On the CUSP: Stop CAUTI
Implementing CUSP to Eliminate CatheterAssociated Urinary Tract Infections (CAUTI)
Pat Posa RN, BSN, MSA
System Performance Improvement Leader
St. Joseph Mercy Health System
Ann Arbor, MI
patposa@gmail.com
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Overview
• Overview of CAUTI
• Comprehensive Unit-Based Safety Program (CUSP) to
eliminate CAUTI
• 4E’s to CAUTI
– Engage: How does this make the world a better place?
– Educate: How will we accomplish this?
– Execute: What do we need to do?
– Evaluate: How will we know we made a difference?
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CUSP & CAUTI Interventions
CUSP
CAUTI
1. Educate on the science of safety
1.
Care and Removal Intervention
Removal of unnecessary catheters
2. Identify defects
Proper care for appropriate catheters
3. Assign executive to adopt unit
2.
4. Learn from Defects
Placement Intervention
Determination of appropriateness
5. Implement teamwork &
communication tools
Sterile placement of catheter
3
Project Goals
• Reduce CAUTI rates in participating units by 25%
– Appropriate placement
– Appropriate continuance
– Appropriate utilization
• Improve patient safety culture on participating
units
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Healthcare-Associated Infections (HAI’s)
ENGAGE: Why should we do this?
• CAUTI are the most common HAI, accounting for 35% of
all HAI’s
• At least 20% of episodes are preventable; perhaps as
much as 70%
(Harbath et al. J Hosp Infect 2003)
• Preventive practices are variably used
• Medicare no longer reimburses U.S. hospitals for the
additional costs of certain infections
• CAUTI prevention is part of the 2012 National Patient
Safety Goal
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Healthcare Facility HAI Reporting to CMS via NHSN
– Current and Future Requirements
HAI Event
CLABSI
CAUTI
SSI
Facility Type
Acute Care Hospitals
Adult, Peds, and Neonatal ICUs
Acute Care Hospitals
Adult and Pediatric ICUs
Acute Care Hospitals
Colon and abdominal hysterectomy
Reporting Start
Date
January 2011
January 2012
January 2012
CLABSI
Long Term Care Hospitals *
October 2012
CAUTI
Long Term Care Hospitals *
October 2012
CAUTI
Inpatient Rehabilitation Facilities
October 2012
MRSA Bacteremia Lab ID
Acute Care Hospitals – facility wide
January 2013
C. difficile LabID Event
Acute Care Hospitals – facility wide
January 2013
HCW Influenza Vaccination
Acute Care Hospitals
January 2013
* Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN
CMS 2012 IPPS final rule released; August 2011 Federal Register
Urinary Catheter-Related Infection:
Background
• Urinary tract infection (UTI) causes ~ 40% of hospitalacquired infections
• Most infections due to urinary catheters
• Up to 25% of inpatients are catheterized
• Leads to increased morbidity and costs
7
Burden-of-illness
• Of patients who receive urethral catheters:
– Bacteriuria rate is ~5% per day
• Among those with bacteriuria:
– ~10% will develop symptoms of UTI
– Up to 3% will develop bacteremia
• Direct medical costs:
– Symptomatic UTI: ~$600 per episode
– Bacteremia: ~$3000 per episode
(Tambyah et al. ICHE 2002; Saint AJIC 1999)
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Clinical Manifestations of CAUTI
• Clinical manifestations vary greatly
• Asymptomatic bacteriuria  overwhelming sepsis
• Symptomatic UTI:
– Lower abdominal, suprapubic, or flank pain
– Systemic symptoms: nausea, vomiting, fever
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Pathogenesis of CAUTI
• Source: colonic or perineal flora
on 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
Urinary Catheter-Related Infection:
Pathophysiology
Intraluminal
Extraluminal
Bladder infection with inflammation
Detrusor spasm
Shedding of cells
Leakage
Obstruction
(+) UA
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Bacteremia
Fever
Hypotension
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)
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A Model For
Implementation Science
Saint S, et al ICHE 2010
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Core Prevention Strategies:(All Category IB)
Educate: How will we accomplish this?
Catheter Use
• Insert catheters only for appropriate indications
• Leave catheters in place only as long as needed
Insertion
Maintenance
• Ensure that only properly
Hand Hygiene
trained persons insert and
maintain catheters
• Insert catheters using
aseptic technique and
sterile equipment (acute
care setting)
Quality Improvement Programs
• Following aseptic
insertion, maintain
a closed drainage
system
• Maintain
unobstructed urine
flow
http://www.cdc.gov/hicpac/cauti/001_cauti.html
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Prevention of CatheterAssociated UTI
 Make sure the catheter is indicated
• Adhere to general infection control principles (eg,
aseptic insertion, proper maintenance, hand hygiene,
education, feedback)
• Remove the catheter as soon as possible
• Consider other methods of prevention
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Table. 2 Appropriate indications for indwelling urethral catheter
use
Patient has acute urinary retention or obstruction
Need for accurate measurements of urinary output in critically ill patients
Perioperative use for selected surgical procedures:
 Patients undergoing surgery or other surgery on contiguous structures of the GU
tract
 Anticipated prolonged duration of surgery (these should be removed in PACU)
 Patients anticipated to receive large-volume infusions or diuretics during surgery
 Operative patients with urinary incontinence
 Need for intraoperative monitoring of urinary output
To assist in healing of open sacral or perineal wounds in incontinent patients
Patient requires prolonged immobilization (e.g. potentially unstable thoracic or
lumbar spine)
To improve comfort for end of life care if needed
Indwelling catheters should not be used:
 As a substitute for nursing care of the patient or resident with incontinence
 As a means of obtaining urine for culture or other diagnostics when the patient can
voluntarily void
 Prolonged post-operative duration without appropriate indications
 Routinely for patients receiving epidural anaesthesia/analgesia
Why are Catheters Used
Inappropriately?
• Perhaps physicians “forget” that their patient has
a urinary catheter
• We determined the extent to which doctors are
aware which of their inpatients have catheters
• Surveyed 56 medical teams at 4 sites
(Saint S, Wiese J, Amory J, et al. Am J Med 2000)
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One Reason Catheters Are Used
Inappropriately
Level
Proportion Unaware
of the Catheter
Medical students
18%
House officers
25%
Attending
physicians
38%
(Saint S, Wiese J, Amory J, et al. Am J Med 2000)
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Urinary Catheters Often Placed in the
Emergency Department: A National U.S. Study
•
Catheters often inserted without clear indications and
may remain in place for convenience rather than
medical necessity
•
An Infection Control Nurse: “our other barrier is the
Emergency Department and this is where most Foleys
are placed. . . . Doctors forget to look under the sheets
to say, ‘Oh yeah, there’s a Foley there’ and … the nurses
aren’t going to take the initiative. . . ”
(Saint et al. Infect Cont Hosp Epid 2008)
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QUESTION ???
What barriers are you facing—or
anticipate to face related to these
indications?
• In the ICU?
• In the ED?
• With specific patient populations?
– IE: patient’s with epidurals
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Prevention of CatheterAssociated UTI
• Make sure the catheter is indicated
 Adhere to general infection control principles (e.g.,
aseptic insertion, proper maintenance, hand hygiene,
education, feedback)
• Remove the catheter as soon as possible
• Consider other methods of prevention
22
CAUTI Prevention:
HICPAC Recommendations, CA-UTI
II. Proper Techniques for Urinary Catheter Insertion
– Perform hand hygiene immediately before and after insertion or any
manipulation of the catheter device or site . (Cat. IB) [see
also:Ehrenkranz NJ ICHE 1991;12:654-62 - alcohol handrub much
more effective than handwash]
– Ensure that only properly trained persons (e.g., hospital personnel,
family members, or patients themselves) who know the correct
technique of aseptic catheter insertion and maintenance are given this
responsibility. (Cat.IC)
– Properly secure indwelling catheters after insertion to prevent
movement and urethral traction. (Cat.IC)
Use Proper Aseptic Technique for
Catheter Insertion
•
NEJM Videos in Clinical Medicine:
– Male Urethral Catheterization
T. W. Thomsen and G. S. Setnik - 25 May, 2006
– Female Urethral Catheterization
R. Ortega, L. Ng, P. Sekhar, and M. Song - 3 Apr, 2008
•
Goal is to avoid contamination of the sterile catheter
during the insertion process
•
Should not assume that the healthcare workers inserting
urinary catheters know how to do so
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Prevention of CatheterAssociated UTI
• Make sure the catheter is indicated
• Adhere to general infection control principles (eg,
aseptic insertion, proper maintenance, hand hygiene,
education, feedback)
 Remove the catheter as soon as possible
• Consider other methods of prevention
25
Early Removal of Indwelling Catheters:
Summary of the Evidence
• 14 studies have evaluated urinary catheter reminders and
stop-orders (written, computerized, nurse-initiated)
– Significant reduction in catheter use
– Significant reduction in infection
– No evidence of harm (ie, re-insertion)
(Meddings J et al. Clin Infect Dis 2010)
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Weeks 1 - 3
Week 4
Weeks 5 & 6
Weeks 7 - 12
Quarterly
Baseline: Collect urinary catheter
prevalence with evaluation for indications
(15 days).
Prepare for implementation.
Implementation: nursing staff education,
daily assessment of urinary catheters and
evaluation for indications, and discussion
with nursing staff about removal of nonindicated catheters. Rationale given to
obtain order to discontinue unnecessary
urinary catheters with nursing (10 days).
Nurse-Initiated
Removal of
Unnecessary
Urinary
Catheters
Program
After Implementation: urinary catheter
prevalence and indications, one day a
week for 6 weeks (6 days). Patient’s nurse
to daily assess need for catheter.
Sustainability: urinary catheter prevalence
and indications, 1 week quarterly (5
consecutive days) for 5 quarters. Patient’s
nurse to daily assess need for catheter.
Data review
and unit
feedback
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QUESTION ???
How many people have or are
considering a nurse driven protocol for
urinary catheter removal??
If so—what barriers are you
anticipating?
Prevention of CatheterAssociated UTI
• Make sure the catheter is indicated
• Adhere to general infection control principles (eg,
aseptic insertion, proper maintenance, hand hygiene,
education, feedback)
• Remove the catheter as soon as possible
 Consider other methods of prevention
30
Other Methods for Preventing
CAUTI
• Alternatives to the indwelling catheter
–Bladder ultrasound
–Intermittent catheterization
–Condom catheter
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Execute: What do we need to do?
• Nurse driven protocols
• Decision algorithm
• Reminders/flags
• Reviewed daily on rounds
• Daily screening
Pocket Card
Remove that Urinary Catheter!
Remove that Urinary Catheter!
Foley Catheters are indicated for:
Foley catheters can cause:
 Infections
 Length of Stay
 Cost
 Patient Discomfort
 Antibiotic Use
Acute urinary retention or obstruction
Perioperative use in selected surgeries
Assist healing of perineal and sacral wounds in
incontinent patients
Hospice/comfort/ palliative care
Required immobilization for trauma or surgery
Chronic indwelling urinary catheter on admission
Accurate measurement of urinary output in the
critically ill patients (intensive care)
Urinary Catheters confine patients to bed,
Foley Catheters are not indicated for:
making them more immobile and thus
Urine output monitoring OUTSIDE intensive care
increasing their risk for skin breakdown.
Incontinence (place on toileting routine, change
PREVENTION IS KEY.
OBTAIN ORDERS TO
DISCONTINUE UNNECESSARY URINARY
CATHETER!
frequently)
Prolonged postoperative use
Patients transferred from intensive care to general
units
Morbid obesity
Immobility (turn patient q 2 hours, up in chair)
Confusion or dementia
Patient request
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Evaluate: How will we know we made a
difference?
Outcome Measures:
• UTI rate/1000 patient days
• UTIs / 1000 catheter days
Process Measures:
• UC days/ 1000 patient days
• Percent appropriate catheters/total
number of catheters
CUSP & CAUTI Interventions
CUSP
1. Educate on the science of safety
CAUTI
1.
Care and Removal Intervention
Removal of unnecessary catheters
2. Identify defects
Proper care for appropriate catheters
3. Assign executive to adopt unit
4. Learn from Defects
2.
Placement Intervention
Determination of appropriateness
5. Implement teamwork &
communication tools
Sterile placement of catheter
The Michigan Keystone ICU Project
saved over 1,500 lives and $200
million by reducing health care
associated infections.
Office of Health Reform,
Department of Health and Human Services
“Needs Improvement” Statewide
Michigan CUSP ICU Results
• Less than 60% of respondents
reporting good safety climate =
“needs improvement”
• Statewide in 2004 84%
needed improvement, in
2007 23%
• Non-teaching and Faith-based
ICUs improved the most
• Safety Climate item that
drives improvement: “I am
encouraged by my colleagues
to report any patient safety
concerns I may have”
37
% of respondents within an ICU reporting good teamwork climate
100
90
80
Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence:
caregivers feel comfortable speaking up if they
perceive a problem with patient care
70
60
50
40
30
20
10
No BSI = 5 months or more w/ zero
No BSI 21%
No BSI 31%
No BSI 44%
0
Health Services Research, 2006;41(4 Part II):1599.
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Can we change practice through
process improvement alone?
or
Will successful change require
an altering of the value structure
within the unit?
How to Get Successful Results
• Both nurses and physicians should evaluate the
indications for urinary catheter utilization
• Physicians should promptly discontinue catheters
when no longer needed
• Nurses evaluating catheters and finding no indication
should contact the physician to promptly discontinue
the catheter
• Partner with different disciplines (e.g., case
management, nursing, infection prevention) to
successfully achieve your goals
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How to Sustain Your Success
• After implementing the program, identify unit champions to
promote the need to evaluate the appropriateness of urinary
catheter use
• Incorporate the following questions during nursing rounds:
– Does the patient have a urinary catheter?
– What is the reason for use?
• Provide feedback on performance to nurse managers related to
prevalence of utilization
• If no improvement in utilization is seen, evaluate appropriateness of
utilization (indications vs. non-indications)
• The long term goal is for the patient care nurses to own the process
of evaluation of urinary catheter need
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Additional Areas to Address
•
•
•
•
•
Leadership support is crucial
Define barriers to implementation
Obtain physician and nursing buy-in
Provide alternatives to the “Foley” catheter
Look closely at the emergency department
and intensive care units. Both areas utilize a
high number of urinary catheters
• Learn from defects and continue to improve
process
QUESTIONS???
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