Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making .
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassPreventing Catheter-Associated Urinary TractInfection (CAUTI): Making It HappenSanjay Saint, MD, MPHChief of Medicine, VA Ann Arbor Healthcare SystemGeorge Dock Professor of Internal MedicineUniversity of Michigan Medical SchoolHosted byPaul mMarch 5, 20152Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com1
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassConsistently Using Evidence-BasedPractices Remains a Challenge 3Hand Hygiene Compliance inHealthcare Workers(Erasmus et al. Infect Control Hosp Epidemiol March 2010) Systematic review of 96 studies Overall median compliance of 40% Lower rates in physicians (32%) than nurses(48%) Lower rates “before” (21%) patient contact ratherthan “after” (47%)4Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com2
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassGiven this Gap Between What Should BeDone and What Is Done Focus on “implementation science” “The scientific study of methods to promotethe systematic uptake of research findingsinto routine practice”(Eccles & Mittman. Implementation Science. Feb 2006)5Healthcare-AssociatedInfections:Common, Costly, & Harmful 1 millionAmericans develop a healthcare-associatedinfection each year 50% of infections could be prevented Preventive practices used inconsistently6Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com3
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassCatheter-AssociatedUrinary Tract Infection (CAUTI) One of the most common infections 1/4 of inpatients receive catheters 1/3 of catheter days unnecessary 1/3 of physicians unaware their patienthas a catheter 1/3 of the time no order for a catheter7Why are some facilitiesbetter than others?What can we learnfrom successful facilities?How can we implement changebroadly to improve care?8Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com4
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassPreventing dUrinary Tract Infection (CAUTI) UTI is a common cause of hospitalacquired infection Most due to urinary catheters Up to 20% of inpatients arecatheterized Leads to increased morbidity andhealthcare costswww.catheterout.orgHosted by Paul Webber paul@webbertraining.comwww.webbertraining.com5
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassSEPTEMBER17, 2013“Many noninfectious catheter-associatedcomplications are at least as common asclinically significant urinary tract infections.”11Disrupting the Lifecycle of the UrinaryCatheter1. Preventing Unnecessary and Improper Placement14. PreventingCatheterReplacement242. MaintainingAwareness &Proper Care ofCatheters33. Prompting Catheter Removal12(Meddings. Clin Infect Dis 2011)Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com6
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassThe Most Common Venue forFoley Placement?EmergencyDepartment132009 Prevention of CAUTI HICPAC Guidelines(Gould et al, Infect Control Hosp Epidemiol 2010; 31: 319-326)Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com7
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassAlternatives to Consider1) Accurate daily weights2) Urinal/commode/bedpan3) Condom catheters4) Intermittent catheterization withbladder scanning15Avoiding Indwelling Catheter Insertion in the ED2 studies have intervened in the ED to reduce insertion:1) Gokula et al. ER staff education and use of a urinarycatheter indication sheet improves appropriate use of Foleycatheters. Am J Infect Control. 2007:– 75% fewer indwelling catheters inserted after the intervention2) Fakih et al. Effect of establishing guidelines on appropriateurinary catheter placement. Acad Emerg Med. 2010:– Physicians ordered 40% fewer insertions after the intervention16Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com8
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassBut if the patient really,really needs a Foley Ensure proper aseptic techniqueis used during insertion17Disrupting the Lifecycle of the UrinaryCatheter1. Preventing Unnecessary and Improper Placement14. PreventingCatheterReplacement242. MaintainingAwareness &Proper Care ofCatheters33. Prompting Catheter Removal18(Meddings. Clin Infect Dis 2011)Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com9
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassProper Maintenance Keep the urinary system closed Make sure flow is unobstructed:– No kinking or coiling– Drainage bag should belower than the bladder– Regularly empty the bag19Disrupting the Lifecycle of the UrinaryCatheter1. Preventing Unnecessary and Improper Placement14. PreventingCatheterReplacement242. MaintainingAwareness &Proper Care ofCatheters33. Prompting Catheter Removal20(Meddings. Clin Infect Dis 2011)Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com10
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassThe Technical:Timely Removal of Indwelling Catheters 30 studies have evaluated urinary catheter reminders andstop-orders– Significant reduction in catheter-associated urinary tractinfection (53%)– No evidence of harm (ie, re-insertion)– Will also address the non-infectious harms of the FoleyMeddings J et al. BMJ Qual Saf 201321What about the ICU?22Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com11
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassNHSN Data: Intensive Care vs. General Wards(Edwards, Am J Infect Control 2009; Dudeck, Am J Infect Control. 2011) Urinary Catheter Use: ICU General UnitsUnit2006- oU1liza1onRa1oICU(med- ‐surg)0.790.72GeneralWards(med- ‐surg)0.220.19(Slide courtesy of M. Fakih)Just because a patient is in theICU does NOT mean that thepatient needs a Foley The Key Question is this:Are hourly assessments ofurine output required?24Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com12
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassTrigger Point: ICU To Floor ICUs have very high urinarycatheter use Utilization may be reducedhospital-wide if patientstransferred out of the ICU areevaluated for catheternecessity at time of transferICUTransferfrom ICUFloor(Slide courtesy of M. Fakih)25Trigger Point: OR To Floor Operating Rooms have veryhigh urinary catheter use Utilization may be reducedhospital-wide if patientstransferred out of the PACUare evaluated for catheternecessity at time of transferPACUTransferfromPACUFloor26Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com13
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassDisrupting the Lifecycle of the UrinaryCatheter1. Preventing Unnecessary and Improper Placement14. PreventingCatheterReplacement242. MaintainingAwareness &Proper Care ofCatheters33. Prompting Catheter Removal27(Meddings. Clin Infect Dis 2011)28Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com14
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassPreventing InfectionTechnicalSocioadaptive29“The hospital is the mostcomplex human organizationever devised ”Peter Drucker30Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com15
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassImplementing Change Across theState of Michigan in 71 HospitalsCAUTI by 25% in Michigan hospitals (95% CI: 13 to 37% )CAUTI by 6% in non-Michigan hospitals (95% CI: 4 to 8% )(Saint et al. JAMA Intern Med 2013)Broad Implementation Federally-funded project aimed to reduce CAUTIrates 4-year project (Sept 2011 – Aug 2015) To date: 40 states, District of Columbia, & Puerto Rico– 1000 hospitals– 30% reduction on medical-surgical units (Fakih IDWeek2014) World Health Organization– Italy, Japan, Africa, Latin America 32Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com16
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training Teleclass33What if you need further helpin preventing CAUTI?34Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com17
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassAdditional Approaches1) Tier 1 & Tier 22) CAUTI GPS3) Applying Mindfulness to CAUTI35Tier 1 Protocol: Use of Indwelling Urinary Catheter KitAssess dailythe necessityof theindwellingcatheterEncourageuse ofalternativesto indwellingcatheterUse standardindwellingurinarycatheter kitwith pre-sealedjunctionMonitor CAUTI rates closely. Proceed toTier 2 if either of the following conditionsare met over a period of 6 months:Ensure properaseptic insertiontechniqueFollowmaintenance andremoval templatefor care andremoval of thecatheterMeasureCAUTIratesmonthly1. ICU 9 CAUTIs/10,000 patient days2 CAUTIs/1,000 catheter days2. Non-ICU, Acute Care 3 CAUTIs/10,000pt days & 2 CAUTIs/1,000 catheter daysTier 2 Protocol: Enhanced Practices – Evaluation ofindication for use, maintenance, and removal techniqueAssess and documentcompetency ofhealthcare workersperforming insertionConsider Root CauseAnalysis or FocusedReview of CAUTI orcatheter use to identifyimprovementopportunitiesMeasure monthly for 6months; re-evaluate. Ifrate has dropped belowindicated levels proceedback to Tier 1Sources:HICPAC CDCGuidelines on CAUTIPreventionwww.catheterout.org(Department of Veterans Affairs, VISN 11)Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com18
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassAdditional Approaches1) Tier 1 & Tier 22) CAUTI GPS3) Applying Mindfulness to CAUTI37Self-Assessment Tool forHospitals and UnitsCAUTI Guide to Patient Safety (“CAUTI GPS”) A 1-page (10-item) trouble-shooting guide Help identify the key reasons why hospitalsmay not be successful in preventing CAUTI Once the barriers are identified, can thenpropose and implement solutions38Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com19
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassCAUTI Guide to Patient Safety (GPS) On-line tool Each question linked to troubleshooting tipswww.catheterout.org39Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com20
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassHosted by Paul Webber paul@webbertraining.comwww.webbertraining.com21
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassAdditional Approaches1) Tier 1 & Tier 22) CAUTI GPS3) Applying Mindfulness to CAUTI43A Dilemma Much of what we do in healthcare – especiallyin the hospital – is reflexive– If a patient is hypoxemic: we give oxygen– Low BP: IV fluids– Positive blood cultures: antibiotics– Frequency, urgency, and dysuria: dx UTI44Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com22
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassA Dilemma These rote responses are usually helpful However, this reflex-like approach can lead toproblems– Pt sick enough to be admitted from the ED:Foley catheter– Asymptomatic catheterized patient has a“dirty” urine: antibiotics45One Possible Solution: “MedicalMindfulness”46Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com23
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassOne Possible Solution: “MedicalMindfulness” Being in the moment and considering decisionscarefully before jumping to reflexive action Daniel Kahneman:– Intuition (System 1): fast, automatic, effortless;difficult to alter– Reasoning (System 2): slower, effortful, & flexible In medicine, we are constantly toggling back-andforth between the reflexive and the complex How can we apply this to everyday practice?47Applying Mindfulness to Bedside Nursing: CatheterAssociated Urinary Tract Infection(Kiyoshi-Teo et al. Infect Cont Hosp Epid 2013) Taking a 5-second “pause” before – Inserting an indwelling catheter– Emptying the drainage bag or transporting thepatient Asking – Is it absolutely necessary to use an indwellingcatheter in this patient? Can I use an alternative?– Am I using proper technique? Do I need to ask forhelp? Can the catheter be removed today? 48Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com24
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassSummary CAUTI and indwelling catheter use are importantpatient safety issues There are proven approaches to reduce catheteruse and thereby prevent CAUTI Both technical and socio-adaptive aspects areimportant in preventing infection Several options if you still have not achieved theresults you would like49ConclusionPreventing CAUTI isa Team Sport!50Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com25
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training TeleclassThank you!saint@umich.edu@sanjaysaint51March 11 (Free WHO Teleclass - Europe)USING THE CORE COMPONENTS OF INFECTION CONTROLDURING THE EBOLA OUTBREAKDr. Sergey Eremin, World Health OrganizationMarch 12 INFECTION PREVENTION AND CONTROL IN CORRECTIONALSETTINGSCarolyn Herzig, Columbia University Mailman School of Public HealthMarch 26 PREVENTION OF CLOSTRIDIUM DIFFICILE INFECTION – WHAT WEFIND IN GUIDELINESProf. Walter Zingg, University of Geneva Hospitals, and Dr. Maria Martin,University Medical Center FreiburgApril 09FAECES MANAGEMENT: TIME TO ADDRESS THE RISKSJim Gauthier, Providence Care, Kingston, OntarioSponsored by Meiko (www.meiko.de)52Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com26
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It HappenProf. Sanjay Saint, University of Michigan School of MedicineA Webber Training Teleclass53Hosted by Paul Webber paul@webbertraining.comwww.webbertraining.com27
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It Happen Prof. Sanjay Saint, University of Michigan School of Medicine . A 1-page (10-item) trouble-shooting guide Help identify the key reasons why hospitals may not be successful in preventing CAUTI Once the barriers are identified, can then
an indwelling urinary catheter. The indwelling urinary catheter is considered a foreign object in the lower urinary tract, which means a CAUTI differs from an infection occurring in the urinary bladder of a patient who is not catheterized (Leidl 2001). CAUTIs do not produce the
Urinary Tract Infections & Treatment Banerjee A & Marotta F 1. Introduction Urinary tract infections (UTI) predominantly occurs in the urinary tract and it is caused by the microorganisms, most often by the bacterial species. The urinary tract comprises of kidney, ureter, bladder and urethra. Based on their infect
Urinary catheter status Defined as the status of a urinary catheter device on the Date of Event One of three options is selected to describe urinary catheter status "In place": an indwelling urinary catheter was present on the date of the event "Removed within last 2 calendar days": an indwelling urinary
pressure ulcers, urinary catheter presence was associated with 1.8 times risk of pressure ulcer compared to those without urinary catheter (p 0.03). The most significant association was between urinary catheterurinary catheter catheter use andcatheter use and stage 2 pressure ulcer. 34 Downloaded from www.catheterout.orgFile Size: 813KBPage Count: 54
Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med. 1999 Apr 26;159(8):800-808. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155:1425-1429.
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Do not change device association during the RIT . Condom catheter (Texas catheter) 17. Unless an indwelling urethral catheter is also present, . complained of urinary frequency: 3/29. No fever: 3/30. Elevated wbc's: 3/31 . Positive urine culture with 105 CFU/ml E coli: The Patient's
course. The course was advertised as a training for social and philanthropic work. Birmingham was the first UK University to give aspiring social workers full status as students. From its founding in 1900 University staff had been actively involved in social welfare and philanthropic work in the City of Birmingham. Through research into the employment and housing conditions of poor people in .
