Title: Utilization of National Surgical Quality Improvement Data and Surgical Care Improvement Protocols to Improve the Rate of Catheter Association Urinary Tract Infection Robert E. Glasgow, MD Department of Surgery University of Utah Salt Lake City, UT
1Utilization of National Surgical Quality
Improvement Data and Surgical Care Improvement
Protocols to Improve the Rate of Catheter
Association Urinary Tract InfectionRobert E.
Glasgow, MDDepartment of SurgeryUniversity of
UtahSalt Lake City, UT
1
2Background
- Catheter-Associated Urinary Tract Infection
(CA-UTI) is a major cause of healthcare
associated morbidity in the United States - Over 80 of patients undergoing major operations
have periprocedural urinary catheterization - Prolonged urinary catheterization is
significantly associated with increased risk of
UTI and 30 day operative mortality - CA-UTI costs the healthcare system approximately
758 per infection and over 330 million annually
Anderson DJ. Infect Control Hosp Epidemiol.
2007 Jul28(7)767-73 Scott RD. The direct
medical costs of healthcare-associated infections
in US hospitals and the benefits of prevention.
Centers for Disease Control and Prevention.
March, 2009
3NSQIP and the University of Utah
- ACS NSQIP is a data-driven, risk-adjusted,
outcomes-based surgical quality improvement
program. - 258 participating hospitals in 2010
- Benefits of participation
- Identifying QI targets
- Improving patient care
- Decreasing institutional costs
- University of Utah joined in 2001
4June 2009 NSQIP Report Urinary Tract Infection
Goal
5June 2009 NSQIP Report Our Hospital O/E Thru
June 2009
6SCIP Core Measure Catheter Associated-UTI
(CA-UTI)
SCIP Core Measures SCIP Compliance November 2009
Urinary catheter removed on POD 1 or POD 2 49.2 N 61
7Timeline
University of Utah High Outlier
June 09
8Timeline
UTI Performance Excellence Team Created
University of Utah High Outlier
Aug 09
June 09
9Nursing
Urology
Performance Excellence Team
10Timeline
Define-Research-Analyze-Improve-Control
UTI-Performance Excellence Team Created
University of Utah High Outlier
Sept 09
Aug 09
June 09
11Define The Problem
- Strict definition of UTI (NSQIP definition)
- Patient had indwelling urinary catheter at
diagnosis or within 48 hours before onset of the
event - Positive urine culture of 100,000 CFU/ml with no
polymicrobia - Identify patient-related variables
- Gender, age, type of surgery, history of urinary
retention (males) and/or UTIs (females),
bacteriuria - Identify healthcare provider-related variables
12Define Ask the right questions
1. Are the right patients getting UC? 2. Are UC
in place for right duration? 3. Are we inserting
UC properly? 4. Are we performing proper
peri-care?
4 Key Questions
13Define The Goals
- Lower the rate of UTI to 1.4 or better and O/E
status to non-outlier - SCIP Core Measure compliance
- Urinary catheter removed on POD 1 or POD 2
- Greater than 90 compliance in non-excluded
patients - Sustained quality improvement
14Research The Standard
- Define evidence-based practices in patient and
urinary catheter management - Management of urinary retention, catheters in
setting of regional anesthesia - Study of nursing training and current practice in
catheter care
15Research - Current practice (2009)
- Review of 48 general surgery patients who
developed UTI lt30 days following surgery - Foley catheter left in place gt48h in 85 of
patients - Average duration of foley catheter placement at 6
days
16Timeline
Action and Results
Define - Research - Analyze - Remedy - Implement
Strategy
Performance Excellence Team Created
Oct 09
University of Utah High Outlier
Sept 09
Aug 09
June 09
17Remedy - The Bladder Bundle
18Remedy - The Bladder Bundle
- NEED
- Use indwelling catheters only when necessary
- PLACEMENT
- Foley placement only by trained personnel
- DURATION
- Remove in the O.R. when possible
- Document reasoning if use gt 24 hours
- CARE
- Contained-single unit catheter systems now in
place - Catheter is well-secured and insertion site is
clean at all times - Keep the drainage bag lower than the bladder to
prevent backflow
19Bladder Bundle
- Prompting Care Givers Physicians, Nurses,
Midlevels - Education and media blitz targeting physicians
nurses - Mid-level, nursing, physician champions
- Visual cue on patient board
- EMR DC or Justify
- Foley a daily part of patient rounding RN and
MD. - Epidural order sets modified
- Data tracked and reported
- Foley insertion/removal compliance (NSQIP, SCIP),
UTI rates
20December 2010 NSQIP Report Urinary Tract
Infection
Includes General and Vascular Surgery Cases
21June 2009 NSQIP Report Our Hospital O/E Ratio
over Time
Bladder Bundle Initiative
22Results SCIP Compliance
- SCIP Compliance
- Goal
- Urinary catheter removal on POD 1 or POD 2
- Result
- Greater than 90 compliance in General and
Vascular Surgery since implementation of Bladder
Bundle protocol
21
11
23With reference to healthcare cost?
- Annual savings
- Reduced our UTI incidence by 86 occurrences per
year - Approximate annual cost savings
- 65,188 per year
24Conclusion
- NSQIP is a powerful tool for identifying
institutional morbidity and setting quality
targets to improve healthcare delivery while
reducing cost. - An evidence based approach to management of
peri-operative urinary tract infections can
reduce the incidence of UTIs - Physician led quality improvement projects can
result in sustained improvement in patient care
and reduced cost