Improving patient outcomes using a collaborative, inter-professional approach

to Catheter Associated Urinary Tract Infection prevention in the ICU.

Jo Ritchie, MSN, RN, CNL

Denise White, BSN, MHA, RN, CCRN, NEA-BC

Highlight the dynamic changes in today’s U.S. healthcare environment as it relates to Catheter Associated Urinary Tract Infection prevention.

Focus on the tenets of infection prevention in the Intensive Care Unit using a collaborative, interprofessional team approach.

• 328 bed; average daily census (ADC) - 200• Not for profit, acute care, community teaching• Serves 272,000 in SW Connecticut• 1 hour 20 min train ride from NYC

http://norwalkhospital.org/about-us/

• 16 bed, mixed Medical/Surgical/Cardiac • ADC = 12 patients

Top Diagnosis Related Grouping (DRG):– Sepsis– Acute Respiratory Failure– Acute Myocardial Infarction– GI bleed– Drug Overdose

• Nursing Leadership Team

• Nursing Staff– Engaged Unit Based Shared Governance – 79% BSN– 14 % MSN – 31% Board Certified

Institute of Medicine (IOM)• To Err is Human (2000)

• Crossing the Quality Chasm (2001)

HITECH act (2009)

• Meaningful Use (2011 – 2016)

•Patient Protection and Affordable Care Act (March 2010)

•Models of Care:– Accountable Care Organizations– Patient Centered Medical Homes

•Payment models:– Bundled Payments– Pay for Performance

In 2008:•Eight preventable HAC

In 2014:•↑ 14 preventable HAC

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

• Urinary Tract Infections (UTI) tied with Pneumonia

• UTIs account for >15% of infections

• Healthcare associated UTI caused by instrumentation

Catheter Associated Urinary Tract Infections (CAUTI)

can be preventedhttp://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

A UTI where an indwelling urinary catheter was in place for more than two calendar days, with

the day of placement considered day one.

Two specific types:•SUTI (Symptomatic UTI)•ABUTI (Asymptomatic Bacteremic UTI)

http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

1. Indwelling urinary catheter in place for more than two calendar days.

2. At least one of the following signs or symptoms: • fever (>38.0°C) • suprapubic tenderness• costovertebral angle pain or tenderness

3. Positive urine culture •no more than two species of organisms

http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

• risk of bacteriuria by 5% for each day of catheterization

• Risk of bacteremia is 1 – 4% of patients with a CAUTI

• hospital stay

• Added complications

• Added cost

• Mortality

CAUTI rates are publicly reported

hospitalcompare.gov

Dudeck et at, 2013

Start of CAUTI prevention team

Dudeck et at, 2013

Start of CAUTI prevention team

Mission, Vision and Values of the Organization– Annual

Five pillars– Care Coordination– Operational Efficiency– Growth and Market Development– Community Health– Workplace of Choice– Quality, Safety and Patient Satisfaction

BackgroundBest practicesPlus/Delta (What works well; Opportunities)Next steps

http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf

•HAIs are reported to National Healthcare Safety Network (NHSN).

•Healthcare Infection Control Practices Advisory committee (HICPAC)

•Qualidigm (CT)

Excellent Resources

Insert only when appropriate Bladder scanAseptic techniqueDaily assessment and documentation of insertion

Trained staffInsertion and maintenance

Hand Hygiene

Closed Systems and Unobstructed flow

Early removal Clinical Decision SupportDocumentation of discontinuationNurse Driven Protocol

Proactive Rounding•“CAUTI Audi”•ICU interdisciplinary goals sheet•Staff engagement•RCA for all CAUTIs

Dashboards•Transparency•External Benchmarks•Change of Shift Hand-offs

Visual Cues• Catheter Use

Education• RN & PA Competency Validation(insertion)

• Technician education (maintenance)• Transport

• Physical Therapy

Equipment ($)•Bladder Scanner•External Urinary Devices with stabilization device•Indwelling Urinary Kits •Intermittent Catheter trays•Mannequins•Skin Care products (Peri-care)

Information TechnologyFoley Indication

Nurse Driven Foley Removal Protocol

Policy•Bladder Scanner Algorithm

(Inpatient and Emergency Dept)•Urine Culture Practice•Nurse Driven Protocol

• Physician Leaders• Nurse leaders• Nursing Shared Governance

• All of us! Why The Foley?

• Core team - Algorithms• Nurse champions• Senior Leadership

Benchmark (Pooled Mean): National Healthcare Safety Network Report, 2012Dudeck et at, 2013

Start of CAUTI prevention team

Benchmark (Pooled Mean): National Healthcare Safety Network Report, 2012Dudeck et at, 2013

Start of CAUTI prevention team

• Engage the frontline• Create a diverse, energetic team• You need a “CAUTI Audi”• Know your stakeholders• Data, Data, Data – Be transparent

Share your success story

Centers for Disease Control and Prevention. (2014). Data and Statistics: HAI Prevalence Survey. Retrieved from http://www.cdc.gov/HAI/surveillance/index.html

Centers for Disease Control and Prevention. (2014). National and State Healthcare Associated Infections Progress Reports. Retrieved from: http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf

Centers for Medicare and Medicaid Services. (2014). Hospital-Acquired Conditions and Present on Admission Indicator Reporting Provision. Retrieved from: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/wPOAFactSheet.pdf

Dudeck, M.A., Weiner, L.M., Allen-Birdson, K., Malpiedi, P.J., Peterson, K.D., Pollock, D.A., Sievert, D.M. and Edwards, J.R. (2013). National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. American Journal of Infection Control, 41 (2013), 1148 – 1166.

Fink, R., Gilmartin, H., Richard, A., Capezuti, E., Boltz, M. and Wald, M. (2012). Indwelling urinary catheter management and catheter associated urinary tract infection prevention practices in nurses improving care for health system elders’ hospitals. American Journal of Infection Control, 1-6.

Gorman, D. (2011). Reducing the incidence of catheter-associated urinary tract infections in the acute care setting using evidence-based guidelines. P. Tenke (Ed.), Urinary Tract Infections (pp. 133-152). Available from: http://www.intechopen.com/books/urinary-tract-infections/reducing-the-incidence-of-catheter-associated-urinary-tract-infections-in-the-acute-care-setting-usi.

Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., Pegues, D.A. and the Healthcare Infection Control Practices Advisory Committee. (2010). Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Infection control and Hospital Epidemiology, 31(4), 319-326.

Hughes, R.G. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. In R.G.Hughes (Ed.), Tools and Strategies for quality Improvement and Patient Safety (pp. 1 – 39). Rockville, Maryland: Agency for Healthcare Research and Quality

Lo, E., Nicolle, L.E., Coffin, S.E., Gould, C., Maragakis, L., Meddings, J., Pegues, D., Pettis, A.M., Saint, Sanjay and Yokoe, D.S. (2014) Strategies to Prevent Catheter – Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology, 35(5), 464-479.

Mikel, G. (2010). Reducing catheter - associated urinary tract infection in the Critical Care Unit. Advanced Critical Care, 21(3), 247-57.

Oman, K.S., Flynn, M.B., Fink, R., Schrader, N., Hulett, t., Keech, T. and Wald, H. (2012). Nurse-directed interventions to reduce catheter - associated urinary tract infections. American Journal of Infection Control, 40, 548-553.