American Journal of Infection Control xxx (2015) 1-3
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Reducing catheter-associated urinary tract infections in a neuroespine intensive care unit Kimberly Schelling MSM, CIC *, Janet Palamone MSN, APN, CNRN, CCRN, Kathryn Thomas MSN, RN, SCRN, Andrew Naidech MD, MSPH, FANA, Christina Silkaitis MT(ASCP), CIC, Jennifer Henry BSN, RN, CNRN, Maureen Bolon MD, MS, Teresa R. Zembower MD, MPH Healthcare Epidemiology and Infection Prevention Department in accordance with the NeuroeSpine Intensive Care Unit, Northwestern Memorial Hospital, Chicago, IL
Key Words: Indwelling urinary catheter Infection prevention Collaborative improvement project
A collaborative effort reduced catheter-associated urinary tract infections in the neuroespine intensive care unit where the majority of infections occurred at our institution. Our stepwise approach included retrospective data review, daily rounding with clinicians, developing and implementing an action plan, conducting practice audits, and sharing of real-time data outcomes. The catheter-associated urinary tract infection rate was reduced from 8.18 to 0.93 per 1,000 catheter-days and standardized infection ratio decreased from 2.16 to 0.37. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Quality outcomes in health care settings continue to gain focus nationally. Urinary tract infections represent at least 30% of all health care-associated infections (HAIs), the majority due to indwelling urinary catheters (IUCs), and are the most common HAI in intensive care units. More than 900,000 patients develop a catheter-associated urinary tract infection (CAUTI) in US hospitals each year, and for patients in intensive care units, this can lengthen their stay by up to 12 days.1-3 Due to the complex nature of neuroespine intensive care unit (NSICU) patients who often have urinary retention and limited mobility, preventing CAUTIs is challenging. NSICUs traditionally have the highest CAUTI rates; thus, novel interventions are needed in this population.4 From July 2011 through July 2012, 48 CAUTIs occurred in 5 intensive care units at our institution, 22 (46%) in the NSICU. METHODS Setting This intervention took place at Northwestern Memorial Hospital in Chicago, Illinois, a tertiary care academic medical center with * Address correspondence to Kimberly Schelling, MSM, CIC, Healthcare Epidemiology and Infection Prevention Department, 645 N Michigan Ave, Suite 900, Chicago, IL 60611. E-mail address: [email protected] (K. Schelling). Conflicts of interest: None to report.
894 beds, 23 of which comprise the NSICU. The NSICU houses a wide range of critically ill neurology, neurosurgery, and orthopedic spine surgery patients and is a designated primary stroke center. CAUTI surveillance and data collection The Infection Prevention Department (IP) at our institution utilizes a data mining system to obtain culture information for surveillance. CAUTI is defined according to National Health Safety Network (NHSN) criteria.5 It should be noted that the NHSN definition changed in January 2013, during the project and our fiscal year. We tracked and reported CAUTIs per the 2012 definition throughout the study period for consistency. Intervention The IP team met with NSICU physicians, nurses, and administrators to attend clinical bedside rounds in the NSICU and gain an understanding of the challenges this population faces. Once rounds and discussions were completed, the NSICU CAUTI-reduction action plan was created. As part of the plan, a nurse leader was assigned to perform daily assessments of IUC necessity on every patient and daily rounds were conducted by either IP staff or nursing leadership. Information was collected on a standardized form to record IUC presence, indication, and possibility of removal. The goal of rounding was to continually prompt conversations with nurses
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.04.184
2
K. Schelling et al. / American Journal of Infection Control xxx (2015) 1-3
Table 1 Timeline of intervention strategies Date June 2012 July and August 2012 September and October 2012 November 2012 December 2012 through June 2013 May 2013 May 2013 June 2013
Intervention Met with entire NSICU care team to share data and discuss high infection rates Rounded with NSICU physician care team to learn about the patient population Met with nursing and hospital leadership to gain support and nursing participation Action plan created and shared with team Weekly audits and conversations with nursing regarding catheter appropriateness, maintenance, and alternatives A new securement product, a pivoting IUC securement device, was implemented Nursing-driven protocol implemented A bowel management program was introduced to reduce diarrhea prevalence amongst patients
IUC, indwelling urinary catheter; NSICU, neuroespine intensive care unit.
Fig 1. Catheter-associated urinary tract infection (CAUTI) rates for the neuroespine intensive care unit (NSICU), fiscal year 2012-2013. NHSH, National Healthcare Safety Network; pt, patient.
regarding catheter appropriateness and maintenance. To improve catheter appropriateness, if 1 of the agreed-upon indications for ICU was not met, the nurse asked the physician to order catheter discontinuation. Also as part of the action plan, hand hygiene and glove changing were emphasized when nurses moved from 1 area of the body to another during routine care (ie, tracheostomy care to catheter care), maintenance of a closed system was emphasized, and alternatives to IUC (such as condom catheter, intermittent catheter, or urinal) were discussed. Additionally, a bowel management program was evaluated because diarrhea was found to be a potential contributor to CAUTIs. Unit rounding occurred Monday through Friday for 3 months followed by 3 times weekly from December 2102-June 2013. See Table 1 for a summary of interventions. RESULTS During clinical rounds and then daily rounds with nurses, 1 consistent finding was that clinicians often selected “need for accurate I/O” as an indication for IUC placement or maintenance; however, when discussions were held at the bedside about what fluid management decisions were actually made during the prior 24 hours based on a patient’s input/output readings, clinicians often reevaluated this indication, and this became a much less common reason for IUCs to be placed and/or maintained. From January-June 2013, there were 2,489 patient-days and 1,456 IUC-days, and 134 IUC daily audits were collected. IUC use for the average of the 6-month time period was 0.58, which is below the NHSN 25th percentile (0.68) of NSICUs nationally. This
remained at 0.60 and did not change significantly during the postintervention period. Catheter securement compliance increased to 100% during the final months of the data collection period. Decreases in the CAUTI rate from 8.18-0.93 per 1,000 catheter-days (Fig 1) and standardized infection ratio from 2.160.37 were achieved in the months following the intervention. DISCUSSION NSICU patients often experience urinary retention and impaired mobility, increasing their need for invasive devices such as IUCs, central lines, and ventilators, which put these patients at higher risk for HAIs.6 CAUTIs are the most common HAI in NSICUs, and at our institution the NSICU accounted for the largest number of intensive care unit CAUTIs. The preintervention rate and standardized infection ratio were well above the NHSN mean. The most important way to reduce CAUTIs is to avoid unnecessary use of IUCs and to remove them as soon as indications for use are no longer present.7 A multifaceted team approach of data sharing, embedding the IP team into daily clinic rounds, discussing IUC use and alternatives with nurses, and implementing a comprehensive action plan that addressed appropriate IUC use and maintenance was successful in reducing CAUTIs and in maintaining the improvement in infection rate in this challenging population. When IUCs are necessary, appropriately securing and maintaining them helps to prevent CAUTI. Securement can help prevent urethral trauma as well as inadvertent catheter removal. Routine securement is recommended nationally; therefore, it is
K. Schelling et al. / American Journal of Infection Control xxx (2015) 1-3
reasonable to implement routine catheter securement in patients who have IUCs.8,9 Catheter securement compliance was increased by implementing a product nursing staff requested. In addition to securement, consistency in placement of the IUC, maintenance of a closed system, and pericare are also important in decreasing CAUTI. Compliance with these factors also improved during the initiative. There were some limitations in the CAUTI reduction plan. The Centers for Disease Control and Prevention altered the CAUTI definition in January 2013, after the start of our interventions and during our fiscal year, prompting us to complete the project using 2012 definitions. Had the 2013 definitions been used, our CAUTI rates may have been higher, but likely would have demonstrated the same proportional drop between the pre- and postintervention periods. The action plan was considered successful by our institution. The number of CAUTIs was largely reduced and change was sustained. The culture of our NSICU now includes an increased mindfulness when evaluating catheter necessity, care, and removal. The success of this patient population-specific intervention serves as a model for future HAI interventions elsewhere in our institution.
3
References 1. Goolsarran VJ, Katz TF. Do not go with the flow, remember indwelling catheters. J Am Geriatr Soc 2002;50:1739-40. 2. Weinstein JW, Mazon D, Pantelick E, Reagan-Cirincione P, Dembry LM, Hierholzer WJ Jr. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol 1999;20:543-8. 3. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 2000;28:68-75. 4. Edwards JR, Peterson KD, Andrus ML, Dudeck MA, Pollock DA, Horan TC. National healthcare safety network (NHSN) report, data summary for 2006 through 2007. Am J Infect Control 2008;36:609-26. 5. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32. 6. Gardam MA, Amihod B, Orenstein P, Consolacion N, Miller MA. Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections. Clin Perform Qual Health Care 1998;6:99-102. 7. Gotelli JM, Merryman P, Carr C, McElveen L, Epperson C, Bynum D. A Quality improvement project to reduce the Complications associated with indwelling urinary catheters. Urol Nurs 2008;28:465-7. 473. 8. Wong ES, Hooton TM. Guideline for prevention of catheter-associated urinary tract infections. Atlanta: Centers for Disease Control and Prevention; 1981. 9. Center for Medicaid and State Operations/Survey and Certification Group. Nursing homes: delay in effective date for revision of Appendix PP, State Operations Manual (SOM), surveyor guidance for incontinence and catheters. Baltimore, MD: Centers for Medicare and Medicaid Services; 2005.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Reducing catheter-associated urinary tract infections in a neuroespine intensive care unit Kimberly Schelling MSM, CIC *, Janet Palamone MSN, APN, CNRN, CCRN, Kathryn Thomas MSN, RN, SCRN, Andrew Naidech MD, MSPH, FANA, Christina Silkaitis MT(ASCP), CIC, Jennifer Henry BSN, RN, CNRN, Maureen Bolon MD, MS, Teresa R. Zembower MD, MPH Healthcare Epidemiology and Infection Prevention Department in accordance with the NeuroeSpine Intensive Care Unit, Northwestern Memorial Hospital, Chicago, IL
Key Words: Indwelling urinary catheter Infection prevention Collaborative improvement project
A collaborative effort reduced catheter-associated urinary tract infections in the neuroespine intensive care unit where the majority of infections occurred at our institution. Our stepwise approach included retrospective data review, daily rounding with clinicians, developing and implementing an action plan, conducting practice audits, and sharing of real-time data outcomes. The catheter-associated urinary tract infection rate was reduced from 8.18 to 0.93 per 1,000 catheter-days and standardized infection ratio decreased from 2.16 to 0.37. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Quality outcomes in health care settings continue to gain focus nationally. Urinary tract infections represent at least 30% of all health care-associated infections (HAIs), the majority due to indwelling urinary catheters (IUCs), and are the most common HAI in intensive care units. More than 900,000 patients develop a catheter-associated urinary tract infection (CAUTI) in US hospitals each year, and for patients in intensive care units, this can lengthen their stay by up to 12 days.1-3 Due to the complex nature of neuroespine intensive care unit (NSICU) patients who often have urinary retention and limited mobility, preventing CAUTIs is challenging. NSICUs traditionally have the highest CAUTI rates; thus, novel interventions are needed in this population.4 From July 2011 through July 2012, 48 CAUTIs occurred in 5 intensive care units at our institution, 22 (46%) in the NSICU. METHODS Setting This intervention took place at Northwestern Memorial Hospital in Chicago, Illinois, a tertiary care academic medical center with * Address correspondence to Kimberly Schelling, MSM, CIC, Healthcare Epidemiology and Infection Prevention Department, 645 N Michigan Ave, Suite 900, Chicago, IL 60611. E-mail address: [email protected] (K. Schelling). Conflicts of interest: None to report.
894 beds, 23 of which comprise the NSICU. The NSICU houses a wide range of critically ill neurology, neurosurgery, and orthopedic spine surgery patients and is a designated primary stroke center. CAUTI surveillance and data collection The Infection Prevention Department (IP) at our institution utilizes a data mining system to obtain culture information for surveillance. CAUTI is defined according to National Health Safety Network (NHSN) criteria.5 It should be noted that the NHSN definition changed in January 2013, during the project and our fiscal year. We tracked and reported CAUTIs per the 2012 definition throughout the study period for consistency. Intervention The IP team met with NSICU physicians, nurses, and administrators to attend clinical bedside rounds in the NSICU and gain an understanding of the challenges this population faces. Once rounds and discussions were completed, the NSICU CAUTI-reduction action plan was created. As part of the plan, a nurse leader was assigned to perform daily assessments of IUC necessity on every patient and daily rounds were conducted by either IP staff or nursing leadership. Information was collected on a standardized form to record IUC presence, indication, and possibility of removal. The goal of rounding was to continually prompt conversations with nurses
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.04.184
2
K. Schelling et al. / American Journal of Infection Control xxx (2015) 1-3
Table 1 Timeline of intervention strategies Date June 2012 July and August 2012 September and October 2012 November 2012 December 2012 through June 2013 May 2013 May 2013 June 2013
Intervention Met with entire NSICU care team to share data and discuss high infection rates Rounded with NSICU physician care team to learn about the patient population Met with nursing and hospital leadership to gain support and nursing participation Action plan created and shared with team Weekly audits and conversations with nursing regarding catheter appropriateness, maintenance, and alternatives A new securement product, a pivoting IUC securement device, was implemented Nursing-driven protocol implemented A bowel management program was introduced to reduce diarrhea prevalence amongst patients
IUC, indwelling urinary catheter; NSICU, neuroespine intensive care unit.
Fig 1. Catheter-associated urinary tract infection (CAUTI) rates for the neuroespine intensive care unit (NSICU), fiscal year 2012-2013. NHSH, National Healthcare Safety Network; pt, patient.
regarding catheter appropriateness and maintenance. To improve catheter appropriateness, if 1 of the agreed-upon indications for ICU was not met, the nurse asked the physician to order catheter discontinuation. Also as part of the action plan, hand hygiene and glove changing were emphasized when nurses moved from 1 area of the body to another during routine care (ie, tracheostomy care to catheter care), maintenance of a closed system was emphasized, and alternatives to IUC (such as condom catheter, intermittent catheter, or urinal) were discussed. Additionally, a bowel management program was evaluated because diarrhea was found to be a potential contributor to CAUTIs. Unit rounding occurred Monday through Friday for 3 months followed by 3 times weekly from December 2102-June 2013. See Table 1 for a summary of interventions. RESULTS During clinical rounds and then daily rounds with nurses, 1 consistent finding was that clinicians often selected “need for accurate I/O” as an indication for IUC placement or maintenance; however, when discussions were held at the bedside about what fluid management decisions were actually made during the prior 24 hours based on a patient’s input/output readings, clinicians often reevaluated this indication, and this became a much less common reason for IUCs to be placed and/or maintained. From January-June 2013, there were 2,489 patient-days and 1,456 IUC-days, and 134 IUC daily audits were collected. IUC use for the average of the 6-month time period was 0.58, which is below the NHSN 25th percentile (0.68) of NSICUs nationally. This
remained at 0.60 and did not change significantly during the postintervention period. Catheter securement compliance increased to 100% during the final months of the data collection period. Decreases in the CAUTI rate from 8.18-0.93 per 1,000 catheter-days (Fig 1) and standardized infection ratio from 2.160.37 were achieved in the months following the intervention. DISCUSSION NSICU patients often experience urinary retention and impaired mobility, increasing their need for invasive devices such as IUCs, central lines, and ventilators, which put these patients at higher risk for HAIs.6 CAUTIs are the most common HAI in NSICUs, and at our institution the NSICU accounted for the largest number of intensive care unit CAUTIs. The preintervention rate and standardized infection ratio were well above the NHSN mean. The most important way to reduce CAUTIs is to avoid unnecessary use of IUCs and to remove them as soon as indications for use are no longer present.7 A multifaceted team approach of data sharing, embedding the IP team into daily clinic rounds, discussing IUC use and alternatives with nurses, and implementing a comprehensive action plan that addressed appropriate IUC use and maintenance was successful in reducing CAUTIs and in maintaining the improvement in infection rate in this challenging population. When IUCs are necessary, appropriately securing and maintaining them helps to prevent CAUTI. Securement can help prevent urethral trauma as well as inadvertent catheter removal. Routine securement is recommended nationally; therefore, it is
K. Schelling et al. / American Journal of Infection Control xxx (2015) 1-3
reasonable to implement routine catheter securement in patients who have IUCs.8,9 Catheter securement compliance was increased by implementing a product nursing staff requested. In addition to securement, consistency in placement of the IUC, maintenance of a closed system, and pericare are also important in decreasing CAUTI. Compliance with these factors also improved during the initiative. There were some limitations in the CAUTI reduction plan. The Centers for Disease Control and Prevention altered the CAUTI definition in January 2013, after the start of our interventions and during our fiscal year, prompting us to complete the project using 2012 definitions. Had the 2013 definitions been used, our CAUTI rates may have been higher, but likely would have demonstrated the same proportional drop between the pre- and postintervention periods. The action plan was considered successful by our institution. The number of CAUTIs was largely reduced and change was sustained. The culture of our NSICU now includes an increased mindfulness when evaluating catheter necessity, care, and removal. The success of this patient population-specific intervention serves as a model for future HAI interventions elsewhere in our institution.
3
References 1. Goolsarran VJ, Katz TF. Do not go with the flow, remember indwelling catheters. J Am Geriatr Soc 2002;50:1739-40. 2. Weinstein JW, Mazon D, Pantelick E, Reagan-Cirincione P, Dembry LM, Hierholzer WJ Jr. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol 1999;20:543-8. 3. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 2000;28:68-75. 4. Edwards JR, Peterson KD, Andrus ML, Dudeck MA, Pollock DA, Horan TC. National healthcare safety network (NHSN) report, data summary for 2006 through 2007. Am J Infect Control 2008;36:609-26. 5. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32. 6. Gardam MA, Amihod B, Orenstein P, Consolacion N, Miller MA. Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections. Clin Perform Qual Health Care 1998;6:99-102. 7. Gotelli JM, Merryman P, Carr C, McElveen L, Epperson C, Bynum D. A Quality improvement project to reduce the Complications associated with indwelling urinary catheters. Urol Nurs 2008;28:465-7. 473. 8. Wong ES, Hooton TM. Guideline for prevention of catheter-associated urinary tract infections. Atlanta: Centers for Disease Control and Prevention; 1981. 9. Center for Medicaid and State Operations/Survey and Certification Group. Nursing homes: delay in effective date for revision of Appendix PP, State Operations Manual (SOM), surveyor guidance for incontinence and catheters. Baltimore, MD: Centers for Medicare and Medicaid Services; 2005.
