FOR YEARS, HEALTHCARE has acknowledged the serious issue of healthcare-associated infections (HAIs). The CDC estimates that approximately 1 out of every 20 hospitalized patients will contract an HAI for an annual direct medical cost ranging from $28.4 to $33.8 billion.1 Infection preventionists have been creative in finding ways to provide education and monitor hand hygiene, sterile technique, isolation precautions, and so on, yet HAIs persist.
In early 2012, Medical Center Health System (MCHS) agreed to participate in “Partnership for Patients (PfP),” a national collaborative sponsored by the U.S. Department of Health and Human Services that was introduced as a new initiative to “improve the quality, safety, and affordability of healthcare for all Americans.”2 Catheter-associated urinary tract infection (CAUTI) was identified as 1 of the 10 preventable HAIs in the collaborative.3 This article describes MCHS's “awakenings” to institutional shortcomings regarding CAUTI prevention and how they were addressed during this major patient safety project, which was launched in July 2012.
Eyes wide open
The first responsibility of a PfP participant is to submit baseline data. Because MCHS hadn't been targeting CAUTI at the beginning of the project, it had no baseline data on this HAI. “You can't manage what you can't measure,” goes the old management saying. This was our first awakening.
The second awakening occurred in the summer of 2012 with the engagement of an electronic health record (EHR) partner to implement software to help monitor quality initiatives. This software provides an at-a-glance status view that gives clinicians real-time feedback about quality bundle compliance via a red/yellow/green symbol, in accordance with best practice standards. MCHS clinicians were aware of the CAUTI quality bundle concept thanks to education from the Institute for Healthcare Improvement, but most of them couldn't name the specific components. And even if they knew the bundle components, they had no dedicated space to document them in the EHR. This was the third awakening. (See CAUTI bundle components.)
MCHS had some serious work to do to educate clinicians about CAUTI prevention and to capture the work being performed.
Fixing the issue
A multidisciplinary team was formed to work on CAUTI prevention, and data collection began in earnest. Overall initial CAUTI rates ranged from 5.86 to 8.09 per 1,000 patient days (National Healthcare Safety Network's definition of number of infections per catheter days x 1,000). Our PfP CAUTI team goal was to reduce our overall CAUTI rate by 50% by the end of 2013.
A separate nursing-intensive team (including an information technology systems analyst) was formed to overhaul urinary catheter documentation in the EHR as part of the work to implement new software, which went live in December 2012. Discrete entries were established for dates/times of catheter insertion and removal, along with insertion criteria, the maintenance bundle (sterile/closed system, securement, collection bag below bladder, unobstructed urine flow, collection bag emptied regularly), and a daily needs assessment. A clinical education carnival was held for all direct caregivers with a focus on CAUTI bundle components. The icing on the cake was the software go-live, which provided a visual cue to the clinical nurse regarding the need to document each step of the bundle on every shift. Clinical nurses now know the components of the CAUTI bundle and are happy to explain them to anyone who asks.
Seeing real results
The MCHS quality and infection prevention staff members are definitely pleased with the results. The real joy of this endeavor involves watching the CAUTI rates decline. The overall CAUTI rate for 2012 was 4.26, and in 2013 it decreased to 0.81. It's been rewarding for the clinical staff, but, of course, the patients benefit the most.
Back in early 2012, a goal of zero CAUTIs seemed unattainable. MCHS clinicians needed the resources of the PfP Collaborative, a dedicated team, and new software to help drive and measure compliance. However, the work on quality and patient safety is never done; we're certain that another awakening is just around the corner.
CAUTI bundle components
- Insert catheters only for appropriate indications.
- Leave catheters in place only as long as needed.
- Ensure that only properly trained persons insert and maintain catheters.
- Insert catheters using sterile technique and sterile equipment (acute care setting).
- Following sterile insertion, maintain a closed drainage system.
- Maintain unobstructed urine flow.
- Maintain hand hygiene and follow standard (or appropriate isolation) precautions.
Resource: CDC. Catheter-associated urinary tract infections (CAUTIs). 2012. http://www.cdc.gov/HAI/ca_uti/uti.html.