Background

1. Utilization of National Surgical Quality Improvement Data and Surgical Care Improvement Protocols to Improve the Rate of Catheter Association Urinary Tract InfectionRobert E. Glasgow, MDDepartment of SurgeryUniversity of UtahSalt Lake City, UT 1

2. Background • Catheter-Associated Urinary Tract Infection (CA-UTI) is a major cause of healthcare associated morbidity in the United States • Over 80% of patients undergoing major operations have periprocedural urinary catheterization • Prolonged urinary catheterization is significantly associated with increased risk of UTI and 30 day operative mortality • CA-UTI costs the healthcare system approximately $758 per infection and over $330 million annually *Anderson DJ. Infect Control Hosp Epidemiol. 2007 Jul;28(7):767-73 Scott RD. “The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention.” Centers for Disease Control and Prevention. March, 2009

3. NSQIP and the University of Utah • ACS NSQIP is a data-driven, risk-adjusted, outcomes-based surgical quality improvement program. • 258 participating hospitals in 2010 • Benefits of participation: • Identifying QI targets • Improving patient care • Decreasing institutional costs • University of Utah joined in 2001

4. Observed Rate: 2.46% Expected Rate: 1.33% O/E Ratio: 1.85 Status: Needs Improvement June 2009 NSQIP Report Urinary Tract Infection Goal

5. June 2009 NSQIP Report Our Hospital O/E Thru June 2009

6. SCIP Core Measure: Catheter Associated-UTI (CA-UTI)

7. Timeline University of Utah High Outlier June 09’

8. Timeline UTI: Performance Excellence Team Created University of Utah High Outlier Aug 09’ June 09’

9. Clinical Staff Education Quality Internal Medicine Anesthesia General Surgery Nursing Urology Performance Excellence Team

10. Timeline Define-Research-Analyze-Improve-Control UTI-Performance Excellence Team Created University of Utah High Outlier Sept 09’ Aug 09’ June 09’

11. Define: The Problem • Strict definition of UTI (NSQIP definition) • Patient had indwelling urinary catheter at diagnosis or within 48 hours before onset of the event • Positive urine culture of 100,000 CFU/ml with no polymicrobia • Identify patient-related variables • Gender, age, type of surgery, history of urinary retention (males) and/or UTIs (females), bacteriuria • Identify healthcare provider-related variables

12. Define: Ask the right questions 1. Are the right patients getting UC? 2. Are UC in place for right duration? 3. Are we inserting UC properly? 4. Are we performing proper peri-care? 4 Key Questions

13. Define: The Goals • Lower the rate of UTI to 1.4% or better and O/E status to non-outlier • SCIP Core Measure compliance • Urinary catheter removed on POD 1 or POD 2 • Greater than 90% compliance in non-excluded patients • Sustained quality improvement

14. Research: The Standard • Define evidence-based practices in patient and urinary catheter management • Management of urinary retention, catheters in setting of regional anesthesia • Study of nursing training and current practice in catheter care

15. Research - Current practice (2009) • Review of 48 general surgery patients who developed UTI <30 days following surgery • Foley catheter left in place >48h in 85% of patients • Average duration of foley catheter placement at 6 days

16. Timeline Action and Results Define - Research - Analyze - Remedy - Implement Strategy Performance Excellence Team Created Oct 09’ University of Utah High Outlier Sept 09’ Aug 09’ June 09’

17. Remedy - “The Bladder Bundle”

18. Remedy - “The Bladder Bundle” • NEED • Use indwelling catheters only when necessary • PLACEMENT • Foley placement only by trained personnel • DURATION • Remove in the O.R. when possible • Document reasoning if use > 24 hours • CARE • Contained-single unit catheter systems now in place • Catheter is well-secured and insertion site is clean at all times • Keep the drainage bag lower than the bladder to prevent backflow

19. Bladder Bundle Prompting Care Givers: Physicians, Nurses, Midlevels • Education and media blitz targeting physicians & nurses: • Mid-level, nursing, physician champions • Visual cue on patient board • EMR: “DC or Justify” • Foley a daily part of patient rounding: RN and MD. • Epidural order sets modified • Data tracked and reported • Foley insertion/removal compliance (NSQIP, SCIP), UTI rates

20. Observed Rate: 1.39% Expected Rate: 1.25% Odds Ratio: 1.10 Status: Non-Outlier December 2010 NSQIP Report Urinary Tract Infection * Includes General and Vascular Surgery Cases

21. June 2009 NSQIP Report Our Hospital O/E Ratio over Time “Bladder Bundle Initiative”

22. Results: SCIP Compliance • SCIP Compliance • Goal: • Urinary catheter removal on POD 1 or POD 2 • Result: • Greater than 90% compliance in General and Vascular Surgery since implementation of “Bladder Bundle” protocol 21 11

23. With reference to healthcare cost? • Annual savings • Reduced our UTI incidence by 86 occurrences per year • Approximate annual cost savings • $65,188 per year

24. Conclusion • NSQIP is a powerful tool for identifying institutional morbidity and setting quality targets to improve healthcare delivery while reducing cost. • An evidence based approach to management of peri-operative urinary tract infections can reduce the incidence of UTIs • Physician led quality improvement projects can result in sustained improvement in patient care and reduced cost