National Healthcare Safety Network (NHSN)

Transcript National Healthcare Safety Network (NHSN)

Kimberlee J Souhrada MM, BSN, CLNC

Clinical Specialist, Rochester Medical Corporation One Rochester Medical Drive Stewartville, MN 55976

Office: 800-615-2364 x609; 507-533-9609 Mobile: 651.319.2714

At her weekly book club meeting, Donna is again embarrassed by the inability to control her bladder.

Author affiliation: Rochester Medical Corporation Memberships: APIC, SUNA, NLN, AACN, AORN, NACLNC

“This program has been approved by the American Association of Critical-Care Nurses (AACN) for 1.0 CERPs, Synergy CERP Category B , File Number 00017795”

Identify and describe the risks and complications associated with CAUTI Review and assess the complexity of Consumer Awareness and Healthcare Reform as they relate to CAUTI Review NHSN hospital reporting system as it pertains to symptomatic UTIs Assess TJC and the 2012 National Patient Safety Goal Analyze the common goals and objectives of agency guides for CAUTI reduction initiatives

“Catheter Fever”

Catheter “To let or send down”  To relieve painful retention of urine since time immemorial  Ancient materials – from 3000 BC!!!

• • • Straw Rolled up palm leaves Dried leaves of allium, gold, silver, copper, brass and lead  11 th Century • Development of malleable catheters with bored holes  19 th and early 20 th Century • Coude’ catheter • Self-catheterization for urinary retention - “Catheter Fever”  1930s - The Foley • Dr. Frederic E.B.Foley; St. Cloud, MN

 Indwelling Urinary Catheters (IUC) are inserted in >5 million patients per year  One out of four hospitalized patients will have an IUC • • 40 – 50% do not have a valid indication for use In a recent study >50% of physicians did not know which patients were catheterized or for how long  ~ 40% of all HAI – most common site of Hospital Acquired Infection (HAI)  UTIs account for more than 8 million doctor visits per year  8% prevalence in the home care setting  Leading cause of secondary bloodstream infection  Most are asymptomatic  900,000 patients with nosocomial bacteriuria in US hospitals each year

 Discomfort  Daily Risk for UTI from an IUC – 3%-7%  Prolong hospital stay  Secondary bacteremia/sepsis  Acute pyelonephritis  Increased use of antimicrobial drug therapy  Urethral stricture  Increased mortality – 5% of all deaths from HAI are associated with urinary catheters  MDRO Infection  Increased cost • • Adds $500 to $3800 to hospitalization cost/ $400M to >$1B annually The CMS no longer reimburses hospitals for the costs associated with the development of HAIs – CAUTI

PRIMARY  Female  Age >50  Diabetes  Urethral colonization  Debilitated health  Incomplete bladder emptying  Fecal incontinence SECONDARY  Dehydration  Sickle-cell anemia  Immobility  Concurrent infections  History of UTI  Colonization with MDROs  Poor personal hygiene

 Lack of hand hygiene prior to catheter manipulation  Drainage spigot contamination  No catheter securement  Catheters in place too long  Poor insertion technique  Breaks in the closed system or non-use of a closed system  Drainage bag raised above the level of the bladder  Lack of use of methods to control incontinence  No sample port on closed system

Historical Timeline of Key Events

 Pioneered the principle of accountability for the results of medical practice

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.”

 Campaigned to improve health standards with measurable outcomes supported by undeniable data

 1985 – First reporting of hospital data to a state agency • Maryland Quality Indicator Project (surgical morbidity)  1991 – NYS inadvertent publication of cardiac surgeon’s mortality rates • Note - with public awareness came a drop in mortality from 4.2% to 1.6% in ~ 10 years  Additional states and new conditions have been added to state reporting as legislation continues to change

Plaintiffs turned Protesters

 “To Err is Human” (1999) • • 98,000 deaths annually (3 full jumbo jets/qod) Medical error total cost is estimated at $17 - $29B

“It is not acceptable for patients to be harmed by the health care system”

 The IOM recommended “Four Tiered Strategy for Improvement” 1.

Establish a national focus Identify and learn from errors through nationwide public reporting Raise performance standards and expectations Implement safety systems in HealthCare Organizations

Centers for Medicare & Medicaid Services (CMS)

“Hello, incontinence helpline – can you hold?”

US Dept of Health & Human Services (HHS)

National Institutes of Health (NIH)

Centers for Disease Control & Prevention

(CDC) National Institute for Occupational Safety & Health Office of Infectious Diseases Food & Drug Administration (FDA) Agency for Healthcare Research & Quality (AHRQ) Center for Quality Improvement and Patient Safety Centers for Outcomes & Evidence

Centers for Medicare & Medicaid Services (CMS)

Nat’l Ctr for Emerging & Zoonotic Infectious Diseases

HICPAC National Health Safety Network (NHSN)

Family Tree

And 21 more!

 CMS has transformed from a passive payer of services into an active purchaser of higher quality, affordable care.  Now rewards providers by linking the payment to the quality and efficiency of care provided

*The CMS main goal: to foster joint clinical and financial accountability in the healthcare system.

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Inpatient and Home Healthcare: Pay-for-Reporting

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Reduction of payment for hospitals and Home Health Agencies not submitting data regarding specified quality measures

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Medicare Home Health Compare and Hospital Compare

www.medicare.gov

Resource link •

More measures continue to be added

 Improve clinical quality, patient safety and efficiency of care  Reduce adverse events  Encourage patient-centered care  Avoid unnecessary costs  Stimulate investment in systems to improve quality and efficiency  Make performance results transparent and understandable for consumer empowerment

National Health Safety Network (NHSN)

 State reporting to CDC initially was voluntary, and not standardized  2005 - NHSN Reporting System was launched • • Standard in HAI surveillance Open enrollment to all types of healthcare facilities in the US  2008 – CMS disallows payment for certain Hospital Acquired Conditions (HAC) such as: • • • • CAUTI Staph Aureaus bloodstream infections Serious bedsores, objects left in pt, blood incompatibility, and air embolism Surgical Site Infections (SSI)

Patient Safety Component Patient Safety Component Central Line Associated BSI - CLABSI Ventilator Associated Pneumonia VAP

Device Associated Model - DA Catheter Associated UTI - CAUTI

Dialysis Incident - DI Procedure Associated Model - PA Medication Associated Model - MA Surgical Site Infection - SSI Post-procedure Pneumonia PPP Antibiotic Use and Resistance - AUR

*Reporting will be publically accessible through www.hospitalcompare.hhs.gov

The NHSN uses the information reported to produce comprehensive rates used for hospital comparison.

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It is very important that the data is collected using exactly the same definitions each time.

 CAUTI: UTI that occurs in a patient who had an indwelling urethral catheter in place within 48 hours prior to specimen collection.

 Transfer Rule: If the UTI develops in a patient within 48 hours of discharge from a location, the discharging location is indicated  NHSN definitions: Reportable CAUTI

http://www.cdc.gov/nhsn/index.html

• Six specific definitions • Four are associated with the patient that had an indwelling urinary catheter at the time of specimen collection, removed within 48 hours prior to specimen collection, and the patient who did not have an IUC • Two definitions for patients < 1 year of age

The new 2012 National Patient Safety Goal (NPSG)

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Founded in 1951 it is the oldest and largest standards setting and accrediting body in healthcare

• Evaluates and accredits >19,000 health care organizations and programs in the US 

Governed by a Board of Commissioners

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Accreditation

• Earned by an entire health care organization 

Certification

• Earned by programs or services based within or associated with an accredited health care organization i.e. diabetes, heart disease, cancer, and more

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2002 – Established to help organizations address specific areas of patient safety concerns

• • Patient Safety Advisory Group determines the highest priority safety issues and how to address them Elements of Performance 

2004 - Aligned with the CDC and endorsed by CMS to standardize common measures

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Public website – www.qualitycheck.org

 Approval of one new NPSG NPSG.07.06.01 – Implement evidence-based practices to prevent

indwelling catheter-associated urinary tract infections (CAUTI)

•   Evidence-based guidelines 2008 SHEA Compendium of Strategies 2009 HICPAC/CDC Guideline •  Phase-in period TJC Survey will ensure planning and preparation for full implementation in 2013 •

This goal is not applicable to

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pediatric populations

Prevention Interventions and Control Practices

 APIC – Association for Professionals in Infection Control and Epidemiology • 2008 Guide to the Elimination of CAUTIs  SHEA – Society for Healthcare Epidemiology of America • 2008 Strategies to Prevent HAI in Acute Care Hospitals  CDC/HICPAC – Healthcare Infection Control Practices Advisory Committee • 2009 Guideline for the Prevention of Catheter-associated Urinary Tract Infections  IDSA – Infectious Diseases Society of America • 2009 Strategies to Reduce the Risk of CAUTI  IHI – Institute for Healthcare Improvement • 2011 How-to Guide: Prevent Catheter-associated Urinary Tract Infections

• Identify the Problem of CAUTI Prevalence and Burden 2.

• Risk Assessment Baseline data to determine patients at highest risk 3.

• Surveillance Monitoring and data collection 4.

• Strategies to Prevent CAUTI Policies, procedures, education, and feedback 5.

• Implementation of Best Practices ABC Bundle, protocols, and techniques

• • Basic Infection Prevention and Antimicrobial Stewardship Programs, Policies and Protocols Systems and Strategies 5.

• • • • UTI Pathogens Endogenous pathogens Contaminated equipment Environmental Long-term IUC 2.

• • Prevalence of Urinary Tract Infections Risk factors Bacteriuria 6.

• • • Pathogenesis Extraluminal Intraluminal Biofilms 3.

Urinary Catheter Use in Healthcare settings 7.

• Diagnosis of CAUTI Specimen collection 4.

Complications of IUCs

• Existing organizational program What systems are in place?

• Population at risk Point prevalence survey 3.

• • • Baseline outcome data Examine CAUTI utilizing pathology reports Assess location, frequency and prevalence Use NHSN definitions 4.

Financial impact Multidisciplinary Team

Surveillance for CAUTI is a dynamic and essential way to turn data into useful information to drive interventions!

 Elements of Surveillance 4.

Assessment of the population Identification of those at greatest risk Determination of observation time period Choice of surveillance methodology Monitoring for outcomes Collection of data Analysis of data Display and distribution of findings

 Clear and Consistent  Document UTIs, assess risk factors, and monitor procedures and practices  Device utilization ratio (NHSN) • • • Numerator – number of events Denominator – number or event-related catheter days or patient days Monthly assessment  Incidence – new cases in a given time period  Prevalence – number of cases at a particular point in time divided by the total population being studied

 Plan: Monthly rate of CAUTI in MICU for one year  Criteria: NHSN criteria for CAUTI  Data collection: Active surveillance of MICU patients  Numerator: Number of new CAUTI per month  Denominator: number of IUC days in MICU  Calculation of Incidence rate: • CAUTI RATE = Number of new CAUTI  Number of catheter days X 1000 • 2 UTI/702 catheter days = .002847 X 1000 = 2.8 per 1000 IUC days

*As of 02/2012 - Zero CAUTI

* Adherence to a sterile, continually closed system has been the cornerstone of CAUTI prevention

Appropriate Infrastructure 1.

Written guidelines for UC use, insertion and maintenance Only trained, dedicated personnel insert UCs Necessary supplies for aseptic technique Documentation system Resources to support surveillance B.

Surveillance Risk assessment and identification of patient units Standardized criteria Appropriate and valid C.

Education and Training

• • • • • Appropriate Technique for IUC Insertion Indications for insertion Alternatives Hand hygiene Aseptic technique and sterile equipment/kit Smallest size catheter E.

• • • • • • • Appropriate Management of IUCs Proper securement Sterile closed system Appropriate sample collection Unobstructed urine flow Empty the bag regularly Keep the bag below the level of the bladder Routine perineal hygiene after insertion F.

• • • Accountability Executive level support Management Direct healthcare providers

• • Remove Unnecessary IUCs Assess the need for an IUC daily Physician reminder systems – EMR, written, daily rounds reminder 2.

• Automatic stop orders Requires renewal of the order for continuation 3.

• • Nurse-driven protocols May be part of an algorithm Independent of a physician order 4.

* Postoperative Urinary Catheter removed on POD 1 or POD 2

Surgical patients – SCIP – 9 Core Measure Indicator Bladder scanners Anti-microbial coated catheters

septic insertion and proper maintenance

ladder ultrasound may avoid IUC

ondom or intermittent catheterization in appropriate patients

o not use IUC unless necessary

arly removal of catheters using reminders or stop orders

Create your own acronym for a Bundle that would work in your organization

 Culture of Patient Safety  • • • Information and education Foundation for surveillance Involvement can make a difference Assemble a Team • • • Oversee the process Be the driving force

“If you only have a hammer, you tend to see every problem as a nail.” -- A. Maslow

Partner with nursing, case management, infection prevention, and physicians  Implement Teamwork and Communication • • Use tools for improvement Identify opportunities and barriers

 Identify and Learn for Defects • • What happened and why What can be done to reduce risk  Engage Senior Executive • • • Bridge the gap Help remove barriers Implement improvement efforts • Everyone is accountable for efforts to reduce risks to patients

0,6 0,4 0,2 0 1,6 1,4 1,2 1 0,8

No of CAUTI/Patient Days*1000

1,37 0,77 18 16 14 12 10 8 2 0 6 4 Preintervention Postintervention

No of CAUTI/Month

16,4 43.3% Reduction 9,3 Preintervention Postintervention

 Catheter bundle implemented with a decrease in CAUTI > 83% in 5 years • St. Joseph Regional Medical Center, Lewiston, ID    In one month # of CAUTI dropped from 8 to 2 As of 1/30/12 no UTIs for 403 days Intervention provided a 98.87% decrease in UTI over 4 years • Tacoma General, Mary Bridge Children’s, Allenmore and Good Samaritan Hospitals, Tacoma, WA

 Bringing about cultural change is difficult but achievable  CAUTI rates can be reduced by a multidisciplinary approach  Review evidence-based resources  Implement recommended practices  Ensure that evidence-based practices are adhered to and embraced by all members of the team  Continuous education and feedback will bring success  Evaluate and re-evaluate your own facility  Do NOT give up the fight to Aim for Zero on CAUTI reduction!!

Finally, the “other” catheter is getting the attention it deserves!

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APIC 2008 Guide to the elimination of Catheter-associated Urinary Tract Infections A Brief History of Report Cards by John Steen Centers for Medicare and Medicaid Services, Roadmap for Implementing Value Driven Healthcare in the traditional Medicare Fee-for-Service Program The CMS. www.cms.hhs.gov

Healthcare Associated Infections: States and Public Reporting. ww.extendingthecure.org

Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention

of Catheter-associated Urinary Tract Infections 2009.

Infection control and Hospital Epidemiology. SHEA Position Paper 2008. Strategies to

Prevent Catheter-associated Urinary Tract Infections in Acute Care Hospitals

Infectious Disease Society of America 2009 International Clinical Practice Guidelines.

Diagnosis, Prevention, and Treatment of Catheter-associated Urinary Tract Infection in Adults

Institute of Medicine. To Err is Human Series: Building a Safer Health System & to Delay is

Deadly.

Jeffers, T.W., The GOAL: Elimination of Catheter Associated Urinary Tract Infections.

Online webinar slide retrieval. August 2011 The Joint Commission. www.jointcommission.org. 2012 Hospital National Patient Safety Goals Mourad,M., Auerbach,A., Improving Use of the “Other” Catheter. Archive of Internal Medicine. Vol 172 (no. 3) Feb. 13,2012. The Recovery Act. Whitehouse.gov/Recovery Responsible Reform for the Middle Class. The Patient Protection and Affordable Care Act The Center for Disease Control and Prevention. www.cdc.gov/nhsn