AHRQ Safety Program for Long-term Care: HAIs/CAUTI
Evidence-Based Practices to
Prevent HAIs/CAUTI and
Improve Resident Safety
Objectives
Upon completion of this module, participants will be able to:
• Describe the goals and benefits of the national long-term
care (LTC) collaborative to reduce HAIs/CAUTI and improve
safety culture;
• Review the evidence-based practices in HAI/CAUTI
prevention; and
• Highlight the role of the prescriber in promoting evidencebased practices in HAI/CAUTI prevention.
2
Annual Impact of HAIs in LTC Setting
1.6-3.8 million HAIs1
150,000-300,000
hospital admissions
Up to 70% of residents
receive an antibiotic4
7-10% of all LTC residents
have a urinary catheter6
• Leading cause of mortality, morbidity, resulting in 388,000
deaths
• 26-50% due to infections
• $673 million-$2 billion for hospitalizations2
• UTI’s most commonly treated infection (32%)3
• Up to 75% of antibiotics prescribed incorrectly4
• $38-137 million on antimicrobial therapy2
• 88% placed in LTC or non-acute care settings5
• 99% of catheterized residents have asymptomatic bacteriuria
within 30 days7
3
LTC Project Goals
Primary Goals—reduce HAIs/CAUTI and improve safety culture
• Develop/adapt evidence-based CAUTI elimination and safety practices
and resources for LTCFs
• Reduce CAUTIs and HAIs
• Improve safety culture
Secondary Goals—support expanded infection prevention
efforts for C. diff, UTI, MDROs, etc. by providing education to:
• Improve hygiene practices (hand, environmental)
• Promote antibiotic stewardship
• Promote catheter stewardship
• Reduce re-hospitalizations
Benefits of the LTC Program
• Improve the Nursing Home Compare Quality Measures
• Enhance data collection skills and prepare for mandatory
reporting of infection data (NHSN)
• Benchmark against other LTC facilities (project-level and
nationally)
• Improve communication and relationships with referring
hospitals that may results in reduced readmissions
• Improve compliance with survey requirements related to
quality of care, infection control, etc.
The Important Role of the Clinician
6
Actively Engage Staff Using
T.E.A.M.S. and C.A.U.T.I.
C.A.U.T.I. Infographic: http://www.hret.org/ltc_safety/resources/Infographics/CAUTI%20Mnemonic%20Poster.pdf
T.E.A.M.S. Infographic: http://www.hret.org/ltc_safety/resources/Infographics/LTC_T.E.A.M.S._FINAL.png
7
Assessing Catheter Necessity
Catheters in newly admitted and readmitted residents should be assessed
for necessity
• Every resident, when clinically possible,
deserves a chance to be “catheter-free”
• Remember, a resident cannot develop a
CAUTI if they do not have a catheter
• NHSN CAUTI definition does NOT include
suprapubic, straight nor condom catheters
8
8
CAUTI Surveillance Criteria
CAUTI Criteria - NHSN Definitions Pocket Card
View Onboarding 2 materials on the NHSN definition for CAUTI here:
http://www.ltcsafety.org/webinars/resources/Onboarding%20Training%20Materials.shtml
9
Avoid Unnecessary Urine Cultures
Chronically-catheterized patients have bacteriuria
99% of the time
• Bacteriuria can be symptomatic or asymptomatic
• Urine cultures, dip sticks and the presence of pyuria cannot be used to
distinguish between CAUTI and asymptomatic bacteriuria (ASB)
• Non-Specific Bacteriuria Signs
•
•
•
•
Urine color
Urine smell
Urine sediment
Cloudy urine
Bacteriuria
ASB
Nicolle L.E., Bradley S., Colgan, R., et al. Infectious Diseases Society of America Guidelines
for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults.Clin Inf Dis 2005;
40:643-54.
CAUTI
10
Ordering Unnecessary Urine Cultures
Can Lead to Resident Harms
Urinary catheter present
Cloudy, odorous urine, sediments
Inappropriate use of urine culture
Over-inflated CAUTI rates
Inappropriate Treatment
and Antibiotic Overuse
Miss the correct diagnosis
More resistant organisms, Clostridium difficile, increased cost,
further health complications
Resident Harms
11
Strategies to Reduce Unnecessary
Urine Cultures and Overuse of Antibiotics
Reduce unnecessary urine cultures
Reduce the overuse of antibiotics
•
Review urine culture data
•
Review antibiotic use data1
•
Assess whether s/s present to collect
urine cultures
•
Confirm s/s and positive urine culture
•
Determine if appropriate antibiotic
prescription was given
•
Identify clinical situations driving
antibiotic use (e.g., asymptomatic
bacteriuria, UTI prophylaxis)
Communicate with nurse, staff, residents and families the harms of
starting antibiotics not clinically indicated
Creating a Culture to Improve Antibiotic Use in Nursing Homes. CDC’s The Core Elements for Antibiotic Stewardship in Nursing Homes.
12
Communication is Critical and
TeamSTEPPS Can Help!
Effective and clear communication between multidisciplinary teams and
nurses and providers leads to better:
– Recognition of acute change of condition (ACOC)
– Timely intervention
– Improve treatment decision-making
– Overarching ACOC management
TeamSTEPPS for Long-term Care version: http://www.ahrq.gov/professionals/education/curriculumtools/teamstepps/longtermcare/index.html
13
How You Can Help
• Be familiar with the NHSN CAUTI Surveillance definition
• Avoid obtaining unnecessary urine cultures
• Initiate care plan discussions with staff, residents and families
to review ways to prevent CAUTI and harms together

Document clinical indications for the catheter

Document signs and symptoms of CAUTI

Prescribe antibiotics only when appropriate
14
Stay Updated with Useful Resources
1.
AHRQ Safety Program for Long-term Care: HAIs/CAUTI Project Website
Login information
Username: ltcsafety
Password: ltcsafety
2.
TeamSTEPPS® for Long-term Care
3.
LTC Safety Toolkit
4.
NHSN CAUTI Definition Pocket Cards
5.
Antibiotic Stewardship Brochure
6.
Letter to LTC physicians re: clinical interventions to reduce CAUTI from Dr. Lona Mody
7.
C.A.U.T.I Infographic
8.
T.E.A.M.S. Infographic
15
References
Module 1: Improving Communication and Decisions about Antibiotic Use in Nursing Homes. June 2014. Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/nh-aspguide/module1/index.html
Al Qas-Hanna, Am J Infect Control 2013;41 (12): 1173-77
Centers for Medicare and Medicaid Services, Long Term Care Minimum Data Set, Resident profile table as of 05/02/2005. Baltimore. MD.
Centers for Disease Control and Prevention (CDC). (2015). Infographic: Antibiotic Stewardship in Nursing Homes. Accessed on 09/23/15 at
http://www.cdc.gov/longtermcare/pdfs/infographic-antibiotic-stewardship-nursing-homes.pdf.
CDC. (2014). Antibiotic Use in Nursing Homes. Accessed on 06/23/15 at http://www.cdc.gov/getsmart/week/downloads/gsw-factsheet-nursinghomes.pdf.
CDC. Healthcare Infection Control Practices Advisory Committee (HICPAC) approved guidelines for the Prevention of catheter-associated urinary tract
infections, 2009. Available at http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.
CDC. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance (online). Accessible at:
http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf.
CDC, National Center for Health statistics, 1999 National Nursing Home Survey. Nursing Home Residents, number, percent distribution, and rate per
10,000, by age at interview, according to sex, race, and region: United States, 1999.
Loeb, M et.al. Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med 2001; 16: 376-383.
National Healthcare Safety Network (NHSN). Long-term Care Facility (LTCF) Component Healthcare Associated Infection Surveillance Module: UTI Event
Reporting [online].
Mody L, Bradley SF, Galecki A, et al. Conceptual model for reducing infections and antimicrobial resistance in skilled nursing facilities: focus on residents
with indwelling devices. Clin Infect Dis. 2011;52:654-61. PMID: 21292670.
Nicolle L.E., Bradley S., Colgan, R., et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in
Adults.Clin Inf Dis 2005; 40:643-54.
Richards CL. Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel. J Am Geriatr Soc 2002;50:570-6.
Smith PW, Bennett G, Bradley SF, et al. SHEA/APIC Guideline: Infection prevention and control in the long-term care facility. Infect Control Hosp Epidemiol
2008; 29:785–814. PMID: 18786461.
Stone ND, Ashraf MS, Calder J. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp
Epidemiol 2012;33(10):965-977.
Trautner, B. (2014). Demystifying CAUTI: When to Culture and When to Treat. AHRQ Safety Program for Long-term Care: HAIs/CAUTI.
http://www.ltcsafety.org/webinars/resources/September%202014%20Content%20Webinar.shtml
Wagner, LM., Roup, B.J., Castle, NG. Impact of infection preventionists on Centers for Medicare and Medicaid quality measures in Maryland nursing homes.
Am J Infect Control 2014; Jan 42(1): 2-6.
16