Transcript On the CUSP: Stop BSI

On the CUSP: Stop CAUTI
Implementing CUSP to Eliminate Catheter-Associated
Urinary Tract Infections (CAUTI)
Project Initiation Call
1
Overview of Today’s Call
• Welcome and introductions
• Why this initiative is important: Overview of CAUTI
• Comprehensive Unit-Based Safety Program (CUSP)
• Project overview and data requirements
– Expected outcomes
– What it requires
• What are the next steps
2
Project Goals
• Reduce CAUTI rates in participating units by 25%
– Appropriate placement
– Appropriate continuance
– Appropriate utilization
• Improve patient safety culture on participating
units
3
Project Overview
Hospitals or Hospital Systems
State Hospital Associations
National Project Team
Project
Management
Clinical Faculty &
Data Management
4
CUSP Faculty
National Project Team
Partner
Team Members
Michigan Health & Hospital Association
Keystone Center for Patient Safety & Quality
Sam Watson, MSA; Chris George, RN, MS
Health Research & Educational Trust
Steve Hines, PhD
Deborah Bohr, MPH
Marchelle Djordjevic, MBA
Centers for Disease Control & Prevention
Katherine Allen-Bridson, RN, BSN, CIC
Carolyn Gould, MD, MSCR
Johns Hopkins Quality Safety Research Group
Sean Berenholtz, MD
Chris Goeschel, MPA, MPS, ScD, RN
Ann Arbor VA Medical Center
University of Michigan Medical School
Sanjay Saint, MD, MPH
Sarah Krein, RN, PhD
St. John Hospital & Medical Center
Mohamad Fakih, MD, MPH
5
Healthcare-Associated Infections
(HAI’s)
• At least 20% of episodes are preventable; perhaps as
much as 70%
(Harbath et al. J Hosp Infect 2003)
• Medicare no longer reimburses U.S. hospitals for the
additional costs of certain infections
• Preventive practices are variably used
• The most common HAI is urinary tract infection
6
Urinary Catheter-Related Infection:
Background
• Urinary tract infection (UTI) causes ~ 40% of hospitalacquired infections
• Most infections due to urinary catheters
• Up to 25% of inpatients are catheterized
• Leads to increased morbidity and costs
7
Clinical Manifestations of CAUTI
• Clinical manifestations vary greatly
• Asymptomatic bacteriuria  overwhelming sepsis
• Symptomatic UTI:
– Lower abdominal, suprapubic, or flank pain
– Systemic symptoms: nausea, vomiting, fever
8
Burden-of-illness
• Of patients who receive urethral catheters:
– Bacteriuria rate is ~5% per day
• Among those with bacteriuria:
– ~10% will develop symptoms of UTI
– Up to 3% will develop bacteremia
• Direct medical costs:
– Symptomatic UTI: ~$600 per episode
– Bacteremia: ~$3000 per episode
(Tambyah et al. ICHE 2002; Saint AJIC 1999)
9
Centers for Medicare & Medicaid Services
(CMS) Rule Changes: 1 October 2008
• CMS now holds U.S. hospitals accountable for not
preventing certain hospital-acquired complications
• CMS required to choose at least 2 conditions that:
– are high cost and/or high volume; and
– could reasonably have been prevented through the
application of evidence-based guidelines
10
CMS Chose More Than 2 Conditions
•
•
•
•
•
•
•
•
•
•
Catheter-associated UTI
Vascular catheter-associated infection
Retained object during surgery
Air embolism
Blood incompatibility
Pressure ulcers
Surgical Site Infections after certain surgical procedures
Falls and Trauma
Manifestations of poor glycemic control
DVT or PE following certain orthopedic surgeries
11
Cost Implications of CMS Rule Change
University of Michigan patient with pneumonia:
• Without complication or comorbidity (CC): $6899
• With CA-UTI (CC): $8495 (~$1600 more)
University of Colorado patient with acute MI:
• Without CC: $5436
• With CA-UTI (CC): $6721 (~$1300 more)
(Wald and Kramer. JAMA 12/19/07)
12
Urinary Catheter-Related Infection:
Pathophysiology
Organisms enter the bladder by 3 ways:
1) At time of catheter insertion
2) Through the catheter lumen (from a colonized
drainage bag)
3) Along external surface of the catheter
(migrate along the catheter-mucosal interface)
(Tambyah, Halvorson, Maki. Mayo Clin Proc 1999)
13
Urinary Catheter-Related Infection:
Pathophysiology
Intraluminal
Extraluminal
Bladder infection with inflammation
Detrusor spasm
Shedding of cells
Leakage
Obstruction
(+) UA
14
Bacteremia
Fever
Hypotension
The Indwelling Urinary Catheter:
A “1-Point” Restraint?
Satisfaction survey of 100 catheterized VA patients:
• 42% found the indwelling catheter to be uncomfortable
• 48% stated that it was painful
• 61% noted that it restricted their ADLs
• 2 patients provided unsolicited comments that their
catheter “hurt like hell”
(Saint et al. JAGS 1999)
15
Catheter-Associated Urinary
Tract Infection
• Background
• Prevention
16
Prevention of CatheterAssociated UTI
 Make sure the catheter is indicated
• Adhere to general infection control principles (eg,
aseptic insertion, proper maintenance, hand hygiene,
education, feedback)
• Remove the catheter as soon as possible
• Consider other methods of prevention
17
UTI Prevention Rule #1: Make Sure the
Patient Really Needs the Catheter
Appropriate indications
Percent unjustified
• Bladder outlet obstruction
50
• Incontinence and sacral wound
40
• Urine output monitored
30
20
0
(Wong and Hooton - CDC 1983)
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Pt Days
• During or just after surgery
10
Initial
• Patient’s request (end-of-life)
Unjustified
(Jain. Arch Int Med 95)
Why are Catheters Used
Inappropriately?
• Perhaps physicians “forget” that their patient has
a urinary catheter
• We determined the extent to which doctors are
aware which of their inpatients have catheters
• Surveyed 56 medical teams at 4 sites
(Saint S, Wiese J, Amory J, et al. Am J Med 2000)
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One Reason Catheters Are Used
Inappropriately
Level
Proportion Unaware
of the Catheter
Medical students
18%
House officers
25%
Attending
physicians
38%
(Saint S, Wiese J, Amory J, et al. Am J Med 2000)
20
Urinary Catheters Often Placed in the
Emergency Department: A National U.S. Study
•
Catheters often inserted without clear indications and
may remain in place for convenience rather than
medical necessity
•
An Infection Control Nurse: “our other barrier is the
Emergency Department and this is where most Foleys
are placed. . . . Doctors forget to look under the sheets
to say, ‘Oh yeah, there’s a Foley there’ and … the nurses
aren’t going to take the initiative. . . ”
(Saint et al. Infect Cont Hosp Epid 2008)
21
Prevention of CatheterAssociated UTI
• Make sure the catheter is indicated
 Adhere to general infection control principles (e.g.,
aseptic insertion, proper maintenance, hand hygiene,
education, feedback)
• Remove the catheter as soon as possible
• Consider other methods of prevention
22
Use Proper Aseptic Technique for
Catheter Insertion
•
NEJM Videos in Clinical Medicine:
– Male Urethral Catheterization
T. W. Thomsen and G. S. Setnik - 25 May, 2006
– Female Urethral Catheterization
R. Ortega, L. Ng, P. Sekhar, and M. Song - 3 Apr, 2008
•
Goal is to avoid contamination of the sterile catheter
during the insertion process
•
Should not assume that the healthcare workers inserting
urinary catheters know how to do so
23
Prevention of CatheterAssociated UTI
• Make sure the catheter is indicated
• Adhere to general infection control principles (eg,
aseptic insertion, proper maintenance, hand hygiene,
education, feedback)
 Remove the catheter as soon as possible
• Consider other methods of prevention
24
Early Removal of Indwelling Catheters:
Summary of the Evidence
• 14 studies have evaluated urinary catheter reminders and
stop-orders (written, computerized, nurse-initiated)
– Significant reduction in catheter use
– Significant reduction in infection
– No evidence of harm (ie, re-insertion)
(Meddings J et al. Clin Infect Dis 2010)
25
Prevention of CatheterAssociated UTI
• Make sure the catheter is indicated
• Adhere to general infection control principles (eg,
aseptic insertion, proper maintenance, hand hygiene,
education, feedback)
• Remove the catheter as soon as possible
 Consider other methods of prevention
26
Other Methods for Preventing
CAUTI
• Alternatives to the indwelling catheter
–Bladder ultrasound
–Intermittent catheterization
–Condom catheter
27
On the CUSP: Stop CAUTI
Recent Guidelines on CAUTI
Prevention
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29
On the CUSP: Stop CAUTI
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
30
Modified HICPAC Categorization
Scheme
All Category I recommendations carry same strength; levels A and B represent the
quality of the evidence underlying the recommendation
31
Core Prevention Strategies:
(All Category IB)
Catheter Use
• Insert catheters only for appropriate indications
• Leave catheters in place only as long as needed
Insertion
Maintenance
• Ensure that only properly
Hand Hygiene
trained persons insert and
maintain catheters
• Insert catheters using
aseptic technique and
sterile equipment (acute
care setting)
Quality Improvement Programs
• Following aseptic
insertion, maintain
a closed drainage
system
• Maintain
unobstructed urine
flow
http://www.cdc.gov/hicpac/cauti/001_cauti.html
32
On the CUSP: Stop CAUTI
Comprehensive Unit-based
Safety Program (CUSP)
33
The Michigan Keystone ICU Project
saved over 1,500 lives and $200
million by reducing health care
associated infections.
Office of Health Reform,
Department of Health and Human Services
34
“Needs Improvement” Statewide
Michigan CUSP ICU Results
• Less than 60% of respondents
reporting good safety climate =
“needs improvement”
• Statewide in 2004 84%
needed improvement, in
2007 23%
• Non-teaching and Faith-based
ICUs improved the most
• Safety Climate item that
drives improvement: “I am
encouraged by my colleagues
to report any patient safety
concerns I may have”
35
Pre CUSP Work
• Create an CUSP/CAUTI team
– Nurse, physician, administrator, infection control,
others
– Assign a team leader
• Measure Culture in your clinical unit
(discuss with hospital association leader)
• Work with hospital quality leader to have a senior
executive assigned to your unit based team
36
Comprehensive Unit-based Safety Program (CUSP)
An Intervention to Learn from Mistakes and Improve Safety Culture
1.
Educate staff on science of safety
http://www.onthecuspstophai.org
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from one defect per quarter
5.
Implement teamwork tools
Timmel J, et al. Jt Comm J Qual Patient Saf 2010;36:252-260.
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Teamwork Tools
• Daily Goals
• AM briefing
• Shadowing
• Culture check up
• TEAMSTepps
38
CUSP Lessons Learned
• Culture is local
– Implement in a few units, adapt and spread
– Include frontline staff on improvement team
• Not linear process
– Iterative cycles
– Takes time to improve culture
• Couple with clinical focus
– No success improving culture alone
– CUSP alone viewed as ‘soft’
– Lubricant for clinical change
39
CUSP & CAUTI Interventions
CUSP
1. Educate on the science of safety
CAUTI
1.
Care and Removal Intervention
Removal of unnecessary catheters
2. Identify defects
Proper care for appropriate catheters
3. Assign executive to adopt unit
4. Learn from Defects
2.
Placement Intervention
Determination of appropriateness
5. Implement teamwork &
communication tools
Sterile placement of catheter
40
Expected Benefits
• Increased awareness of appropriate indications for
indwelling urinary catheter use
• Reduced use of indwelling urinary catheters
• Improved caregiver accountability to assess need and
trigger UC discontinuation when UC no longer
necessary
• Reduced risk of urethral trauma with reduction in
utilization
• Reduced patient discomfort
41
Expected Benefits
• Reduction in bacteriuria
• Reduction in symptomatic UTIs
• Shortened Length of Stay
• Decreased Cost per stay
• Improved sensitivity to “patient dignity”
42
What Participation Requires
Data Submission
Intervention
Measure
Suggested
Collector
Frequency
Readiness Assessment
Baseline
HSOPS
Baseline and post
All staff on unit
intervention
Team Check-up Tool
Quarterly
CUSP
Care and
Removal
Process Prevalence &
Appropriateness
Outcome
- UTI Rate / Device Days
Weekly within
Protocol
Monthly within
Protocol
Monthly within
- UTI Rate / Patient Days
Protocol
Insertion
TBD
TBD
43
Project Lead
Project team
Unit staff
Infection
Prevention
TBD
7
14
21
28
IMPLEMENTATION
SUSTAINABILITY
PERIOD 1
4
11
18
25
2
9
16
23
30
Baseline Data Collected
1
2
3
4
5
8
9
10
11
12
15
16
17
18
19
22
23
24
25
26
29
30
31
Intervention Data Collected
1
2
5
6
7
8
9
12
13
14
15
16
19
20
21
22
23
26
27
28
29
30
Intervention Data Collected
3
10
17
24
31
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
6
13
20
27
3
10
17
24
1
8
15
22
29
JUN 2011
JUL 2011
2
9
16
23
30
AUG 2011
BASELINE PERIOD
3
10
17
24
31
4
11
18
25
S
SEPT 2011
5
12
19
26
S
OCT 2011
S
Cohort 2 PROCESS
M
T
W
T
F
No Data Collected
1
2
3
6
7
8
9
10
13
14
15
16
17
20
21
22
23
24
27
28 29
30
No Data Collected
1
4
5
6
7
8
11
12
13
14
15
18
19
20
21
22
25
26
27
28
29
5
12
19
26
3
10
17
24
31
7
14
21
28
4
11
18
25
2
9
16
23
30
Cohort 2 OUTCOME
M
T
W
T
F
Baseline Data Collected
1
2
3
6
7
8
9
10
13
14
15
16
17
20
21
22
23
24
27
28 29
30
Baseline Data Collected
1
4
5
6
7
8
11
12
13
14
15
18
19
20
21
22
25
26
27
28
29
Baseline Data Collected
1
2
3
4
5
8
9
10
11
12
15
16
17
18
19
22
23
24
25
26
29
30
31
Intervention Data Collected
1
2
5
6
7
8
9
12
13
14
15
16
19
20
21
22
23
26
27
28
29
30
Intervention Data Collected
3
10
17
24
31
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
S
4
11
18
25
2
9
16
23
30
BASELINE PERIOD
6
13
20
27
3
10
17
24
IMPLEMENTATION
1
8
15
22
29
SUSTAINABILITY
PERIOD 1
No Data Collected
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
NOV 2011
No Data Collected
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
1
2
3
No Data Collected
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
25
26
27
28
29
30
DEC 2011
No Data Collected
4
5
6
7
8
9
10
11
12
13
14
15
16
17
24
18
19
20
21
22
23
24
31
25
26
27
28
29
30
31
Post-Intervention Data Collected
SUSTAINABILITY
PERIOD 2
Post-Intervention Data Collected
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
JAN 2012
SUSTAINABILITY
PERIOD 2
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
45
Data Collection Schedule
MEASURE
CAUTI Rates (Outcome)
1. Number of Symptomatic CAUTI’s
attributable to your unit for that month
2. Number of urinary catheter days per
month (number of patients with urinary
catheter device is collected daily at the
same time each day and the total is
summed for the month)
3. Number of patient days per month
Prevalence & Appropriateness (Process)
1. Assess each patient on the unit for the
presence of a urinary catheter
2. Record the reason for the catheter
DATA COLLECTION SCHEDULE
DATES
Collect monthly for 5 months beginning in 2011:
June and quarterly thereafter (JuneJune 1-30
August will be considered baseline)
July 1-31
August 1-31
September 1-30
October 1-31
2012:
January 1-31
April 1-30
July 1-31
October 1-31
Baseline: Mon-Fri for 3 weeks
Baseline: August 1-5, 8-12, 15-19,
2011
Prospective: Mon-Fri for 2 weeks, 1 day Prospective: September 5-9, 12-16,
per week for 6 weeks then one week per 20 & 27
quarter thereafter
October 4, 11, 18, 25
2012:
January 9-13
April 9-13
July 9-13
October 15-19
What are the Next Steps
Timeline at a glance
March 2
Unit attends first immersion call
March -May
Unit attends Kick Off Meeting and begins participating in
national content/coaching calls
March - May
- Participate in content and coaching calls
- Collect and report quarterly data to monitor change
June
Unit begins base line data collection and culture survey
47
Questions
• Content – Sam Watson, MHA Keystone
– [email protected]
• Participation–Kristina Davis, HRET
– [email protected]
48