In Our Unit Elimination of Catheter-Associated Urinary Tract Infections in an Adult Neurological Intensive Care Unit Maria Vacca, RN, BSN, PCCN, CIC Diane Angelos, RN, MSN, CCRN
P
ennsylvania Hospital is the nation’s first hospital. Located in Philadelphia, Pennsylvania, and founded by Benjamin Franklin, our institution is rich in culture and history. As part of the prestigious University of Pennsylvania Health System, our 450-bed facility uses evidence as the foundation to guide all practice. Staff members in our 8-bed adult neurological intensive care unit (ICU) are well accustomed to using evidence-based “bundles” to guide their practice. Yet, the unit’s rate of catheter-associated urinary tract infections (CAUTIs) from June 2011 to July 2012 was continuously above the national benchmark for a neurological ICU. With such a high incidence of CAUTIs, and an inability to sustain more than 1 month free from CAUTIs in the previous 13 months, the staff in our neurological ICU realized that there was a problem with their current approach to CAUTI prevention. Since the inception of our project 10 months ago, our team has successfully eliminated CAUTIs on our unit by using a proactive approach to CAUTI prevention. We wanted to share our process with the readers of this article, because we believe our accomplishments can easily be replicated on any unit, in any hospital, without expense.
Background With 1.7 million cases reported annually, hospital-associated infections are one of the top 10 leading causes of death in the United States.1 CAUTIs account for approximately 36% of all hospital-associated infections.1 Authors Maria Vacca works in infection prevention and Diane Angelos works in nursing education at Pennsylvania Hospital in Philadelphia. Corresponding author: Maria Vacca, RN, BSN, PCCN, CIC, Pennsylvania Hospital, 800 Spruce St, Philadelphia, PA 19107 (e-mail: [email protected]). To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. ©2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013998
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About 3% of patients in whom CAUTIs develop go on to have bacteremia develop,1 and the mortality rate for CAUTI is 2.8%.2 With CAUTIs having an incidence of close to 2 million cases per year, the Centers for Medicare and Medicaid Services have identified CAUTI as a “never event,” limiting reimbursement to acute care hospitals.3
Prior Process At our institution, the prior process for implementation of the CAUTI prevention bundle4 consisted of the following: (1) education on insertion, care, and maintenance of indwelling urinary catheters was provided on an as-needed basis by the infection prevention team; (2) point prevalence studies were performed infrequently and not on a set schedule; and (3) automatic stop orders for urinary catheters were in place on all patients. The process for when a CAUTI was identified consisted of the infection prevention team notifying all members of the multidisciplinary unitbased clinical leadership team that a CAUTI had occurred and providing details of the infection. The notification e-mail included a debriefing form.
Vol 33, No. 6, DECEMBER 2013
Downloaded from http://ccn.aacnjournals.org/ at UCSF LIBRARY & CKM on December 8, 2014
www.ccnonline.org
The nurse educator, nurse manager, and nurses who cared for the patient were asked to complete the debriefing form. Once completed, the unit-based clinical leadership team would meet and do a mini root cause analysis. The education and notification process for CAUTI identification was problematic for several reasons. The debriefing procedure was ineffective because too much time would elapse between when the infection was identified and when the team would meet to analyze the infection. Education was performed sporadically and not in real time. Lastly, the automatic stop orders were ineffective in their purpose to get catheters out because they occurred for all patients, even those who still needed a catheter.
New Beginnings As we saw no improvement in our infection rate when a retrospective approach to CAUTI prevention was used, we recognized that a new approach was warranted. Studies have shown that the implementation of a formalized rounding process in ICUs decreases device-related infections and increases nurses’ satisfaction.5 Using this idea as the foundation for our initiative, we developed a new, proactive approach to CAUTI prevention that incorporated a formalized rounding process. This process consisted of the infection preventionist in alliance with the clinical nurse education specialist going room to room and assessing all catheters on a consistent, weekly basis. A rounding tool was developed that we used to assess that all care and maintenance elements of the CAUTI prevention bundle were met, including the following: maintenance of a
www.ccnonline.org
closed drainage system, securement of drainage tubing to the patient’s thigh, drainage bag off the floor, drainage bag not overfilled, and drainage tubing not kinked. Immediately after rounds, patients’ records were reviewed with the nurse to assess if the patient still met criteria for maintaining a urinary catheter. Education would occur in real time as issues were identified and corrected. Our process concluded with the infection preventionist summarizing rounding data and communicating findings the same day, via e-mail to all involved health care providers.
Success We are proud of our unit’s accomplishment in the past 10 months in sustaining a zero infection rate. When the current CAUTI rates are compared with rates for the same 10-month period, 1 year prior, the difference is statistically significant (P=.05). From a financial perspective, our neurological ICU has been able to sustain positive measureable outcomes. We were able to estimate a cost avoidance of $55000 since the inception of our rounding. The cost savings could be even greater if more units were able to have similar results by taking our proactive approach to CAUTI prevention. Meanwhile, word of the success of our initiative has spread throughout the hospital. Multiple units have expressed an interest in duplicating our project. As a result, use of the rounding tool, along with rounding by the nurses, has been successfully adopted by other clinical units. On a daily basis, nurses play a vital role in the care and maintenance of indwelling urinary catheters. Our
rounding process strengthens nurses’ assessment skills and empowers them to advocate for catheter removal when the situation is appropriate. Our team promotes a systematic approach to preventing any adverse events for patients who have an indwelling urinary catheter by using a proactive approach to advocate for patient safety and fiscal stewardship.
Summary Prevention of a CAUTI is a national patient safety goal for 2013 to 2014. Every hospital should welcome the opportunity to promote patient safety by having zero tolerance for infections. Our rounding tool can easily be used by staff nurses to allow them to assess CAUTI prevention measures on a regular basis. On the basis of their findings, nurses are able to collaborate with physicians and advanced practice providers to obtain orders for prompt removal of catheters. Lastly, the changes involve no financial outlay for an organization, just real-time data to act on to promote patient safety and prevent infections. CCN Financial Disclosures None reported. Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ccnonline.org and click “Submit a response” in either the full-text or PDF view of the article.
References 1. Association for Professionals in Infection Prevention and Control (APIC). Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs). Washington, DC: APIC; 2008. http://www.apic.org /Professional-Practice/Implementation -guides. Accessed September 30, 2013. 2. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50: 625-663.
CriticalCareNurse
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Downloaded from http://ccn.aacnjournals.org/ at UCSF LIBRARY & CKM on December 8, 2014
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3. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of CatheterAssociated Urinary Tract Infections, 2009. http://www.cdc.gov/hicpac/pdf/cauti /cautiguideline2009final.pdf. Accessed September 30, 2013. 4. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Healthcare Quality. IHI. Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2012. 5. Gurses AP, Xiao Y. A systematic review of the literature on multidisciplinary rounds to design information technology. J Am Med Inform Assoc. 2006;13(3):267-276.
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In Our Unit
In Our Unit highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an In Our Unit article, send it to Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; e-mail, [email protected].
Vol 33, No. 6, DECEMBER 2013
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Downloaded from http://ccn.aacnjournals.org/ at UCSF LIBRARY & CKM on December 8, 2014
Elimination of Catheter-Associated Urinary Tract Infections in an Adult Neurological Intensive Care Unit Maria Vacca and Diane Angelos Crit Care Nurse 2013, 33:78-80. doi: 10.4037/ccn2013998 © 2013 American Association of Critical-Care Nurses Published online http://www.cconline.org
Subscription Information http://ccn.aacnjournals.org/subscriptions Information for authors http://ccn.aacnjournals.org/misc/ifora.xhtml
Submit Manuscript www.editorialmanager.com/ccn
E-mail alerts http://ccn.aacnjournals.org/subscriptions/etoc.xhtml
Critical Care Nurse is the official peer-reviewed clinical journal of the American Association ofCritical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2011 by AACN. All rights reserved. Downloaded from http://ccn.aacnjournals.org/ at UCSF LIBRARY & CKM on December 8, 2014
P
ennsylvania Hospital is the nation’s first hospital. Located in Philadelphia, Pennsylvania, and founded by Benjamin Franklin, our institution is rich in culture and history. As part of the prestigious University of Pennsylvania Health System, our 450-bed facility uses evidence as the foundation to guide all practice. Staff members in our 8-bed adult neurological intensive care unit (ICU) are well accustomed to using evidence-based “bundles” to guide their practice. Yet, the unit’s rate of catheter-associated urinary tract infections (CAUTIs) from June 2011 to July 2012 was continuously above the national benchmark for a neurological ICU. With such a high incidence of CAUTIs, and an inability to sustain more than 1 month free from CAUTIs in the previous 13 months, the staff in our neurological ICU realized that there was a problem with their current approach to CAUTI prevention. Since the inception of our project 10 months ago, our team has successfully eliminated CAUTIs on our unit by using a proactive approach to CAUTI prevention. We wanted to share our process with the readers of this article, because we believe our accomplishments can easily be replicated on any unit, in any hospital, without expense.
Background With 1.7 million cases reported annually, hospital-associated infections are one of the top 10 leading causes of death in the United States.1 CAUTIs account for approximately 36% of all hospital-associated infections.1 Authors Maria Vacca works in infection prevention and Diane Angelos works in nursing education at Pennsylvania Hospital in Philadelphia. Corresponding author: Maria Vacca, RN, BSN, PCCN, CIC, Pennsylvania Hospital, 800 Spruce St, Philadelphia, PA 19107 (e-mail: [email protected]). To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. ©2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013998
78
CriticalCareNurse
About 3% of patients in whom CAUTIs develop go on to have bacteremia develop,1 and the mortality rate for CAUTI is 2.8%.2 With CAUTIs having an incidence of close to 2 million cases per year, the Centers for Medicare and Medicaid Services have identified CAUTI as a “never event,” limiting reimbursement to acute care hospitals.3
Prior Process At our institution, the prior process for implementation of the CAUTI prevention bundle4 consisted of the following: (1) education on insertion, care, and maintenance of indwelling urinary catheters was provided on an as-needed basis by the infection prevention team; (2) point prevalence studies were performed infrequently and not on a set schedule; and (3) automatic stop orders for urinary catheters were in place on all patients. The process for when a CAUTI was identified consisted of the infection prevention team notifying all members of the multidisciplinary unitbased clinical leadership team that a CAUTI had occurred and providing details of the infection. The notification e-mail included a debriefing form.
Vol 33, No. 6, DECEMBER 2013
Downloaded from http://ccn.aacnjournals.org/ at UCSF LIBRARY & CKM on December 8, 2014
www.ccnonline.org
The nurse educator, nurse manager, and nurses who cared for the patient were asked to complete the debriefing form. Once completed, the unit-based clinical leadership team would meet and do a mini root cause analysis. The education and notification process for CAUTI identification was problematic for several reasons. The debriefing procedure was ineffective because too much time would elapse between when the infection was identified and when the team would meet to analyze the infection. Education was performed sporadically and not in real time. Lastly, the automatic stop orders were ineffective in their purpose to get catheters out because they occurred for all patients, even those who still needed a catheter.
New Beginnings As we saw no improvement in our infection rate when a retrospective approach to CAUTI prevention was used, we recognized that a new approach was warranted. Studies have shown that the implementation of a formalized rounding process in ICUs decreases device-related infections and increases nurses’ satisfaction.5 Using this idea as the foundation for our initiative, we developed a new, proactive approach to CAUTI prevention that incorporated a formalized rounding process. This process consisted of the infection preventionist in alliance with the clinical nurse education specialist going room to room and assessing all catheters on a consistent, weekly basis. A rounding tool was developed that we used to assess that all care and maintenance elements of the CAUTI prevention bundle were met, including the following: maintenance of a
www.ccnonline.org
closed drainage system, securement of drainage tubing to the patient’s thigh, drainage bag off the floor, drainage bag not overfilled, and drainage tubing not kinked. Immediately after rounds, patients’ records were reviewed with the nurse to assess if the patient still met criteria for maintaining a urinary catheter. Education would occur in real time as issues were identified and corrected. Our process concluded with the infection preventionist summarizing rounding data and communicating findings the same day, via e-mail to all involved health care providers.
Success We are proud of our unit’s accomplishment in the past 10 months in sustaining a zero infection rate. When the current CAUTI rates are compared with rates for the same 10-month period, 1 year prior, the difference is statistically significant (P=.05). From a financial perspective, our neurological ICU has been able to sustain positive measureable outcomes. We were able to estimate a cost avoidance of $55000 since the inception of our rounding. The cost savings could be even greater if more units were able to have similar results by taking our proactive approach to CAUTI prevention. Meanwhile, word of the success of our initiative has spread throughout the hospital. Multiple units have expressed an interest in duplicating our project. As a result, use of the rounding tool, along with rounding by the nurses, has been successfully adopted by other clinical units. On a daily basis, nurses play a vital role in the care and maintenance of indwelling urinary catheters. Our
rounding process strengthens nurses’ assessment skills and empowers them to advocate for catheter removal when the situation is appropriate. Our team promotes a systematic approach to preventing any adverse events for patients who have an indwelling urinary catheter by using a proactive approach to advocate for patient safety and fiscal stewardship.
Summary Prevention of a CAUTI is a national patient safety goal for 2013 to 2014. Every hospital should welcome the opportunity to promote patient safety by having zero tolerance for infections. Our rounding tool can easily be used by staff nurses to allow them to assess CAUTI prevention measures on a regular basis. On the basis of their findings, nurses are able to collaborate with physicians and advanced practice providers to obtain orders for prompt removal of catheters. Lastly, the changes involve no financial outlay for an organization, just real-time data to act on to promote patient safety and prevent infections. CCN Financial Disclosures None reported. Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ccnonline.org and click “Submit a response” in either the full-text or PDF view of the article.
References 1. Association for Professionals in Infection Prevention and Control (APIC). Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs). Washington, DC: APIC; 2008. http://www.apic.org /Professional-Practice/Implementation -guides. Accessed September 30, 2013. 2. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50: 625-663.
CriticalCareNurse
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Downloaded from http://ccn.aacnjournals.org/ at UCSF LIBRARY & CKM on December 8, 2014
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3. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of CatheterAssociated Urinary Tract Infections, 2009. http://www.cdc.gov/hicpac/pdf/cauti /cautiguideline2009final.pdf. Accessed September 30, 2013. 4. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Healthcare Quality. IHI. Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2012. 5. Gurses AP, Xiao Y. A systematic review of the literature on multidisciplinary rounds to design information technology. J Am Med Inform Assoc. 2006;13(3):267-276.
80
CriticalCareNurse
In Our Unit
In Our Unit highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an In Our Unit article, send it to Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; e-mail, [email protected].
Vol 33, No. 6, DECEMBER 2013
Downloaded from http://ccn.aacnjournals.org/ at UCSF LIBRARY & CKM on December 8, 2014
www.ccnonline.org
Downloaded from http://ccn.aacnjournals.org/ at UCSF LIBRARY & CKM on December 8, 2014
Elimination of Catheter-Associated Urinary Tract Infections in an Adult Neurological Intensive Care Unit Maria Vacca and Diane Angelos Crit Care Nurse 2013, 33:78-80. doi: 10.4037/ccn2013998 © 2013 American Association of Critical-Care Nurses Published online http://www.cconline.org
Subscription Information http://ccn.aacnjournals.org/subscriptions Information for authors http://ccn.aacnjournals.org/misc/ifora.xhtml
Submit Manuscript www.editorialmanager.com/ccn
E-mail alerts http://ccn.aacnjournals.org/subscriptions/etoc.xhtml
Critical Care Nurse is the official peer-reviewed clinical journal of the American Association ofCritical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2011 by AACN. All rights reserved. Downloaded from http://ccn.aacnjournals.org/ at UCSF LIBRARY & CKM on December 8, 2014
