Title: CAUTI: Reform, Reimbursement, Refocus
1CAUTI Reform, Reimbursement, Refocus
- Kimberlee J Souhrada MM, BSN, CLNC
- Clinical Specialist, Rochester Medical
Corporation - One Rochester Medical Drive
- Stewartville, MN 55976
- kjsouhrada_at_rocm.com
- Office 800-615-2364 x609 507-533-9609
- Mobile 651.319.2714
2At her weekly book club meeting, Donna is again
embarrassed by the inability to control her
bladder.
3Disclosure Statement
- Author affiliation
- Rochester Medical Corporation
- Memberships
- APIC, SUNA, NLN, AACN, AORN, NACLNC
This program has been approved by the American
Association of Critical-Care Nurses (AACN) for
1.0 CERPs, Synergy CERP Category B , File
Number 00017795
4Objectives
- Identify and describe the risks and complications
associated with CAUTI - Review and assess the complexity of Consumer
Awareness and Healthcare Reform as they relate to
CAUTI - Review NHSN hospital reporting system as it
pertains to symptomatic UTIs - Assess TJC and the 2012 National Patient Safety
Goal - Analyze the common goals and objectives of agency
guides for CAUTI reduction initiatives
5Catheter-Associated Urinary Tract Infection
(CAUTI)
6A Brief Catheter History
Catheter To let or send down
- To relieve painful retention of urine since time
immemorial - Ancient materials from 3000 BC!!!
- Straw
- Rolled up palm leaves
- Dried leaves of allium, gold, silver, copper,
brass and lead
- 11th Century
- Development of malleable catheters with bored
holes - 19th and early 20th Century
- Coude catheter
- Self-catheterization for urinary retention -
Catheter Fever - 1930s - The Foley
- Dr. Frederic E.B.Foley St. Cloud, MN
7The Burden of CAUTI
- Indwelling Urinary Catheters (IUC) are inserted
in gt5 million patients per year - One out of four hospitalized patients will have
an IUC - 40 50 do not have a valid indication for use
- In a recent study gt50 of physicians did not know
which patients were catheterized or for how long - 40 of all HAI most common site of Hospital
Acquired Infection (HAI) - UTIs account for more than 8 million doctor
visits per year - 8 prevalence in the home care setting
- Leading cause of secondary bloodstream infection
- Most are asymptomatic
- 900,000 patients with nosocomial bacteriuria in
US hospitals each year
8Why Focus on CAUTI?
- Discomfort
- Daily Risk for UTI from an IUC 3-7
- Prolong hospital stay
- Secondary bacteremia/sepsis
- Acute pyelonephritis
- Increased use of antimicrobial drug therapy
- Urethral stricture
- Increased mortality 5 of all deaths from HAI
are associated with urinary catheters - MDRO Infection
9Risk Factors for developing a CAUTI
- Female
- Age gt50
- Diabetes
- Urethral colonization
- Debilitated health
- Incomplete bladder emptying
- Fecal incontinence
- Dehydration
- Sickle-cell anemia
- Immobility
- Concurrent infections
- History of UTI
- Colonization with MDROs
- Poor personal hygiene
10Care Provider related Risk Factors
- Lack of hand hygiene prior to catheter
manipulation - Drainage spigot contamination
- No catheter securement
- Catheters in place too long
- Poor insertion technique
- Breaks in the closed system or non-use of a
closed system - Drainage bag raised above the level of the
bladder - Lack of use of methods to control incontinence
- No sample port on closed system
11Consumer Awareness and Healthcare Reform
- Historical Timeline of Key Events
12Florence Nightingale (1820 - 1910)
- Pioneered the principle of accountability for the
results of medical practice - Campaigned to improve health standards with
measurable outcomes supported by undeniable data
It may seem a strange principle to enunciate as
the very first requirement in a hospital that it
should do the sick no harm.
13Hospital Report Card Highlights
- 1985 First reporting of hospital data to a
state agency - Maryland Quality Indicator Project (surgical
morbidity) - 1991 NYS inadvertent publication of cardiac
surgeons mortality rates - Note - with public awareness came a drop in
mortality from 4.2 to 1.6 in 10 years - Additional states and new conditions have been
added to state reporting as legislation continues
to change
14 Consumer Awareness is born!
Plaintiffs turned Protesters
15The Institute of Medicine (IOM) Report
- To Err is Human (1999)
- 98,000 deaths annually (3 full jumbo jets/qod)
- Medical error total cost is estimated at 17 -
29B - It is not acceptable for patients to be harmed
- by the health care system
- The IOM recommended Four Tiered Strategy for
Improvement - Establish a national focus
- Identify and learn from errors through nationwide
public reporting - Raise performance standards and expectations
- Implement safety systems in HealthCare
Organizations
16US Department of Health and Human Services
- Centers for Medicare Medicaid Services
- (CMS)
17Hello, incontinence helpline can you hold?
18 The US Department of HHS
19CMS
- CMS has transformed from a passive payer of
services into an active purchaser of higher
quality, affordable care. - Now rewards providers by linking the payment to
the quality and efficiency of care provided - The CMS main goal to foster joint clinical
and financial accountability in the healthcare
system.
20Value Based Purchasing (VBP)Prospective Payment
System
- Inpatient and Home Healthcare Pay-for-Reporting
- Reduction of payment for hospitals and Home
Health Agencies not submitting data regarding
specified quality measures - Medicare Home Health Compare and Hospital
Compare - www.medicare.gov
- Resource link
- More measures continue to be added
21Goals of Healthcare Reform and VBP
- Improve clinical quality, patient safety and
efficiency of care - Reduce adverse events
- Encourage patient-centered care
- Avoid unnecessary costs
- Stimulate investment in systems to improve
quality and efficiency - Make performance results transparent and
understandable for consumer empowerment
22Centers for Disease Control Prevention (CDC)
- National Health Safety Network
- (NHSN)
23CDC-CMS-NHSN
- State reporting to CDC initially was voluntary,
and not standardized - 2005 - NHSN Reporting System was launched
- Standard in HAI surveillance
- Open enrollment to all types of healthcare
facilities in the US - 2008 CMS disallows payment for certain Hospital
Acquired Conditions (HAC) such as - CAUTI
- Staph Aureaus bloodstream infections
- Serious bedsores, objects left in pt, blood
incompatibility, and air embolism - Surgical Site Infections (SSI)
24 NHSN Reporting Structure
- Reporting will be publically accessible through
www.hospitalcompare.hhs.gov -
25Mandatory Reporting
26- The NHSN uses the information reported to produce
comprehensive rates used for hospital comparison. -
- It is very important that the data is collected
using exactly the same definitions each time.
27Reportable CAUTI
- CAUTI UTI that occurs in a patient who had an
indwelling urethral catheter in place within 48
hours prior to specimen collection. - Transfer Rule If the UTI develops in a patient
within 48 hours of discharge from a location,
the discharging location is indicated - NHSN definitions Reportable CAUTI
- http//www.cdc.gov/nhsn/index.html
- Six specific definitions
- Four are associated with the patient that had an
indwelling urinary catheter at the time of
specimen collection, removed within 48 hours
prior to specimen collection, and the patient who
did not have an IUC - Two definitions for patients lt 1 year of age
28The Joint Commission (TJC)
- The new 2012 National Patient Safety Goal (NPSG)
29Background The Joint Commission (TJC)
- Founded in 1951 it is the oldest and largest
standards-setting and accrediting body in
healthcare - Evaluates and accredits gt19,000 health care
organizations and programs in the US - Governed by a Board of Commissioners
- Accreditation
- Earned by an entire health care organization
- Certification
- Earned by programs or services based within or
associated with an accredited health care
organization i.e. diabetes, heart disease,
cancer, and more
30National Patient Safety Goals (NPSG)
- 2002 Established to help organizations address
specific areas of patient safety concerns - Patient Safety Advisory Group determines the
highest priority safety issues and how to address
them - Elements of Performance
- 2004 - Aligned with the CDC and endorsed by CMS
to standardize common measures - Public website www.qualitycheck.org
312012 Goals
- Approval of one new NPSG
- NPSG.07.06.01 Implement evidence-based
practices to prevent indwelling
catheter-associated urinary tract infections
(CAUTI) - Evidence-based guidelines
- 2008 SHEA Compendium of Strategies
- 2009 HICPAC/CDC Guideline
- Phase-in period
- TJC Survey will ensure planning and preparation
for full implementation in 2013
- This goal is not applicable to
- pediatric populations
32Guides, Guidelines, and Strategies
- Prevention Interventions and Control Practices
33CAUTI Prevention Resources
- APIC Association for Professionals in Infection
Control and Epidemiology - 2008 Guide to the Elimination of CAUTIs
- SHEA Society for Healthcare Epidemiology of
America - 2008 Strategies to Prevent HAI in Acute Care
Hospitals - CDC/HICPAC Healthcare Infection Control
Practices Advisory Committee - 2009 Guideline for the Prevention of
Catheter-associated Urinary Tract Infections - IDSA Infectious Diseases Society of America
- 2009 Strategies to Reduce the Risk of CAUTI
- IHI Institute for Healthcare Improvement
- 2011 How-to Guide Prevent Catheter-associated
Urinary Tract Infections
34Shared Goals
- Identify the Problem of CAUTI
- Prevalence and Burden
- Risk Assessment
- Baseline data to determine patients at highest
risk - Surveillance
- Monitoring and data collection
- Strategies to Prevent CAUTI
- Policies, procedures, education, and feedback
- Implementation of Best Practices
- ABC Bundle, protocols, and techniques
35Identify the Problem in your Facility
- Basic Infection Prevention and Antimicrobial
Stewardship - Programs, Policies and Protocols
- Systems and Strategies
- Prevalence of Urinary Tract Infections
- Risk factors
- Bacteriuria
- Urinary Catheter Use in Healthcare settings
- Complications of IUCs
- UTI Pathogens
- Endogenous pathogens
- Contaminated equipment
- Environmental
- Long-term IUC
- Pathogenesis
- Extraluminal
- Intraluminal
- Biofilms
- Diagnosis of CAUTI
- Specimen collection
36CAUTI Risk AssessmentFacility-wide or Unit Based
- Existing organizational program
- What systems are in place?
- Population at risk
- Point prevalence survey
- Baseline outcome data
- Examine CAUTI utilizing pathology reports
- Assess location, frequency and prevalence
- Use NHSN definitions
- Financial impact
- Multidisciplinary Team
37Surveillance Methodology
- Surveillance for CAUTI is a dynamic and essential
way - to turn data into useful information to drive
interventions!
- Elements of Surveillance
- Assessment of the population
- Identification of those at greatest risk
- Determination of observation time period
- Choice of surveillance methodology
- Monitoring for outcomes
- Collection of data
- Analysis of data
- Display and distribution of findings
38Surveillance Considerations and Definitions
- Clear and Consistent
- Document UTIs, assess risk factors, and monitor
procedures and practices - Device utilization ratio (NHSN)
- Numerator number of events
- Denominator number or event-related catheter
days or patient days - Monthly assessment
- Incidence new cases in a given time period
- Prevalence number of cases at a particular
point in time divided by the total population
being studied
39Example of CAUTI Surveillance
- Plan Monthly rate of CAUTI in MICU for one year
- Criteria NHSN criteria for CAUTI
- Data collection Active surveillance of MICU
patients - Numerator Number of new CAUTI per month
- Denominator number of IUC days in MICU
- Calculation of Incidence rate
- CAUTI RATE Number of new CAUTI X 1000
- Number of catheter days
- 2 UTI/702 catheter days .002847 X 1000 2.8
per 1000 IUC days
40Display and Distribution of Findings
- As of 02/2012 - Zero CAUTI
41Strategies to Prevent CAUTI
Adherence to a sterile, continually closed
system has been the cornerstone of CAUTI
prevention
- Appropriate Infrastructure
- Written guidelines for UC use, insertion and
maintenance - Only trained, dedicated personnel insert UCs
- Necessary supplies for aseptic technique
- Documentation system
- Resources to support surveillance
- Surveillance
- Risk assessment and identification of patient
units - Standardized criteria
- Appropriate and valid
- Education and Training
42- Appropriate Technique for IUC Insertion
- Indications for insertion
- Alternatives
- Hand hygiene
- Aseptic technique and sterile equipment/kit
- Smallest size catheter
- Appropriate Management of IUCs
- Proper securement
- Sterile closed system
- Appropriate sample collection
- Unobstructed urine flow
- Empty the bag regularly
- Keep the bag below the level of the bladder
- Routine perineal hygiene after insertion
- Accountability
- Executive level support
- Management
43Special Considerations for CAUTI Prevention
- Remove Unnecessary IUCs
- Assess the need for an IUC daily
- Physician reminder systems EMR, written, daily
rounds reminder - Automatic stop orders
- Requires renewal of the order for continuation
- Nurse-driven protocols
- May be part of an algorithm
- Independent of a physician order
- Surgical patients SCIP 9 Core Measure
Indicator - Bladder scanners
- Anti-microbial coated catheters
Postoperative Urinary Catheter removed on POD 1
or POD 2
44The APIC CAUTI Bundle Approach
- A septic insertion and proper maintenance
- B ladder ultrasound may avoid IUC
- C ondom or intermittent catheterization in
appropriate patients - D o not use IUC unless necessary
- E arly removal of catheters
- using reminders or stop orders
Create your own acronym for a Bundle that would
work in your organization
45Implementation of Best Practices
- Culture of Patient Safety
- Information and education
- Foundation for surveillance
- Involvement can make a difference
- Assemble a Team
- Oversee the process
- Be the driving force
- Partner with nursing, case management, infection
prevention, and physicians - Implement Teamwork and Communication
- Use tools for improvement
- Identify opportunities and barriers
If you only have a hammer, you tend to see
every problem as a nail. -- A. Maslow
46Implementation of Best Practices
- Identify and Learn for Defects
- What happened and why
- What can be done to reduce risk
- Engage Senior Executive
- Bridge the gap
- Help remove barriers
- Implement improvement efforts
- Everyone is accountable for efforts to reduce
risks to patients
47Results after ImplementationScott White
Memorial Hospital, Temple, TX, 1208-0410
No of CAUTI/Patient Days1000
No of CAUTI/Month
43.3 Reduction
48Results after Implementation
- Catheter bundle implemented with a decrease
- in CAUTI gt 83 in 5 years
- St. Joseph Regional Medical Center, Lewiston, ID
- In one month of CAUTI dropped from 8 to 2
- As of 1/30/12 no UTIs for 403 days
- Intervention provided a 98.87 decrease in UTI
over 4 years - Tacoma General, Mary Bridge Childrens,
Allenmore and Good Samaritan Hospitals, Tacoma,
WA
49Closing Thoughts
- Bringing about cultural change is difficult but
achievable - CAUTI rates can be reduced by a multidisciplinary
approach - Review evidence-based resources
- Implement recommended practices
- Ensure that evidence-based practices are adhered
to and embraced by all members of the team - Continuous education and feedback will bring
success - Evaluate and re-evaluate your own facility
- Do NOT give up the fight to Aim for Zero on CAUTI
reduction!!
50Finally, the other catheter is getting the
attention it deserves!
51(No Transcript)
52References
- APIC 2008 Guide to the elimination of
Catheter-associated Urinary Tract Infections - A Brief History of Report Cards by John Steen
- Centers for Medicare and Medicaid Services,
Roadmap for Implementing Value Driven Healthcare
in the traditional Medicare Fee-for-Service
Program - The CMS. www.cms.hhs.gov
- Healthcare Associated Infections States and
Public Reporting. ww.extendingthecure.org - Healthcare Infection Control Practices Advisory
Committee. Guideline for Prevention of
Catheter-associated Urinary Tract Infections
2009. - Infection control and Hospital Epidemiology.
SHEA Position Paper 2008. Strategies to Prevent
Catheter-associated Urinary Tract Infections in
Acute Care Hospitals - Infectious Disease Society of America 2009
International Clinical Practice
Guidelines. Diagnosis, Prevention, and Treatment
of Catheter-associated Urinary Tract Infection in
Adults - Institute of Medicine. To Err is Human Series
Building a Safer Health System to Delay
is Deadly. - Jeffers, T.W., The GOAL Elimination of Catheter
Associated Urinary Tract Infections. Online
webinar slide retrieval. August 2011 - The Joint Commission. www.jointcommission.org.
2012 Hospital National Patient Safety Goals - Mourad,M., Auerbach,A., Improving Use of the
Other Catheter. Archive of Internal Medicine.
Vol 172 (no. 3) Feb. 13,2012. - The Recovery Act. Whitehouse.gov/Recovery
- Responsible Reform for the Middle Class. The
Patient Protection and Affordable Care Act - The Center for Disease Control and Prevention.
www.cdc.gov/nhsn