On the CUSP: Stop CAUTI National Content Webinar 1 Welcome to the National Content Webinar!...

On the CUSP: Stop CAUTI National Content Webinar

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Welcome to the National Content Webinar!

Today’s Topic:

Interdisciplinary Academy for Coaching and Teamwork (I-ACT): Successes and Lessons Learned

Access slides, audio recording and transcript of today’s webinar on the national project website:

http://www.onthecuspstophai.org/on-the-cuspstop-cauti/educational-sessions/content-calls/

Today’s Presenters

Scott Flanders, MDClinical Professor

Department of Internal Medicine

University of Michigan

Eugene Chu, MD Director of Hospital Medicine

Boulder Community Hospital

Jenna Goldstein, MADirector

The Center for Hospital Innovation and Improvement

Society for Hospital Medicine

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Today’s Learning Objectives

Upon completion of today’s webinar, participants will be able to:• Articulate what the I-ACT course is and how the methodologies taught

in the course were developed to assist leaders with key strategies for addressing impediments to preventing and reducing the occurrence of catheter-associated urinary tract infection (CAUTI)

• Demonstrate the applicability of socioadaptive strategies and tools on CAUTI prevention to other key quality improvement initiatives in other harm areas

• Understand how employing key skills taught in the I-ACT course such as forming a multidisciplinary team can be maximized to reduce patient harm in your hospital

• Explain how the I-ACT methodologies could translate into long-term sustainability for multiple quality improvement initiatives in your hospital

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What is I-ACT?

• I-ACT was developed as an interactive one day workshop based upon the framework of the Society of Hospital Medicine’s Mentor University model

• I-ACT Attendees:– Faculty experts– State hospital association leads

• I-ACT Goals– Provide training on technical solutions and

socioadaptive strategies for CAUTI prevention4

Identifying the Need for I-ACT

• State leads and faculty experts were familiar with strategies for CAUTI prevention but…– Even “straightforward” technical solutions fail– Hospitals experience multiple socioadaptive impediments

to facilitating culture change– Examples: resistant physicians, no teamwork, workload

• State leads and faculty experts needed additional support and training to appropriately address these barriers

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Identifying the Need for I-ACT

• I-ACT was developed to address CAUTI prevention, but….– Improvement experts working with hospitals will need to

tackle many other problems (falls, C-diff, Abx use)– Participants needed to be equipped with implementation

skills that could be broadly applied across harm initiatives

• I-ACT addressed key socioadaptive elements – Promoting culture change, – Overcoming institutional impediments to change – Identifying and empowering MD and RN champions

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I-ACT Content

• I-ACT was designed as an advanced-level course to address– Complex clinical CAUTI challenges– Socioadaptive issues among multidisciplinary team members– Effective coaching

• 28 participants from multiple medical societies– Association of Professionals in Infection Control and

Epidemiology (APIC)– Emergency Nurses Association (ENA)– Society of Hospital Medicine (SHM)– Society of Healthcare Epidemiology of America (SHEA)

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I-ACT Content

• The agenda was developed by a planning committee with a goal of facilitating interactive sessions to explore CAUTI topics which addressed socioadaptive strategies in greater detail

• Interactive breakout sessions– Facilitate participation of all members of a CAUTI

prevention team including infection preventionists, hospitalists, nurses and state leads to best mirror the interactions of multidisciplinary teams

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Key I-ACT Topics

• Meeting presentations and topics included:– How to Coach the Team– Just Culture– Implementing and Sustaining Change to Prevent

CAUTI– How Practice and Surveillance Affect Your CAUTI

Efforts– Improving Teamwork and Patient Safety Culture– Redefining Appropriateness Criteria for Urinary

Catheters in Hospitalized Patients

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The I-ACT agenda

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Applying the I-ACT Tools

• Interactive sessions at I-ACT included:– Didactic sessions provided an overview of key

CUSP tools and strategies– Case studies paralleled scenarios encountered

in everyday practice – Small group sessions addressed strategies to

mitigate the most common barriers to creating and sustaining change

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Evaluating the Impact of I-ACT

• A survey was administered to assess participants’ perceptions of the I-ACT meeting:Comfortable With Pre PostData collection barriers 46% 71%Nonsupportive team members 32% 75%Complex catheter issues 18% 71%

• 100% rated their satisfaction with the course as good or excellent– skills learned could be applied to their daily work

• All rated the interactive components of the training beneficial and valued the ability to learn from experts in an in-person setting

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Key I-ACT Outcomes

• Participants learned in an in-person interactive forum using team based exercises

• I-ACT equipped faculty experts and state leads who serve as mentors, with the tools to assist hospitals with adequately addressing socioadaptive barriers to preventing and reducing the occurrence of CAUTI o The socioadaptive techniques assist in addressing some of the

most common impediments to real sustained change• I-ACT emphasizes the applicability of these socioadaptive

techniques to all quality improvement initiatives for improved safety and better patient outcomes

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Key I-ACT Outcomes

• But did these faculty help hospitals improve?– True impact cannot be quantified

• On the CUSP: Stop CAUTI– 985 Units enrolled– 32% reduction in CAUTI in non-ICUs!

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How can I-ACT Assist in Sustaining Change?

• Hospital teams continue to address complex quality problems like CAUTI, falls and other HAIs– Ultimately the same issues related to engagement,

communication and teamwork arise

• The socioadaptive strategies discussed at I-ACT are especially effective because they translate beyond one clinical condition– The tools can be consistently applied to all quality

improvement initiatives to facilitate and sustain change

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How can I-ACT Assist in Sustaining Change?

• Sustained change is made possible by effectively addressing the root causes to reducing harm including facilitating teamwork and enhancing communication

• These tools and strategies should be taught to frontline staff and consistently implemented so that they become a reliable part of everyday practice

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More about I-ACT

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I-ACT – A Journey of One

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The I-ACT Team

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The I-ACT Team

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Sanjay Saint, MD, MPH

Value based leadership.

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Polling Question: You are the CEO

The orthopedic surgeon states: “Once you go to medical school, you can tell me how to care for my patients.”

The surgeon is quite prominent and has threatened, in the past when confronted, that he will take his patients to a rival hospital.

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Polling Question: What do you do?

A. Explain to the nurse that the surgeon is invaluable to the hospital’s financial viability.

B. Ask the nurse why she thinks her Foley catheter is more important than a surgeon’s time.

C. Apologize to the surgeon for the nurse’s behavior.D. Tell the surgeon he is free to leave if he can not

interact respectfully with the staff.E. Ignore the situation. It’s come up before and will

pass.

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Answer: What do you do?





pass.

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Polling Question: What have you observed most CEO’s do in this situation?





pass.

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Answer: What have you observed most CEO’s do in this situation?





pass.

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Leadership Success Equation

Technical Acumen

Leadership Intelligence

Execution Competence

Performance Results

Values Based Leadership• Ethical Dilemmas• Ethical Decision Making• Corporate Responsibility• Sustainable Development• Intersections between

Ethics and Law

Values and Ethical Foundation

Dynamic Context

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Mohamad Fakih, MD, MPH

Change happens.

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Mean CAUTI Rates: Changes with New Definition(Edwards, Am J Infect Control 2009; 37:783-805, Dudeck, Am J Infect Control. 2011;39(5):349-367; Am J

Infect Control 2011;39(10):798-816 )

Unit2006-8 NHSN

CAUTI Rate* (per 1,000 catheter

days)

2009 NHSN S-CAUTI Rate (per 1,000 catheter

days)

2010 NHSN S-CAUTI Rate (per 1,000 catheter

days)ICU (med-surg, major teaching)

4.7 2.3 2.2

ICU (med-surg, >15 beds)

3.1 1.2 1.3

General wards (med-surg)

5.9 1.6 1.5

*Prior to the new SUTI definition

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(Fakih et al, Am J Infect Control 2012; 40: 359-64)

CAUTI Rate Changes

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Luke Hansen, MD MHS

The many faces of coaching.

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The many facets of the externalclinician improvement role

• Motivator (the coach)• Expert (the instructor, the librarian)• Guide (the navigator)• Advisor (the counselor)

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34



35



36



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Leadership Repertoire

Commanding(1)

Pacesetting(2)

Visionary(3)

Affiliative(4)

Democratic(5)

Coaching(6)

Modus Operandi

Demands Immediate

Compliance

Sets High Standard for Performance

Mobilized People Towards a Vision

Creates Harmony and Builds Bonds

Forges Alignment Through

ParticipationDevelops People

for the Future

In a phrase Do what I tell you Do as I do, now Come with me People come first What do you think? Try this

EI Competencies

Drive to achieve, initiative, self-

control

Drive to achieve, initiative,

conscientiousness

Self confidence, empathy, change

catalyst

Empathy, building

relationships, communication

Collaboration, team leadership, communication

Developing others, empathy, self-awareness

Color Energy RED RED/BLUE RED/YELLOW GREEN YELLOW GREEN/YELLOW

Works Best•Crisis•Kick start•Problem employees

•Quick results from motivated and competent team

•Change required•Clear direction needed

•Heal rifts in a team

•Stressful situations

•Build buy-in•Get input from valuable employees

•Help improve performance

•Long-term development

Adapted from: Primal Leadership: Goleman, Boyatzis & McKee

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Matching Styles with Figures

Commanding Pacesetting Visionary Affiliative Democratic Coaching

Modus Operandi

Demands Immediate

Compliance

Sets High Standard for Performance

Mobilized People Towards a Vision

Creates Harmony and Builds Bonds

Forges Alignment Through

ParticipationDevelops People

for the Future

In a phrase Do what I tell you Do as I do, now Come with me People come first What do you think? Try this

EI Competencies

Drive to achieve, initiative, self-

control

Drive to achieve, initiative,

conscientiousness

Self confidence, empathy, change

catalyst

Empathy, building

relationships, communication

Collaboration, team leadership, communication

Developing others, empathy, self-awareness

Color Energy RED RED/BLUE RED/YELLOW GREEN YELLOW GREEN/YELLOW

Works Best•Crisis•Kick start•Problem employees

•Quick results from motivated and competent team

•Change required•Clear direction needed

•Heal rifts in a team

•Stressful situations

•Build buy-in•Get input from valuable employees

•Help improve performance

•Long-term development

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David Pegues, MD

There’s no magic pill.

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Other Strategies

Q—Couldn’t we just use <INSERT device, medication, magic pixie dust> to solve our problem?

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Other Prevention Approaches

Approach Recommendation

Antimicrobial irrigation or placement in drainage bag

Not recommended

Prophylactic antimicrobials at catheter removal

Not recommended

Prophylactic antibiotics during catheterization

Not recommended due to concerns for emergence of resistant pathogens

Cranberry juice Not recommended routinely

Methenamine salts May be useful in patients s/p surgery catheterized for ≤7 days

Hooton TM, et al. Clin Infect Dis 2010;50:625-63.

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Antimicrobial Catheters for Reducing CAUTIs

• Methods: – Unblinded, randomized clinical trial; 24 UK hospitals– 7102 patients requiring short-term urinary catheterization– Randomized 1:1:1 to receive silver alloy-latex vs. nitrofural-silicone vs. standard

urinary catheter

• Results:

• Conclusion: – Routine use of antimicrobial-impregnated catheters was ineffective in reducing

symptomatic UTI rates

Catheter SUTI Rate by 6 wks AOR (95% CI)

Silver alloy 263/2097 (12.5%) 0.99 (0.81-1.22)

Nitrofural 228/2153 (10.6%) 0.81 (0.65-1.01)

Standard 271/2144 (12/6%) reference

Pickard R, et al. Lancet 2012;380:1927-35.

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Russ Olmsted, MPH, CIC

Victory is won in the trenches.

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CRITICAL CONTROL POINTS FOR BLOCK & TACKLE OF CAUTIS

Avoid use

unless appropri

ate indicatio

n

Promptly remove

of catheter when no

longer indicated

Reduction in

Inappropriate

Urinary Catheter

Use

Clear Identification of what is considered an appropriate indication

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CRITICAL CONTROL POINTS FOR BLOCK & TACKLE OF CAUTIS

Avoid use

unless appropri

ate indicatio

n

Promptly remove

of catheter when no

longer indicated

Reduction in

Inappropriate

Urinary Catheter

Use

Clear Identification of what is considered an appropriate indication

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Ian Jenkins, MD

Everyone is busy.

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My Brain on Call

WRITE NOTES

Call rheum consult

Obey DRG Nonsense

RN calling about colace

Angry patient wants “real doctor”

Ms. Smith fell

Renew medications

Conference presentation

LOOK GOOD ON ROUNDS

Coffee deficiency

Grand rounds in 10 min!

Discharge Jones & ChenDischarge prescriptions

Why is Nunez altered?

BEEP!

BEEP!

BEEP!

BEEP!BEEP!

. . . Safety Initiative

New Admission!

urinate > daily

Salvage marriage

HEART ATTACK

BEEP!

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My Brain on Call

WRITE NOTES

Call rheum consult

Obey DRG Nonsense

Angry patient wants “real doctor”

Renew medications

Conference presentation

LOOK GOOD ON ROUNDS

Coffee deficiency

Grand rounds in 10 min!

Discharge prescriptions

Why is Nunez altered?

BEEP!

BEEP!

BEEP!

BEEP!BEEP!

. . . Safety Initiative

New Admission!

urinate > daily

Salvage marriage

HEART ATTACK

BEEP!

Discharge Jones & Chen

Ms. Smith fell

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RN calling about the Foley

Karen Jones, RN, BSN

Who’s breaking the seal?

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Know How to Care for It

Use securement deviceMaintain a closed drainage system

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Who’s “breaking the seal”?

• Point-prevalence on some ICU units indicated >50% seals were not intact

• Most required urine meters for accurate I’s & O’s – what was happening?

• Spoke to nursing staff on ICU units• Reviewed charts• Met with managers• Collaborative approach with ED, OR,

ICUs, med-surg units

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Barbara Edson, RN, MBA, MHA

It’s “just” culture.

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Managing Behavior - Just Culture

Design Examples

Barriers Differentiation

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Mohamad Fakih, MD, MPH

The culture of culturing.

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Polling Question: Appropriate a urine culture in asymptomatic patients with urinary catheters

1. Urine with sediments 2. Screening urinalysis with WBCs=303. Chronic urinary catheters on admission4. Before resection of a urinary bladder lesion5. 2 and 36. None

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Appropriate a urine culture in asymptomatic patients with urinary catheters

1. Urine with sediments 2. Screening urinalysis with WBCs=303. Chronic urinary catheters on admission4. Before resection of a urinary bladder lesion5. 2 and 36. None

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Resident physicians (n=106) and Nurses (n=159): triggers for cultures in catheterized patients

(Sibai et al, ID Week 2013, presentation 205 )

Trigger for Urine Culture

Resident Physicians (Answered Yes)

Nurses(Answered Yes)

Foul smelling urine 75 (70.8%) 146 (94.8%)Cloudy urine 84 (79.2%) 146 (94.8%)Sediments in urine 57 (53.8%) 129 (84.3%)Darker urine 39 (36.8%) 72 (47.7%)Chronic UC on admission

46 (43.4%) 115 (74.2%)

All of the above should not trigger a urine culture in catheterized patients!

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Chris Goeschel, ScD, MPA, MPS, RN, FAAN

Teamwork is a matter of perspective.

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48% 48%54% 59%

83% 88% 90% 93%

0

10

20

30

40

50

60

70

80

90

100

L&D RN/O B O R RN/Surgeon ICU RN/MD CRNA/Anesthesiologist

Physicians and RN Collaboration

RN rates Physician Physician rates RN

% o

f res

pond

ents

repo

rtin

g ab

ove

adeq

uate

team

wor

k

L&D RN/MD ICU RN/MD OR RN/Surg CRNA/Anesth

Physician and RN Collaboration

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Teamwork Disconnect

• MD: Good teamwork means the nurse does what I say

• RN: Good teamwork means I am asked for my input

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0

10

20

30

40

50

60

70

80

90

100

% o

f res

pond

ents

with

in a

n IC

U re

port

ing

good

team

wor

k cl

imat

eTeamwork Climate Across Michigan ICUs

No BSI 21% No BSI 44% No BSI 31%

No BSI = 5 months or more w/ zero

The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care

Health Services Research, 2006;41(4 Part II):1599.

Teamwork climate across Michigan ICUs

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Characteristics

Common PurposeClear Roles

Accepted LeadershipEffective ProcessesSolid Relationships

Excellent Communication

Thiel D. A process to build high performance teams. 2007

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David Pegues, MD

There is a right way.

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Question from a CNA/CAUTI Champion

Q—What is the optimal approach to specimen collection and catheter management in case of suspected CAUTI?

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Polling Question: Management of Suspected CAUTI

A. Send RUA. If RUA positive, send UC. Do not change IUC.

B. Send RUA. If RUA positive, change IUC and resend RUA. If positive, send UC.

C. Send RUA. If RUA positive, change IUC and send RUA and UC.

D. Send RUA and UC. Do not change IUC.E. All of the above.F. None of the above67

Answer: Management of Suspected CAUTI

A. Send RUA. If RUA positive, send UC. Do not change IUC.

B. Send RUA. If RUA positive, change IUC and resend RUA. If positive, send UC.

C. Send RUA. If RUA positive, change IUC and send RUA and UC.

D. Send RUA and UC. Do not change IUC.E. All of the above.F. None of the above68

Urine Culture and Catheter Replacement before Treatment, IDSA

If an indwelling catheter has been in place for >2 weeks at the onset of CA-UTI and is still indicated, the catheter should be replaced to hasten resolution of symptoms and to reduce the risk of subsequent CA-bacteriuria and CA-UTI (A-I).

– i. The urine culture should be obtained from the freshly placed catheter prior to the initiation of antimicrobial therapy to help guide treatment (A-II).Hooton TM, et al. Clin Infect Dis 2010;50:625-63.

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Sanjay Saint, MD, MPH

Sticks and stones.

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Conformity & Social Learning

Conformity & social learning are universal

Conformity: tendency to prefer behavior that is common in the local population despite previous preferences for other options

Social learning: when the beliefs and behavior of a group are internalized by an individual

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This cultural transmission of behavior is a “second inheritance system”

culture

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“Because if I do not bring my own bags into Whole Foods, I

get dirty looks.”

culture

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I-ACT

Leader – Follower

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I-ACT

Coach – Mentor

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I-ACT

Process – Person

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I-ACT

Hard – Soft

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Thank You

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Thank You!

Questions for our presenters?

Press *1 to ask a question.

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Your feedback is important

Thank you for participating in today’s call. Please take a moment to fill out

this evaluation: https://www.surveymonkey.com/s/CAUTI_Content

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https://www.surveymonkey.com/s/CAUTI_Content

Upcoming National Content Webinars

Date Time/Duration Topic

3/10/1512 ET/11 CT/10 MT/9

PT(60 minutes)

2015 NHSN CAUTI Definition Changes

4/14/1512 ET/11 CT/10 MT/9

PT(60 minutes)

Sustainability & Spread

5/12/1512 ET/11 CT/10 MT/9

PT(60 minutes)

Project Report Out

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March National Content Webinar

2015 NHSN CAUTI Definition Changes

Katherine Allen-Bridson, RN, BSN, MScPH, CICProtocol and Training Team Lead

Division of Healthcare Quality PromotionCenters for Disease Control and Prevention

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On the CUSP: Stop CAUTI National Content Webinar 1 Welcome to the National Content Webinar!...

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