1. On the CUSP: Stop CAUTI 1 National Expansion: Implementing CUSP to Eliminate Catheter-Associated Urinary Tract Infections (CAUTI) Project Initiation Call

2. 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

3. Project Goals Reduce CAUTI rates in participating units by 25% – Appropriate placement – Appropriate continuance – Appropriate utilization Improve patient safety culture on participating units 3

4. Project Overview Hospitals or Hospital Systems State Hospital Associations National Project Team Project Management Clinical Faculty & Data ManagementCUSP Faculty 4

5. National Project Team 5 PartnerTeam Members Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality Sam Watson, MSA; Chris George, RN, MS Health Research & Educational TrustSteve Hines, PhD Deborah Bohr, MPH Marchelle Djordjevic, MBA Centers for Disease Control & PreventionKatherine Allen-Bridson, RN, BSN, CIC Carolyn Gould, MD, MSCR Johns Hopkins Quality Safety Research GroupSean 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 CenterMohamad Fakih, MD, MPH

6. 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

7. 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 7

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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) Urinary Catheter-Related Infection: Pathophysiology (Tambyah, Halvorson, Maki. Mayo Clin Proc 1999) 13

14. Intraluminal Extraluminal Detrusor spasm Shedding of cells Bacteremia Leakage Obstruction Fever (+) UA Hypotension Bladder infection with inflammation Urinary Catheter-Related Infection: Pathophysiology 14

15. 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

16. Background Prevention Catheter-Associated Urinary Tract Infection 16

17. 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 Prevention of Catheter- Associated UTI 17

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) 18

19. 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) 19

20. One Reason Catheters Are Used Inappropriately (Saint S, Wiese J, Amory J, et al. Am J Med 2000) 20

21. 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

22. 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 Prevention of Catheter- Associated UTI 22

23. 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 Use Proper Aseptic Technique for Catheter Insertion 23

24. 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 Prevention of Catheter- Associated UTI 24

25. 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

26. 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 Prevention of Catheter- Associated UTI 26

27. Alternatives to the indwelling catheter – Bladder ultrasound – Intermittent catheterization – Condom catheter Other Methods for Preventing CAUTI 27

28. On the CUSP: Stop CAUTI 28 Recent Guidelines on CAUTI Prevention

29. 29

30. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf On the CUSP: Stop CAUTI 30

31. 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

32. Core Prevention Strategies: (All Category IB) Catheter Use Insertion Maintenance 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 http://www.cdc.gov/hicpac/cauti/001_cauti.html Quality Improvement Programs 32

33. Comprehensive Unit-based Safety Program (CUSP) On the CUSP: Stop CAUTI 33

34. 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

35. “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

36. Pre CUSP Work Create an ICU 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

37. 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.safercare.net http://www.safercare.net 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. 37

38. Teamwork Tools Call list Daily Goals AM briefing Shadowing Culture check up TEAMSTepps 38

39. 39 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

40. CUSP & CAUTI Interventions 1. Educate on the science of safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from Defects 5. Implement teamwork & communication tools CUSPCAUTI 1.Care and Removal Intervention Removal of unnecessary catheters Proper care for appropriate catheters 2. Placement Intervention Determination of appropriateness Sterile placement of catheter 40

41. 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

42. Expected Benefits Reduction in bacteriuria Reduction in symptomatic UTIs Shortened Length of Stay Decreased Cost per stay Improved sensitivity to “patient dignity” 42

43. What Participation Requires Data Submission InterventionMeasureFrequency CUSP Technology and Exposure Assessment Baseline HSOPS Baseline and post intervention Team Check-up ToolQuarterly Care and Removal Process Prevalence & Appropriateness Weekly within Protocol Outcome Monthly within Protocol - UTI Rate / Device Days - UTI Rate / Patient Days Monthly within Protocol InsertionTBD 43

44. 44 PROCESS OUTCOME SMTWTFSSMTWTFS BASELINE PERIOD No Data Collected JAN 2011 Baseline Data Collected BASELINE PERIOD 1 1 23456782345678 91011121314159101112131415 1617181920212216171819202122 2324252627282923242526272829 3031 3031 No Data Collected FEB 2011 Baseline Data Collected 12345 12345 67891011126789101112 1314151617181913141516171819 2021222324252620212223242526 2728 2728 Baseline Data Collected MAR 2011 Baseline Data Collected 12345 12345 67891011126789101112 1314151617181913141516171819 2021222324252620212223242526 2728293031 2728293031 INTERVENTION PERIOD 1 Intervention Data Collected APR 2011 Intervention Data Collected INTERVENTION PERIOD 1 12 12 34567893456789 1011121314151610111213141516 INTERVENTION PERIOD 2 1718192021222317181920212223 2425262728293024252627282930 Intervention Data Collected MAY 2011 Intervention Data Collected INTERVENTION PERIOD 2 12345671234567 891011121314891011121314 1516171819202115161718192021 2223242526272822232425262728 293031 293031

45. 45 PROCESS OUTCOME SMTWTFSSMTWTFS POST-INTERVENTION PERIOD 1 No Data Collected JUN 2011 No Data Collected POST-INTERVENTION PERIOD 1 1234 1234 567891011567891011 1213141516171812131415161718 1920212223242519202122232425 2627282930 2627282930 No Data Collected JUL 2011 No Data Collected 12 12 34567893456789 1011121314151610111213141516 1718192021222317181920212223 2425262728293024252627282930 31 Post-Intervention Data Collected AUG 2011 Post-Intervention Data Collected 123456 123456 7891011121378910111213 1415161718192014151617181920 2122232425262721222324252627 28293031 28293031

46. Next Steps: Cohort 1 Timeline at a glance Cohort 1Fall 2010 OctoberUnit attends first immersion call October- JanuaryUnit attends Kick Off Meeting and begins participating in national content calls November- January - Participate in content and coaching calls - Collect and report quarterly data to monitor change JanuaryUnit begins HSOPS JanuaryUnit begins submitting CAUTI and TCT data 46

47. Next Steps: Cohort 2 Timeline at a glance Cohort 2Spring 2011 MarchUnit attends first immersion call March- AprilUnit attends Kick Off Meeting and begins participating in national content calls April- June - Participate in content and coaching calls - Collect and report quarterly data to monitor change JuneUnit begins HSOPS JuneUnit begins submitting CAUTI and TCT data 47

48. 48 Questions Content – Sam Watson, MHA Keystone – swatson@mha.org swatson@mha.org Participation–Marchelle Djordjevic, HRET – mdjordjevic@aha.org mdjordjevic@aha.org