Transcript CMS Inpatient Prospective Payment System Final Rule

Deborah A. Lichtenberg, RN, BSN, CIC
Infection Preventionist
Bard Medical
1
I am an employee of C. R. Bard, Inc., Bard Medical.
Any discussion regarding Bard products during my
presentation is limited to information that is
consistent with Bard labeling for those products.
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Describe the impact of CAUTIs on patient
outcomes and hospital costs.
Explain the pathogenesis of CAUTIs including
the role of biofilm.
Identify 4 changes/updates impact CAUTI
surveillance and prevention.
Review changes in practice identified above
and the role of the hospital ICP.
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Urinary tract infections are the most common type of
healthcare-associated infection, accounting for more
than 30% of infections reported by acute care
hospitals.
◦ Virtually all healthcare-associated UTIs are caused by
instrumentation of the urinary tract.
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Between 15% and 25% of hospitalized patients may
receive short-term indwelling urinary catheters.
Reported rates of UTI among patients with urinary
catheters vary substantially.
◦ National data from NHSN acute care hospitals in 2006
showed a range of pooled mean CAUTI rates of 3.1-7.5
infections per 1000 catheter-days.
 The highest rates were in burn ICUs, followed by inpatient
medical wards and neurosurgical ICUs
 The lowest rates were in medical/surgical ICUs.
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Average cost of each uncomplicated UTI in
1992 was reported at $6804
- Based on total of 84 patients
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Average cost impact of each UTI reported in
1996 was $3,8035
- Based on 675 cases, 5,337 controls
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 At
time of insertion
◦ Mechanical
 during catheter insertion the catheter
picks up organisms
 urethral trauma during insertion
◦ Blockage of periurethral glands
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•
Extraluminal
•
Intraluminal
–
–
–
–
Biofilm
Encrustation
Organisms migration
Fecal incontinence
– Disconnection of catheter/drainage system
– Contamination of outlet tube
– Encrustation
– Biofilm
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“Ports of
Entry”
◦ Catheter /
Meatal Junction
◦ Catheter / Tube
Junction
◦ Outlet Tube
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Bacteria switch from a free-floating
(planktonic) state where they function as
individuals to a sessile state where they
function as communities
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Catheter coatings are available to reduce
bacterial adherence and prevent biofilm
formation
Silver
– Bardex® I.C. Anti-Infective Foley Catheter*
– Dover™ Silver Foley Catheter
– Silvertouch™ Foley Catheter
•
Nitrofurazone
– Release-NF® Anti-Infective Foley Catheter
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Pseudomonas aeruginosa
Reduced densities of bacteria
@ 2hrs on a Silver and
Hydrogel coated Foley catheter
Pseudomonas aeruginosa
Note extensive cell damage to
organisms
12
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It all begins with Awareness
– What is the clinical impact of CAUTI ?
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• UTIs account for 40% of all HAIs and of these, 80% are associated
with urinary catheterization.
– What CAUTI lack in terms of severity they make up with in terms of
volume
• UTIs are the second most common cause of bloodstream infections
and due to their frequency and subsequent treatment they are one
of the largest breeding grounds for antibiotic resistant organisms
– What is the financial impact of CAUTI ?9
• UTIs cost U.S. hospitals more than $500 million per year to treat
and can increase a patient’s length of stay by 3.8 days
– Cost to Treat
– Additional length of stay
– Loss of CMS reimbursement
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CMS Reimbursement Changes
for HAIs
HICPAC /CDC CAUTI
Guideline
Changes
2008/2009
Revised SCIP Guideline
APIC Guide to Elimination of
CAUTIs
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Changes in Reimbursement for
Healthcare Acquired CAUTI
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◦ Hospitals will not receive additional
payment for cases where the condition
was not present upon admission
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Blood incompatibility
Air embolism
Object left after surgery
Mediastinitis after CABG surgery
Injuries from falls
Vascular catheter associated infection
Pressure ulcers
Catheter associated urinary tract infection
(CAUTI)
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600000
561,667
500000
400000
322,946
300000
248,678
200000
175,000
100000
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108
764
0
Wrong
Blood
Air Embolism Mediastinitis
Objects Left
in Post
Surgery
Injuries from
Falls
Vascular
Catheter
Infections
Pressure
Ulcers
CA-UTI
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•
High Volume: CDC reports there are 561,667
CAUTI every year
– Most common healthcare-associated infection
•
High Cost: APIC HAI Cost Calculator estimates
cost to treat urinary tract infection $1,006 plus
6.3 days excess length of stay
•
Assignment to Higher Paying DRG: Code 996.64
•
Reasonably Preventable: Prevention guidelines
exist
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◦ 10% of Medicare discharges had a secondary diagnosis of
UTI (2006 MedPAR)
◦ Hospitals reimbursed $216M for these infections
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Medicare believes this will provide hospitals
with additional incentive to engage in
quality improvement efforts such as HAI
reduction measures
Presently they are developing a Value-Based
Purchasing Rule (VBP) based on criteria from
the Patient Protection and Affordable Care
Act (ACA) 2010
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Change in NHSN/CDC Definition for CA-UTIs7
New HICPAC/CDC Guidelines for UTI
Prevention9
Surgical Care Improvement Project (SCIP)10
APIC Guide to Elimination of CatheterAssociated Urinary Tract Infections (CAUTIs)11
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UTI Definition for Patients with an
Indwelling Foley Catheter7
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# of symptomatic UTI / 1,000 urinary
catheter days as measured in NHSN
◦ National 5-Year Prevention Target: 25% decrease
from baseline
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Appendix G in HHS plan discusses a new
type of metric, the standardized infection
ratio (SIR)
http://www.hhs.gov/ophs/initiatives/hai/prevtargets.html
http://www.hhs.gov/ophs/initiatives/hai/appendices.html
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Examples of metrics:
◦ Number of CAUTI per 1000 catheter-days
◦ Number of BSI secondary to CAUTI per 1000
catheter-days
◦ Catheter utilization ratio (urinary catheterdays/patient-days) x 100
Use CDC/NHSN definitions for numerator
data (SUTI only):
http://www.cdc.gov/nhsn/library.html
http://www.cdc.gov/hicpac/cauti/001_cau
ti.html
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Symptomatic Infection
Do catheterized patients have symptoms?
Asymptomatic Bacteriuria
Is it or is it not just colonization?
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NHSN SUTI 1-A
NHSN SUTI 2-A
CLINICAL CAUTI 8
NHSN ABUTI
FOLEY
1a-1 Foley is currently
in place
1a-2 Foley is out within
last 48 hours
2a-1 Foley is currently
in Place
2a-2 Foley is out within
last 48 hours
Is in place or out within
last 48 hours
Is in place or out within last 48 hours
COLONY
COUNT
≥100,000
≥100,000
≥1,000 and <100,000
≥1,000 and <100,000
≥100,000
≥100,000
SIGNS,
SYMPTOMS
MARKERS
1 of the following
--Temp 38C or >
--CVA pain/tender
--S/P pain/tender
1 of the following
--Temp 38C or >
--CVA pain/tender
--S/P pain/tender
--Urgency
--Frequency
--Dysuria
1 of the following
--Temp 38C or >
--CVA pain/tender
--S/P pain/tender
1 of the following
--Temp 38C or >
--CVA pain/tender
--S/P pain/tender
--Urgency
--Frequency
--Dysuria
--Fails NHSN def
PLUS
1 of the following
--MS changes
--Urine character
--PVR/retention
--CBC leukocytosis
--No symptoms
--Matched BC
(at least 1 org)
PLUS
1 of the following
--Positive dipstick
--Positive pyuria
PLUS
1 of the following
--Positive dipstick
--Positive pyuria
PLUS
1 of the following
--Positive dipstick
--Positive pyuria
PLUS
--Physician treated
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What are clinically relevant infections?8
◦ Clinical indicators
◦ Physician diagnosis/treatment
8
McGeer A., et al.. Definitions of Infections for Surveillance in Long Term Care
Facilities, Am J Infect Control 1991; 19(1); 1-7.
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Examples of programs that have been demonstrated to
be effective include:
◦ A system of alerts or reminders to identify all patients with
urinary catheters and assess the need for continued
catheterization
◦ Guidelines and protocols for nurse-directed removal of
unnecessary urinary catheters
◦ Education and performance feedback regarding appropriate
use, hand hygiene, and catheter care
◦ Guidelines and algorithms for appropriate peri-operative
catheter management, such as:
 Procedure-specific guidelines for catheter placement and
postoperative catheter removal
 Protocols for management of postoperative urinary
retention, such as nurse-directed use of intermittent
catheterization and use of ultrasound bladder scanners
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• Although there have been several articles related to decreasing catheter
usage, not all of these studies measured CAUTI as an outcome
– At urinary catheter removal, 51 participants (19%) in the stop-order group developed urinary
tract infection compared with 51 (20%) in the usual care group, relative risk 0.94, (95% CI,
0.66 to 1.33), P=0.71
– At 7 days post catheterization, 28 of those tested (21.1%) in the stop-order group compared
to 19 (16.7%) in the usual care group had urinary tract infections, relative risk 1.26 (95% CI,
0.75 to 2.14), P=0.38.
•
Study demonstrated that Foley catheter stop orders safely reduced Foley catheter
usage but failed to reduce CAUTI
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If the CAUTI rate is not decreasing after implementing a
comprehensive 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 (Category IB)
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•
CAUTI Prevention Techniques
•
CAUTI Prevention Technology
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Appropriate Foley catheter Utilization
Proper Foley catheter Insertion, Maintenance, Removal
Monitoring Compliance
Continuing Education and Training
– Bladder Scanners
– Antimicrobial Foley Catheters
Its not about what type of CAUTI prevention
method works best; its about using every
available method to try and prevent every CAUTI
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PURPOSE
To provide evidence-based practice guidance
for the prevention of Catheter Associated
Urinary Tract Infection (CAUTI) in acute and
long term settings.
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“Although infection control measures are the
mainstay approach for preventing device-related
infection, adherence to such measures is often
inconsistent. That is why infection control
measures need to be complemented with truly
protective technology.”
- Rabih O. Darouiche,
M.D.
Taken From Medical Devices Pose Big Infection Threat Copyright 2009 by Virgo
Publishing. By: By Michelle Beaver Posted on: 08/28/2008
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The Surgical Care Improvement Project (SCIP)
is a national quality partnership of
organizations focused on improving surgical
care by significantly reducing surgical
complications. 10
The SCIP goal is to reduce the incidence of
surgical complications nationally by 25
percent by the year 2010.
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SCIP-Inf-9
◦ Urinary catheter removed on Postoperative Day
(POD) 1or 2.
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3 data elements added
◦ Urinary Catheter
◦ Catheter removal
◦ Reasons for continuing urinary catheterization
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Policy and best practice
expertise
Provision of
surveillance data and
risk assessment
Consultation on
infection prevention
interventions
Facilitation of CAUTIrelated surveillance
improvement projects.
For Infection
Preventionist
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Proper insertion of the
Foley catheter
Proper care and
maintenance of the
Foley catheter system
Must be held
accountable for
compliance with
interventions.
Direct Patient Caregiver
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Purpose
◦ To develop a surveillance, prevention and control
plan based on facility specific data and conditions
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Assess whether an effective organizational
program exists.
Assess population at risk
◦ Point Prevalence Survey
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Assess baseline outcome data
Determine financial impact
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Criteria for CAUTI
Coding
HAI Surveillance
Data
Physician documentation of
UTI, cystitis, urethritis or
pyelonephritis
Used to establish UTI
Surveillance definition must
be used
Documentation or
clarification UTI associated
with catheter
MD must document
Code 996.64 assigned
Documentation by MD not
used.
Presence of catheter is
documented by direct
observation or in chart
Antibiotic Treatment
Not sole criteria but coder
may seek MD clarification
Not used. Must use
surveillance definition
Lab Data
Not used to establish UTI
May be used to seek
clarification by coder
Surveillance definition.
Combined with other criteria
in some cases
Clinical Signs and Symptoms
No coder may query MD for
clarification but may query
for cause of S/S
Surveillance definition.
Combined with other criteria.
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Assess need for Foley on a daily basis
•
Implement early removal processes
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Early Foley removal for the surgical patient
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Consider routine use of bladder scanners
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Consider technology as addition to the
comprehensive prevention plan
– Physician reminder systems
– Nurse driven protocols
– Automatic stop orders
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•
•
•
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Aseptic insertion and maintenance
Bladder ultrasound may avoid indwelling
catherization
Condom or intermittent catherization in
appropriate patients
Do not use the indwelling catheter unless you
must.
Early removal of the catheter using reminders
or stop orders.
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Are CAUTIs a Target for Improvement?
◦ Change in CDC Definition/Reporting to NHSN
◦ Changes in CMS Reimbursement
◦ Guidelines
 SHEA Compendium
 HICPAC/CDC
 SCIP
 APIC Guide to Elimination of CAUTIs
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CAUTIs Are Important
CAUTIs Have Serious Clinical and
Economic Consequences
Actions Can be Taken to Reduce CAUTIs
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QUESTIONS?
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Weinstein RA. Nosocomial Infection Update. Emerging Infectious Diseases.
1998; 4(3): 416-420.
Salgado CD, Karchmer TB, and Farr BM. Prevention of Catheter-Associated
Urinary Tract Infection. In Prevention and Control of Nosocomial Infections,
4thEd. Wenzel RP Ed. Philadelphia: Lippincott, Williams, and Wilkins, 2003.
Saint S and Chenoweth CE. Biofilms and catheter-associated urinary tract
infections. Infect Dis Clin N Am. 2003; 17:411-432.
Public health focus: surveillance, prevention and control of nosocomial
infections. MMWR Morb Mortal Wkly Rep. 1992; 41:783-787.
Classen D. Assessing the effect of adverse hospital events on the cost of
hospitalization and other patient outcomes. University of Utah, 1993.
SHEA Compendium, Strategies to Prevent Catheter Associated Urinary Tract
Infections in Acute Care Hospitals. Infect Control Hospital Epidemiol 2008; 29:
S41-S0.
National Healthcare Safety Network (NHSN) Manual, March 2009.
McGeer A., et al.. Definitions of Infections for Surveillance in Long Term Care
Facilities, Am J Infect Control 1991; 19(1); 1-7.
HICPAC. Guideline for Prevention of Catheter-Associated Urinary Tract
Infections; 2009.
Surgical Care Improvement Project., 2010; Version 3.0a.
APIC Guide to the Elimination of Catheter-Associated Urinary Tract Infections
(CAUTIs), 2008.
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www.APIC.org
www.SHEA-online.org
www.cfmc.org/hospital/hospital_SCIP.html
www.cdc.gov/ncidod/dhap/hicpac_pub.html
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Compliance with hand hygiene
Compliance with educational program
Compliance with documentation of catheter
insertion and removal
Compliance with documentation of
indications for catheter placement
http://www.cdc.gov/hicpac/cauti/001_cau
ti.html
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Intermittent catheterization – consider for:
◦ Patients requiring chronic urinary drainage for
neurogenic bladder
 Spinal cord injury
 Children with myelomeningocele
◦ Postoperative patients with urinary retention
◦ May be used in combination with bladder
ultrasound scanners
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External (i.e., condom) catheters – consider
for:
◦ Cooperative male patients without obstruction or
urinary retention
http://www.cdc.gov/hicpac/cauti/001_cauti.html
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Consideration of alternatives to indwelling
urinary catheterization (II)
Use of portable ultrasound devices for
assessing urine volume to reduce
unnecessary catheterizations (II)
Use of antimicrobial/antisepticimpregnated catheters (IB, after first
implementing core recommendations for
use, insertion, and maintenance )
The following slides will provide further
details on supplemental strategies…
httpwww.cdc.gov/hicpac/cauti/001_cauti.html ://

Implement quality improvement
programs to enhance appropriate use
of indwelling catheters and reduce
risk of CAUTI
Examples:
―Alerts or reminders
―Stop orders
―Protocols for nurse-directed removal of
unnecessary catheters
―Guidelines/algorithms for appropriate
perioperative catheter management
http://www.cdc.gov/hicpac/cauti/001_cauti.
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Maintain unobstructed urine flow
◦ Keep catheter and collecting tube free from
kinking
◦ Keep collecting bag below level of bladder at all
times (do not rest bag on floor)
◦ Empty collecting bag regularly using a separate,
clean container for each patient. Ensure
drainage spigot does not contact nonsterile
container.
http://www.cdc.gov/hicpac/cauti/001_cauti.html

Following aseptic insertion, maintain a
closed drainage system
◦ If breaks in aseptic technique, disconnection, or
leakage occur, replace catheter and collecting
system using aseptic technique and sterile
equipment
◦ Consider systems with preconnected, sealed
catheter-tubing junctions (II)
◦ Obtain urine samples aseptically
http://www.cdc.gov/hicpac/cauti/001_cauti.html

Insert catheters using aseptic technique and
sterile equipment (acute care setting)
◦ Perform hand hygiene before and after insertion
◦ Use sterile gloves, drape, sponges, antiseptic or
sterile solution for periurethral cleaning, singleuse packet of lubricant jelly
◦ Properly secure catheters
http://www.cdc.gov/hicpac/cauti/001_cauti.html
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Insert catheters only for appropriate
indications
◦ Minimize use in all patients, particularly those at
higher risk of CAUTI and mortality (women,
elderly, impaired immunity)
◦ Avoid use for management of incontinence
◦ Use catheters in operative patients only as
necessary
http://www.cdc.gov/hicpac/cauti/001_cauti.html
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Insert catheters only for appropriate
indications
http://www.cdc.gov/hicpac/cauti/001_cauti.html
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Insert catheters only for appropriate
indications
Leave catheters in place only as long as
needed
Ensure that only properly trained persons
insert and maintain catheters
Insert catheters using aseptic technique and
sterile equipment (acute care setting)
Following aseptic insertion, maintain a
closed drainage system
Maintain unobstructed urine flow
Hand hygiene and Standard (or appropriate
isolation) Precautions
http://www.cdc.gov/hicpac/cauti/001_cauti.html

Core Strategies
◦ High levels of
scientific evidence
◦ Demonstrated
feasibility

Supplemental
Strategies
◦ Some scientific
evidence
◦ Variable levels of
feasibility
*The Collaborative should at a minimum include core prevention strategies.
Supplemental prevention strategies also may be used. Most core and
supplemental strategies are based on HICPAC guidelines. Strategies that are not
included in HICPAC guidelines will be noted by an asterisk (*) after the
strategy. HICPAC guidelines may be found at www.cdc.gov/hicpac
Symptomatic UTI
Bacteriuria
Prolonged catheterization*
Disconnection of drainage system*
Female sex†
Lower professional training of inserter*
Older age†
Placement of catheter outside of OR†
Impaired immunity†
Incontinence†
Diabetes
Meatal colonization
Renal dysfunction
Orthopaedic/neurology services
* Main modifiable risk factors † Also inform
recommendations