092211--CAUTI-Thomas

Palmetto Health Baptist 1501 Sumter St Columbia, SC

Lendon Thomas, BS, CIC

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Catheter Associated Urinary Tract Infections are an ongoing issue in health care Recent changes in the landscape of CAUTI prevention Growing interest by many stakeholders

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I am an employee of C.R. Bard, Inc., Bard Medical Division. Any discussion regarding Bard products during my presentation is limited to information that is consistent with Bard labeling for those products.

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Review/update the problem of CAUTI Outline many newer events within the last five years Discuss the latest concepts in prevention strategy  From literature and published guidelines

 Locally at Palmetto Health System

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100 million indwelling urethral catheters sold worldwide anually 24 million in the U.S. 25% of hospitalized patients exposed to catheters during their stay UTI = up to 40% of all HAI Vast majority of UTI are catheter related Not without increased cost and morbidity

Saint S, Kaufman S, Thompson M, Rogers M, Chenoweth C. A Reminder Reduces Urinary Catheterization in Hospitalized Patients. Journal on Quality and Patient Safety. 2005 August. (31)8; 455-62

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CAUTI accounts for 36% of all HAI Incidence of catheter associated bacteriuria is 26% in patients with indwelling catheter for 2 to 10 days 24% of those acquiring bacteriuria will advance to CAUTI Approximately 3% will develop bacteremia of urinary origin

Greene L, Marks J, Oriola S. Association for Professionals in Infection Control. Guide to The Elimination of Catheter Associated Urinary Tract Infections (CAUTIs). 2008, p. 5.

Federal Agencies/Mandates CMS

State Involvement

SCIP Public Reporting of HAI

HICPAC CDC

CAUTI

Michigan Keystone

AHRQ Organizations Private Websites CatheterOut.org Workingtowardzero

APIC

SHEA

JCAHO IDSA Consumer Groups

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Original CDC Guidelines for CAUTI prevention, 1981 HICPAC (Healthcare Infection Control Practices Advisory Committee)  Revised the Guidelines for Prevention of CAUTI in

2008  DHHS Document from CDC = 321 pages  Abbreviated guidelines issued 2009 Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Guideline for Prevention of Catheter Associated Urinary Tract Infections 2008, DHHS, Centers for Disease Control and Prevention

HICPAC/CDC Guidelines

Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS, Centers for Disease Control and Prevention, 2009

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CMS now holds U.S. hospitals accountable for not preventing certain hospital-acquired complications

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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 Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides] CatheterOut.org website, University of Michigan. CR5499 Instruction on the CMS web site at http://www.com.hhs.gov/Transmittals/downloads/R 1240CP.pdf

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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

42 CFR Parts 411, 412, 413, and 489; August 2007 Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides] CatheterOut.org website, University of Michigan.

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DHHS: Med-Par Data, 2006: 42 CFR Parts 411, 412, 413, and 489; August 2007

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Surgical Care Improvement Project1  11 SCIP Performance Measures  Reported publically on CMS “Hospital Compare” website  SCIP-INF-9: Urinary catheter removed on post-operative

day 1 or post-operative day 2 with day of surgery being day 0.  PHB showed 96% on Hospital Compare. (Site qualified by saying small sample, less than a quarter).2 1Hospitals.tmf.org

[Internet]. TMF Health Quality Institute. SCIP Quality Indicators. Available from http:/hospitals.tmf.org/SCIP/SCIPQuality Indicators/tabid/678/Default.aspx 2HHS.gov

[Internet]. Medicare Hospital Compare Process of Care Measures. Surgical Care Improvement Project Process of Care Measure. Available from http://www.hospitalcompare.hhs.gov

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As of last year, 2010:  27 states require public reporting of selected HAI  2 states report “confidentially” to state agencies

 3 states have “voluntary” public reporting  5 states made laws to study the issue of public

reporting  13 states and DC have no public reporting laws. RID—Committee to Reduce Infection Deaths. State Legislation and Initiatives on HealthcareAssociated Infections, [Updated March 2010, cited 2011 Aug 13]. Available from http://hospitalinfection.org/legislation.shtml

Infectious Disease Society of America (IDSA)

Hooton T, Bradley S, Cardenas D, Colgan R, Geerlings S, Rice J, Saint S et. al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Disease Society of America. CID 2010:50 (1 March) 000

Association for Professionals in Infection Control

Greene L, Marks J, Oriola S. Association for Professionals in Infection Control. Guide to The Elimination of Catheter Associated Urinary Tract Infections (CAUTIs). 2008

Society for Healthcare Epidemiology of America (SHEA)

Lo E, Nicolle L, Classen D, Arias K, Podgorny K, Anderson D, Burstin, H et. al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:S41-S50

 JCAHO  New National Patient Safety Goal (NPSG.07.06.01)—May 9, 2011  “Implement evidence based practices to prevent

indwelling catheter-associated urinary tract infections (CAUTI)”  

2012 = Get Ready Year January 2013—in surveys. Dings included.

JCAHO. 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-Publication Version. DivSSM, May 9, 2011.

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All these guidelines/mandates, etc, point to the same direction Care Process Strategies Change in the culture of the organization Medical Staff Patient Care Staff Administrative/Management Staff

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Make sure the catheter is indicated Adhere to general infection control principles (aseptic insertion, proper maintenance, hand hygiene, properly trained staff, feedback to care providers) Remove the catheter as soon as possible Consider alternatives to indwelling catheters

Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides] CatheterOut.org website, University of Michigan.

Acute urinary retention or bladder outlet obstruction  Critical output monitoring in critically ill patients (hourly output measurement)  Peri-operatively in selected surgical procedures 

 GU tract or its contiguous structures  Long procedures (remove the catheter in PACU)  Large volume infusions or diuretics during surgery  Intra-operative urinary output monitoring Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS, Centers for Disease Control and Prevention, 2009

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Assist healing of open sacral or perineal wounds in incontinent patients Prolonged immobilization [further defined as]  Unstable thoracic or lumbar spine  Multiple traumatic injuries

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Improve comfort for end of life care

Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS, Centers for Disease Control and Prevention, 2009

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Incontinence1 Obtaining urine for culture or diagnostic test (when the patient can void)1 Prolonged post-operative duration (more than 1 or 2 days)2

1Gould

CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS, Centers for Disease Control and Prevention, 2009 2CMS. Measure ID# SCIP-Inf-9. Specifications Manual for National Hospital Inpatient Quality Measures, 2009.

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Munasinghe et. al, looked at 836 medical admissions over a 1 month period  10% of the admissions had indwelling catheter

placed within 24 hours of admission  38% had no justifiable indication Munasinge RL, Yazdani H, Siddique M, Hafeez W. Appropriateness of use of Indwelling Urinary Catheters in Patients Admitted to the Medical Service. Infection Control and Hospital Epidemiology. 2001 October 22(10), 617

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Gardam, et. al, in a similar study reported:  20% indwelling catheter rate  Only 50% of the catheters justifiable

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Jain, et. al, reported 34% unjustified catheters

Gardam Ma, Amihod B, Orienstein P, Consolacion N, Miller MA. Overutilization of indwelling catheters and the development of nosocomial urinary tract infections. Clinical Performance and Quality Healthcare. 1998, (6) 99-102 Jain P, Parada JP, David A, Smith LG. Overuse of indwelling urinary tract catheter in hospitalized medical patgients. Arch. Intern. Med. 1995; 155:1425-1429

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Caretakers forget to assess the risk

Maki DG, Tambyah PA. CDC. Engineering Out the Risk of Infection with Urinary Catheters. Emerging Infectious Diseases. 2001 Mar-Apr; 7(2): 1-12.

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Risk Awareness In patients with indwelling catheters:  Risk of bacteriuria increases by 5% every day the

catheter remains indwelling  10% of those becoming bacteruric advance to symptomatic CAUTI.  Around 3% will develop urinary associated bacteremia Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides] CatheterOut.org website, University of Michigan.

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Forget the catheter is in place

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Survey of 288 physicians (attending, house staff, interns and medical students). 469 patients in their care—25% with catheters by observation

Saint S, Wiese J, Amory JK, Bernstein MI, Patel UD, Zemencut JK, et. al. Are physicians aware of which of their patients have indwelling urinary catheters? Am. J. Med, 2000 Oct 15; 109 (6): 476-80

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Survey Findings Percent UNAWARE their patient had catheter Medical Students

21%

Interns

22%

Residents

27%

Attendings

38%

31% of the catheters were inappropriate

Saint S, Wiese J, Amory JK, Bernstein MI, Patel UD, Zemencut JK, et. al. Are physicians aware of which of their patients have indwelling urinary catheters? Am. J. Med, 2000 Oct 15; 109 (6): 476-80

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Appropriateness and Duration

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Insertion checklists Removal reminder systems Automatic stop orders

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C.R. Bard, Inc. Bard ADVANCE Foley Tray System [component], 2010

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Recent Study, Meddings et. al, 2010  Systematic review and meta-analysis

 Reviewed published interventional studies that

used reminders to physicians or nurses that urinary catheter in use or stop orders to prompt catheter removal in hospitalized patients Meddings J, Rogers MA, Macy M, Saint S. Systematic Review and meta-analysis: reminder systems to reduce catheter associated urinary tract infections and urinary catheter use in hospitalized patients. Clin. Infect. Dis. 2010 Sept 1; 51(5): 550-60

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Results:  CAUTI rate reduced by 52% (p =