Healthcare system leaders are finding that prolonged multipronged efforts can lead to reduced infection rates, though some experts caution about the potential for unintended consequences.
This article first appeared in the March 2016 issue of HealthLeaders Magazine.
Kerri Scanlon, RN, MSN, knows how important prevention of catheter-associated urinary tract infections is because, at age 20, she acquired one postsurgery.
“I was young and able to fight it off, but an 80-year-old patient with no reserves can’t fight off a CAUTI,” says Scanlon, chief nursing officer at North Shore University Hospital, an 812-staffed-bed teaching hospital in Manhasset, New York, and deputy chief nurse executive for the hospital’s parent system, Northwell Health, a 21-hospital network based in Great Neck, New York.
Today Scanlon champions efforts in her hospital and the health system overall to slash CAUTI rates. CAUTIs occur when germs—usually bacteria—enter the urinary tract through the urinary catheter and cause infection, according to the Centers for Disease Control and Prevention. Such infections have been associated with increased morbidity, mortality, healthcare costs, and length of stay.
In 2008, the Centers for Medicare & Medicaid Services announced Medicare’s nonpayment policy for the additional care required as a result of hospital-acquired conditions, including CAUTIs, and have instituted a rigorous reporting protocol.
Scanlon says that in addition to patient health, which is of primary concern, CAUTI infections put at risk a portion of Northwell’s $9.5 million CMS payment bundle, which includes CAUTIs.
In 2015, the health system’s executive leadership committed to its initiative to improve CAUTI rates and felt it was so important that the effort was tied to executive compensation as its model quality indicator. “Linking CAUTI performance to compensation showed a level of commitment, that this was a priority,” she says.
Scanlon and the CAUTI team set in place an aggressive goal to decrease incidence of CAUTIs by 25%, as well to increase and sustain compliance for catheter care and removal. Their baseline: The hospital’s 2012 standardized infection ratio of 1.7 against CMS’ threshold of 0.85 or less. The SIR compares the number of infections in a facility or state to the number of infections that would be expected to have occurred based on previous years of reported data (national baseline).
As part of the CAUTI project, Scanlon and her team identified 188 employee champions in critical care areas, including nursing assistants, nurses, and advanced practice providers; reeducated the staff and patient transporters on insertion practices; and evaluated aseptic techniques such as perineal care.
They instituted four key prevention techniques from the Agency for Healthcare Research and Quality (AHRQ): pause and validate the need for Foleys before insertion; involve a second person during insertion to facilitate aseptic technique; evaluate continued need daily; and empower the nursing staff to discontinue catheter use as soon as possible.
The pause rule helped staff to figure out if alternative methods for measuring urine intake and output—including bladder screeners/scanners, condom catheters, female and male urinals, and straight intermittent catheterization—could avoid the risk of an indwelling catheter.
Scanlon and other leadership closely followed—and continue to follow—the hospital’s progress through a unit-level and hospital-based dashboard that shows how many Foleys are inserted daily, how long they’ve been in, and any potential CAUTIs. An interdisciplinary root cause analysis team meets monthly to review CAUTI incidents and uncover breaches in protocol and resolve them.
These comprehensive changes have resulted in dramatic improvement. Foley days decreased 22.5% from 2012 to 2015, with a 73% reduction in critical care CAUTIs. And the hospital’s CMS SIR is now 0.57, which is better than the 0.85 threshold. The hospital estimates CAUTI reductions saved $522,000 between 2012 and 2015. The CAUTI project has now been extended to noncritical care units as well.
As a health system, Northwell Health decreased Foley days 24%, reduced CAUTIs 60% with an estimated cost savings of $2,561,000 from 2012 to 2015. The system SIR is 0.74, which is better than the CMS threshold.
“When we started the CAUTI project at the hospital, we had 82 patients with infections in our critical care environment; we are now at the end of 2015 at 20 patients with a CAUTI. We are saving lives,” Scanlon says, adding Northwell as a whole has seen significant improvements with CAUTI incidence.
A collaborative approach
Russell N. Olmsted, MPH, CIC, director of infection prevention and control at Michigan-based Trinity Health, an integrated delivery network with 85 acute care hospitals in 22 states, was a member of the team that developed AHRQ's CAUTI prevention tools, including those used by North Shore University Hospital.
Trinity participated in AHRQ's nationwide “On the CUSP: Stop CAUTI” program, which included 1,200 hospitals in 42 states and ran from 2011 to August 2015. The collaborative focused on the acute care setting, aiming to make decreased CAUTI rates sustainable in the long term by fostering a culture of safety.
In addition to a 7% drop in the use of catheters, the collaborative’s participating hospitals reported a 32% drop in their CAUTI rates, what Olmsted calls “pretty impressive.”
A key component of the program, he says, was to study catheter use in emergency departments. Not only did the collaborative study the initial need for a Foley in the ED, but also what happens when the patient gets transferred to the ICU or patient floor.
“When patients move from the emergency department to inpatient, we want emergency teams to assess whether the patient still needs the device. If not, then we want them to discontinue it before transporting,” Olmsted says. Doing so directly impacts the potential for CAUTIs to arise.
At Trinity, Olmsted says CAUTIs have been on the radar for quite some time and are included in the monthly systemwide measurement scorecard. While some hospitals perform better than the CMS recommended rate, others have missed the target at times, he says, drawing attention to the need for CAUTI prevention.
Olmsted says a change across the healthcare system is the elevation of nurse input on Foley removal. “Catheters are a nurse-centered device and, therefore, they should be empowered to remove it,” he says. Trinity’s executives have made this shift clear so that nurses feel supported and won’t be critiqued by other clinicians.
The health system also is in the process of integrating the American Nurses Association’s CAUTI Prevention Tool into its EMR system, but have found it challenging, as the system has numerous EMR programs. “We have a workgroup trying to incorporate logic from the ANA tool across Epic, Cerner, and other platforms,” he says.
Olmsted expects a larger shift in the healthcare industry away from the thought that “catheters are innocuous.” People now recognize, he says, that catheters “carry significant risk.” In addition to potential for infections, catheters can keep a patient bedridden, which can lead them to experience deconditioning of muscles and delirium. “The longer a patient lies around, the more challenging it is for clinicians to get them back up and normal,” he says.
The first 48 hours
Cheryl Christ-Libertin, DNP, RN-BC, NE-BC, CPNP-PC, is evidence-based practice coordinator at Akron Children’s Hospital in Ohio, which has nearly 800,000 patient visits each year to the hospital’s two campuses and network of locations. She learned through her organization’s CAUTI prevention project that the length of time the catheter is in place is the strongest predictor for CAUTI.
In 2012, she and the hospital’s infection control manager started a pilot study in the burn unit. Using the six-step Rosswurm and Larrabee model to develop evidence-based guidelines for implementing the prevention bundle, the pilot study reported significant results for 2013, including reducing catheter days by about 75% and reducing infection incidence by more than 90%. The unit also was able to sustain a CAUTI rate of zero for all of 2015, according to Christ-Libertin.
The team used the study’s outcomes to springboard elsewhere in the organization and to find opportunities for impactful change. For instance, they found the diaper wipes did not have antimicrobial agents so nurses now start with a diaper wipe and then do a peri wipe. They also realized through their pilot that more than 50% of catheters were placed in the operating room, so the operating room staff applied the bundles appropriately.
Akron Children’s Hospital joined the Ohio Children’s Hospitals’ Solutions for Patient Safety Collaborative, which includes more than 80 children’s hospitals and is focused on reducing harm by preventing readmissions, serious safety events, and 10 specific hospital-acquired conditions, including CAUTI. Between 2015 and 2016, the collaborative aims to reduce hospital-acquired conditions such as CAUTI by 40%.
Christ-Libertin says it is a hospital’s responsibility to be a good steward of antibiotics and, therefore, avoid infections that could require their usage. “We don’t want to contribute to antibiotic resistance,” she says.
In addition to implementing prevention techniques similar to North Shore University Hospital, Akron Children’s Hospital has online modules that address each of these areas, and peer practice groups that help improve clinicians’ catheter skills. To ensure that everyone who deals with catheters is up to date on best practices, catheter care is built into the hospital’s graduate resident education program and taught to parents, who sometimes have to catheterize their children. “We’ve also integrated catheter reviews into the team rounding process so each day the risk/benefit of a patient’s catheter can be weighed,” Christ-Libertin says.
The hospital, having now achieved a 70% reduction in catheter days in the ICU, is turning its attention to general units and is currently gathering data for a baseline.
The right windmill?
As many hospitals target resources toward CAUTI to ensure patient safety and CMS payment, Michael Edmond, MD, MPH, MPA, the chief quality officer and associate chief medical officer at the University of Iowa Hospitals and Clinics, a 730-bed facility that annually admits 32,000 patients for in-patient hospital care, calls CAUTI “a distraction” that is diverting resources away from other higher-impact prevention activities.
CAUTIs, he says, “have low preventability, high levels of misclassification, low impact because significant morbidity is uncommon and death is rare, and a high opportunity cost.”
He cites a 2013 JAMA Internal Medicine study that although CAUTI was more common than CLABSI, another HAI, the cost per infection was significantly lower, accounting for only $0.03 billion annually for CAUTI vs. $1.85 billion for CLABSI. And hospitals spent $110 on SSIs for every $1 spent on CAUTI.
Edmond says that while the mortality rate of secondary bloodstream infections from CAUTIs is notable at 11%, the actual risk of getting a secondary bloodstream infection from CAUTI is relatively low, with Baylor University finding that 1.6% of patients with CAUTIs acquire a secondary bloodstream infection and the University of Wisconsin reporting 0.4%.
Edmond uses the Stop CAUTI Project’s Comprehensive Unit-based Safety Program model to determine that a 900-bed hospital with 49,000 catheter days per year would avoid only one additional secondary bloodstream infection every five years and one additional death every 50 years.
Removing catheters too soon can lead to other issues, he says, such as patient falls as they walk to the bathroom, and the need for more nursing resources on the patient floors. “You can’t look at CAUTIs in isolation; prevention can have adverse unintended consequences.”