Preventing Catheter-Associated Urinary Tract Infections Institute for Healthcare Improvement

Scientific Partners APIC Centers for Disease Control and Prevention Infectious Diseases Society of America Society for Healthcare Epidemiology of America

Goal Reduce and ultimately prevent cases of symptomatic CA-UTI What is “symptomatic CA-UTI”? Infection-causing symptoms as defined by the CDC’s National Health Safety Network (NHSN) in the setting of an indwelling urinary catheter that is in place or has been removed within the past 48 hours

Why CA-UTI? Most common hospital-acquired infection: 40% of all HAIs > 1 million cases annually (hospitals & nursing homes) 12-25% of all hospitalized patients receive a urinary catheter Half of these found to not have valid indication

Potential Impact Increased length of stay 0.5 – 1 day Estimated cost per case of CA-UTI ranges from $500-$3,000 Cost to health care system up to $450 million annually according to CMS CA-UTI not documented as present on admission can no longer code patient to higher reimbursement DRG for Medicare

Evidence-Based Guidelines APIC CA-UTI Elimination Guide www.apic.org/CAUTIGuide SHEA-IDSA Compendium http://www.shea-online.org/about/compendium.cfm CDC Guideline http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html# N.b. An update to CDC guidelines is expected in early 2009.

Evidence of Success Numerous published studies reporting reductions in CA-UTI rates of 48-81% Use of reminders Nurse-driven protocols Reduction in duration of catheter days “The duration of catheterization is the most important risk factor for development of infection.” SHEA-IDSA Compendium, October 2008

Preventing CA-UTI Avoid unnecessary urinary catheters Insert using aseptic technique Maintain catheters based on recommended guidelines (daily care) Review catheter necessity daily and remove promptly

1. Avoid unnecessary urinary catheters Studies: 21% of catheters not indicated at insertion 41-58% in place found to be unnecessary Catheters Are uncomfortable for patients Decrease mobility, which may impair recovery and contribute to other complications (e.g., pressure ulcers, deep vein thrombosis) Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med. 1999 Apr 26;159(8):800-808. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155:1425-1429.

Indications for Indwelling Urinary Catheters Based on expert guidelines and published literature: Perioperative use for selected surgical procedures Urine output monitoring in critically ill patients Management of acute urinary retention and urinary obstruction Assistance in pressure ulcer healing for incontinent patients As an exception, at patient request to improve comfort (SHEA-IDSA) or for comfort during end-of-life care (CDC)

Avoidance Strategies External condom catheters for appropriate male patients Intermittent catheterization multiple times per day Assessing urinary retention with bladder ultrasound

Changes to Avoid Unnecessary Catheters Develop criteria for appropriate insertion and verify prior to every insertion Empower nurses to contact physicians before insertion if criteria are not met Use a checklist of criteria – include this with the insertion kits Determine where most catheters are inserted (probably the ED) and start there

2. Insert urinary catheters using aseptic technique Utilize appropriate hand hygiene practice. Insert catheters using aseptic technique and sterile equipment, specifically using: gloves, a drape, and sponges; sterile or antiseptic solution for cleaning the urethral meatus; and single-use packet of sterile lubricant jelly for insertion. Use as small a catheter as possible that is consistent with proper drainage, to minimize urethral trauma.

Changes to Ensure Consistency of Technique Standard insertion kits with all necessary supplies Include technique in checklist for insertion (along with criteria) Design processes to ensure consistent stock of supplies in needed areas

3. Maintain catheters based on recommended guidelines Maintain a sterile, continuously closed drainage system. Keep catheter properly secured to prevent movement and urethral traction. Keep collection bag below the level of the bladder at all times. Maintain unobstructed urine flow. Empty collection bag regularly, using a separate collecting container for each patient, and avoid allowing the draining spigot to touch the collecting container. Maintain meatal care with routine hygiene (bathing).

Practices to Avoid Irrigating catheters, except in cases of catheter obstruction Disconnecting the catheter from the drainage tubing Replacing catheters routinely (in the absence of obstruction or infection); if the collection system must replaced, use aseptic technique These practices may actually increase the risk of infection and other complications.

Changes to Ensure Reliable Care Include daily maintenance items in routine documentation - consider every shift. Ensure all supplies are routinely available at the point of care. Engage patients and families in ensuring consistency such as checking bag placement.

4. Daily review of necessity with prompt removal “The duration of catheterization is the most important risk factor for development of infection.” SHEA-IDSA Compendium, October 2008 74% of hospitals surveyed did not monitor catheter duration. 47% of patient days had no justification for continued catheterization. 41% of the time, physicians were unaware of patients inappropriately catheterized. Saint S, Kowalski. 2008. Jain P, Parada JP.1995.

Daily Review of All Urinary Catheters Determine need for continuation Remove if not indicated Possible strategies: Nursing assessments at every shift, with requirement to contact physician if criteria are not met Nursing protocols for removal of urinary catheters based on criteria Automatic stop orders for 48 to 72 hours after insertion, continuation only when indication is documented in renewal order Reminders in patient records requiring physicians to document indication for continuation of catheter

Measurement Outcome Measure: Urinary catheter-associated UTI rate # Symptomatic CA-UTI* # Urinary catheter days * Infection-causing symptoms as defined by the NHSN in the setting of an indwelling urinary catheter that is in place or has been removed within the past 48 hours X 1000

To Be Successful Set an aim: “Reduce the incidence of CA-UTI by 50% by May 2009.” Plan well: Adopt a change methodology that accelerates improvement such as The Model for Improvement. In order to be successful, start small.

Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? In order to move this work forward, IHI recommends using a proven tool used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes. The Model for Improvement,* developed by Associates in Process Improvement, is a simple yet powerful tool for accelerating improvement. Rather than spending hours in meetings to plan changes, the model for improvement uses small tests of changes that allows for quick modifications. The results are rapid testing, increased involvement, better acceptance and a method to determine if the change results in an improvement. The model has two parts: Three fundamental questions, which can be addressed in any order. (Describe the model) The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of a change to determine if the change is an improvement. (Describe the PDSA cycle) More information is available in the How-to kit as well as on www.ihi.org. Act Plan Study Do

This is not work for one! Form… a team Identify… a project champion Include a diverse staff. MDs, RNs, ICPs, nursing assistants / technicians Identify… a project champion Someone who maintains visibility on nursing unit Identify… a process owner For concerns now and in the future

Role of Leadership Committed: Staff cannot improve without supportive leadership. Set the standard: “This is how we will practice.” Resources: Make time to work on testing. Share data: To motivate staff for change As with any change, senior leaders must be committed. Support comes not only in the form of assigning a team, but in choosing the correct individuals to lead. Leaders should set up regularly scheduled meetings with teams to hear about progress, barriers and next steps. Setting the standard is essential to adoption and spread. Allowing some staff to opt out of the agreed upon system will result in multiple systems, confusion and lack of improvement. Ensure that those participating in the testing have time allocated to do this work. In order to be successful in testing and implementation, we will have to make specific allocations for individuals involved in the testing. Assigning this work to someone who already is overloaded will result in delays and failure of the project. Key team members will need some time to review, discuss and plan tests. One way to facilitate testing as teams move forward is to include the testing as part of daily functions. Testing a form on one patient during the course of the day is not overwhelming and places the work in the environment in which it is intended to be tested. Use data to make your case as well as to determine if the changes made are resulting in improvement. Only by tracking our data over time, will a hospital know if all of the testing and changes result in a decrease in the rate of unreconciled medications as defined in the aim.

Small Tests of Change Small tests... 1 nurse, 1 doctor, 1 patient Move on to pilot test in one nursing unit: - Refine the process. - Test on all shifts. - Test on all patients with catheters. Measure your results to know if a change was an improvement. In order to be successful, start small.

Tips for Success STOP the line Standard equipment packs Empower nurses to stop catheter insertion if indications are not met Leadership support & culture Evidence Standard equipment packs Clinical appropriateness