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CAUTI: Reform, Reimbursement, Refocus


Objectives. Identify and describe the risks and complications associated with CAUTI. Review and assess the complexity of Consumer Awareness and Healthcare Reform as ... – PowerPoint PPT presentation

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Title: CAUTI: Reform, Reimbursement, Refocus

CAUTI Reform, Reimbursement, Refocus
  • Kimberlee J Souhrada MM, BSN, CLNC
  • Clinical Specialist, Rochester Medical
  • One Rochester Medical Drive
  • Stewartville, MN  55976
  • Office   800-615-2364 x609 507-533-9609
  • Mobile  651.319.2714

At her weekly book club meeting, Donna is again
embarrassed by the inability to control her
Disclosure Statement
  • Author affiliation
  • Rochester Medical Corporation
  • Memberships

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
  • 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
  • Review NHSN hospital reporting system as it
    pertains to symptomatic UTIs
  • Assess TJC and the 2012 National Patient Safety
  • Analyze the common goals and objectives of agency
    guides for CAUTI reduction initiatives

Catheter-Associated Urinary Tract Infection
  • Catheter Fever

A Brief Catheter History
Catheter To let or send down
  • To relieve painful retention of urine since time
  • 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
  • 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

The 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

Why 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

Risk Factors for developing a CAUTI
  • Primary
  • Secondary
  • 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

Care Provider related Risk Factors
  • Lack of hand hygiene prior to catheter
  • 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
  • Lack of use of methods to control incontinence
  • No sample port on closed system

Consumer Awareness and Healthcare Reform
  • Historical Timeline of Key Events

Florence 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.
Hospital Report Card Highlights
  • 1985 First reporting of hospital data to a
    state agency
  • Maryland Quality Indicator Project (surgical
  • 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

Consumer Awareness is born!
Plaintiffs turned Protesters
The 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 -
  • It is not acceptable for patients to be harmed
  • by the health care system
  • The IOM recommended Four Tiered Strategy for
  • Establish a national focus
  • Identify and learn from errors through nationwide
    public reporting
  • Raise performance standards and expectations
  • Implement safety systems in HealthCare

US Department of Health and Human Services
  • Centers for Medicare Medicaid Services
  • (CMS)

Hello, incontinence helpline can you hold?
The US Department of HHS
  • Family Tree

  • 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

Value Based Purchasing (VBP) Prospective Payment
  • 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
  • Resource link
  • More measures continue to be added

Goals 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

Centers for Disease Control Prevention (CDC)
  • National Health Safety Network
  • (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
  • Staph Aureaus bloodstream infections
  • Serious bedsores, objects left in pt, blood
    incompatibility, and air embolism
  • Surgical Site Infections (SSI)

NHSN Reporting Structure
  • Patient Safety Component
  • Reporting will be publically accessible through

Mandatory Reporting
  • 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.

Reportable 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//
  • 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

The Joint Commission (TJC)
  • The new 2012 National Patient Safety Goal (NPSG)

Background The Joint Commission (TJC)
  • Founded in 1951 it is the oldest and largest
    standards-setting and accrediting body in
  • 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

National 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
  • Elements of Performance
  • 2004 - Aligned with the CDC and endorsed by CMS
    to standardize common measures
  • Public website

2012 Goals
  • Approval of one new NPSG
  • NPSG.07.06.01 Implement evidence-based
    practices to prevent indwelling
    catheter-associated urinary tract infections
  • 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

Guides, Guidelines, and Strategies
  • Prevention Interventions and Control Practices

CAUTI Prevention Resources
  • APIC Association for Professionals in Infection
    Control and Epidemiology
  • 2008 Guide to the Elimination of CAUTIs
  • SHEA Society for Healthcare Epidemiology of
  • 2008 Strategies to Prevent HAI in Acute Care
  • 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

Shared Goals
  • Identify the Problem of CAUTI
  • Prevalence and Burden
  • Risk Assessment
  • Baseline data to determine patients at highest
  • Surveillance
  • Monitoring and data collection
  • Strategies to Prevent CAUTI
  • Policies, procedures, education, and feedback
  • Implementation of Best Practices
  • ABC Bundle, protocols, and techniques

Identify the Problem in your Facility
  • Basic Infection Prevention and Antimicrobial
  • 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

CAUTI Risk Assessment Facility-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

Surveillance Methodology
  • Surveillance for CAUTI is a dynamic and essential
  • to turn data into useful information to drive
  • 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

Surveillance 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

Example of CAUTI Surveillance
  • Plan Monthly rate of CAUTI in MICU for one year
  • Criteria NHSN criteria for CAUTI
  • Data collection Active surveillance of MICU
  • 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

Display and Distribution of Findings
  • As of 02/2012 - Zero CAUTI

Strategies to Prevent CAUTI
Adherence to a sterile, continually closed
system has been the cornerstone of CAUTI
  • Appropriate Infrastructure
  • Written guidelines for UC use, insertion and
  • Only trained, dedicated personnel insert UCs
  • Necessary supplies for aseptic technique
  • Documentation system
  • Resources to support surveillance
  • Surveillance
  • Risk assessment and identification of patient
  • Standardized criteria
  • Appropriate and valid
  • Education and Training

  • 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

Special 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
  • Bladder scanners
  • Anti-microbial coated catheters

Postoperative Urinary Catheter removed on POD 1
or POD 2
The 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
Implementation 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
Implementation 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

Results after Implementation Scott White
Memorial Hospital, Temple, TX, 1208-0410
No of CAUTI/Patient Days1000
No of CAUTI/Month
43.3 Reduction
Results 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,

Closing Thoughts
  • Bringing about cultural change is difficult but
  • CAUTI rates can be reduced by a multidisciplinary
  • 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
  • Evaluate and re-evaluate your own facility
  • Do NOT give up the fight to Aim for Zero on CAUTI

Finally, the other catheter is getting the
attention it deserves!
(No Transcript)
  • 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
  • The CMS.
  • Healthcare Associated Infections States and
    Public Reporting.
  • Healthcare Infection Control Practices Advisory
    Committee. Guideline for Prevention of
    Catheter-associated Urinary Tract Infections
  • 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
  • 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.
    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.
  • Responsible Reform for the Middle Class. The
    Patient Protection and Affordable Care Act
  • The Center for Disease Control and Prevention.