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.