1. Implementing Change: The Technical & Socio-Adaptive Aspects of Preventing CAUTI
Sanjay Saint, MD, MPH
Professor of Medicine
Ann Arbor VA Medical Center
University of Michigan Medical School
I would like to begin by acknowledging my collaborators.

2. Consistently Using Evidence-Based Practices Remains a Challenge…

3. Hand Hygiene Compliance in Healthcare Workers (Erasmus et al
Hand Hygiene Compliance in Healthcare Workers (Erasmus et al. Infect Control Hosp Epidemiol March 2010)
Systematic review of 96 studies
Overall median compliance of 40%
Lower rates in physicians (32%) than nurses (48%)
Lower rates “before” (21%) patient contact rather than “after” (47%)

4. Given this Gap Between What Should Be Done and What Is Done…
Focus on “implementation science”
“The scientific study of methods to promote the systematic uptake of research findings into routine practice” (Eccles & Mittman. Implementation Science. Feb 2006)
Synonyms:
“T3” translation
Theory-practice gap
Knowledge transfer
Knowledge utilization

5. How can we better implement evidence-based practices in infection prevention?

6. Implementation Science: Conceptual Model
In the last 6 decades, “knowledge utilization” field dominated by one person: Everett Rogers, PhD (Estabrooks et al. Implementation Science. Nov 2008)
Rogers’ “Diffusion of Innovation” Model is the canonical model since World War 2
Originally developed for the study of agriculture

7. “Diffusion of Innovation” Model of Everett Rogers, PhD
Definitions:
Diffusion = spread
Innovation = a new practice
A “descriptive” model – not a “prescriptive” one
Describes what is occurring rather than what to do

8. 4E’s Model of Implementation (Pronovost et al. BMJ 2008)
Needs Assessment: measure baseline performance, identify local barriers, select interventions to implement
Engage (discuss importance of intervention)
Educate (share specifics of the intervention)
Execute (provide an intervention toolkit)
Evaluate (intended and unintended consequences)

9. Several Challenges for Implementation Researchers
Ensuring Sustainability
Understanding Context

10. The Importance of Context (Davidoff JAMA Dec 2009; Greenhalgh et al
The Importance of Context (Davidoff JAMA Dec 2009; Greenhalgh et al. Milbank Q 2004)
Implementation within healthcare is “context” specific: dependent on the setting, hospital leadership and followership, & organizational culture (and micro-culture)
Healthcare settings are unpredictable and generally non-linear: if ‘A’ then ‘B’ or ‘C’ or ‘X’…
Implementation is both a clinical and a social discipline: has both “technical” components and “adaptive” ones
Use tools from social science – such as “qualitative research” – to better understand the context
I have divided these overarching themes into barriers and facilitators. First the barriers: One of the important barriers we discovered [HIT RETURN FOR NEXT BULLET] was the presence of organizational “constipators” who we define as passive-aggressive types who undermine change without active resistance. These individuals appear to be supportive of change but end up ‘gumming’ up the system, thereby requiring others to erect work-arounds to get by them. [HIT RETURN FOR NEXT BULLET]
Another important barrier was the presence of silos. These were either “Clinical/work-unit silos”: in which everyone is in their own little world; And “Economic silos” in which the cost of the practice comes from a different bucket than where the benefits flow

11. What is Qualitative Research?
A method of inquiry used in many different disciplines
Increasingly being used in biomedical research
Used to obtain an in-depth understanding of human behavior and the reasons for such behavior
Investigates the why and how
Information is gathered using open-ended data collection: interviews, focus groups, and direct observation
Organizing the data in the words and categories of participants (“themes”) can be compelling
JANE
Artistic = Intuitive and non-linear thinking
Interpreting the meaning of e.g., “size"
(Johnson & Onwuegbuzie. Educ Researcher 2004; Forman et al. AJIC 2008) 11

12. Implementation Science
The Technical and Socio-Adaptive Aspects of Preventing CAUTI

13. Healthcare-Associated Infection (HAI)
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
Infection control is a good model for understanding implementation – both successes and failures

14. Urinary Catheter-Related Infection: Background
Urinary tract infection (UTI) causes ~ 40% of hospital-acquired infections
Most infections due to urinary catheters
Up to 25% of inpatients are catheterized
Leads to increased morbidity and costs
Urinary tract infection causes over 40% of hospital-acquired infections, making it the most common nosocomial infection.
Most of these infections are due to urinary catheters.
25% of inpatients are catheterized at some time during their hospital stay.
Nosocomial UTI leads to increased morbidity and increased costs.

15. 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

16. 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

17. Prevention of Catheter-Associated 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

18. UTI Prevention Rule #1: Make Sure the Patient Really Needs the Catheter
Appropriate indications
Bladder outlet obstruction
Incontinence and sacral wound
Urine output monitored
Patient’s request (end-of-life)
During or just after surgery
(Wong and Hooton - CDC 1983)
(Jain. Arch Int Med 95)

19. One Reason Catheters Are Used Inappropriately
As seen in this table, 18% of medical students, 22% of interns, 28% of residents, and 35% of attending physicians were unaware that the patients that they were responsible for had an indwelling catheter.
(Saint S, Wiese J, Amory J, et al. Am J Med 2000)

20. Prevention of Catheter-Associated 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

21. 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

22. Prevention of Catheter-Associated 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

23. 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)
Because of these increased morbidity and costs, several preventive strategies have been attempted.
Silver-coated catheters are one such intervention used to prevent catheter-related infection.
The rationale for using silver is that this substance has in vitro antibacterial activity and is commonly used to prevent infection in burn patients.
The efficacy of silver alloy catheters in preventing urinary tract infection was shown in a recent meta-analysis of randomized trials that we performed.

24. Prevention of Catheter-Associated 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

25. Other Methods for Preventing CA-UTI
Antimicrobial catheters
Alternatives to the indwelling catheter
Bladder ultrasound
Intermittent catheterization
Condom catheter

26. Recent Guidelines on CAUTI Prevention

27. CA-UTI Prevention: Concise Summary of Recommendations
Adherence to infection control principles (eg, aseptic insertion, proper maintenance, education) is important
Bladder ultrasound may avoid indwelling catheterization
Condom or intermittent catheterization in appropriate pts
Do not use the indwelling catheter unless you must !
Early removal of the catheter using reminders or stop-orders appears warranted
(Saint et al. Jt Comm J Qual Saf 2009)

28. What are Hospitals Using to Prevent CA-UTI?
National survey of U.S. hospitals (focused on device-related infection)
719 hospitals surveyed (Spring 2005)
Lead Infection Control Professional filled out the survey
72% response rate
(Saint et al. Clin Infect Dis 2008)

29. Urinary Catheter-Related Infection Prevention Practices
Regularly using
Antimicrobial catheters
30%
Bladder ultrasound scanner
29%
Condom catheters in men
12%
Urinary catheter reminder 9%
Antimicrobials in the drainage bag 3%
(Saint et al. Clin Infect Dis 2008)

30. Translating Research Into Practice
No common strategy used in hospitals to prevent UTI
Less than 10% of U.S. hospitals using catheter reminders or stop-orders
Next Step: Evaluate why interventions are used in some hospitals but not in others

31. Why Are Some Hospitals Better than Others in Preventing Infection?
Quantitative Qualitative
phase phase
Part 1
Part 2
Part 3
Surveyed infection control personnel at 719 U.S. hospitals
Phone interviews with key informants at 14 hospitals
Site visits at 6 hospitals across the U.S. ( )
(Krein et al. Am J Infect Cont 2006)

32. Qualitative UTI Themes: 2006-07
1) Urinary catheter-related infection is a low priority, but timely removal of catheters considered important
2) Identifying a committed “champion” facilitated prevention activities in several sites
(Saint et al. Infect Cont Hosp Epid 2008)

33. But a lot has changed in the last 3 years…
Since qualitative research focuses on discovering underlying “themes”, I will discuss one of these themes,
Namely…
Urinary catheter-related infection is a low priority, but timely removal of the catheters was considered important
I provide illustrative quotes to explain this theme on the next few slides.

34. Current Sequential Mixed-Methods Study
Quantitative Qualitative
Part 1
Survey of infection control personnel 2005 &
All MI hospitals (~130)
Stratified random sample U.S. hospitals (~600)
Response rates 70%/80%
Part 2
Purposeful sample
12 hospitals in MI
Phone interviews with key informants (n = 18)
Site visits at 3 hospitals in MI
Part 3
Facilitated implementation intervention
Study is using a sequential mixed methods approach.
Started with a survey
The survey response rate was70%/80% in MI
Next we moved to the qualitative phase of the study focusing only on hospitals in Michigan to better understand some of the complexities in practice use and implementation, which often can’t be quantified. Survey responses were used to implement a purposeful sampling strategy, resulting in the selection of 12 hospitals. Selection was based on participation in the Keystone Bladder Bundle initiative (already implemented vs. just starting), reported ease of implementation, geographic location, facility-wide vs. unit specific implementation, hospital size.
Interviewed 18 individuals, 1-3/hospital
3 of the12 hospitals have been selected for site visits, which provided an opportunity to gather more information about issues emerging from our data analysis and obtain perspectives from a wider variety of staff
The third part of the study is the intervention component but as that is still under development I will only be sharing preliminary results from parts 1 and 2.

35. Hospital Characteristics
2005
(national)*
2009
(MI)
Number of hospital beds
mean (95% CI)
229
( )
226
( )
238
(187 – 289)
Have hospitalists
57%
75%
76%
Number of full-time equivalent infection preventionists (IP)
1.3
(1.2 – 1.4)
1.5
(1.4 – 1.7)
1.7
(1.2 – 2.1)
Lead IP certified in infection control
59%
58%
Participate in a collaborative effort to reduce HAI
42%
68%
99%
Point out percent with hospitalists and the percent participating in a collaborative effort (IHI, Keystone, other regional or state base initiatives)
*Weighted estimates

36. Report Regularly Using to Prevent CAUTI: National Sample
In the interest of time I will just be focusing on a few practices and on practices that we asked about in both 2005 and 2009.

37. Report Regularly Using to Prevent CAUTI: Comparing Michigan with U.S.
MI in maize and blue

38. Summary of Quantitative Findings
Increase in the percentage of U.S. hospitals (in Michigan and across the U.S.) using several practices to prevent CAUTI
Notable differences in the types of practices used; Michigan hospitals focusing more on reducing unnecessary catheter use
Our data show

39. Qualitative UTI Themes from Michigan’s CAUTI Experience: 2009-2010
Where Do We Go From Here?
Qualitative UTI Themes from Michigan’s CAUTI Experience:
Tailoring
Workflow
Leadership

40. The Importance of Tailoring
May need to tailor (ie, modify) your approach to CAUTI given your specific context and circumstances
We saw different solutions at different hospitals; different solutions within different units at the same hospital
Examples:
Educating nurses about urinary catheters
Who assesses for catheter appropriateness
Modifying the indications for catheter use (slightly)
Focus on insertion or early removal or both?

41. The Challenge: How to Make Urinary Catheter Removal Part of the Workflow
The intervention(s) should become part of the workflow: both removal (floor) and insertion (ED)
Nursing workload was a big issue - since Foleys can be easier for the nurses, this may be a disincentive to remove

42. The Challenge: How to Make Urinary Catheter Removal Part of the Workflow
The intervention(s) should become part of the workflow: both removal (floor) and insertion (ED)
Nursing workload was a big issue - since Foleys can be easier for the nurses, this may be a disincentive to remove
For insertion, ED is paramount
Foleys put in for specimen collection and left in
ED nurses may think they’re doing floor nurses a favor
Nursing aides often insert Foleys in the ED with improper technique

43. The Importance of Leadership
Leadership at various levels appears to be important, especially at the nurse manager level
Physicians often play an important role
Behind-the-scenes (getting buy-in from medical executive committees and other physicians)
Front-line (eg, hospitalists, hospital epidemiologists)

44. The Importance of Leadership
Leadership at various levels appears to be important, especially at the nurse manager level
Physicians often play an important role
Behind-the-scenes (getting buy-in from medical executive committees and other physicians)
Front-line (eg, hospitalists, hospital epidemiologists)
The type of champion that is needed depends on organizational culture
Not a one-size-fits-all strategy
Nurse manager or charge nurse may be best option

45. Qualitative UTI Themes from Michigan’s CAUTI Experience: 2009-2010
Tailoring
Workflow
Leadership