CAUTI: Reform, Reimbursement, Refocus

1
CAUTI 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  [phone]

2
At her weekly book club meeting, Donna is again
embarrassed by the inability to control her
bladder.
3
Disclosure 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
4
Objectives

• 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

5
Catheter-Associated Urinary Tract Infection
(CAUTI)

• Catheter Fever

6
A 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

7
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

8
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

9
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

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Care 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

11
Consumer Awareness and Healthcare Reform

• Historical Timeline of Key Events

12
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.
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Hospital 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

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Consumer Awareness is born!
Plaintiffs turned Protesters
15
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 -
  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

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US Department of Health and Human Services

• Centers for Medicare Medicaid Services
• (CMS)

17
Hello, incontinence helpline can you hold?
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The US Department of HHS

• Family Tree

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CMS

• 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.

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Value 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

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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

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Centers for Disease Control Prevention (CDC)

• National Health Safety Network
• (NHSN)

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CDC-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)

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NHSN Reporting Structure

• Patient Safety Component

• Reporting will be publically accessible through
  www.hospitalcompare.hhs.gov

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Mandatory 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.

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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//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

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The Joint Commission (TJC)

• The new 2012 National Patient Safety Goal (NPSG)

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Background 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

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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
  them
• Elements of Performance
• 2004 - Aligned with the CDC and endorsed by CMS
  to standardize common measures
• Public website www.qualitycheck.org

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2012 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

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Guides, Guidelines, and Strategies

• Prevention Interventions and Control Practices

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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
  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

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Shared 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

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Identify 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

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CAUTI 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

37
Surveillance 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

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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

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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
  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

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Display and Distribution of Findings

• As of 02/2012 - Zero CAUTI

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Strategies 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

43
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
  Indicator
• Bladder scanners
• Anti-microbial coated catheters

Postoperative Urinary Catheter removed on POD 1
or POD 2
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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
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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
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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

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

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Closing 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!!

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Finally, the other catheter is getting the
attention it deserves!
51
(No Transcript)
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References

• 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