ml Proteus mirabilis Patient has a SUTI BUT is not a CAUTI because the time since discontinuation of the catheter is > 48 hours 42

  43. CAUTI Surveillance Flow Chart 43

  44. CAUTI Surveillance Flow Chart 44

  45. ABUTI Flow Chart 45

  46. Calculation of CAUTI Rate Numerator: # CAUTIs for May 2011, Unit A Denominator: Tot. number of catheter days for Unit A in May 2011 RATE: The CAUTI rate per 1000 urinary catheter days is calculated by dividing the number of CAUTIs by the number of catheter days and multiplying the result by 1000 Example: 1 CAUTI, Unit A, 05/11______ 250 urin.cath.days,Unit A, 05/11 X 1,000 = 4.0 46

  47. NHSN Summary Data Report Edwards JR, et al. Am J Infect Control 2009;37:783-805. 47

  48. Perspectives on Role of the Infection Preventionist on CAUTI Prevention Teams • Nurse, and ideally, Physician Champion(s) in the Clinical Care Area Are Critical Element of Success • We were fortunate to have engagement of clinical leadership of our CAUTI Prevention Team • Infection Preventionist – key stakeholder and subject matter expertise, but not necessarily Team Leader or Unit-based Champion. • [Note: this was the model from Keystone ICU involving prevention of VAP & CLABSI] • A member of Infection Prevention & Control Services at SJMH does collect ongoing, periodic, unit-based data on processes of care involving IUCs. • Ongoing monitoring to sustain gains is important; aka keeping your eye on the ball [Meaningful Use of Surveillance]

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

  50. A Model For Implementation Science Saint S, et al ICHE 2010 50

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