Implementing Strategies To Reduce Hospital-Acquired .
Implementing Strategies to ReduceHospital-Acquired Catheter-AssociatedUrinary Tract InfectionJennifer A. Meddings, MD, MScUniversity of Michigan Medical SchoolFunding: none fromto disclose.Downloadedwww.catheterout.org
The Problem Urinary catheters are often placed unnecessarily,in place without physician awareness andnot removed promptly when no longer needed.1 Prolonged catheterization is the #1 risk factor forcatheter-associated urinary tract infection.2Saint, S. et al. The American Journal of Medicine, Oct 15 2000; 109(6):476-480.B. The American Journal of Medicine, 113 Suppl 1A, pp. 5s-13s, 2002.3Saint S, Meddings J, et al. Annals of Internal Medicine, Jun 16 2009;150(12):877-884.12Foxman,Downloaded from www.catheterout.org
The Problem Urinary catheters are often placed unnecessarily,in place without physician awareness andnot removed promptly when no longer needed.1 Prolonged catheterization is the #1 risk forcatheter-associated urinary tract infection.2 Catheter-associated urinary tract infection (CAUTI) is the #1 nosocomialinfection: 1 million cases in hospitals and nursing homes nationwide.2 New motivation to prevent CAUTI:3Hospital-Acquired Conditions Initiative (October 2008):no additional payment for diagnosis of hospital-acquired CAUTI.Saint, S. et al. The American Journal of Medicine, Oct 15 2000; 109(6):476-480.B. The American Journal of Medicine, 113 Suppl 1A, pp. 5s-13s, 2002.3Saint S, Meddings J, et al. Annals of Internal Medicine, Jun 16 2009;150(12):877-884.12Foxman,Downloaded from www.catheterout.org
The Problem Urinary catheters are often placed unnecessarily,in place without physician awareness andnot removed promptly when no longer needed.1 Prolonged catheterization is the #1 risk forcatheter-associated urinary tract infection.2 Catheter-associated urinary tract infection (CAUTI) is the #1 nosocomialinfection: 1 million cases in hospitals and nursing homes nationwide.2 New motivation to prevent CAUTI:3Hospital-Acquired Conditions Initiative (October 2008):no additional payment for diagnosis of hospital-acquired CAUTI.Saint, S. et al. The American Journal of Medicine, Oct 15 2000; 109(6):476-480.B. The American Journal of Medicine, 113 Suppl 1A, pp. 5s-13s, 2002.3Saint S, Meddings J, et al. Annals of Internal Medicine, Jun 16 2009;150(12):877-884.12Foxman,Downloaded from www.catheterout.org
“Lifecycle” of the Urinary CatheterCatheter Placement1CatheterReplacement243Downloaded from www.catheterout.orgCatheter RemovalCatheter Care
Disrupting the Lifecycle of theUrinary Catheter1. Prevent Unnecessary and Improper Placement14. Prevent4CatheterReplacement233. Prompting Catheter RemovalDownloaded from www.catheterout.org2. MaintainAwareness andProper Care ofCatheters in Place
1Outline4A. Strategies to Disrupt the Lifecycleof the Urinary Catheter1. Avoiding Unnecessary, Improper Placement32. Maintaining Awareness and Care of Urinary Catheters3. Getting Catheters Removed by Default4. Preventing Catheter ReplacementB. Translating Recommendations into Practice:Champions, “Bladder Bundles,” Pearls and PitfallsC. Take-Home PointsDownloaded from www.catheterout.org2
11. Avoid Unnecessary andImproper Placement24Recommendations Insert Catheters only for Appropriate Indications.3 Ensure only properly trained persons insert catheters, andinsert using aseptic technique and sterile equipment.1Gould C, et al. Infection Control & Hospital Epidemiology, 2010;31:319-326.T, et al. IDSA Urinary Catheter Guidelines, CID 2010;50 (1 March):625-663.2HootonDownloaded from www.catheterout.org
1. Avoid Unnecessary PlacementTo place or not to place? 21-50% catheterizations wereunjustified11423Downloadedfrom www.catheterout.orgT, et al. IDSA Urinary Catheter Guidelines, CID 2010;50 (1 March):625-663.1Hooton
1. Avoid Unnecessary PlacementTo place or not to place? 21-50% catheterizations wereunjustified11423Just SayNoto UrinaryCatheters!Downloadedfrom www.catheterout.orgT, et al. IDSA Urinary Catheter Guidelines, CID 2010;50 (1 March):625-663.1Hooton
1. Avoid Unnecessary PlacementTo place or not to place? 21-50% catheterizations wereunjustified11423Just SayNoto UrinaryCatheters!So why is thisso hard?Downloadedfrom www.catheterout.orgT, et al. IDSA Urinary Catheter Guidelines, CID 2010;50 (1 March):625-663.1Hooton
1. Avoid Unnecessary PlacementChallenges142 Multiple environments:1. Emergency Department,2. Pre/Post Operating Room,33. Inpatient Unit: acute care, ICU, rehabilitation, long-term care. Different systems of care: unique procedures for ordering/placingcatheters, with varying resources, stakeholders, priorities.Downloaded from www.catheterout.org
1. Avoid Unnecessary PlacementChallenges412 Multiple environments:1. Emergency Department,32. Pre/Post Operating Room,3. Inpatient Unit: acute care, ICU, rehabilitation, long-term care. Different systems of care: procedures, resources, stakeholders, priorities.Infection Control Nurse: “.our other barrier is the EmergencyDepartment and this is where most Foleys are placed.Doctors forgetto look under the sheets to say ‘Oh yeah, there’s a Foley there’.and thenurses aren’t going to take the initiative.”Saint S, Kowalski CP,FormanJ, et al. A multicenter qualitative study on preventing hospital-acquired urinary tract infection in USDownloadedfromwww.catheterout.orghospitals. Infect Control Hosp Epidemiol 2008;29:333-41
Changing Catheter Use, by EnvironmentSettingSpecific StrategyReferencesEmergencyDepartmentIndication checklists, stickersattached to catheter kitsGokula, 2005ICUDaily checklists used in multidisciplinary roundsDumigan, 1998Jain, 2006Reilly, 2008Huang, 2004Peri-Procedure Procedure-specific protocols for Stephan, 2006catheter placement and post-op Multiple genitourinarycatheter protocol studies.stop orders.GeneralAdmissionsReminders vs. stop orderwritten, verbal, electronicDownloaded from www.catheterout.orgSaint, 2005Fakih, 2008Topal, 2005Crouzet, 2007Apisarnthanarak, 2007
1. Avoid Unnecessary Placement1Challenges42 Multiple environments, with different systemsof care and different stakeholders/priorities:1. Emergency Department,32. Pre/Post Operating Room,3. Inpatient Unit: acute care, ICU, rehabilitation, long-term care. No Single Source for Distribution (unlike Pharmacy):moredifficult to regulate, monitor and provide feedback regarding use ofurinary catheters. Lack of Consensus on Appropriate Indications for CathetersDownloaded from www.catheterout.org
Appropriate Catheter IndicationsPatient has acute urinary retention or obstructionNeed for accurate measurements of urinary output in critically ill patients.Perioperative use for selected procedures: urologic surgery or other surgery on contiguous structures of genitourinary tract,anticipated prolonged surgery duration (removed in post-anesthesia unit),anticipated to receive large-volume infusions or diuretics in surgery,operative patients with urinary incontinence,need to intraoperative monitoring of urinary output.To assist in healing of open sacral or perineal wounds in incontinent patients.Requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine)To improve comfort for end of life care if needed.Gould C, et al. InfectionControl& Hospital Epidemiology, 2010;31:319-326.Downloadedfromwww.catheterout.org
Appropriate Catheter Indication Lists Limited Evidence of Use ofCatheter as Intervention. Literature Review Expert Consensus.but which experts?physicians (medical, surgical),nurses, infection controlprofessionals, medicaldirectors, microbiology.Downloaded from www.catheterout.orgDifferent Processes & Lists:Loeb, 2008Apisarnthanarak, 2007Topal, 2005Stephan, 2006Saint, 2005Huang, 2004Fakih, 2008Dumigan, 1998Weitzel, 2008Lo, 2008
Not Appropriate Indications for Catheters Substitute for incontinence care tasks. Means to obtain urine for diagnostic tests when patientcan voluntarily void. Prolonged postoperative duration without appropriateindications. Routinely for patients receiving epidural anesthesia/analgesia.Gould C, et al.fromInfectionControl & Hospital Epidemiology, 2010;31:319-326.Downloadedwww.catheterout.org1
Not Appropriate Indications for Catheters Substitute for incontinence care tasks. Means to obtain urine for diagnostic tests when patientcan voluntarily void. Prolonged postoperative duration without appropriateindications. Routinely for patients receiving epidural anesthesia/analgesia.But what about the other well-intended reasons using catheters?Downloaded from www.catheterout.org
The Other Reasons Reduce skin wetness (pressure ulcer risk)? Decrease fall risk if unsteady gait? Difficulty turning/lifting patients to provide incontinence care:– weight (obesity, severe edema), combativeness, extreme frailty. Patient Request: fatigue, to avoid pain with walking.Downloaded from www.catheterout.org
The Other Reasons Reduce skin wetness (pressure ulcer risk)? Decrease fall risk if unsteady gait? Difficulty turning/lifting patients to provide incontinence care:– weight (obesity, severe edema), combativeness, extreme frailty. Patient Request: fatigue, to avoid pain with walking.The Other Risks UTIbacteremia, sepsis, joint infection. “One-point restraint” decreased mobility:blood clots (DVT/PE), pressure ulcers,delirium, pneumonia, deconditioning,fall risk by tripping over catheter. Patient discomfort, need to retrain bladder.Downloaded from www.catheterout.org
The Other Reasons Reduce skin wetness (pressure ulcer risk)? Decrease fall risk if unsteady gait? Difficulty turning/lifting patients to provide incontinence care:– weight (obesity, severe edema), combativeness, extreme frailty. Patient Request: fatigue, to avoid pain with walking.The Other Risks UTIbacteremia, sepsis, joint infection. “One-point restraint” decreased mobility:blood clots (DVT/PE), pressure ulcers,delirium, pneumonia, deconditioning,fall risk by tripping over catheter. Patient discomfort, need to retrain bladder.Downloaded from www.catheterout.org Longer length-of-stay(more exposure tonosocomial hazards) Higher risk of death,disability.
The Other Reasons*Short-term* Reduce skin wetness (pressure ulcer risk)? Decrease fall risk if unsteady gait? Difficulty turning/lifting patients to provide incontinence care:– weight (obesity, severe edema), combativeness, extreme frailty. Patient Request: fatigue, to avoid pain with walking.The Other Risks UTIbacteremia, sepsis, joint infection. “One-point restraint” decreased mobility:blood clots (DVT/PE), pressure ulcers,delirium, pneumonia, deconditioning,fall risk by tripping over catheter. Patient discomfort, need to retrain bladder.Downloaded from www.catheterout.org*Long-term* Longer length-of-stay(more exposure tonosocomial hazards) Higher risk of death,disability.
The Other Reasons Reduce skin wetness (pressure ulcer risk)? Decrease fall risk if unsteady gait? Difficulty turning/lifting patients to provide incontinence care:– weight (obesity, severe edema), combativeness, extreme frailty. Patient Request: fatigue, to avoid pain with walking.Strategies to decrease catheter use need to provide resources toaddress these temptations to use catheters: “People power”: lift teams, care assistants to help with frequentbedside tasks, adjust RN/patient ratios for these tasks. Readily-available supplies for catheter alternatives.Downloaded from www.catheterout.org
1. Avoid Unnecessary PlacementTools142Require physician order for placement.Require appropriate indications for catheter placement.3Bladder scanners to evaluate/confirm urinary retention.Catheter Orders with Decision Support: Embed reminders for appropriate indications, Embed reminders about alternatives to indwelling catheter use, Start clock (24-48o) for catheter removal reminders or stop orders.Downloaded from www.catheterout.org
1. Avoid Unnecessary PlacementTools142Require physician order for placement.Require appropriate indications for catheter placement.3Bladder scanners to evaluate/confirm urinary retention.Catheter Orders with Decision Support: Embed reminders for appropriate indications, Embed reminders about alternatives to indwelling catheter use, Start clock (24-48o) for catheter removal reminders or stop orders.Downloaded from www.catheterout.org
1. Avoid Unnecessary PlacementTools142Require physician order for placement.Bladder scanners to evaluate urinary retention.3Require appropriate indications for catheter placement.Catheter Orders with Decision Support: Embed reminders for appropriate indications, Embed reminders about alternatives to indwelling catheter use, Start clock (24-48o) for catheter removal reminders or stop orders.Downloaded from www.catheterout.org
1. Avoid Unnecessary PlacementAlternative to Consider IndicationsBladder ultrasoundUrinary retention protocols, to avoidcatheterization if no significant urine presentIntermittentcatheterizationChronic neurogenic bladder: spinal cordinjury/disorder, other neurologic disease.Prostate enlargementPost-operative urinary retentionExternal catheters“Condom” catheters: Cooperative malepatients with other catheter indications, butno obstruction or urinary retention.Female external catheters: being testedOther care strategies Bedside commodes, garments/pads, barriercreams, prompted toileting, “people power”Downloaded from www.catheterout.org
What are Hospitals Using to Prevent CAUTI? National survey of U.S. hospitals (focusedon device-related infection) 719 hospitals surveyed (Spring 2005) Lead Infection Control Professional filledout the survey 72% response rateSaint S, et al. Clinical Infectious Diseases 2008;46:243-50Downloaded from www.catheterout.org
Snapshot of Hospital Practices to Prevent CAUTIFigure 2. Urinary catheter–related infection prevention practices for Veterans Affairs (VA) hospitals versus non‐VA hospitalsDownloadedfrom www.catheterout.orgFrom Saint et al, CLIN INFECT DIS 2008:46(2):243-250. 2007 by the Infectious Diseases Society of America. All rights reserved.
Patterns of Urinary Catheter Use inHospital-Acquired CAUTI casesNon-Indwelling:Intermittent straight catheteror Condom/ExternalIndwellingcatheter inplace priorto admit21%14%Indwellingcatheterplaced ddings J, Saint S, McMahon,Infection Control and Hospital Epidemiology, 2010;31(6):627-633.
11. Avoid Unnecessary andImproper Placement“Ensure only properly trained personsinsert catheters, and insert using aseptictechnique and sterile equipment.”14231Gould C, et al. Infection Control & Hospital Epidemiology, 2010;31:319-326.Downloaded from www.catheterout.org
11. Avoid Unnecessary andImproper Placement“Ensure only properly trained personsinsert catheters, and insert using aseptictechnique and sterile equipment.”1423“Operator has been deemed competent for this procedure,or is being supervised by a competent operator.”21Gould C, et al. Infection Control & Hospital Epidemiology, 2010;31:319-326.Carolina Manual to Prevent Catheter Associated Urinary Tract (CAUTI), Version 2.0, February 2008.Downloaded from www.catheterout.org2North
11. Avoid Unnecessary andImproper Placement“Ensure only properly trained personsinsert catheters, and insert using aseptictechnique and sterile equipment.”1423“Operator has been deemed competent for this procedure,or is being supervised by a competent operator.”2,3 Hospital personnel who provide catheter care should be givenperiodic in-service training of correct technique. If patient/family perform catheterization at home, “clean”technique by patient/family can continue, with evaluation bynursing to ensure/reinforce correct technique.Gould C, et al. Infection Control & Hospital Epidemiology, 2010;31:319-326.T, et al. IDSA Urinary Catheter Guidelines, CID 2010.3North Carolina Manual to Prevent CAUTI, Version 2.0, February 2008.12HootonDownloaded from www.catheterout.org
1. Avoid Unnecessary andImproper PlacementEnsure only properly trained personsinsert catheters, and insert using “aseptictechnique and sterile equipment.”1-31423 Supplies: sterile catheter (smallest bore)/gloves/drape/sponges,antiseptic or sterile solution for periurethral cleaning, single uselubricant jelly. Hand Hygiene immediately before and after insertion. Secure catheter to leg to prevent movement, urethral trauma/irritation. Position bag below bladder (“dependent”) with closed unobstructedtubing.Gould C, et al. Infection Control & Hospital Epidemiology, 2010;31:319-326.T, et al. IDSA Urinary Catheter Guidelines, CID 2010.3North Carolina Manual to Prevent CAUTI, Version 2.0, February 2008.12HootonDownloaded from www.catheterout.org
1. Avoid Unnecessary andImproper PlacementEnsure only properly trained personsinsert catheters, and insert using “aseptictechnique and sterile equipment.”1-31423 Supplies: sterile catheter (smallest bore)/gloves/drape/sponges,antiseptic or sterile solution for periurethral cleaning, single uselubricant jelly. Hand Hygiene immediately before and after insertion. Secure catheter to leg to prevent movement, urethral trauma/irritation. Position bag below bladder (“dependent”) with closed unobstructedtubing.*Consider Catheter Insertion Checklists*Downloaded from www.catheterout.org
2. Maintain Catheter Awarenessand Proper CareLevel of TrainingMedical StudentsProportion Unaware ofCatheter Status118%House Officers25%Attending Physicians38%11423Saint et al. The American Journal of Medicine, Oct 15 2000; 109(6):476-480.Options: Daily care checklists, more obvious catheter documentation,Routine reminders of catheter presence to physicians/nursesDownloaded from www.catheterout.org
2. Maintain Catheter Awarenessand Proper Care14Catheter Maintenance Care:Properly Secured catheters.Maintain closed drainage system.Obtain urine samples aseptically.Maintain unobstructed urine flow.No kinking of catheter tube.Keep bag below bladder at all times.Empty into separate clean container for eachpatient, with no contact with non-sterile container.23Who impacts this?Nurses, patient care assistants, patient, family members, transportersDownloaded from www.catheterout.org
13. Prompt Catheter Removal 30-50% of continued catheterizationdays were unnecessary142 Prolonged catheterization is the #1 riskfactor for catheter-associated urinarytract infection.2Traditional Steps to Catheter Removal:1. Physician recognizes catheter is present.2. Physician recognizes catheter is no longer needed.3. Physician writes order to remove catheter.4. Nurse sees order and plans to remove the catheter.5. Urinary catheter is removed.Hooton T, et al. IDSAfromUrinarywww.catheterout.orgCatheter Guidelines, CID 2010;50 (1 March):625-663.DownloadedFoxman, B. The American Journal of Medicine, 113 Suppl 1A, pp. 5s-13s, 2002.123
13. Prompt Catheter Removal Reminder:reminds that a urinarycatheter is still in use; may also remind ofappropriate indications to continuecatheterization.423 Stop Order:prompts removal of urinary catheter based uponspecified time after placement (e.g., 24 hours), based upon clinicalcriteria. Can be directed at physicians or nurses (reminder vs. empowered) Can be written, verbal, or electronic (computer order entry)Downloaded from www.catheterout.org
13. Prompt Catheter Removal Reminder:reminds that a urinarycatheter is still in use; may also remind ofappropriate indications to continuecatheterization.423 Stop Order:prompts removal of urinary catheter based uponspecified time after placement (e.g., 24 hours), based upon clinicalcriteria. Can be directed at physicians or nurses (reminder vs. empowered) Can be written, verbal, or electronic (computer order entry) Nurse to Nurse communication during transitions (ED, ICU): “Doesthis patient have a foley? Why?” If not indicated, ask for foley to beDownloadedwww.catheterout.orgremoved frombeforetransfer.
Downloaded from www.catheterout.org
Snapshot of Hospital Practices to Prevent CAUTIFigure 2. Urinary catheter–related infection prevention practices for Veterans Affairs (VA) hospitals versus non‐VA hospitalsDownloadedfrom www.catheterout.orgFrom Saint et al, CLIN INFECT DIS 2008:46(2):243-250. 2007 by the Infectious Diseases Society of America. All rights reserved.
Catheter Reminders & Stop Orders:Impact on Days of Catheter Use (Mean int*StephanCrouzetWeitzelBefore/ControlAfter Intervention, *p 0.050Meddings, et al. ClinicalfromInfectiouswww.catheterout.orgDiseases, in press.Downloaded36811
Catheter Reminders & Stop Orders:Impact on Catheter Use (% Days ControlAfter Intervention, *p 0.05025Meddings, et al. ClinicalfromInfectiouswww.catheterout.orgDiseases, in press.Downloaded5075100
Catheter Reminders & Stop Orders:Impact on CAUTI ratesOverall, the rate of CAUTI (episodes per 1000 catheter-days) wasreduced by 52% with use of a reminder or stop order (95% CI: 32% to72% ang*JainDumigan*Before/ControlAfter Intervention, *p 0.05013Meddings, et al. ClinicalfromInfectiouswww.catheterout.orgDiseases, in press.Downloaded253850
Catheter Reminders & Stop Orders:Pearls and PitfallsPearls: Tailor reminder type to care setting (stickers, electronic, etc),Embed appropriate indications to guide catheter use,Remember to include catheter alternatives,Automated, timed reminders/stop orders,Direct to primary care team (not consultants, etc),Empower nurses to remove without obtaining additionalorder from physician team.Pitfalls: Reminders often ignored. Some catheter orders can increase catheter use. Challengingto sustain impact of reminders/stop orders.Downloadedfrom www.catheterout.org
4. Prevent Catheter ReplacementDo Reminders or Stop Orders lead to increasedneed for re-catheterization?No evidence to support higher re-catheterizationneeds, by 4 studies (Loeb, 2008; Crouzet, 2007;Saint, 2005; Cornia, 2003).Meddings, et al. ClinicalfromInfectiouswww.catheterout.orgDiseases, in press.Downloaded1423
4. Prevent Catheter ReplacementDo Reminders or Stop Orders lead to increasedneed for re-catheterization?No evidence to support higher re-catheterizationneeds, by 4 studies (Loeb, 2008; Crouzet, 2007;Saint, 2005; Cornia, 2003).1423Tools to prevent catheter replacement: Urinary retention evaluation protocols: use ofbladder scan, straight catheters, withoutrequiring contact with physicians. Same tools as preventing initial placement:Catheter-order restrictions, indication guidanceMeddings, et al. ClinicalfromInfectiouswww.catheterout.orgDiseases, in press.Downloaded
4. Prevent Catheter ReplacementDo Reminders or Stop Orders lead to increasedneed for re-catheterization?No evidence to support higher re-catheterizationneeds, by 4 studies (Loeb, 2008; Crouzet, 2007;Saint, 2005; Cornia, 2003).1423Tools to prevent catheter replacement: Urinary retention evaluation protocols: use ofbladder scan, straight catheters, withoutrequiring contact with physicians. Same tools as preventing initial placement:Catheter-order restrictions, indication guidancebut, with sticking power to survive changein caregivers, night shifts.Downloaded from www.catheterout.org
4. Prevent Catheter Replacement1423Tools to prevent catheter replacement: Urinary retention evaluation protocols: use ofbladder scan, straight catheters, withoutrequiring contact with physicians.Same tools as preventing initial placement:r etehtCatheter-order restrictions, indication guidanceCa airybut, with sticking power to survive change inFcaregivers, night shifts. “catheter fairies.”Downloaded from www.catheterout.org
Translating Recommendations into Practice:assembling and using the tools The Importance of ChampionsExamples of Successful ProjectsBladder Bundles: Defining, Early ResultsCautions: What is Not Recommended?Take-Home PointsDownloaded from www.catheterout.org
ChampionsDefinition: Advocate who takes ownership of theproblem (hospital-acquired CAUTI) and is willing touse his or her position to get a practice implementedby rallying others to help solve the problem. Respected by others at the hospital, Persuasive, Value of nurse champions: any staff nurse viewedon the unit as the “go to” RN.Saint S, Kowalski CP, Forman J, et al. A multicenter qualitative study on preventing hospitalacquired urinarytractwww.catheterout.orginfection in US hospitals. Infect Control Hosp Epidemiol 2008;29:333-41Downloadedfrom
Prior Success Stories Focused on non-infectious complications of urinary catheters:patient discomfort, impaired patient mobility, delayed discharge. Team-based financial incentives to decrease catheter use andreduce CAUTI rates. Nurse-initiated Projects to remove urinary catheters:increase nurse awareness of which patients have catheters,educate that decreasing catheter use will decrease UTI rates.Saint S, Kowalski CP, Forman J, et al. A multicenter qualitative study on preventing hospitalacquired urinarytractwww.catheterout.orginfection in US hospitals. Infect Control Hosp Epidemiol 2008;29:333-41Downloadedfrom
Nurse buy-in is crucial!A physician administrator: “Because the nurses onthe geriatrics unit wanted to have their patientsregain mobility they viewed ambulation andmobility as a very important goal versus theother units where the nurses didn’t necessarilyfeel that was a real goal in the patient’s plan forthat day.”Saint S, Kowalski CP, Forman J, et al. A multicenter qualitative study on preventing hospitalacquired urinarytractwww.catheterout.orginfection in US hospitals. Infect Control Hosp Epidemiol 2008;29:333-41Downloadedfrom
Use of “Bladder Bundles”Aseptic insertion and proper maintenance is paramountBladder ultrasound may avoid indwelling catheterizationCondom or intermittent catheterization in appropriate patientsDo not use the indwelling catheter unless you must!Early removal of the catheter using reminders or stop-ordersappears warranted.Saint S, Olmsted RN, Fakih M, et al. Translating Health Care-Associated Urinary Tract Infection Prevention Research into Practice via the BladderBundle. The Joint Commission Journal on Quality and Patient Safety 2009;35:449-55Downloaded from www.catheterout.org
Implementing “Bladder Bundles”Diagnose the Problem: Perform a Needs Assessment to “diagnosis thehospital”: What is the current status of UTI prevention, resources,technology? This information is needed to tailor strategies to addresseach hospital’s needs.Treat the Problem: Using the Johns Hopkins University “4E’s”collaborative model for transformational change: Engage and Educate: participating hospitals receive info bypresentations, conference calls, website, face-to-face workshops,including bundle toolkit to describe intervention steps and measures. Execute: identify at enlist at least one nurse champion to lead theinitiative and organize a bladder bundle team, usually with 1 physician. Evaluate: 1) conduct baseline assessment, including point-prevalencestudy of catheter use, 2) daily patient rounds (“catheter patrol”), 3)routine feedback on catheter use rates and necessity.Saint, et al. The Joint Commissionon Quality and Patient Safety 2009;35:449-55Downloadedfrom Journalwww.catheterout.org
Use of Bladder Bundles: Early ResultsFrom Michigan Health & Hospital AssociationKeystone Project for Hospital-Acquired Infection: Early 2008: 16 early implementer hospitals, resulted inestimated reduction of catheter use from 32,000 patientsto 29,000 patients, reducing more than 1000 unnecessaryhospital days and estimated 1 million avoided costs. On-line survey 2009, 2nd Qtr: 72% participants reportedthat implementing CAUTI prevention made a positivedifference in reducing the use of foley cathetersDownloadedfrom g/hai overview.htm
Not Recommended Routine screening for UTI in asymptomatic patients.Routine antimicrobial prophylaxis.Bladder irrigation as method to prevent infection.Adding antimicrobials to urine collection bags.Routinely changing catheters or collection bags.Vigorous periurethral cleaning.So what about antimicrobial coated catheters?Downloaded from www.catheterout.org
What about antimicrobial coated catheters?Figure 2. Urinary catheter–related infection prevention practices for Veterans Affairs (VA) hospitals versus non‐VA hospitalsDownloadedfrom www.catheterout.orgFrom Saint et al, CLIN INFECT DIS 2008:46(2):243-250. 2007 by the Infectious Diseases Society of America. All rights reserved.
Antimicrobial coated catheters Options: Antiseptic: Silver alloy (note: silver oxide is no longer marketed),Antibiotic: Nitrofuranzone-releasing/imprenated/coated. Cost: 5 more than non-coated catheter (latex or silicone)Evidence (summarized from 20 RCT trials): Silver alloy1,2 and nitrofurzone-coated catheters1-3 had decreased risk of asymptomaticbacteriuria in hospitalized adults with short-term catheter use (most effective 1week). Caveats: Studies have not been powered to study impact of catheters on symptomaticUTI, or bacteremia related to UTI. No head-to-head trials have compared silver alloywith nitrofuranzone-coated catheters.CDC/HICPAC guideline: “should be considered if CAUTI rates are not decreasing afterimplementing a comprehensive strategy” regarding use, insertion, maintenance care.1 Schummand Lam, Cochane Database of Systematic Reviews 2008, Issue 2.et al, Annals of Internal Medicine 2006;144:116-126.3Stensballe et al, Annals of Internal Medicine 2007;147:285-293.2JohnsonDownloaded from www.catheterout.org
Take-Home Points Nurse “buy-in” is extremely important. Reminders and Stop Orders can disrupt the catheter“lifecycle” at all stages: placement, awareness ofcontinued use, prompting removal, and preven
Catheter-associated urinary tract infection (CAUTI) is the #1 nosocomial infection: 1 million cases in hospitals and nursing homes nationwide.2 New motivation to prevent CAUTI:3 Hospital-Acquired Conditions Initiative (October 2008): no additional payment f
23 Eastman Dental Hospital 24 Royal National Throat, Nose & Ear Hospital 25 The Nuffield Hearing and Speech Centre 26 Moorfields Eye Hospital 27 St. Bartholomew's Hospital 28 London Bridge Hospital 29 Guy's Hospital 30 Churchill Clinic 31 St. Thomas' Hospital 32 Gordon Hospital 33 The Lister Hospital 34 Royal Hospital Chelsea 35 Charter .
3 Reduce Reduce V 1 V 2 V 3 barrier Map Map V Map V 1 V 2 V 3 Reduce Reduce V 1 V 2 3 Map Map Reduce Map V 1 V 2 V 3 V 1 V 2 Reduce V 3 V 1 V 2 Reduce 3 Reduce Reduce V 1 V 2 V 3 V 1 V 2 Reduce 3 SPLIT: enough work for one GPU NO MEMORY LIMIT CPU GPU execution CPU GPU execution on each node Final reduction in cluster Aggregate nodes results Network
3. Benishiekh General Hospital 4.Biu General Hospital 5. Shani General Hospital 6. Gubio General Hospital 7. Magumeri General Hospital 8. Konduga General Hospital 9. Dikwa General Hospital 10. Mamman Shuwa Memorial Hospital 11. Mafa General Hospital Those rehabilitated but not fully equipped are: 1. Damb
32. appolo hospital, Delhi 33. naraya hrudayalaya 34. kanpur medical Centre, U.P 35. narayana nathralaya 36. Sparsh narayana hridyalaya 37. Videhi medical College hospital 38. manipal hospital 39. Trinity hospital 40. Rajarajeshwari hospital 41. Raveendanath Tagor hospital 42. appolo hospital (Bilaspur) 43. Thrivanathapuram hospital Placement .
work/products (Beading, Candles, Carving, Food Products, Soap, Weaving, etc.) ⃝I understand that if my work contains Indigenous visual representation that it is a reflection of the Indigenous culture of my native region. ⃝To the best of my knowledge, my work/products fall within Craft Council standards and expectations with respect to
Religare Health Insurance Co. Ltd. State City Hospital Name Address Pin code Alternate Hospital Name MAHARASHTRA Mumbai Dr.Mahajan's Hospital R-831,Rabale TTC,Thane,Belapur Road,Navi Mumbai 400708 Sanjivani Hospital/Sai Seva Hospital & ICU/Mody Hospital and
2 Adventist Medical Center, Portland. 3 Castle Medical Center. 4 Central Valley General Hospital. 5 Feather River Hospital. 6 Glendale Adventist Medical Center. 7 Hanford Community Medical Center. 8 Howard Memorial Hospital. 9 Redbud Community Hospital. 10 St. Helena Hospital. 11 San Joaquin Community Hospital. 12 Selma Community Hospital, Inc.
home health of harrison county hospital harrison county hospice harrison county community hospital harrison county community hospital-snf dialysis clinic clinton kansas avenue dialysis golden valley memorial hospital hha twin lakes hospice golden valley memorial hospital golden valley memorial hospital rehab unit royal oaks hospital and clinics