On the CUSP: Stop CAUTI in ICU

Implementation Guide for Team LeadsA Practical Resource for Improving Safety in Your Unit

Prepared for:Agency for Healthcare Research and Quality (AHRQ)

U. S. Department of Health and Human Services (HHS)

Contract Number: 290-06-00022I-8

Contract Title:

National Implementation of the Comprehensive Unit-based Safety Program (CUSP) to Reduce Catheter-associated Urinary Tract Infection (CAUTI)

Contractor:

Health Research & Educational Trust, Chicago, IL

Prepared by:

Health Research & Educational Trust

Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality

Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality

Ann Arbor VA Medical Center and the University of Michigan Patient Safety Enhancement Program

St. John Hospital and Medical Center

Updates:

November 2012 – Updated Section III narrative on insertion, appendices added.

October 2013 – Resources and guidelines for ED Improvement Intervention participants added.

February 2014 – Resources and guidelines for ED Improvement Intervention updated.

January 2015 – Guide adapted for ICU Intervention.

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February 2015

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Table of Contents I. Purpose and Project Overview 4

The Purpose of This Guide.......................................................................................4

Project Goals...........................................................................................................4

Project Funder.........................................................................................................4

Project Overview.....................................................................................................5

II. Culture Change and Improvement 7The 4 E’s Model.......................................................................................................8

Comprehensive Unit-based Safety Program..........................................................10

III. Interventions to Prevent CAUTI 11Step 1: Appropriate Catheter Use Intervention.....................................................12

Step 2: Proper Catheter Insertion and Maintenance Intervention.........................16

Step 3: Prompt Catheter Removal Intervention.....................................................17

Tools...................................................................................................................... 19

IV. Measuring Progress 21Outcome Measurement.........................................................................................21

Data Collection and Submission Instructions.........................................................22

V. Implementing On the CUSP: Stop CAUTI 23Project Timeline.....................................................................................................23

Unit Team Expectations........................................................................................24

Education Program Overview................................................................................26

VI. Sustainability and Spread 27Sustainability.........................................................................................................27

Spread Strategy....................................................................................................28

VII. References 29

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I. Purpose and Project Overview

The Purpose of This Guide This manual is intended as a guide for Team Leads implementing the On the CUSP: Stop CAUTI in ICU in units that have committed to reducing catheter-associated urinary tract infections (CAUTI) and improving safety culture in intensive care units. This manual describes the collaborative model, presents teamwork and project management tools, delineates roles and responsibilities of unit-level project leaders, and defines how progress will be measured in the accelerated time frame of Cohort 9—the last cohort of the program. In addition to this guide, there are archived webinars; there are tools and resources available on the national project web site, http://www.onthecuspstophai.org/on-the-cuspstop-cauti/cohort-9-icu-initiative/.

In addition to this guide and the project website, your State Lead and the State Clinical Leads for your state will help you successfully implement the program through monthly coaching calls and individual support, if needed. Your State Lead is a quality/safety leader at your state hospital association and your Clinical Leads are a nurse and a physician with significant experience in the ICU setting.

Project Goals This national project focuses on both evidence-based clinical interventions (technical aspects of care) and on improving unit safety culture using the Comprehensive Unit-based Safety Program (CUSP), or the adaptive aspects of care.

The national goals of On the CUSP: Stop CAUTI are to:1. Reduce mean CAUTI rates in participating clinical units by 25 percent2. Improve safety culture, as evidenced by improved teamwork and

communication, by implementing CUSP

The unit-level objectives of the project are to:1. Promote the appropriate use of indwelling catheters2. Improve the culture of safety, teamwork, and communication3. Improve proper placement technique, care and prompt removal of the

catheter

Project Funder AHRQ funds this and other initiatives to prevent health care associated infections. AHRQ’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. The research sponsored, conducted, and

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disseminated by AHRQ provides information that helps people make better decisions about health care. For more information about AHRQ, visit http://www.ahrq.gov/

Project OverviewThe On the CUSP: Stop CAUTI project includes the following adaptive and technical interventions to reduce CAUTI:

ADAPTIVE1. 4 E’s Model2. The Comprehensive Unit-based Safety Program (CUSP)

TECHNICAL3. Appropriate Catheter Use Intervention 4. Proper Catheter Insertion and Maintenance Intervention5. Prompt Catheter Removal Intervention

1. The 4 E’s ModelThe Armstrong Institute for Patient Safety and Quality developed the 4 E’s model to help implement patient safety interventions. This model includes four key elements: Engage, Educate, Execute, and Evaluate. 1

Step 1: Engage . Unit teams help staff understand the impact of preventable harm caused by CAUTI by sharing stories about patients who develop these infections, and by estimating the number of patients who are harmed given the unit’s current infection rates.

Step 2: Educate . Unit teams ensure staff and senior leaders understand what they need to do to prevent infections.

Step 3: Execute . Execution is based on the principles of safe system design: simplify the system, create redundancy, and learn from mistakes.

Step 4: Evaluate . Using standardized NHSN definitions for CAUTI, teams will regularly collect and submit CAUTI rates along with the prevalence and appropriateness of urinary catheter use.

This model will be used in conjunction with the CUSP model to help unit teams create change and improve patient safety in their units.

2. The Comprehensive Unit-based Safety Program (CUSP) CUSP is designed to improve patient safety on a clinical unit by providing a common platform for understanding the science of safety, then integrating key habits and steps into the daily routines of a unit or clinical area. CUSP draws on the wisdom of

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frontline providers who have practical knowledge regarding safety risks to their patients and provides a mechanism to help analyze and reduce the risk of those hazards. The CUSP model has five components:

1. Assemble the team,2. Engage senior leadership,3. Understand the science of safety,4. Identify and learn from defects and 5. Implement teamwork and communication tools.

In addition, CUSP emphasizes the importance of a diverse team, focuses on the input of direct care providers, discusses the importance of a common goal, identifies issues that the team can successfully solve, and integrates these elements as part of the team’s routine work. CUSP is associated with improvements in patient safety, clinical outcomes, and safety culture. 2, 3, 4, 5 In the context of CUSP, culture has been diagnostic of unit strengths and weaknesses, responsive to interventions, and relevant to the unit frontline providers. Moreover, in the work with the Michigan Keystone: ICU program, linking culture through CUSP with focused clinical interventions (for example, to reduce CLABSI, or central line-associated bloodstream infections) led to sustained reductions in infection rates . 2, 3,

4, 5

3. Appropriate Catheter Use InterventionNursing workload has been cited as a significant issue in reducing infections because urinary catheters can ease nursing workflows, and there may be a perceived incentive for catheter placement. The Appropriate Catheter Use Intervention includes education for staff on appropriate indications and ways to avoid urinary catheter placement.

4. Proper Catheter Insertion and Maintenance InterventionIf appropriate indications for an indwelling urinary catheter exist, clinicians can reduce the risk of infection by following evidence-based recommendations for proper catheter insertion and maintenance. Key elements of the Proper Catheter Insertion and Maintenance Intervention include ensuring that only properly trained clinicians have responsibility for catheter insertion and maintenance, use of aseptic technique for insertion, and maintenance of a sterile, continuously closed drainage system.

5. Prompt Catheter Removal InterventionMore than 14 studies have evaluated the effectiveness of urinary catheter reminders and stop-orders, including written, computerized, and nurse-initiated stop-orders in reducing infections. The evidence indicates that reminders and stop-

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orders result in significant reduction in catheter use and significant reduction in infection, and there is no evidence of harm, such as a need for re-insertion. Education and Coaching SupportSafety is in everyone’s hands, especially front-line workers. A key component to implementing this work is the efficient and effective dissemination of information to frontline staff and providers charged with changing processes to improve patient safety, care delivery, teamwork, and culture. The On the CUSP: Stop CAUTI project delivers educational content primarily through monthly webinars and monthly coaching calls, as well as one in-person or virtual learning session at mid-project.

Measuring SuccessUsing CAUTI rate data to monitor progress is critical to demonstrating whether your technical and cultural interventions are working in your unit. The timing of the data collection is closely linked to the timing of interventions allowing for real-time improvement. Further, if your unit is already submitting data into NHSN, you can confer rights to HRET group for seamless data transfer. Or, use easy web interface for data submission. The two program measures being monitored are:

Indwelling catheter utilization CAUTI rates

Project Infrastructure

National Project TeamOn the CUSP: Stop CAUIT has been developed by experts in CAUTI prevention and patient safety and quality improvement. The National Project Team consists of 11 organizations that each contribute unique knowledge and experience to support the improvement effort and to build program capacity at the national, state, hospital, and hospital unit levels. Representatives of many of these partners serve as expert faculty. They include:

Agency for Healthcare Research and Quality (Funder) Health Research & Educational Trust of the American Hospital Association Society for Critical Care Medicine New Jersey Hospital Association Michigan Health & Hospital Association Keystone Center for Patient Safety &

Quality St. John Hospital and Medical Center Johns Hopkins Armstrong Institute for Patient Safety and Quality (Armstrong

Institute) Association for Professionals in Infection Control and Epidemiology Emergency Nurses Association Society for Healthcare Epidemiology of America

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Society of Hospital Medicine

State PartnersYour state partners—your State Lead and your Clinical Leads—will help you successfully implement On the CUSP: Stop CAUTI. You should reach out to these individuals as soon as you have any questions, concerns or experience any barriers in implementing the technical or adaptive aspects of the program.

Your State Lead will support you by sharing a monthly newsletter with resources and reminders, as well as providing logistical support related to:

registration and data submission, monthly content call and coaching call calendar and dial-in information, access to website resources and expert faculty support and hospital leadership challenges.

Your Clinical Leads will be reviewing your monthly CAUTI rates and are available to discuss strategies for:

Implementing evidence-based practice, Overcoming resistance from clinical staff and other clinical challenges and Dealing with behaviors that may, or are currently, impeding program

progress.

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II. Culture Change and Improvement

The 4 E’s Model The Armstrong Institute developed the 4 E’s model to help implement patient safety interventions.1 This model includes four stages that seek to answer the following questions:

1. Engage: How will this make the world a better place?2. Educate: How will we accomplish this?3. Execute: What do we need to do? 4. Evaluate: How will we know we made a difference?

Engage: How does this make the world a better place?

The first E focuses on engagement. This is the step where you help your entire organization to understand the significance of reducing CAUTI. Project leaders talk to senior leaders, team leaders, and bedside staff about the prevalence of catheter use, the risk to patients, and the health care costs associated with CAUTI. To engage your colleagues, first make the problem real by telling the story of a patient who developed a CAUTI in your clinical area or hospital. Identify a patient in your clinical area who has suffered needless harm from a catheter, and share the patient’s story with your colleagues. Work with risk management at your hospital to share this story openly with your colleagues and leadership.

Share the following CAUTI facts that will help engage your unit team: Millions of urinary catheters are placed each year in the United States,

particularly in the hospital setting. However, up to half of urinary catheter device days in the hospital setting may not have a valid indication for use. 6, 7

Urinary catheter use has been associated with urinary tract infections and trauma.

Approximately 600,000 patients develop hospital-acquired urinary tract infections per year. Approximately seventy-five percent of these episodes are CAUTIs. 8, 9, 10, 11

Hospital-acquired bacteriuria or candiduria occurs in 25 percent of those patients who have urinary catheters in place for one week. The risk per day of bacteriuria is about 5 percent, and 3 percent of those with bacteriuria develop a bloodstream infection.8, 9

The longer the urinary catheter is used, the higher risk of infection. If the urinary catheter is not present, CAUTI does not occur.

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The cost of a hospital-acquired CAUTI averages between $500 and $1,000. Catheter-related bacteremia increases the cost of care by at least $2,800 per patient.8, 9

More Tips to Engage Your Unit Team: Share a story of a patient who developed CAUTI. The goal should be that no

patient suffers harm from a preventable complication while in your clinical area.

Make everyone aware of the CAUTIs on your unit:o Post the number of people who developed a CAUTI each month and the

total number of CAUTIs for the previous year in your clinical area, and o Post a trend line so your team can see the CAUTI rate and changes

over time. Post a “Days Since Last CAUTI” poster and increase the number on the poster

each day your ICU has no CAUTI identified by the team when working with your Infection Preventionist. This way, nurses, physicians, and other staff can see at a glance your CAUTI rate and how it changes over time.

Use team meetings and in one-on-one huddles to talk about the interventions and about unit specific infection rates.

Recognize providers who follow guidelines for the appropriate use of urinary catheters.

Invite your hospital infection preventionist to become an active member of your team and draw on his or her expertise to address specific challenges.

Educate: How will we accomplish this?

The second E, educate, is key to accomplishing your goal. The following are the recommended steps for educating your unit team:

1. Educate staff on the CUSP model beginning with the Science of Safety video .2. Educate staff about the appropriate indications for indwelling catheters using

definitions by the Healthcare Infection Control Practices Advisory Committee (HICPAC) for use and proper care of urinary catheters. There are examples of presentations and educational materials provided in this manual in section III , Table 1 : CAUTI Prevention Policies and Educational Materials .

3. Educate staff who are collecting outcome data on the definition of CAUTI. 4. Participate in monthly content and coaching webinars.5. Share the number of people infected per month and your quarterly infection

rates with the unit, medical staff and the executive sponsor. If your team has low rates, it may be better to share the number of inappropriate catheters.

6. Learn from at least one defect per quarter using the Learning from Defects tool, preferably one or more a month.

Execute: What do we need to do?

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The third E focuses on how you will execute the program. Even well-conceived, successful programs can fail if they are poorly implemented. Successful patient safety projects share some key characteristics. They have a well-functioning team with a strong team leader and executive, nursing and physician champions; have explicit aims and a means of measuring progress; involve all team members; have well-defined roles and responsibilities of each team member; and adequate support from management to carry out the safety interventions.

The recommended steps for executing this project are: Assemble a team, engage staff, and partner with a senior executive. Understand the technical or clinical CAUTI interventions. Understand how to apply CUSP to daily routine to improve patient safety

culture. Understand the risks to patients with inappropriate catheter use. Ensure that monthly data on CAUTI rates is submitted and monitor CAUTI

rates monthly for improvement. Use teamwork and communication tools relevant to the unit, (e.g.

TeamSTEPPS).

You will receive step-by-step instructions on how to implement the program through the monthly content and coaching webinars, in addition to what is contained in this guide. It is extremely important to attend all National Content Webinars, as the content builds on previous presentations. If implementation does not go as planned, share your challenges on your monthly coaching call and/or contact your State Lead or Clinical Leads, depending on the type of problem you are having. Evaluate: How will we know we made a difference?

The fourth E focuses on the evaluation process. In this step, your Team is toanalyze data that has been collected in order to determine the success and where improvements should be made.

Comprehensive Unit-based Safety Program

Overview of the CUSP Model

The CUSP model is designed to equip frontline unit staff with a framework and tools to improve patient care and make your unit safer. CUSP is a model that can and should be used for any safety concern in your unit. For this project, CUSP will serve as a model that will help your unit staff to understand the risks of CAUTI associated with non-compliance with appropriate use and care of the catheter, and the role and shared responsibility of every unit staff member to help change your unit’s work

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processes to reduce the risk of those infections for patients in your care. Culture is a major focus because it represents a set of shared attitudes, values, goals, practices, and behaviors that have a direct impact on patient safety. The CUSP framework is comprised of five components, each summarized in this section.

More information on the CUSP Toolkit and the modules including PowerPoint slides, tools, and videos can be found on the AHRQ website: http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/index.html CUSP Components and Implementation Guidance

Assemble the TeamTo assemble an effective team:

Understand the importance of a CUSP team and characteristics of successful teams and potential barriers to teams being high performing, and

Build a multidisciplinary team.

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Engage the Senior ExecutiveEngage the Senior Executive: This step invites a senior hospital executive to partner with your unit in order to:

Educate leaders about the clinical issues and safety hazards, Provide staff with resources to mitigate hazards and assist with removal of

barriers, Improve frontline providers’ attitudes about leadership and Help to hold staff accountable for reducing patient risks and open the lines of

communication.

Understand the Science of SafetyCUSP provides a thirty-minute Science of Safety video to help your unit staff to:

Understand that safety is a system property; Understand the basic principles of safe system design, e.g., work

standardization, creating independent checks for key processes (including checklists) and learning from mistakes;

Recognize that the principles of safe design apply to technical as well as adaptive work; and

Understand that teams make wise decisions when there is diverse and independent input.

Identify and Learn from DefectsThis step asks your staff to think about how the next patient on your unit may be harmed, particularly in regard to inappropriate urinary catheter use as well as introducing a structured process to learn from medical and other errors by examining: what happened; why it happened; what you did to reduce risk; and how you measure whether risks were actually reduced

Implement Teamwork and CommunicationThis step helps your unit learn and use specific tools that will help to improve teamwork, work processes, and communication on your unit.

III. Interventions to Prevent CAUTIThere is clinical evidence that demonstrates the effectiveness of certain strategies to prevent CAUTIs. In the acute care setting, prevention efforts must focus on three key steps to prevent CAUTI: 1) appropriate urinary catheter use, 2) proper catheter insertion and maintenance and 3) prompt catheter removal.

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Step 1. Appropriate Catheter Use InterventionThe key elements of the Appropriate Catheter Placement Intervention include:

1. Insert urinary catheters only for appropriate indications. All urinary catheter insertions require a physician’s order. The evidence-based HICPAC/CDC Guideline 2009 specifies appropriate indications for urinary catheter insertion and use.

2. Optimize the use of alternatives to indwelling urinary catheters, including the use of bladder scanners to identify and manage acute urinary retention, condom catheters, male and female urinal, super absorbent pads for incontinence and non-invasive methods of measuring urine output.

Step 2. Proper Catheter Insertion and Maintenance InterventionTo follow proper insertion and maintenance:

1. Ensure that only trained staff whose competency has been validate by observation of aseptic catheter insertion and maintenance are given these responsibilities,

2. Insert catheters using aseptic technique and sterile equipment,3. Maintain a sterile, continuously closed drainage system and4. Do not disconnect the catheter and urinary drainage system unless the

catheter must be irrigated manually because of obstruction. Assessing the need for urometer use guides the choice of the correct closed urinary drainage system at the time of catheter insertion, thereby preventing the system being opened to add one later.

Step 3. Prompt Catheter Removal InterventionRemove catheters as soon as possible. Patients should be monitored daily for catheter use and if an appropriate indication for catheter use is no longer present, the catheter should be promptly removed.

Step 1: Appropriate Catheter Use Intervention

Ensure the catheter is indicated based on the current HICPAC/CDC Guideline

In 2009, HICPAC and CDC recommended a list of appropriate and inappropriate indications for urinary catheter placement based on a critical review of the available medical literature. Because of the absence of high-quality studies examining indications for urinary catheterization, the recommended indications for catheter use primarily represented consensus expert opinion. After recent evaluation of

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nearly 299 clinical indications by a multi-disciplinary panel of physicians and nurses using the RAND/UCLA Appropriateness Method 12, "critical illness" that justifies use and risks of a Foley catheter should be clarified. Patient location within an ICU is not an appropriate indication for a Foley catheter; the patient still requires a specific medical indication for the Foley catheter's need. Use of Foleys to obtain urine volume measurements needed in care of "critical illness" are recommended to be restricted to patients who require hourly urine volume measurement to inform and provide treatment, such as patients who have hemodynamic instability requiring multiple titrations per day of ongoing bolus fluid resuscitation, vasopressors, inotropes or diuretics, patients with acute respiratory failure requiring invasive ventilation or hourly titrations of diuretics, or hourly management of urine studies or urine volumes to manage life-threatening laboratory abnormalities. Foley use for assessing daily urine volume measurement that is being used to provide treatment should be limited to patients for whom volume status truly cannot be adequately or reliably assessed without a Foley such as by daily weight, exam, or urine collection or monitoring by urinal, commode, bedpan, external catheter or bladder scanner.

Appropriate indications for urinary catheterization based on HICPAC guidelines include the following:

1. Acute urinary retention or obstruction —Urinary catheters are indicated for the management of acute urinary retention due to mechanical obstruction. Urethral or bladder outlet obstruction is commonly related to benign prostatic hypertrophy, severe edema with penile swelling, urethral stricture or urinary blood clots. Urinary catheters also are indicated for acute urinary retention related to a neurogenic bladder most often related to spinal cord injury or progressive neurological disease or to medications that reduce bladder muscle contractility or sensation.

2. Accurate measurement of urinary output in critically ill patients —Catheters are indicated when accurate measurement of urinary output is required in critically ill patients receiving care in the intensive care setting. ICU patients who are hemodynamically stable and cooperative often do not require urinary catheters and are appropriate candidates for alternate means of measuring urine output (see Consider alternatives to indwelling urinary catheters subsection below).

3. Perioperative use in selected surgeries —Urinary catheters are indicated perioperatively for selected surgical procedures. Catheters should be used when a surgery is expected to be prolonged, when a patient will require large volume infusions during surgery, or when there is a need for intraoperative urinary output monitoring. Catheters also are indicated for urologic surgeries or other surgeries on contiguous structures of the genitourinary tract. Urinary catheters should not be used routinely for patients receiving epidural anesthesia or analgesia. Among these patients, the risk of acute urinary

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retention can be reduced by prompt discontinuation of the epidural medication and by the use of bladder scanners to monitor for acute urinary retention in the immediate post-operative period (see Consider alternatives to indwelling urinary catheters subsection below).

4. To assist healing of moderate to severe perineal and sacral wounds in incontinent patients—This is a relative indication for urinary catheter use when there is concern that urinary incontinence is leading to worsening skin integrity in areas where there already is skin breakdown. Urinary catheters should not be used as a substitute for the use of skin care, skin barriers, and other methods to manage incontinence and limit skin breakdown.

5. Hospic e/comfort/palliative care —This is an acceptable indication for catheter use in end-of-life care, if it helps with patient comfort.

6. Required immobilization for trauma or surgery —Urinary catheters may be used when patients require prolonged immobilization following trauma or surgery. Examples include instability in the thoracic or lumbar spine, multiple traumatic injuries, such as pelvic fractures, and acute hip fracture when there is risk of displacement with movement.

7. Chronic indwelling urinary catheter on admission —Patients admitted from home or an extended care facility with a chronic indwelling catheter are considered to have an acceptable indication for catheter use. Note, this indication is not listed as one of the HICPAC urinary catheter indications.

Inappropriate indications for urinary catheterization include the following:

1. Urine output monitoring when the patient’s acuity would allow an alternate process —Monitoring urine output in patients is not an appropriate indication for urinary catheter insertion and use whenever the patient’s acuity supports an alternative choice. This includes use for patients with congestive heart failure who are receiving diuretics. Some potential solutions are use of condom catheters for men, male and female urinals and hats for those patients able to use a bedside commode or a bathroom toilet, the weighing of briefs and super absorbent pads and daily weights. For patients with congestive heart failure, consider involving the patients themselves. Providing patients with educational materials on how to document their urine output and daily weight may assist in this process.

2. Incontinence without a sacral or perineal pressure sore — Urinary catheter should not be placed for management of urinary incontinence. Patients admitted from home or from extended care facilities with incontinence manage their incontinence without problems before admission. Mechanisms to keep the skin intact need to be used. Some potential solutions for the management of incontinence include use of skin barrier creams for protection, use of a bedpan, or assisting the patient up to the commode regularly. Check for any wet bed linen, and change linens if they are wet

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when the patient is being turned in bed. In addition, external (”condom”) catheters may be an alternative to manage urinary incontinence in cooperative male patients without urinary retention or obstruction.

3. Prolonged post-operative use —Urinary catheters should be promptly discontinued within 24 hours or less of surgery unless there is an appropriate indication for continued post-operative catheter use (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia as assessed using a bladder scanner, etc.).

4. Other inappropriate uses of urinary catheters: a. Patients who have been transferred from intensive care to a floor —A

urinary catheter should be discontinued promptly when the ICU patient no longer meets an appropriate indication. The handoff communication between assigned ICU and floor nurse should include a discussion of the patient’s urinary system and need for an indwelling urinary catheter. If the patient no longer meets an approved indication, the ICU nurse should remove the catheter prior to transfer to the floor unit.

b. Morbid obesity or immobility —Morbid obesity or immobility should not be a trigger for urinary catheter placement. Patients who are morbidly obese have functioned without a urinary catheter prior to admission. The combination of immobility and morbid obesity may lead to inappropriate urinary catheter use. However, this may lead to more immobility with the urinary catheter being a “one-point restraint.” Some potential solutions include scheduled toileting every two hours, use of a bedpan or urinal, or assisting the patient out of bed.

c. Confusion or dementia —Patients with confusion or dementia should not have a urinary catheter placed unless one of the seven indications for appropriate placement is present. External “condom” catheters are an alternative to urethral catheters for the management of incontinence in male patients who are cooperative (see Consider alternatives to indwelling urinary catheters subsection below).

d. Patient or Family request —Patients or their family member’s request should not be a reason for placement of unnecessary urinary catheters. Explain to the patient the risk of infection, trauma, and immobility related to the use of the urinary catheter, and consider providing the patient with educational materials on the risks of CAUTI. The only exception would be for patients who are receiving end-of-life or palliative care (appropriate indication #5 described above). For example, if a patient is on diuretics and does not want to move out of bed multiple times, a catheter should not be used. Education is key! Explain to the patient that their safety is paramount and the increased risks associated with use of a urinary catheter: urine infection, skin breakdown, and deep venous thrombosis due to immobility.

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What the team needs to do:Ensure that unit teams and care providers are properly educated in the seven appropriate indications for urinary catheters and the four inappropriate indications outlined above. Several educational tools are available in the appendices of this manual and at http://www.onthecuspstophai.org/on-the-cuspstop-cauti/cohort-9-icu-initiative/icu-implementation-guide/, including two posters on urinary catheters, a brochure, fact sheet, and pocket card, which all outline the seven indications for catheter use. See Table 1: CAUTI Prevention Policies and Educational Materials.

Consider alternatives to indwelling urinary cathetersAlternatives to an indwelling urinary catheter should be considered based on a patient’s acuity-based individual care needs. Why? In general, alternative devices and procedures provide a much lower risk of infectious and other complications—such as urethral trauma, discomfort and immobility—that are associated with indwelling urethral catheters.

Before placing an indwelling catheter, consider if these alternatives would be more appropriate:

1. Bedside commode, male and female urinal, or continence garments:   to manage incontinence. Additional planning and personnel resources may be required to ensure that patients are regularly prompted and assisted with voiding or assessed for incontinence. Engage all patient care providers (e.g., Physical Therapy, Occupational Therapy, Recreational Therapy), to assist the patient with scheduled voiding or toileting.

2. Bladder scanner: to assess and confirm acute urinary retention, before placing catheter to release urine. Portable bladder ultrasound is a non-invasive tool for diagnosing and managing urinary outflow dysfunction. For example, portable bladder ultrasound is useful on medical, surgical or rehabilitation units to detect that a patient has urinary retention to justify catheterization. Nurse-driven protocols and handheld bladder scanners have been shown to reduce the risk of CAUTI. 13 An example of a Bladder Scan Policy is available in Appendix ICU-B and at http://www.onthecuspstophai.org/on-the-cuspstop-cauti/cohort-9-icu-initiative/icu-implementation-guide/ and can help your facility put this important method of reducing catheter use into practice.

3. Straight catheter : for intermittent, or chronic voiding needs . Intermittent catheterization is most often used in patients with neurogenic bladder or spinal cord injury, and lessens the risk of urinary tract infection. Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. When the patient returns to the community, intermittent catheterization enhances patient privacy and

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dignity, and facilitates return to activities of daily living. It is important to perform intermittent catheterization at regular scheduled intervals to avoid over-distending the bladder. Among hospitalized patients, intermittent catheterization is often used in combination with a portable bladder ultrasound. 

4. External “condom” catheter : appropriate for cooperative men without urinary retention or obstruction. External catheters are useful especially for management of incontinence in elderly male patients with dementia but remain underutilized.14 In a randomized clinical trial among 75 male patients at a VA Medical Center, condom catheters reduce the cumulative risk of urinary tract infection or death and were better tolerated than indwelling urinary catheters. 15 When using condom catheters, it is important to choose an appropriate size to improve fit and adherence to limit the risk of urine leakage or penile trauma.

What the team needs to do:Identify new patient care supplies or equipment alternatives to indwelling urinary catheters that you plan to implement and the target populations. Obtain multiple choices of available products in the marketplace and involve frontline staff in trialing samples of new supplies and equipment with an evaluation system to identify which choices are most effective in their patient population to guide purchasing decisions. By including frontline staff in trials and choice of patient care supplies and equipment, their project buy-in and engagement is increased, leading to more successful CAUTI prevention program implementation.

Step 2: Proper Catheter Insertion and Maintenance Intervention

Trained Clinicians with Validated Competency

Ensure that only trained staff who have demonstrated competency, the correct technique of aseptic technique maintaining sterile equipment and catheter for insertion and maintenance are given responsibility for catheter placement.

Aseptic Insertion of Urinary Catheters

Supplies necessary for placing urethral catheters include the following: Water-absorbent under pad Sterile drape Sterile gloves Preparation swabs Forceps Antiseptic solution

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Catheter Tubing Collection bag Sterile water for balloon inflation Sterile lubricating jelly

Most of these supplies can be purchased as prepackaged kits. Staff competency training includes the use of all supplies provided in each kit; nothing should be thrown away without use. Catheters vary widely by design, size, and construction material. The Foley catheter, a double-lumen, straight-tip catheter, is used most frequently.

Always place urethral catheters using aseptic technique, wearing sterile gloves. If using a catheterization kit, remove the kit from its outer packaging, and open the inner paper wrapping to form a sterile field. To avoid contaminating the gloves, with washed hands carefully retrieve the absorbent pad from the top of the kit, and place it beneath the patient’s buttocks, with the plastic side down. Then put the gloves on, and cover the patient’s abdomen and superior pubic region with the drape. Organize the contents of the tray on the sterile field, on a bedside table within reach. Techniques for catheterization of female and male patients vary. The New England Journal of Medicine has published two widely referenced articles with accompanying instructional videos on catheterization of females and males.16, 17

Consider the need for an assistant during the procedure to help hold patient positioning or to obtain replacement catheter should contamination of the sterile on occur thereby increasing the successful aseptic insertion.Appropriate Maintenance of Urinary Catheters

If there are breaks in aseptic technique, disconnection of tubing, or leakage from the bag, replace the drainage system. Disinfect the catheter-tubing junction before connecting to the new drainage system. If the catheter becomes contaminated, replace the catheter.

Make sure urinary flow is not obstructed . Ensure the catheter is not kinked. Drainage bags should always be placed below the level of the patient’s bladder to facilitate drainage and to prevent stasis of fluid. Urine in drainage bags should be emptied at least once each shift and before any transport off the unit using a container designated for that patient only. Care must be taken to keep the outlet valve from becoming contaminated. Use gloves and perform proper hand hygiene before and after handling the drainage bag.

Do not change urinary catheters and drainage bags routinely . Consider changing the urinary catheter and drainage system in the event of infection, obstruction, or a break or leak of the closed system.

Do not open or disconnect the closed drainage system from the urinary catheter. Avoid irrigation unless necessary (such as in the case of a catheter

On the CUSP: Stop CAUTI in ICU Implementation Guide - Revised February 201521

obstruction). The catheter tubing junction should be disinfected before irrigation. When sampling urine, wait for the disinfectant to dry on the sampling port prior to penetration. Frequently washing the meatus with povidone-iodine or soap is not associated with lower infection risk . In fact, frequent meatal cleaning may be associated with increased risk of CAUTI. Routine perineal hygiene during daily bathing with soap and water is appropriate.

Only nursing staff, family members, or patients themselves who know the correct technique of aseptic insertion and maintenance of the catheter should handle catheters. Health care workers and others who take care of catheters should be given periodic education and training, stressing the correct techniques and potential complications of urinary catheterization. Consider adding orientation and annual catheter insertion and maintenance proficiency testing to the staff education.

What the team needs to do:Implement a urinary catheterization policy such as the one found in Appendix ICU-A which contains all evidence-based practices proven to reduce the risk for CAUTI. The purpose of the policy is to standardize urinary catheterization to facilitate urinary drainage when medically necessary, include a list of the appropriate indications for indwelling urinary catheter use per the CDC It should contain the process for catheter removal when the patient’s condition no longer meets one of the appropriateness indications for catheter use.

Step 3: Prompt Catheter Removal Intervention

Nurses and physicians should be aware of the indications for urinary catheter use and should continually monitor a patient’s ongoing need for a catheter. Physicians should promptly order discontinuation of catheters that are no longer indicated, and nurses evaluating catheters and finding no indication should follow a nurse-driven removal protocol (if available) or promptly contact the physician for an order to discontinue the catheter.Inappropriate catheter use may be a lack of awareness among clinicians of a patient’s current catheter use. In a study published in 2000, 18 percent of medical students, 22 percent of interns, 28 percent of residents, and 35 percent of attending physicians were unaware that the patients for whom they were responsible had an indwelling catheter.18S

Multidisciplinary rounds done at the ICU patient’s bedside facilitate discussion between frontline nurses , physicians, and patients and their families about the patient’s readiness for removal of invasive devises such as indwelling urinary catheters. This team approach is optimal and can be further strengthened by leadership and tone displayed by the ICU physician. Unit leaders should encourage

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ICU physician input and support, which will help convey the message that each team member has a valuable role to play in the patient’s comfort and safety. . This in turn, should encourage staff to speak up and act as the patient’s advocate.

Reminders and Stop Orders

Reminders that a urinary catheter is still in use and stop orders are low cost and high impact methods of reducing the duration of catheter use and help to change the default mind set of health care providers from “persistent use” to “timely removal.” Reminders can be written, verbal, or electronic (e.g., computer order entry) and may include appropriate indications to continue catheter use and alternatives to indwelling catheters. Reminders are especially useful at the time of transition of care (e.g., admission from the Emergency Department or OR/Post Anesthesia Care Unit, transfer from ICU to floor, transfer from floor to rehabilitation unit) when direct nurse-to-nurse communication can prompt removal of catheters that are no longer indicated. Automatic stop orders prompt removal of urinary catheters based upon a specified time (e.g., within 24 hours of surgery) or clinical criteria. In a systematic review of 14 studies of urinary catheter reminder systems, daily reminders and automatic stop orders reduced the overall risk of CAUTI by 48 percent and the average duration of catheter use by 2.6 days and were not associated with an increased rate of catheter reinsertion compared to standard care. 19

What the team needs to do:Daily monitoring of patient catheter appropriateness is key. The Urinary Catheter Decision-Making Algorithm (Appendix ICU-E), Urinary Catheter Pocket Card (Appendix ICU-G) and Urinary Catheter Brochure (Appendix ICU-I) can aid in reinforcing practices among teams.

Tools

A number of helpful tools to aid in implementing or expanding focused CAUTI prevention efforts can be found in the appendices and at http://www.onthecuspstophai.org/on-the-cuspstop-cauti/toolkits-and-resources/on-the-cusp-stop-cauti-implementation-guide/. These tools are listed below in Table 1: CAUTI Prevention Policies and Educational Materials and Table 2: CAUTI Prevention Presentations and Templates. Adaptation to the needs of your particular environment as needed is encouraged.

Table 1 : CAUTI Prevention Policies and Educational Materials

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Name of Tool Purpose Appendix

Urinary Catheterization Policy

Apply evidence-based practice to reduce CAUTI. ICU-A

Bladder Scan Policy Apply evidence-based practice to reduce CAUTI. ICU-B

Urinary Catheter Poster (Option 1)

Educate health care staff and patients and families in: Risks of catheter use Indications and non-indications

ICU-C

Urinary Catheter Poster (Option 2)

Educate health care staff and patients and families in indications for catheter use. ICU-D

CAUTI InfographicEducate health care staff and patients and families on the s steps of the CAUTI Prevention Bundle.

Urinary Catheter Decision-Making Algorithm

Educate health care staff and patients and families in catheter indications and need for monitoring.

ICU-E

Urinary Catheter Project Fact Sheet

Educate health care staff and patients and families in: The problem of CAUTI Project goals Indications Catheter removal

ICU-F

Urinary Catheter Pocket Card

Educate health care staff and patients and families in: Catheter removal Risks of catheter use Indications and non-indications

ICU-G

Catheter Care Pocket Card

Educate health care staff and patients and families in evidence-based practices in catheter maintenance.

ICU-H

Urinary Catheter Brochure

Educate health care staff and patients and families in: Catheter removal Alternate solutions for incontinence The problem of CAUTI Catheter use algorithm Indications and non-indications

ICU-I

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Name of Tool Purpose Appendix

Nurse-Driven Protocol for Catheter Removal

Empower nurses to evaluate and discontinue unnecessary urinary catheters. ICU-J

Frequently Asked Questions

Refine evidence-based practice for appropriate indications, and care and removal of catheters. ICU-K

Skin Care in the Incontinent Patient

Educate caregivers on how to prevent skin breakdown. ICU-L

Helpful Hints Consider approaches that will help you to be effective in educating and engaging nurses. ICU-M

Improving the Culture of Culturing: Avoiding Unnecessary Urine Cultures in Catheterized Patients

This brief practical guide by Dr. Mohamad Fakih for Ascension Health addresses appropriate use of urine cultures.

www.catheterout.org A web site developed by a team of CAUTI

experts that provides CAUTI prevention guidance along with supporting evidence.

Table 2: CAUTI Prevention Presentations and TemplatesName of

Tool/Reference Purpose Appendix

Presentation to Manager

Educate nurse managers in: Project goals Project timeline Indications Non-indications

ICU-N

Presentation to Nursing Staff

Educate nurses in: Project goals Project implementation Indications Non-indications Helpful tips

ICU-O

Presentation of Data Present CAUTI data in a compelling way to encourage project sustainability. ICU-P

Implementation of Encourage engagement in program ICU-Q

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Name of Tool/Reference Purpose Appendix

Urinary Catheter Initiative Letter implementation.Completion of Staff Education Letter

Encourage engagement in program implementation. ICU-R

Unit Rounds to Begin Letter

Encourage engagement in program implementation. ICU-S

Unit Results Letter Encourage engagement in program implementation. ICU-T

IV. Measuring Progress

Engaging Everyone in Monitoring ProgressThe collection and reporting of CAUTI-related data are essential for determining the effectiveness of program interventions. Unit Team Leads (e.g., Nurse Champion) need to share CAUTI rate trends with all members of the ICU team, especially the Physician Champion. It is very important for the ICU team to share program progress with the frontline staff to reinforce the positive changes they are working to make or to indicate that more effort is needed to optimize safe care of patients with catheters. All CAUTIs should be investigated using the CUSP Tool, Learning from Defects. Zero CAUTIs are the aim. Some teams will state that as their immediate goal, while other teams will opt to set incremental reduction goals, for example, to decrease CAUTI rates in the unit by 10% in three months Program success is dependent on frontline staff buy-in and engagement, which is created and sustained by all staff being kept aware of progress toward eliminating CAUTIs on the unit. This information should be shared with frontline staff through newsletters, posters, staff meetings, huddles, and in one-on-one conversations. When goals are reached planned celebrations and recognition by hospital leadership can help sustain the gains.

Changes To Data Collection And Reporting For Cohort 9In addition to CAUTI rates, previous cohorts in On the CUSP: Stop CAUTI collected process data (catheter appropriateness) and staff perceptions of safety culture. However, given the compressed timeframe of Cohort 9, data collection will be limited to CAUTI rates. However, the National Project Team urges all units to look at the appropriateness of catheter placement, maintenance and prompt removal as well as the use of AHRQ’s Hospital Survey on Patient Safety Culture (HSOPS) to track changes in patient culture over time and to evaluate the impact of patient safety interventions.

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As indicated in the following chart, you are required to provide three months of baseline CAUTI rate data, as well as monthly concurrent CAUTI rates. The CDC National Healthcare Safety Network (NHSN) 2015 definitions are used for determining symptomatic CAUTIs (Appendix ICU-U). In addition, HRET requires units to complete a Unit Demographics form that provides important information to HRET/NPT and your state partners.

Table 3: Data Collection Requirements

Measures Submission Frequency Data Submission

Unit Demographics Once, January 2015 HRET Comprehensive Data Set (CDS)

Symptomatic CAUTIs

# symptomatic CAUTIs divided by # catheter days, multiplied by 1,000 OR# symptomatic CAUTIs divided by number of patient days, multiplied by 10,000

Baseline: Oct, Nov, Dec, 2014

Monthly: Jan-July, 2015

HRET Comprehensive Data Set (CDS)

OR

NHSN (rights conferred to HRET

or State Hospital Association)

Data Collection and Submission Instructions Whether you submit your own data into CDS or confer rights to your state hospital association or to HRET, you will be able to review and track over time your unit’s CAUTI rates in CDS. You will receive information from your State Hospital Association (SHA) Lead on how to:

Confer rights to your NHSN data to your SHA Lead or to HRET, Submit baseline and monthly CAUTI rate data into CDS if you choose not to

confer rights and Download reports from CDS to view your CAUTI rate trends over time.

In addition, your State Hospital Association Lead or State Clinical Leads may send you additional reports for your use. You will be able to compare your unit’s performance with others in your state and other participating states across the nation.

Table 4: Data Collection Tools

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Name of Tool/Reference

Purpose Appendix

2015 NHSN Definition for

Symptomatic CAUTI

Implement a surveillance process, including use of an indwelling

urinary catheter, a positive urine culture, and the presence of certain

clinical signs and symptoms.

ICU-U

HICPAC Guidelines for Appropriate

Indications

Continually assess patient need for urinary catheters.

ICU-V

CAUTI Process Data Collection Tool

(optional)

The form helps units to collect prevalence and appropriateness

data.

ICU-W

www.hretcds.org The secure, web-based data portal of the ED Improvement Intervention

Enter project data and run reports to track and communicate progress.CDS QUICK START GUIDE

www.cdc.gov/nhsn Home of the National Healthcare Safety Network, the web-based

surveillance system of the Centers for Disease Control and Prevention

ABOUT NHSN Purposes of NHSN Confidentiality Use of Data

NHSN MANUALSCONTACT NHSN

www.catheterout.org

A web site developed by a team of CAUTI experts that provides CAUTI

prevention guidance along with supporting evidence.

Supporting Evidence

Engaging Clinicians and Administrators

V. Implementing On the CUSP: Stop CAUTI This section of the guide addresses provides the project timeline, unit team expectations, and provides an overview of the educational program and the resources you will find on the project website.

Project TimelinePrint the project timeline and post in your unit.

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Unit Team Expectations

To help ensure the successful implementation of the On the CUSP: Stop CAUTI interventions in the ICU, the Team Lead should:

Set up a multi-disciplinary team Promote the program goals to all staff Engage at least monthly with the executive, physician and nurse champions Attend monthly national content webinars (2nd Wednesday of the month at

2:00 Central Time; starts January 14, 2015) Attend monthly regional coaching calls (set by your coaches—MHA, NJHA or

SCCM) Learn, teach and implement the technical and adaptive interventions Participate in monthly team meetings to monitor progress and discuss

challenges and successes Set interim program goals and plan for celebrations when goals are met. Ask for help whenever needed; contact:

o Your State Lead regarding logisticso Your Clinical Leads regarding technical and adaptive interventions

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Assemble Your Team

By now you have submitted to your State Lead your Team Roster, which explains the roles and expectations of different team members and asked you name key team players. If you have not already done so, please do so no later than January 30 and e-mail a copy to your State Lead. If you are continuing to engage physicians and senior executives for your team, review the Assessing CAUTI C-Suite Champion Potential for Success and Assessing CAUTI Physician Champion Potential for Success tools to help guide these choices and explain responsibilities to them.

Develop Processes for Project Implementation

Develop a process to evaluate the appropriateness of urinary catheters on your unit. The process should be one that best fits your unit. Consider making this a part of rounding process that already exists. Most importantly, the process for evaluating the appropriateness of catheters must be standardized and used consistently. Write this process up using the Hospital Unit Action Plan.

Determine who will contact the physician to request an order for discontinuance of inappropriate urinary catheters unless a nurse approved protocol for the removal of catheters exists. o Teamwork tools such as those found in the CUSP Toolkit or TeamSTEPPS

may be helpful to facilitate communication about the appropriateness of catheters and the recommendation for catheter discontinuance.

o Consider revising current processes, policies and procedures to include automatic stop orders or removal protocols.

o The process may be enforced by integrating it into the patient’s daily nursing assessment or multidisciplinary patient care rounds by the ICU team responsible for care decisions.

Educate Staff

Educate unit staff on the science of safety and on appropriate indications for urinary catheter use.

Watch the Science of Safety video with your unit:o This should include a formal instructional session about CAUTI, and

appropriate indications for catheter use. o You may also provide staff with printed educational material, lectures,

posters, and pocket cards found in the Appendices and on the website.

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The most important education occurs during rounds where a project champion discusses the appropriate indications for urinary catheter use with the unit staff:

o A champion (usually a nurse, infection preventionist, or quality improvement health care worker who is knowledgeable of indications for urinary catheter utilization) participates in a daily process to assess each patient for the presence and appropriateness of urinary catheters.

o This may occur during daily rounding, in which nursing staff assess each patient for urinary catheter presence. The nurses should be educated in the indications for urinary catheter utilization. A pocket card listing indications is available here: If a patient has a urinary catheter, review the reasons for use with the nurse caring for the patient.

o If there are no valid indications for the urinary catheter, the nurse should contact the physician to order the urinary catheter to be removed.

Use Teamwork and Communication Tools

Use tools described in section five to improve teamwork and communication in your unit. Your On the CUSP: Stop CAUTI team can decide which tools are most appropriate for use in your unit.

Learn from Defects Investigate all infections. Regularly identify defects and walk through at least one defect each quarter

with your team. Use this as an opportunity to learn from defects. This can occur at your CUSP team meeting or in another setting.

Monthly Team Meetings

Meet at least once per month with your On the CUSP: Stop CAUTI team including your executive partner, team leader, nurse champion, and physician champion. Meet more frequently if your team finds it useful to do so. Use this time to review CAUTI data, perform Learning from Defects exercise using a CAUTI case, plan staff education, assess system changes that could be made to reduce harm and improve the culture of safety on your unit.

Monitor Progress

Educate unit staff about improvements the team is making by:

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o Posting a CAUTI calendar bannero Displaying reminders around the unito Holding unit education sessionso Sharing and recognizing achievementso Sharing data with staff by regularly posting reports for staff (e.g., days

since last CAUTI poster)

Educate Other UnitsEngage others outside of your unit and increase awareness of your team’s efforts by:

Displaying CAUTI posters outside of your unit Invite patient care staff from outside of your unit to become ad hoc CAUTI

team members, based on your action plan; OR/ER staff, Physical Therapy, Occupational Therapy, Recreational Therapy, Patient Transportation, Radiology Technician, and Central Supply Purchasing Agent.

Posting reminders outside of your unit Creating an elevator speech to inform others you meet in passing Including monthly progress reports on bulletin boards or in newsletters Post updates on hospital Intranet Exhibit your CAUTI Team’s work during hospital quality improvement/patient

safety fairs and other nursing focused opportunities for presentation.

Education Program Overview All educational programming will be via webinar, except for those states holding an in-person mid-course meeting. Your State Lead will provide you with information about whether the state will be hosting an in-person or a virtual meeting in late spring.

WebinarsYou are required to attend two webinars a month: a national ICU content webinar and a regional ICU coaching webinar. Both calls will be approximately an hour. It is very important for Team Leads to attend and attendance by physician and nurse champions is very strongly encouraged. Other team members are also welcome to attend. In the rare instance that a team is unable to attend the live webinar, team members may access the webinar slides and recording on the project web site.

Monthly National ICU Content Webinars: The What and WhyParticipation on the monthly content webinars is very important. Presentations by expert faculty and successful ICU teams will provide the “what and why” of implementing the program. Share the link to the webinar recording with your team members along with the information you receive from State Leads.

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Team Leads, the unit nurse champion and the physician champion at a minimum should attend the 8 monthly content webinars. Facts about the webinars:

The webinars occur monthly from January through August, 2015. Experts in CAUTI prevention and in CUSP will present national experts in

CAUTI prevention and in CUSP Most webinars will have brief presentations by ICU teams successful in

reducing CAUTIs. Slide decks can be downloaded from the program website for use in sharing

the content with your ICU’s staff.

Monthly Regional ICU Coaching Webinars: The HowIt is equally important for Team Leads to attend the monthly ICU coaching webinars, which address the “how” of program implementation. The nurse and physician champions are strongly encouraged to attend, along with other staff. Key features of the coaching webinars include:

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Other Program Implementation Support

Monthly NewsletterEach month your State Lead will send you a newsletter with information about upcoming webinars and program milestones. Included in the newsletter will be a link to short columns on different aspects of the successful program implementation called “Making It Work.” Please be sure to read each newsletter.

24/7 Tools and Other Resources on the Program Website:Visit the Cohort 9 ICU Initiative section of the national program website http://www.onthecuspstophai.org/on-the-cuspstop-cauti/cohort-9-icu-initiative/ to access ICU initiative information and resources. Examples of what is available on the website include:

Archived webinar recordings and slide decks and The tools that have been discussed in previous sections of this guide.

VI. Sustainability and SpreadSustainabilitySustainability is marked by the ability to continue the components of On the CUSP: Stop CAUTI as part of routine workflows. Planning for sustainability is most successful when begun at the start of the program. Careful integration of evidence-based practices into the structure of the care provided in the unit will increase the longevity of these improvements, (e.g., revise nursing policy, protocol and procedures to include evidence-based care to prevent CAUTI). This can be accomplished by building assessments into the daily work. Reinforce the importance of compliance with catheter indications by presenting feedback data even after the period of required data collection has ended. Identify a facilitator who will take responsibility for reinforcing the process after the initial intervention is completed. This could be a nurse, a case manager, a discharge planner, or a team member of another discipline, but it should be someone who is committed to this role. Create a plan for continuation and integration. This could include education in new staff orientation, annual competencies, or a strategy to address resurgent rates. It is important to understand that although the On the CUSP: Stop CAUTI program has a limited duration; it is based on the 4 E’s, a cyclical, continuous process of improvement.

Sustainability will depend on having a trained champion to continue this effort on the unit; providing periodic feedback on performance to the unit’s project team, nurses, medical staff and administration; and implementing CUSP principles on the

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unit, to emphasize patient safety, engage staff participation and encourage empowerment, and identify and learn from safety defects.

Spread StrategyIn the implementation stage, begin reaching out to teach other units about the initiative. Continue these activities over time to spread learning to other units. You may do this by displaying CAUTI posters outside of your unit, posting updates on the hospital intranet, or posting reminders outside of your unit. Simply put, spread within a hospital is about actively disseminating effective practices and knowledge about an intervention to all relevant care settings in the hospital. Explain to other unit’s nurses and staff about your hospital acquired infection prevention program during hospital-wide nursing meetings, in hospital newsletters, blogs or tweets.

To facilitate spread, consider volunteering to meet with interested units to share what you have learned or to communicate the success you’ve had in reducing CAUTI rates in your unit. Start with units with higher CAUTI rates. Share this manual and the other resources available on the project web site with the unit, and make yourself available to coach other unit teams in CAUTI prevention and in the CUSP model.

You may take a more proactive approach and offer to train team leaders to serve as mentors for other units. Teaching other units not only benefits the rest of your hospital, but it can also benefit you. Through teaching others, you can solidify your own knowledge of the subject plus learn from the unique challenges that other units face. It is also a way for your team to ensure equal protection for all patients in your hospital.

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VII. References

1. Pronovost PJ, Berenholtz SM, and Needham DM. Translating Evidence into Practice: A Model for Large Scale Knowledge Translation. BMJ 2008; 337:1714

2. Pronovost PJ et al. Sustaining Reductions in Catheter-Related Bloodstream Infections in Michigan Intensive Care Units: An Observational Study. BMJ 2010; 340.

3. Pronovost PJ et al. An Intervention to Decrease Catheter-Related Blood Stream Infections in the ICU. N Engl J Med 2006; 355:2725-32.

4. Sexton JB et al. Assessing and Improving Safety Climate in a Large Cohort of ICUs. Crit Care Med 2011; 39(5):1-6.

5. Berenholtz SM et al. An Intervention to Reduce Ventilator- Associated Pneumonia in the ICU. Infect Control Hosp Epidemiol. 2011; 32(4):305-314.

6. Saint S, Veenstra DL, Sullivan SD, Chenoweth C, Fendrick AM. The potential clinical and economic benefits of silver alloy urinary catheters in preventing urinary tract infection. Arch Intern Med. 2000; 160:2670-2675

7. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 1995; 155:1425-9.

8. Klevens RM, Edwards J, Richards C, Horan T, Gaynes R, Pollock D, Cardo D. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports 2007; 122:160-166.

9. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 2000; Feb; 28(1):68–75.

10.Haley RW et al. Nosocomial Infections in US Hospitals, 1975-1976. Estimated Frequency by Selected Characteristics of Patients. Am J Med. 1981; 70:947-59.

11.Krieger JN, Kaiser DL, Wenzel RP. Urinary Tract Etiology of Bloodstream Infections in Hospitalized Patients. J Infec Dis. 1983; 148(1):57-62

12.Meddings J, Saint S, Fowler KE, Gaies E, Hickner A, Krein SL, Bernstein SJ. The Ann Arbor criteria for appropriate urinary catheter use in hospitalized medical patients: results using the RAND/UCLA Appropriateness Method. Annals of Internal Medicine, in press.

13.Ontario Health Technology Assessment Series 2006; Vol.6, No.11:1-51. Available at:

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http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_pbu_040106.pdf. Last accessed on October 9, 2012.

14.Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 2008; 46:243-50.

15.Saint S, Kaufman SR, Rogers MA, Baker PD, Ossenkop K, Lipsky BA. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc. 2006; 54:1055-61.

16.Ortega R, Ng L, Sekhar P, Song M. Female Urethral Catheterization. New England Journal of Medicine 2008; 358(14):e15-18.

17.Thomsen TW, Setnik GS. Male Urethral Catheterization. New England Journal of Medicine 2006; 354(21):e22-24.

18.Saint S, Weiss J, Amory JK, et al. Are physicians aware of which of their patients have indwelling catheters? Am J Med 2000 Oct 15; 109(6):476-80.

19.Meddings J et al. Systematic Review and Meta-Analysis: Reminder Systems to Reduce Catheter-Associated Urinary Tract Infections and Urinary Catheter Use in Hospitalized Patients.” Clin Infec Dis 2010; 51(1 September):550-560.

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