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Catheter-Associated Urinary Tract Infections
(CAUTI)
Tennessee Performance Trends
Key Percentiles for Facility-Specific Catheter-Associated Urinary Tract Infection
(CAUTI) Standardized Infection Ratios (SIRs) in Adult and Pediatric Intensive Care
Units (ICUs) by Reporting Year, Tennessee, 01/01/2012 - 12/31/2013
SIR AND 95%
Key Percentiles
FACS WITH
CONFIDENCE INTERVAL FACS WITH FACS WITH
≥1 PRED. SIG. LOW SIR SIG. HIGH SIR
LOWER UPPER INFECTION
N (%)
N (%)
PRED SIR
10% 25% 50% 75% 90%
LIMIT LIMIT
# of INFECTIONS
YEAR No. UC Days
OBS
2013
92
325,892
935
680.94 1.37
1.29
1.46
68
5 (7%)
18 (26%)
0.00 0.40 0.85 1.57 2.61
2012
93
332,810
1004
700.07 1.43
1.35
1.53
67
6 (9%)
14 (21%)
0.00 0.39 1.16 1.82 2.44
Data reported as of September 4, 2014
No. = number of facilities; UC Days = urinary catheter days; OBS = observed number of CAUTI
PRED = statistically 'predicted' number of CAUTI; SIR = standardized infection ratio (observed/predicted number of CAUTI)
Key percentiles include facilities with at least one predicted infection
Red highlighting indicates SIR for reporting period is significantly higher than national 2009 SIR of 1.0
Green highlighting indicates SIR for reporting period is significantly lower than national 2009 SIR of 1.0
CAUTI Performance
January – June 2014
• 403 CAUTI events January – June 2014
• Of the 18 hospital “outliers” for 2013
– 11 showing some improvement
• 4 hospitals showing over 50% reduction
– 3 getting worse
– 4 no change in performance
CAUTI Recommendations – Call to Action from Deep
Dive Session Fall 2013 with CMO’s
– Focused leadership attention and accountability.
– Include CAUTI performance on organizational scorecards and in performance
evaluations of leaders/staff.
– Make hospital and unit level data visible to staff and physicians by posting on units.
– Utilize communication strategies such as daily staff huddles, communication
boards and bedside shift reports to identify, share and discuss patient safety
risks and mitigation plans.
– Define clinical protocols for indications for catheter placement to decrease
utilization.
– Develop and utilize nurse-driven protocols for prompt removal of catheters when
criteria for use are no longer met.
– Utilize daily multi-disciplinary rounds to assess continued need for any device
including urinary catheters.
Tennessee Center for Patient Safety
The THA Board accepted the recommendations from the THA Quality
Committee to address CAUTI performance:
•
•
•
THA board set a specific goal for a 40 percent reduction in CAUTI within
next 12 months (by July 2015)
– 371 fewer events July 2014-June 2015 compared to 2013
– THA staff focus on outlier hospitals to show clinical and financial impact
of poor performance and provide targeted resources
Hospitals share data on MRSA, C-difficile and healthcare worker
vaccinations with THA to include in TCPS summary reports and hospital
scorecards
– No new data collection required by hospitals. Hospitals would confer
rights to access in CDC reporting system
THA collect and monitor hospital performance for long-term acute care
(LTAC) and rehabilitation facilities using publicly reported metrics for CAUTI,
CLABSI, MRSA, C-difficile and healthcare worker vaccinations
Chris Edwards, MD, FHM
Chief Medical Officer
Maury Regional Medical Center
Lynnelle Murrell, RN,BSN,CIC
Director, Infection Prevention
Maury Regional Medical Center
8
ON THE CUSP:
A CAUTI Prevention Project
September 26, 2014
Number of CAUTI By Unit for 2013 and 2014
Unit
2013
2014
CCU
13
3
1W
3
1
2W
6
1
3W
2
1
MBU
0
0
5W
1
3
6W
0
2
CAUTI By Unit for 2014
Unit
Month
CCU
January
1W
August
2W
January
3W
February
MBU
0
5W
January x2, July
6W
March, June
Project Kickoff
oInvolved the whole facility
oIdentified Champions:
multidisciplinary and house wide
oPresented data in a personal form
oDeclared Zero Infections Tolerated
oA culture change regarding how we
think about urinary catheters
Measures
o Science of Safety video mandatory for staff
o Added Patient Safety Rounding for inpatient and
outpatient areas and
o Daily Multidisciplinary Rounds
– Included how many patients have urinary
catheters
– What is the plan for removal?
– Do you feel comfortable using the nurse
driven protocol for removal?
Policy Changes
o Added observer when inserting UC
o Implemented Nurse Driven Removal Protocol
• Tightened the indications for insertion, maintenance,
and removal to mirror the 2009 HICPAC guidelines
• Updated GU Shift assessment to include a hard
stop where staff would assess whether UC still
appropriate
o With rounding learned some staff were not
comfortable using protocol for removal without
physician’s order
• have to keep checking back with, educating staff
Measures
o Maintenance Bundle
– Monthly Point Prevalence Study with feedback
• Changed our ED to stock only urimeter kits so
admissions to CC would already have urimeter in
place
• Beds do not have an appropriate hanger for
catheter bag while in the low position
• CT Table no place to hang catheter bag
• Catheter Care charting not being done in EMR
– Educated Nurse Techs and added to charting
Measures
o Education and competencies
•
Every area that had the potential to touch a UC
- Nsg, Nurse techs, Radiology, Transportation,
PT/OT
• Developed a checklist and standard work related to
urinary catheter insertion
• Required demonstration for all licensed staff that will
insert and care for urinary catheters
• We know that practices change over the years
• Puts all staff on same page (standard work)
when observing insertions
Measures
o CHG bathing for critical care patients
• Survey about bathing practices before and after implementation
• People’s mindsets changed about the need for a daily soap and
water bath
• Has branched out to other areas of the hospital after seeing
outcomes
o Physician IP Education – contains HICPAC
indications for UC placement to put everyone on the
same page
Measures
o Status board built in Meditech – PCS
charting to quickly access UC related data
• Used by lead charge nurse for rounding on all
patients each shift
• To ensure interventions in place: Is it hanging
in the right place? Secured to leg? Is it still
needed?
Internal Reporting
o Event Analysis presentations at IP Council
• All HAI device infections and C. difficile are
reviewed by frontline staff involved in the
patient’s care.
• Frontline staff bring opportunities to meeting
to be discussed
• Frontline engagement and buy-in for IP
measures
• Leadership buy-in needed to make sure FLS
can get to the meeting
Internal Reporting
o Help staff connect the dots
• Standing agenda item on staff nurse, charge
nurse meetings
o Event analysis sent to Nurse Manager in
real time
o Monthly scorecard to individual units
o Data reported to Infection Control
Committee, Patient Safety Committee
and Quality Council
Real Time Reporting
Lean initiative: Visual
Management Boards
posted on the units contain
number of days infection
free
Attachments
• Hospitalist Multidisciplinary Round Guide.doc
• Urinary Catheter Insertion Care and Removal.pdf
• Urinary Catheter Removal Nurse Clinical Practice
Guideline.pdf
• MRH Urinary Catheter Insertion Assessment.doc
• CAUTI Prevention Pocket Card.doc
• Female Foley (insertion) Checklist.doc
• Physician IP Education.doc
Questions?
WEST TENNESSEE HEALTHCARE
SHERRI MCALEXANDER, RN, IP
JACKSON MADISON COUNTY
GENERAL HOSPITAL
635-bed tertiary care center
 Serves 17-county area of rural West
Tennessee
 5 adult intensive care units as well as a
neonatal intensive care unit
 Not-for-profit organization

CAUTI PREVENTION INITIATIVE






We began in September 2012
Started out with a CAUTI Bundle following the
HICPAC recommendations for CAUTI Prevention:
appropriate catheter usage, proper insertion and
maintenance, and prompt removal interventions
Rolled out education to the staff
CHG usage in ICUs
Bard Stat-lock
Rochester Medical Spirit condom catheters
Urinary
catheter
in place?
NO
No action necessary.
Reassess daily. Avoid
catheter placement.
YES
Criteria to continue:
*Urinary retention
Does the
patient meet
criteria for
the catheter?
*Urinary obstruction
YES
NO
*Assessment of UOP in critically ill ICU
patients: I&O q hour, chemically sedated on a
vent, pregnant pts on Magnesium drips
*Patients having selected surgeries:
gynecological, genitourinary, or surgeries on
contiguous (adjacent) structures such as
colorectal or abdominal/pelvic surgeries
*Assist in healing of perineal/sacral wounds in
incontinent patients
Remove
catheter
*Required immobilization for trauma or
surgery
*Hospice/Comfort/Palliative care patients
Catheters NOT indicated for:






Incontinence with no skin breakdown
Unable to ambulate
Close monitoring of urine output outside ICUs
Morbid obesity
Patient request
Confusion or dementia
*Chronic indwelling urinary catheters present
on admission
Continue to monitor
catheter need on a DAILY
basis.
Catheter Use
•Insert only for appropriate
indications
•Leave in place only as long as
needed
Catheter Insertion
•Ensure only properly trained
persons insert and maintain
catheters
•Insert using aseptic technique and
sterile equipment
Catheter Maintenance
•Maintain a closed drainage system
•Maintain unobstructed urine flow
PILOT AREAS

Non-ICU area’s DUR went from 0.28 in Jan 2014 to 0.19 in
April 2014 and 0.13 by June 2014

Medical ICU’s DUR went from 0.79 in Jan 2014 to 0.68 in April
2014

Coronary ICU’s DUR went from 0.87 in Jan 2014 to 0.55 in April
2014

Medical ICU had no CAUTI the first 7 months of 2014!
IN SUMMARY

House-wide, our device utilization ratio
has dropped from 0.36 in June of 2012 to
0.27 in April 2014
 In
our ICUs we have dropped our
CAUTI rate from 7.03 in December
2013 to 1.51 as of August 2014!
Upcoming Events
•
OB Monthly Team Webinar- September 29, 2014; 10:00am CST
•
TCPS October Monthly Webinar- October 17, 2014; 9:00am CST
•
OB Monthly Team Webinar- October 27, 2014; 10:00am CST
•
2014 THA Leadership Summit
th
– Wednesday November 5 at the Gaylord Opryland Hotel and Convention
Center in conjunction with THA’s Annual Meeting. Make plans to showcase
your improvement work by submitting a poster for presentation. Contact
Chris Clarke at [email protected] for details
Other Reminders
• Webinar Evaluation: Earn contact hours for webinar
participation after completing
• TCPS Newsletter: Sent every Tuesday afternoon
• IHI Open School: THA is providing free access to the IHI Open
School curriculum for 2014 to employees and trustees of our safety
partner hospitals.
• AHRQ Hospital Survey on Patient Safety (HSOPS): The Tennessee
Center for Patient Safety offers the survey to all safety partners at
NO COST. Go to www.tnpatientsafety.comTools and Resources
AHRQ Culture Survey for more information.
IHI Open School 2014
•
•
•
•
•
1.
2.
3.
4.
THA is providing free access to the IHI Open School curriculum to
employees and trustees of our safety partner hospitals.
21 online, self-paced courses including 72 lessons and corresponding
resources—videos, case studies, podcasts, featured articles, exercises,
networking
Free app for the iPhone and iPad by logging onto iTunes
Over 25 contact hours available for CME, CNE, CPHQ and ACPE credit
Certificate of completion
Register using instructions. Type “Tennessee Hospital Association” as
your facility to receive free membership.
Once registered, go to the course page: www.ihi.org/lms
Click the online learning tab and choose a lesson
Click Begin Lesson
34
Questions