1. Reduction in Catheter Associated Urinary Tract Infection Rates and Device Utilization in a Medical and a Respiratory Stepdown Unit Primary Author: Marie K. Moss, MPH, RN, CIC Co-Authors: Aileen Tanafranca, MSN, RN, CCRN, NE-BC; Brian Koll, MD,FIDSA, Executive Director, Infection Prevention; Margaret Amato-Hayes, CNO, MSN,RN,NE-BC; Barbara Barnett, MD, CMO; Leslyn Williamson, RN, MPH, MSN, DNP, RN, NEA-BC, Director, PCS; Robbie Freeman, MSN, RN-BC Floor Leadership: Samuel Acquah, MD, Medical Director 5 Linsky, Joanna Mecca, MD, Physician Leader, Mary Harris, MD, Physician Leader, Irene Jankowski, RN, Director, WOCN, Ryu Peter Hambrook Tofts, MD, Pulmonary Fellow, Jason Filopei, MD, Pulmonary Fellow

2. Background Hospital acquired urinary tract infections are the third most common nosocomial infection 75% are associated with a urinary catheter A framework for daily inter-disciplinary communication of catheter necessity and monitoring of maintenance bundle practices is needed to reduce catheter utilization and the risk for catheter associated urinary tract infections (CAUTIs) Effective communication strategies and monitoring tools will decrease CAUTI and device utilization rates

3. Methods Two units with fluctuating CAUTI rates, standardized infection ratios (SIR), and device utilization rates were chosen as the study units Patients with indwelling urinary catheters were followed on a daily basis for a period of two years The first year established baseline rates which were compared to post- intervention rates during the second year of the project All rates, SIRs, and percentiles were compared to NHSN benchmarks using the “Rate Table for Catheter-Associated UTI Data” and the "SIR for All Catheter-Associated UTI Data“ analysis reports

4. The CAUTI Prevention Team 4

5. Interdisciplinary CAUTI Prevention Education  CUSP Education  CAUTI Prevention SLMs for Nursing, PCAs, and transporters  CAUTI Prevention Presentation to Nursing Quality Champions at the Patient Quality and Safety Workshop  Monthly CAUTI prevention education classes for Skin Saver Champions  5 Linsky “Bladder Bulletin”  TeamStepps™ Training Mount Sinai / Presentation Slide / December 27, 20125

6. Self-Learning Module Post Test --- URINARY CATHETERS Exercising Care to Prevent Complications of Infection Post Test for Transporters and Technicians You keep the catheter secured safely by: 1.Pulling it taut and taping to leg 2.Securing the catheter at connection site to thigh 3.Allowing enough loop in catheter to prevent kinking or pulling 4.All of the above 5.B and C The urinary drainage bag must be kept: 1. At the level of the bed 2. Below the upper side rail 3. Below the level of the bladder 4. on the abdomen Urinary drainage bag must never be: Above the level of bladder On the abdomen Raised across the abdomen when moving patient Touching the floor a. All of the above b. 1 and 2 c. 1, 2, and 4 d. 2 and 3 When transferring a patient with an indwelling urinary catheter from bed to stretcher: Keep bag in low position during transfer Place the bag on patient’s abdomen Let the bag hang loose on opposite side of bed Hang the bag form the IV pole

7. TeamStepps™ Training CAUTI Scenarios

8. The Two Challenge Rule Scenario Information Conflict Jay Stewart RN, believes that his patient, Mrs. K, no longer needs to have a Foley catheter. Using the urinary catheter algorithm, he determines that the patient no longer meets criteria. Jay approaches the patient’s MD, Dr. Gray, and states, “Dr. Gray, Mrs. K no longer needs to have a Foley. Can you write an order for D/C?” Dr. Gray responds, “Mmm…she has a Foley? Wow, look at the time! Got to run - I’m really late for Grand Rounds.” Dr. Gray quickly turns and starts to walk away. How can the Two Challenge Rule be used to resolve this situation?  Role play using the Two Challenge Rule (Remember: This is used when an initial assertion is ignored)  It is your responsibility to assertively voice your concern at least two times to ensure that it has been heard.  The member being challenged must acknowledge  If the outcome is still not acceptable:  Take a stronger course of action  Use supervisor or chain of commandTeamSTEPPS™

9. The DESC Scenario Personal Conflict Laura the PCA is happy that her patients’ Foleys are being removed when no longer necessary. Although this is great for the patients, she now has several incontinent patients on her assignment each day. She feels that the nurses ignore her when she asks them for help. One day Laura, feeling overwhelmed, asks Martha the RN to help her change a patient. Martha responds that she can’t do it at that moment because she is giving out meds. Laura responds angrily, raising her voice in front of the visitors and other staff in the room.  How can DESC script be used to resolve this situation?  Role play using DESC:  D — Describe the specific situation  E — Express your concerns about the action  S — Suggest other alternatives  C — Consequences should be stated Ultimately, consensus shall be reached.TeamSTEPPS™

10. Urinary Catheter Assessment Tools

11. Urinary Catheter Maintenance Assessment Tool UNIT: DATE: Answer 'Yes', 'No', or 'N/A' to the questions below. Provide comments as applicable. Assessments made 3x/week. MR# Is hand hygiene performed before and after handling the urinary catheter? (Observation) Are gloves worn when handling the urinary catheter? (Observation) Is the closed system continuously maintained? (Observation) Is the urinary catheter bag positioned below the level of the bladder for effective drainage? (Observation) Is the urinary catheter secured to the thigh allowing enough loop in the catheter to prevent kinking or pulling? (Observation) Are sterile catheter urine specimens taken aseptically using the needle port? (Observation) COMMENTS: Mount Sinai / Presentation Slide / December 27, 201211

12. Mount Sinai / Presentation Slide / December 27, 201212 Daily Assessment of Need for Urinary Catheter

13. Urinary Catheter Removal Algorithm for Nurses Mount Sinai / Presentation Slide / December 27, 201213

14. Urinary Catheter Stop Orders

15. Stop Orders for Urinary Catheters in the Electronic Medical Record Short Term Urinary Catheter (Good for < 48 hours) Acute Urinary Retention I and O’s on a critically ill patient < 48 hours post-op Prolonged Urinary Catheter (Good for < 7 days) Terminal Care Neurogenic bladder Post–op urological procedure Assist in healing an open sacral wound Prolonged immobilization

16. Results UnitCAUTI Rate 2013 CAUTI Rate 2014 CAUTI SIR 2013 CAUTI SIR 2014 DU 2013 DU 2014* 5 Linsky1.500.9022 nd Percentile 9 th Percentile 5 Linsky Stepdown 2.801.5070 th Percentile 38 th Percentile 16 5 Linsky Respiratory Step Down unit has achieved and maintained a zero CAUTI rate for the year 2014 to date. Catheter device utilization decreased from the 70 th to the 38 th percentile. 5 Linsky Medical Unit has achieved and maintained a zero CAUTI rate for the year 2014 to date. Catheter device utilization decreased from the 22 nd to the 9 th percentile. *Significant reduction in DU for both units: p < 0.00001

17. Pulmonary Step Down Surveillance Catheter Associated Urinary Tract Infections 2013 – 2014

18. Medical Unit Surveillance Catheter Associated Urinary Tract Infections 2013 – 2014

19. Conclusions Implementation of daily interdisciplinary communication strategies and bundle monitoring tools led to a significant decrease in CAUTI rates, SIRs, and device utilization on both units Tools that guide health care providers to ensure compliance with maintenance bundles and removal of urinary catheters in a timely manner leads to the prevention of CAUTIs in hospitalized patients