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.