1. Project Initiation Call
On the CUSP: Stop CAUTI
Implementing CUSP to Eliminate Catheter-Associated Urinary Tract Infections (CAUTI)
Project Initiation Call
Good afternoon and thank you Kimberly for the opportunity to update the Missouri teams on the national CAUTI project. This project is still in development, with plans to launch this fall.
My name is Marchelle Djordjevic, I am a program manager at HRET- the research affiliate of the American Hospital Association. My primary responsibility is overall national project management for the CUSP projects. I have several years project management experience working in healthcare research and quality where most recently I was the program manager at the American College of Surgeons for the ACS NSQIP. I started with HRET at the beginning of this year.
I work closely with Deb Bohr, who is also a Program Manager for the CUSP projects at HRET. Deb manages state recruitment and is here to help address any questions you may have about state and hospital recruitment.

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
Here is the agenda for this presentation. Basically, I want to cover why the project is important, who is involved, and what we hope to accomplish… then leave a little time for questions.

3. Project Goals Reduce CAUTI rates in participating units by 25%
Appropriate placement
Appropriate continuance
Appropriate utilization
Improve patient safety culture on participating units
This project has two primary goals
To reduce CAUTIs in participating units by 25% by using education & reinforcing appropriate management of urinary incontinence (using the New CDC guideline that has a emphasis on appropriate use of the catheter- outlines specific criteria); and by promoting the appropriate UC utilization in hospitals
The second goals is to improve patient safety culture through the implementation of CUSP

4. Project Overview Hospitals or Hospital Systems
State Hospital Associations
National Project Team
Project Management
Clinical Faculty & Data Management
CUSP Faculty
The On the CUSP: Stop CAUTI project is an AHRQ funded demonstration project to reduce Catheter associated urinary tract infections in 10 states nation wide.
This is a collaborative initiative between several entities, with the work being lead by expert faculty out of MHA Keystone.
Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center .
AND
Mohamad Fakih Infectious Diseases Faculty, St John Hospital and Medical Center, also in Michigan
are leading the development of the project interventions with MHA Keystone.
JHU will provide expert faculty on CUSP and HRET is responsible for project management.

5. 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

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

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
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.

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

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)

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

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

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)

13. 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)

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

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)

16. Catheter-Associated Urinary Tract Infection
Background
Prevention

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. 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)
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.

20. 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)

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)
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.

22. Prevention of Catheter- Associated 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

23. 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

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. 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.

26. 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

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

28. Recent Guidelines on CAUTI Prevention
On the CUSP: Stop CAUTI
Recent Guidelines on CAUTI Prevention
Good afternoon and thank you Kimberly for the opportunity to update the Missouri teams on the national CAUTI project. This project is still in development, with plans to launch this fall.
My name is Marchelle Djordjevic, I am a program manager at HRET- the research affiliate of the American Hospital Association. My primary responsibility is overall national project management for the CUSP projects. I have several years project management experience working in healthcare research and quality where most recently I was the program manager at the American College of Surgeons for the ACS NSQIP. I started with HRET at the beginning of this year.
I work closely with Deb Bohr, who is also a Program Manager for the CUSP projects at HRET. Deb manages state recruitment and is here to help address any questions you may have about state and hospital recruitment.

30. On the CUSP: Stop CAUTI

31. Modified HICPAC Categorization Scheme
IB: Even though there may be low to very low quality evidence directly supporting the benefits of the intervention, the theoretical benefits are clear, and the theoretical risks are marginal.
All Category I recommendations carry same strength; levels A and B represent the quality of the evidence underlying the recommendation

32. 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
Following aseptic insertion, maintain a closed drainage system
Maintain unobstructed urine flow
Ensure that only properly trained persons insert and maintain catheters
Insert catheters using aseptic technique and sterile equipment (acute care setting)
Hand Hygiene
Quality Improvement Programs

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

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

35. “Needs Improvement” Statewide Michigan CUSP ICU Results
Less than 60% of respondents reporting good safety climate = “needs improvement”
Statewide in % needed improvement, in %
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”

36. 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

37. Comprehensive Unit-based Safety Program (CUSP) An Intervention to Learn from Mistakes and Improve Safety Culture
Educate staff on science of safety
Identify defects
Assign executive to adopt unit
Learn from one defect per quarter
Implement teamwork tools
Timmel J, et al. Jt Comm J Qual Patient Saf 2010;36:

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

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
Care and Removal Intervention
Removal of unnecessary catheters
Proper care for appropriate catheters
Placement Intervention
Determination of appropriateness
Sterile placement of catheter
This slides summarizes the interventions of this effort:
The 5 elements of the Comprehensive Unit-based Safety Program or CUSP
Care and Removal
Removal of unnecessary indwelling catheters based on HICPAC recommendations
Proper care for appropriate indwelling catheters
3) Placement Intervention
Determination of appropriateness of indwelling catheter based on HICPAC recommendations
Sterile placement of indwelling catheter

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
The expected short-term outcomes are:
Increased awareness of appropriate use for catheter
Reduced use of urinary catheters
Improved ability to assess the need or discontinuation of a catheter
Reduced patient discomfort
Improved patient “dignity”

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

43. What Participation Requires Data Submission
Intervention
Measure
Frequency
Suggested Collector
CUSP
Readiness Assessment
Baseline
Project Lead
HSOPS
Baseline and post intervention
All staff on unit
Team Check-up Tool
Quarterly
Project team
Care and Removal
Process Prevalence & Appropriateness
Weekly within Protocol
Unit staff
Outcome
Monthly within Protocol
Infection Prevention
- UTI Rate / Device Days
- UTI Rate / Patient Days
Insertion
TBD

44. Baseline Data Collected 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Cohort 2 PROCESS
Cohort 2 OUTCOME S M T W F
BASELINE PERIOD
No Data Collected
JUN 2011
Baseline 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
JUL 2011 29 31
AUG 2011
IMPLEMENTATION
Intervention Data Collected
SEPT 2011
SUSTAINABILITY
PERIOD 1
OCT 2011

45. Post-Intervention Data Collected
SUSTAINABILITY
PERIOD 2
No Data Collected
NOV 2011 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
DEC 2011 31
Post-Intervention Data Collected
JAN 2012

46. Data Collection Schedule
MEASURE
DATA COLLECTION SCHEDULE
DATES
CAUTI Rates (Outcome)
Number of Symptomatic CAUTI’s attributable to your unit for that month
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)
Number of patient days per month
Collect monthly for 5 months beginning in June and quarterly thereafter (June-August will be considered baseline)
2011:
June 1-30
July 1-31
August 1-31
September 1-30
October 1-31
2012:
January 1-31
April 1-30
Prevalence & Appropriateness (Process)
Assess each patient on the unit for the presence of a urinary catheter
Record the reason for the catheter
Baseline: Mon-Fri for 3 weeks
Baseline: August 1-5, 8-12, 15-19, 2011
Prospective: Mon-Fri for 2 weeks, 1 day per week for 6 weeks then one week per quarter thereafter
Prospective: September 5-9, 12-16, 20 & 27
October 4, 11, 18, 25
January 9-13
April 9-13
July 9-13
October 15-19

47. 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

48. Questions Content – Sam Watson, MHA Keystone swatson@mha.org
Participation–Kristina Davis, HRET