CAUTI Prevention Pillar #3 Maintain Bug-Free Catheters Optimize day-to-day urinary catheter care

Transcription

1 CAUTI Prevention Pillar #3 Maintain Bug-Free Catheters Optimize day-to-day urinary catheter care A CAUTI Action Network Prevention Series Webinar Thursday March 15, 2012 Jennifer Palagi, MPH, BSN, RN, CIC Quality Improvement Consultant Tina Schwien, MN, MPH Quality Improvement Consultant C A U T I P r e v e n tio n P illa r s Avoidance Removal Insertion Maintenance 2 1

2 Today s Agenda Patient story Best practice Hospital Story Discussioni Next in Series 3 Patient Story Defect Analysis: What could have prevented this CAUTI? 4 2

3 Patient Story: 63 year old Male Admit date: 11/1/11 Found Down with core body Temp of 80 Degrees Fahrenheit h Temp Sensing silver-latex Foley and rectal temp probe placed 11/1/11 with negative urine cx. 11/5/11 Temp and >100,000cfu Staph Hominis from Urine cx. Pt c/o Pain/Burning Organism 100% NF susceptible based on published in vitro data. Are temp sensing Foley Catheters necessary? 5 Guiding Principle Design processes so maintenance occurs reliably for Every patient Every time Every shift Every clinical caregiver 6 3

4 Routine Maintenance: Do Practices to Avoid: Do Not Maintain a sterile, continuously closed drainage system Irrigate catheters, except in cases of catheter obstruction Keep catheter properly secured to prevent urethral traction Disconnect the catheter from the drainage tubing Keep collection bag below level of the bladder at all times-not on floor Replace catheters routinely; if you must, use aseptic technique Maintain unobstructed urine flow Clean periurethral area with antiseptics while catheter in place Empty collection bag regularly; don t allow draining spigot to touch the collecting container Break junction between catheter and collection tubing when collecting for urine samples IHI Improvement Map. Getting Started Kit: Prevent Catheter-Associated Urinary Tract Infections How-to Guide; HICPAC Guideline for Prevention of CAUTIs Bundle Approach as an Option Example Bundle from Health Protection Scotland project 8 4

5 Education, Training, & Assessment Train and verify competency of all clinical staff who may insert and maintain urinary catheters Do not assume staff are competent Standardized education/training materials Periodic re-training or assessment 9 St. Luke s Meridian Medical Center Meredith Hotchkiss BSN, RN Infection Prevention Practitioner hotchkim@slhs.org Aimee Baerlocher, BS, CIC Infection Prevention Practitioner baerloca@slhs.org 10 5

6 St Luke s Meridian Med/Surg July, Two year retrospective study, including process audits, identified d several issues EBP was reviewed Foley care skills labs for all CNA s Basin bathing was eliminated Charge nurse report sheet tracks Foley days/physician orders. Physician letter in chart to renew order. 11 Comfort Baths Pros and Cons Pros Cost Easy to use UTI prevention EBP Standardize product Efficiency Cons Cost Pt satisfaction (needs scripting) Nurse/CAP satisfaction 12 6

7 Meridian 5th Floor Catheter Associated UTI's per 1000 Foley Days (Jan 2008-Dec 2011) Use of Comfort Bath began Dec Catheter Associated UTI's per 1000 Foley Days Meridian 6th Floor Catheter Associated UTI's per 1000 Foley Days (Mar Dec 2011) Use of Comfort Bath began Dec Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Catheter Associated UTI's per 1000 Foley Days 14 7

8 Next Steps for Housewide Implementation Approval Gather # of warmers each unit needs (no charge) Determine go live date Ordering information Education CNA skills lab (return demonstration) 15 Swedish Medical Center Cherry Hill Eric Wolak, MSN, RN, NE-BC, CCNS, CCRN-CSC Nurse Manager Cardiovascular ICU and Emergency Department Erik.Wolak@swedish.org 16 8

9 Swedish Slides 17 Kootenai Health / Kootenai Medical Center Marc Chavez BSN, RN-CIC Infection Prevention Coordinator mchavez@kmc.org 18 9

10 Measuring the Effect of a Multi-Factorial Intervention to Decrease CAUTI in the Acute Care Setting Marc Chavez BSN, RN-CIC; Carol Williams RN, BSN, CHPN; Carmen Sincerbeaux RN, MA, CNOR; Lee Rieken RN, CIC; Marian Wilson RN- BC, MPH; Ashley English RN, BSN Kootenai Medical Center Coeur d Alene Idaho 246-bed Not for profit district hospital ANCC Magnet Designation Awarded February

11 Background Indwelling urinary catheters can place patients at high risk for catheter associated urinary tract infection (CAUTI). These infections can: o Prolong Hospitalization o Increase Healthcare Costs o May Result in Sepsis or Death Evidence-based guidelines have been developed to standardize care and reduce risk, however, no clear consensus exists on most effective implementation. Objectives This study aims to evaluate the effects of a hospital-wide intervention by measuring 1) Catheter Associated UTI (CAUTI) Rates 2) Rate of Device Utilization (indwelling urinary catheter days) 3) Percentage of Devices Removed by Postoperative Day Two (SCIP Inf-9) 11

12 Methods A pre-test post-test intervention study design was used to evaluate outcomes. o Descriptive Statistics o Independent t-tests The multi-factorial intervention was based on current evidence for CAUTI prevention and included: o Policy Revision o Daily Medical Necessity Documentation o Computerized Education Module o Systematic Surveillance and Feedback Intervention Policy Revision Included: o Criteria for Insertion of Foley o Daily Medical Necessity Order Checklist o Pre Insertion Perineum Care o Securement Device o Collection Bag Maintenance Below Level of the Bladder o Perineum care changed from each shift to every day based on Evidence Based Practice recommendations 12

13 Intervention Computerized Education Module o Developed utilizing Health Stream o Required by all staff with patient contact o Nursing Module in depth training o Ancillary staff module i.e. Radiology, PT, OT, and Patient Transport which focused on drainage bag placement. Methods Data collected from 9 inpatient units o Pre-intervention period March 2009 through March 2010 o Post-intervention period April 2010 through o Post intervention period April 2010 through December

14 Results Rate per 1000 Catheter days CAUTI Rate Hospital Wide February 1, 2010 House wide Education for new policy and trial on general Medical Unit 2.1 April 1, 2010 Facility wide implementation of CA-UTI Reduction Bundle Pre Intervention Rate 2.0 Post Intervention Rate 1.4 P= CAUTI Rate CA-UTI Trend Results Hospital Wide Catheter Utilization Rate P =0.005 Catheter Days/Patient Days x month Pre-Intervention 9 month Post-Intervention 14

15 Conclusions A significant reduction in device utilization was accomplished. A statistically significant reduction in CAUTI rate was not achieved during the 9-month time period o Goal of 30% rate reduction was achieved Limitations Variation among units in compliance with the new practices likely influenced these findings Tools and processes are needed to improve clinician compliance with daily assessments for medical necessity of catheters 15

16 Healthcare Infection Control Practices Advisory Committee 2009 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 (see Section III. Implementation and Audit). (Category IB) (Key Question 2B) 16

17 Objectives The purpose of this pilot study is to evaluate the effects of a product conversion from silver impregnated latex Foley catheters to Nitrofurazone impregnated silicone Foley catheters on. CAUTI Rate Facility Cost Utilization of Antibiotic for treatment of CAUTI Background: Based on In Vitro testing Johnson, Delavari & Azar. (1999). Activities of a nitrofurazone-contaning catheter and a silver hydrogel catheter against multidrug-resistant bacteria characteristic of catheter-associated UTI. Antimicrob Agents Chemother, 43(12): CA-UTI By Organism Total Pathogens Nitrofurazone Susceptability E-Coli 10 Susceptable K Pneumonia 5 Susceptable Enterococcus Faecalis 4 Susceptable Proteus 3 Not Susceptable Enterobacter t 2 Susceptable Citrobacter 2 Susceptable Morganella 1 Susceptable Total 27 17

18 Background: Based on In Vitro testing Johnson, Delavari & Azar. (1999). Activities of a nitrofurazone-contaning catheter and a silver hydrogel catheter against multidrug-resistant bacteria characteristic of catheter-associated UTI. Antimicrob Agents Chemother, 43(12): CA-UTI By Nitrofurazone Organism Total Pathogens Susceptability E-Coli 9 Susceptable Enterococcus Faecalis 4 Susceptable K Pneumonia 1 Susceptable Enterococcus Faecium 1 Susceptable Total 15 Housewide CA-UTI Data Temp Sensing case 7/13/11, Urinary Catheter same day as rollout 20.0% 18.6% % 15.8% 16.0%16.0%16.1% 16.3% 16.9% 16.2% 16.3%16.2% 16.9% 15.3%15.2% 15.3% % 13.6% 13.9% 14.4% 14.8% 15.0% 14.2% 13.4% 13.7% 13.6% 5.0 Utilization Rate 10.0% % Infection Rate 5.0% % CA-UTI Housewide Cases - 27 Rate CA-UTI Housewide Cases - 15 Rate CA-UTI Housewide Cases - 10 Rate 1.1 CAUTI Rate Kootenai Device Utilization Linear (CAUTI Rate) 2010 CA-UTI Utilization Rate15.2% 2011 CA-UTI Utilization Rate % Goal CA-UTI Rate

19 Cusum Chart Significance and Implications: Internal average cost per case of CAUTI using Premier Software $18,003 per incident. Using this number a nursing-led research initiative potentially saved the facility more than $800, over a two year period. 19

20 Significance and Implications: Nitrofurazone-impregnated catheter may reduce CAUTI events among hospitalized inpatients. Longer time periods will be needed to increase confidence in the preliminary findings. New products may allow organizations to reach goals of zero CAUTI events Contact Information Marc Chavez RN BSN o o mchavez@kmc.org 20

21 References 1. Fekete, Calderwood, & Baron. (2009) Urinary tract infection associated with indwelling bladder catheters. Retrieved July 2009 from 2. Lo E. Nicole L. Classen D. et. al. Strategies to prevent catheter associated urinary tract infections in acute care hospitals. InfectControl Hosp Epidemiol 2008:29:S41-S R. Douglas Scott II et. Al. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and Benefits of Prevention Centers for Disease Control and Prevention March Foxman B. Epidemiology of urinary tract infections: incidence, mortality, and economic costs. Am J Med. 2002;113(1A):5S-13S. 5. Centers for Disease Control. Cathter-associated urinary tract infection (CAUTI) event Atlanta Ga: CDC. March Retrieved February 2009 http// pdf 6. Gould C. et. Al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections Healthcare Infection Control Practices Advisory Committee. Retrieved References 7. Leclair, et al. (2000). Effect of a nitrofurazone-impregnated urinary catheter on the incidence of catheter-associated UTI in burn patients. Presented 4th Decennial International Conference on Nosocomial and dhealthcare-associated t dinfections: Atlanta. t 8. Stensballe et al. (2007). Infection risk with nitrofurazone-impregnated urinary catheters in trauma patients. Ann Int Med, 147(5): Johns Hopkins. ( ). Bayview foley-associated UTI before and after implementation of nitrofurazone foley catheter. Unpublished. 10. Johnson, Delavari & Azar. (1999). Activities of a nitrofurazone-contaning catheter and a silver hydrogel catheter against multidrug-resistant resistant bacteria characteristic of catheter-associatedassociated UTI. Antimicrob Agents Chemother, 43(12):

22 Discussion What excited you about what you heard? What can you do by next Tuesday What might get in your way? Any offers/requests? 43 Next Up in the Series NEW DATE!!!!! Avoidance Jan 19, 2012 Insertion Feb 16, 2012 Maintenance Mar 15, 2012 Removal May 3,

23 Thank You Please complete the brief survey monkey evaluation when you close out of the webinar. Washington Tina Schwien QI Consultant Patient Safety (206) Idaho Jennifer Palagi QI Consultant Patient Safety (208) For more information: This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C7-QH