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CAUTI Prevention Pillar #3

Maintain Bug-Free CathetersOptimize day-to-day urinary catheter care

A CAUTI Action Network Prevention Series Webinar

Thursday March 15, 2012

Jennifer Palagi, MPH, BSN, RN, CIC Quality Improvement Consultant

Tina Schwien, MN, MPHQuality Improvement Consultant

C A U T I P r e v e n t i o n P i l l a r s

Avoidance

InsertionRemoval

2

Maintenance

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Today’s Agenda

Patient story

Best practice

Hospital Story

Di i

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Discussion

Next in Series

Patient Story

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Defect Analysis: What could have prevented this CAUTI?

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Patient Story: 63 year old Male

• Admit date: 11/1/11 “Found Down” with core body Temp of 80 D F h h it80 Degrees Fahrenheit

• Temp Sensing silver-latex Foley and rectal temp probe placed 11/1/11 with negative urine cx.

• 11/5/11 Temp 100.6 and >100,000cfu Staph Hominis from Urine cx. Pt c/o Pain/Burning

• Organism 100% NF susceptible based on published in vitro

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gdata.

• Are temp sensing Foley Catheters necessary?

Guiding Principle

Design processes so maintenance occurs reliably for

• Every patient

• Every time

• Every shift

• Every clinical caregiver

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Routine Maintenance: Do

Maintain a sterile, continuously closed drainage system

Practices to Avoid: Do Not

Irrigate catheters, except in cases of catheter obstruction

Keep catheter properly secured to prevent urethral traction

Keep collection bag below level of the bladder at all times-not on floor

Maintain unobstructed urine flow

Disconnect the catheter from the drainage tubing

Replace catheters routinely; if you must, use aseptic technique

Clean periurethral area with antiseptics

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IHI Improvement Map. Getting Started Kit: Prevent Catheter-Associated Urinary Tract Infections How-to Guide; HICPAC Guideline for Prevention of CAUTIs 2009

Maintain unobstructed urine flow

Empty collection bag regularly; don’t allow draining spigot to touch

the collecting container

p pwhile catheter in place

Break junction between catheter and collection tubing when collecting for

urine samples

Bundle Approach as an Option

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Example Bundle from Health Protection Scotland projecthttp://www.hps.scot.nhs.uk/haiic/ic/CAUTIPreventionBundle.aspx

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Education, Training, & Assessment

• Train and verify competency of all clinical staffTrain and verify competency of all clinical staff who may insert and maintain urinary catheters

• Do not assume staff are competent

• Standardized education/training materials

• Periodic re-training or assessment

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Meredith Hotchkiss BSN, RN

St. Luke’s Meridian Medical Center

Infection Prevention Practitioner208.706.1194 hotchkim@slhs.org

Aimee Baerlocher, BS, CICInfection Prevention Practitioner

208.381.2091 baerloca@slhs.org

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St Luke’s Meridian Med/Surg

July, 2010- Two year retrospective study, including dit id tifi d l iprocess audits, identified several issues

EBP was reviewed

Foley care skills labs for all CNA’s

Basin bathing was eliminated

Charge nurse report sheet tracks Foley days/physician orders.

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days/physician orders.

Physician letter in chart to renew order.

Comfort Baths Pros and Cons

ConsPros

• Cost

• Pt satisfaction (needs

scripting)

• Nurse/CAP satisfaction

• Cost

• Easy to use

• UTI prevention

• EBP

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• Standardize product

• Efficiency

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6 00

7.00

Meridian 5th FloorCatheter Associated UTI's per 1000 Foley Days

(Jan 2008-Dec 2011)

1.00

2.00

3.00

4.00

5.00

6.00

Use of Comfort Bath began Dec-2010

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0.00

Catheter Associated UTI's per 1000 Foley Days

25.00

30.00

Meridian 6th FloorCatheter Associated UTI's per 1000 Foley Days

(Mar 2008 - Dec 2011)

5.00

10.00

15.00

20.00Use of Comfort Bath began Dec. 2010

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0.00

5.00

Mar

-08

Apr

-08

May

-08

Jun-

08Ju

l-08

Aug

-08

Sep

-08

Oct

-08

Nov

-08

Dec

-08

Jan-

09F

eb-0

9M

ar-0

9A

pr-0

9M

ay-0

9Ju

n-09

Jul-0

9

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10F

eb-1

0M

ar-1

0A

pr-1

0

May

-10

Jun-

10Ju

l-10

Aug

-10

Sep

-10

Oct

-10

Nov

-10

Dec

-10

Jan-

11F

eb-1

1

Mar

-11

Apr

-11

May

-11

Jun-

11Ju

l-11

Aug

-11

Sep

-11

Oct

-11

Nov

-11

Dec

-11

Catheter Associated UTI's per 1000 Foley Days

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Next Steps for HousewideImplementation

ApprovalApproval

Gather # of warmers each unit needs (no charge)

• Determine go live date

• Ordering information

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• Education

• CNA skills lab (return demonstration)

Swedish Medical Center – Cherry Hill

Eric Wolak, MSN, RN, NE-BC, CCNS, CCRN-CSCNurse Manager –

Cardiovascular ICU and Emergency DepartmentErik.Wolak@swedish.org

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Swedish Slides

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M Ch BSN RN CIC

Kootenai Health / Kootenai Medical Center

Marc Chavez BSN, RN-CICInfection Prevention Coordinator

mchavez@kmc.org

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Measuring the Effect of a Multi-Factorial Intervention

to Decrease CAUTI in the Acute Care Setting

Marc Chavez BSN, RN-CIC; Carol Williams RN, BSN, CHPN; Carmen Sincerbeaux RN, MA, CNOR; Lee Rieken RN, CIC; Marian Wilson RN-

BC, MPH; Ashley English RN, BSN

Kootenai Medical Center

• Coeur d’Alene IdahoIdaho

• 246-bed

• Not for profit district hospital

• ANCC Magnet D i tiDesignation Awarded February 2006

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Background

• Indwelling urinary catheters can place patients at high risk for catheter associated

f (C )urinary tract infection (CAUTI).

• These infections can:o Prolong Hospitalization

o Increase Healthcare Costs

o May Result in Sepsis or Death

• Evidence-based guidelines have been developed to standardize care and reduce risk, however, no clear consensus exists on most effective implementation.

Objectives

This study aims to evaluate the effects of a hospital-wide intervention by measuring

1) Catheter Associated UTI (CAUTI) Rates

2) Rate of Device Utilization (indwelling urinary catheter d )days)

3) Percentage of Devices Removed by Postoperative Day Two (SCIP Inf-9)

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Methods

• A pre-test post-test intervention study design was used to evaluate outcomes. o Descriptive Statistics

o Independent t-tests

• The multi-factorial intervention was based on current evidence for CAUTI prevention and included: o Policy Revision

o Daily Medical Necessity Documentation

o Computerized Education Module

o Systematic Surveillance and Feedback

Intervention

• Policy Revision Included:yo Criteria for Insertion of Foley

o Daily Medical Necessity Order Checklist

o Pre Insertion Perineum Care

o Securement Device

o Collection Bag Maintenance Below Level of the Bladder

o Perineum care changed from each shift to every day based on Evidence Based Practice recommendations

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Intervention

• Computerized Education Moduleo Developed utilizing Health Stream

o Required by all staff with patient contacto Nursing Module in depth training

o Ancillary staff module i.e. Radiology, PT, OT, and Patient Transport which focused on drainage bag placement.

Methods

• Data collected from 9 inpatient units

o Pre-intervention period March 2009 through March 2010

o Post-intervention period April 2010 througho Post intervention period April 2010 through December 2010

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Results

4.0 4.0

3.7

3.5

4.0

4.5

CAUTI Rate Hospital WideApril 1, 2010

Facility wide implementation of CA-UTI Reduction Bundle

Pre Intervention Rate 2.0Post Intervention Rate 1 4

3.0 3.03.2

2.9

2.3

2.1

2.4

2.7

1.31.5

1.31.2 1.2

1.0

1.5

2.0

2.5

3.0

Rate per 1000 Catheter days

February 1, 2010House wide

Education for new policy and trial on

general Medical Unit

Post Intervention Rate 1.4P= 0.68

0.0 0.0 0.0 0.0 0.00.0

0.5

CAUTI Rate CA-UTI Trend

Results

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Hospital Wide Catheter Utilization Rate

4

6

8

10

12

14

16

18.2 14.8Catheter Days/Patient

Days x1000

P =0.005

0

2

4

12 month Pre-Intervention

9 month Post-Intervention

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Conclusions

• A significant reduction in device utilization was accomplished.

• A statistically significant reduction in CAUTI rate was not achieved during the 9-month time periodo Goal of 30% rate reduction was achieved

Limitations

• Variation among units in compliance with the new practices likely influenced these findings

• Tools and processes are needed to improve clinician compliance with daily assessments for medical necessity ofassessments for medical necessity of catheters

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Healthcare Infection Control Practices Advisory Committee 2009

If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTIcomprehensive strategy to reduce rates of CAUTI, consider using antimicrobial/antiseptic-impregnated catheters.

The comprehensive strategy should include, at a minimum, the high priority

recommendations for urinary catheter use, aseptic insertion and maintenance (seeinsertion, and maintenance (see

Section III. Implementation and Audit). (Category IB) (Key Question 2B)

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Objectives

• The purpose of this pilot study is to evaluate the effects of a product conversion from silver impregnated latex Foley catheters to Nitrofurazoneimpregnated silicone Foley catheters on.– CAUTI Rate– CAUTI Rate

– Facility Cost

– Utilization of Antibiotic for treatment of CAUTI

Background: Based on In Vitro testingJohnson, Delavari & Azar. (1999). Activities of a nitrofurazone-contaning catheter and a silver hydrogelcatheter against multidrug-resistant bacteria characteristic of catheter-associated UTI. Antimicrob Agents Chemother, 43(12):2990-5

2009 CA-UTI By Organism Total Pathogens Nitrofurazone Susceptability

E C li 10 S blE-Coli 10 Susceptable

K Pneumonia 5 Susceptable

Enterococcus Faecalis 4 Susceptable

Proteus 3 Not Susceptable

E t b t 2 S t blEnterobacter 2 Susceptable

Citrobacter 2 Susceptable

Morganella 1 Susceptable

Total 27

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Background: Based on In Vitro testing

Johnson, Delavari & Azar. (1999). Activities of a nitrofurazone-contaning catheter and a silver hydrogel catheter against multidrug-resistant bacteria characteristic of catheter-associated UTI. Antimicrob Agents Chemother, 43(12):2990-5

2010 CA-UTI By Organism Total Pathogens

Nitrofurazone SusceptabilityOrganism Total Pathogens Susceptability

E-Coli 9 Susceptable

EnterococcusFaecalis 4 Susceptable

K Pneumonia 1 SusceptableK Pneumonia 1 Susceptable

EnterococcusFaecium 1 Susceptable

Total 15

18.6%

15.8%

13.6%

15.3%15.2%

13.9%14.4%

13.4%

15.3%14.8%

16.0%16.0%16.1%

13.7%

16.7%

14.8%

16.3%16.9%

16.2%16.3%16.2%16.9%

14.2%13.6%

5.0

6.0

7.0

8.0

15.0%

20.0%

Housewide CA-UTI Data

1 case 7/13/11, same day as rollout1 case 7/13/11, same day as rollout

Temp Sensing Urinary Catheter

0.0 0.0

4.0

2.4

3.7

2.7

1.31.5

1.3

0.0

1.2 1.2

0.0

3.0

1.1

0.0

3.4

1.1

2.5

0.0 0.0 0.0

1.4

0.0 0.0

10.6%

0.0

1.0

2.0

3.0

4.0

0.0%

5.0%

10.0%

Infe

ctio

n R

ate

Uti

liza

tio

n R

ate

CAUTI RateKootenai Device UtilizationLinear (CAUTI Rate)

2009 CA-UTI Housewide Cases - 27 Rate 2.82010 CA-UTI Housewide Cases - 15 Rate 1.62011 CA-UTI Housewide Cases - 10 Rate 1.1

2009 CA-UTI Housewide Cases - 27 Rate 2.82010 CA-UTI Housewide Cases - 15 Rate 1.62011 CA-UTI Housewide Cases - 10 Rate 1.1

2010 CA-UTI Utilization Rate15.2%2011 CA-UTI Utilization Rate - 15.7%

Goal CA-UTI Rate 0.0

2010 CA-UTI Utilization Rate15.2%2011 CA-UTI Utilization Rate - 15.7%

Goal CA-UTI Rate 0.0

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Cusum Chart

Significance and Implications:

• Internal average cost per case of CAUTI using Premier Software $18,003 per incident.

• Using this number a nursing-led research initiative potentially saved the facility more than $800 000 over a two year periodthan $800,000 over a two year period.

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Significance and Implications:

• Nitrofurazone-impregnated catheter may reduce CAUTI events among hospitalized inpatientsCAUTI events among hospitalized inpatients.

• Longer time periods will be needed to increase confidence in the preliminary findings.

• New products may allow organizations to reach goals of zero CAUTI events

Contact Information

• Marc Chavez RN BSNo 208-666-3018

o mchavez@kmc.org

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References

1. Fekete, Calderwood, & Baron. (2009) Urinary tract infection associated with indwelling bladder catheters. Retrieved July 2009 from www.utd.com/online/content/topic.do?topicKey=uti

2. Lo E. Nicole L. Classen D. et. al. Strategies to prevent catheter associated urinary tract infections in acute care hospitals. InfectControl Hosp Epidemiol 2008:29:S41-S50.

3. R. Douglas Scott II et. Al. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and Benefits of Prevention Centers for Disease Control and Prevention March 2009

4. Foxman B. Epidemiology of urinary tract infections: incidence, mortality, and economic costs. Am J Med. 2002;113(1A):5S-13S.

5. Centers for Disease Control. Cathter-associated urinary tract infection (CAUTI) event Atlanta Ga: CDC. March 2009. Retrieved February 2009 http//www cdc gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent pdfRetrieved February 2009 http//www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf.

6. Gould C. et. Al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Healthcare Infection

Control Practices Advisory Committee. Retrieved

References

• 7. Leclair, et al. (2000). Effect of a nitrofurazone-impregnated urinary catheter on the incidence of catheter-associated UTI in burn patients. Presented 4th Decennial International Conference on N i l d H lth A i t d I f ti Atl tNosocomial and Healthcare-Associated Infections: Atlanta.

• 8. Stensballe et al. (2007). Infection risk with nitrofurazone-impregnated urinary catheters in trauma patients. Ann Int Med, 147(5):285-93.

• 9. Johns Hopkins. (2007-2008). Bayview foley-associated UTI before and after implementation of nitrofurazone foley catheter. Unpublished.

• 10. Johnson, Delavari & Azar. (1999). Activities of a nitrofurazone-contaning catheter and a silver hydrogel catheter against multidrug-resistant bacteria characteristic of catheter-associated UTI.hydrogel catheter against multidrug resistant bacteria characteristic of catheter associated UTI. Antimicrob Agents Chemother, 43(12):2990-5

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Discussion

• What excited you about what you heard?

• What can you do “by next Tuesday”

• What might get in your way?

• Any offers/requests?

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Next Up in the Series

NEW

Avoidance

Jan 19, 2012

Insertion

Feb 16, 2012

Removal

May 3, 2012

Maintenance

Mar 15, 2012

DATE!!!!!

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Thank You

Please complete the brief survey monkey evaluation when you close out of the webinar.y

IdahoJennifer PalagiQI ConsultantPatient Safety(208) 383-5944

WashingtonTina SchwienQI Consultant Patient Safety(206) 288-2466

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For more information: www.QualisHealthMedicare.orgThis material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.The contents presented do not necessarily reflect CMS policy. ID/WA-C7-QH-742-03-12

jenniferp@qualishealth.orgtinas@qualishealth.org