CAUTI: Issues and Solutions Deborah A. Lichtenberg, RN, BSN, CIC Infection Preventionist Bard Medical

Disclaimer 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.

OBJECTIVES 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.

Catheter-Associated Urinary Tract Infections 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. 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.

Cost of UTIs Average cost of each uncomplicated UTI in 1992 was reported at $6804 - Based on total of 84 patients Average cost impact of each UTI reported in 1996 was $3,8035 - Based on 675 cases, 5,337 controls

Mechanisms of Infection At time of insertion Mechanical during catheter insertion the catheter picks up organisms urethral trauma during insertion Blockage of periurethral glands

Mechanisms of Infection Extraluminal Biofilm Encrustation Organisms migration Fecal incontinence Intraluminal Disconnection of catheter/drainage system Contamination of outlet tube

Catheters and UTIs 3 “Ports of Entry” Catheter / Meatal Junction Catheter / Tube Junction Outlet Tube

Stages of biofilm formation Bacteria switch from a free-floating (planktonic) state where they function as individuals to a sessile state where they function as communities

In a biofilm microorganisms are protected from antimicrobials

Preventing Biofilm on Foley Catheters 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

Silver and Hydrogel Foley Catheter Pseudomonas aeruginosa Reduced densities of bacteria @ 2hrs on a Silver and Hydrogel coated Foley catheter Pseudomonas aeruginosa Note extensive cell damage to organisms

Prevention is Primary!

How do you get people focused on CAUTIs? It all begins with Awareness What is the clinical impact of CAUTI ? 9 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

The Changing Face of Prevention 2008/2009 Changes CMS Reimbursement Changes for HAIs HICPAC /CDC CAUTI Guideline Revised SCIP Guideline APIC Guide to Elimination of CAUTIs

Centers for Medicare and Medicaid Services (CMS) Changes in Reimbursement for Healthcare Acquired CAUTI

Hospital Acquired Conditions Hospitals will not receive additional payment for cases where the condition was not present upon admission 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)

Estimated Incidence of “Conditions”

Why are CAUTIs included? 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

CAUTIs and Medicare Patients 10% of Medicare discharges had a secondary diagnosis of UTI (2006 MedPAR) Hospitals reimbursed $216M for these infections

Are there additional benefits besides saving money? 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

SO…What Was New in 2009? 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 Catheter- Associated Urinary Tract Infections (CAUTIs)11

NHSN Definition Change for 2009 UTI Definition for Patients with an Indwelling Foley Catheter7

Background: HHS Metrics and Prevention Targets # of symptomatic UTI / 1,000 urinary catheter days as measured in NHSN National 5-Year Prevention Target: 25% decrease from baseline Appendix G in HHS plan discusses a new type of metric, the standardized infection ratio (SIR) Several challenges and needs related to the measurement of CAUTIs were identified. Participants suggested a comparison of NHSN symptomatic UTI (or available state data collecting similar variables) to administrative discharge data and a review of the UTI definition in non-acute care settings to validate data quality and ensure monitoring of the full burden of CAUTIs. Many experts pointed out current limitations of the UTI definition and proposed that the metric should focus only on bloodstream infections secondary to UTIs. In addition, participants suggested that strategies to widely implement “best practices” in the prevention of CAUTIs in a range of settings be developed. Participants felt that these actions would help identify targets and play a vital role in the selection of future metrics. http://www.hhs.gov/ophs/initiatives/hai/prevtargets.html http://www.hhs.gov/ophs/initiatives/hai/appendices.html

Measurement: Recommended Outcome Measures Examples of metrics: Number of CAUTI per 1000 catheter-days Number of BSI secondary to CAUTI per 1000 catheter-days Catheter utilization ratio (urinary catheter- days/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_cauti.html

CAUTI Definitions Symptomatic Infection Do catheterized patients have symptoms? Asymptomatic Bacteriuria Is it or is it not just colonization?

2009 CDC/NHSN Surveillance Definitions 7 8 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 COLONY COUNT ≥100,000 ≥1,000 and <100,000 SIGNS, SYMPTOMS MARKERS 1 of the following --Temp 38C or > --CVA pain/tender --S/P pain/tender --Urgency --Frequency --Dysuria PLUS --Positive dipstick --Positive pyuria --Fails NHSN def --MS changes --Urine character --PVR/retention --CBC leukocytosis --Physician treated --No symptoms --Matched BC (at least 1 org)

Does a change in definition change the outcome? 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.

Examples 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

Automatic Foley Catheter Stop Orders 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

What are the risks and benefits associated with antimicrobial Foley Catheters? 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)

HOW DO WE GET TO “ZERO” CAUTI ? CAUTI Prevention Techniques Appropriate Foley catheter Utilization Proper Foley catheter Insertion, Maintenance, Removal Monitoring Compliance Continuing Education and Training CAUTI Prevention Technology 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

2009 APIC CAUTI Elimination Guide11 PURPOSE To provide evidence-based practice guidance for the prevention of Catheter Associated Urinary Tract Infection (CAUTI) in acute and long term settings.

“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

One more reason to follow the patient with a Foley …… 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.

SCIP 2009-2010 ver. 3.0a10 SCIP-Inf-9 3 data elements added Urinary catheter removed on Postoperative Day (POD) 1or 2. 3 data elements added Urinary Catheter Catheter removal Reasons for continuing urinary catheterization

Overview of personnel roles in effort to reduce the incidence of CAUTIs Policy and best practice expertise Provision of surveillance data and risk assessment Consultation on infection prevention interventions Facilitation of CAUTI- related surveillance improvement projects. Proper insertion of the Foley catheter Proper care and maintenance of the Foley catheter system Must be held accountable for compliance with interventions. For Infection Preventionist Direct Patient Caregiver

Conducting a CAUTI Risk Assessment Purpose To develop a surveillance, prevention and control plan based on facility specific data and conditions

Steps for Conducting a Risk Assessment Assess whether an effective organizational program exists. Assess population at risk Point Prevalence Survey Assess baseline outcome data Determine financial impact

The Difference Between Coding and Surveillance and Reimbursement11 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.

Additional Prevention Practice Measures Assess need for Foley on a daily basis Implement early removal processes Physician reminder systems Nurse driven protocols Automatic stop orders Early Foley removal for the surgical patient Consider routine use of bladder scanners Consider technology as addition to the comprehensive prevention plan

The Bladder Bundle Concept 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.

Summary – Connecting the Dots! 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

Why Prevent CAUTIs CAUTIs Are Important CAUTIs Have Serious Clinical and Economic Consequences Actions Can be Taken to Reduce CAUTIs

Thank you! QUESTIONS?

References 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.

WEB SITES for Guidelines/Compendiums www.APIC.org www.SHEA-online.org www.cfmc.org/hospital/hospital_SCIP.html www.cdc.gov/ncidod/dhap/hicpac_pub.html

Measurement: Examples of Process Measures 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_cauti.html

Intermittent catheterization – consider for: Supplemental Prevention Strategies: Alternatives to Indwelling Catheterization 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 External (i.e., condom) catheters – consider for: Cooperative male patients without obstruction or urinary retention http://www.cdc.gov/hicpac/cauti/001_cauti.html

Supplemental Prevention Strategies: Examples 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/antiseptic- impregnated 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 ://

Core Prevention Strategies: Specific recommendations (IB) 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.html

Core Prevention Strategies Specific recommendations (IB) 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

Core Prevention Strategies Specific recommendations (IB) 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

Core Prevention Strategies Specific recommendations (IB) 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, single- use packet of lubricant jelly Properly secure catheters http://www.cdc.gov/hicpac/cauti/001_cauti.html

Core Prevention Strategies Specific recommendations (IB) 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

Core Prevention Strategies Specific recommendations (IB) Insert catheters only for appropriate indications http://www.cdc.gov/hicpac/cauti/001_cauti.html

Core Prevention Strategies (all Category IB) 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

Prevention Strategies Supplemental Strategies Some scientific evidence Variable levels of feasibility Core Strategies High levels of scientific evidence Demonstrated 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

Evidence-based Risk Factors for CAUTI 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