Transcript National Healthcare Safety Network (NHSN)

Kimberlee J Souhrada MM, BSN, CLNC
Clinical Specialist, Rochester Medical Corporation
One Rochester Medical Drive
Stewartville, MN 55976
[email protected]
Office: 800-615-2364 x609; 507-533-9609
Mobile: 651.319.2714
At her weekly book club meeting,
Donna is again embarrassed by the inability
to control her bladder.
Author affiliation:
Rochester Medical Corporation
Memberships:
APIC, SUNA, NLN, AACN, AORN, NACLNC
“This program has been approved by the American Association of Critical-Care Nurses (AACN) for
1.0 CERPs, Synergy CERP Category B , File Number 00017795”
1.
Identify and describe the risks and complications associated with CAUTI
2.
Review and assess the complexity of Consumer Awareness and
Healthcare Reform as they relate to CAUTI
3.
Review NHSN hospital reporting system as it pertains to symptomatic
UTIs
4.
Assess TJC and the 2012 National Patient Safety Goal
5.
Analyze the common goals and objectives of agency guides for CAUTI
reduction initiatives
“Catheter Fever”
Catheter
“To let or send down”

To relieve painful retention of
urine since time immemorial

11th Century
• Development of malleable
catheters with bored holes

Ancient materials – from 3000
BC!!!

• Coude’ catheter
• Straw
• Self-catheterization for urinary
• Rolled up palm leaves
retention - “Catheter Fever”
• Dried leaves of allium, gold, silver,
copper, brass and lead
19th and early 20th Century

1930s - The Foley
• Dr. Frederic E.B.Foley; St. Cloud,
MN

Indwelling Urinary Catheters (IUC) are inserted in >5 million patients per
year

One out of four hospitalized patients will have an IUC
• 40 – 50% do not have a valid indication for use
• In a recent study >50% of physicians did not know which patients were
catheterized or for how long

~ 40% of all HAI – most common site of Hospital Acquired Infection (HAI)

UTIs account for more than 8 million doctor visits per year

8% prevalence in the home care setting

Leading cause of secondary bloodstream infection

Most are asymptomatic

900,000 patients with nosocomial bacteriuria in US hospitals each year

Discomfort

Daily Risk for UTI from an IUC – 3%-7%

Prolong hospital stay

Secondary bacteremia/sepsis

Acute pyelonephritis

Increased use of antimicrobial drug therapy

Urethral stricture

Increased mortality – 5% of all deaths from HAI are associated with
urinary catheters

MDRO Infection

Increased cost
• Adds $500 to $3800 to hospitalization cost/ $400M to >$1B annually
• The CMS no longer reimburses hospitals for the costs associated with the
development of HAIs – CAUTI
PRIMARY
SECONDARY

Female

Dehydration

Age >50

Sickle-cell anemia

Diabetes

Immobility

Urethral colonization

Concurrent infections

Debilitated health

History of UTI

Incomplete bladder emptying

Colonization with MDROs

Fecal incontinence

Poor personal hygiene

Lack of hand hygiene prior
to catheter manipulation

Drainage spigot
contamination


Breaks in the closed system
or non-use of a closed
system

Drainage bag raised above
the level of the bladder

Lack of use of methods to
control incontinence

No sample port on closed
system
No catheter securement

Catheters in place too long

Poor insertion technique
Historical Timeline of Key Events

Pioneered the principle of accountability for the results of
medical practice
“It may seem a strange principle to enunciate as the very first
requirement in a hospital that it should do the sick no harm.”

Campaigned to improve health standards with measurable
outcomes supported by undeniable data

1985 – First reporting of hospital data to a state agency
• Maryland Quality Indicator Project (surgical morbidity)

1991 – NYS inadvertent publication of cardiac surgeon’s
mortality rates
• Note - with public awareness came a drop in mortality from 4.2% to
1.6% in ~ 10 years

Additional states and new conditions have been added to
state reporting as legislation continues to change
Public protest nosocomial
infections
at Louisville
KY hospital (8/06)
Consumer
Awareness
is born!
Plaintiffs turned Protesters

“To Err is Human” (1999)
• 98,000 deaths annually (3 full jumbo jets/qod)
• Medical error total cost is estimated at $17 - $29B
“It is not acceptable for patients to be harmed
by the health care system”

The IOM recommended “Four Tiered Strategy for
Improvement”
1.
2.
3.
4.
Establish a national focus
Identify and learn from errors through nationwide public
reporting
Raise performance standards and expectations
Implement safety systems in HealthCare Organizations
Centers for Medicare & Medicaid Services
(CMS)
“Hello, incontinence helpline – can you hold?”
Family Tree
US Dept of
Health & Human
Services (HHS)
National
Institutes of
Health (NIH)
Centers for
Disease Control
& Prevention
(CDC)
National
Institute for
Occupational
Safety & Health
Food & Drug
Administration
(FDA)
Agency for
Healthcare
Research &
Quality (AHRQ)
Center for
Quality
Improvement
and Patient
Safety
Office of
Infectious
Diseases
Centers for
Medicare &
Medicaid
Services (CMS)
And 21 more!
Centers for
Outcomes &
Evidence
Nat’l Ctr for
Emerging &
Zoonotic
Infectious
Diseases
HICPAC
National Health
Safety Network
(NHSN)
18

CMS has transformed from a passive payer of services into an
active purchaser of higher quality, affordable care.

Now rewards providers by linking the payment to the quality
and efficiency of care provided
*The CMS main goal: to foster joint clinical and financial
accountability in the healthcare system.
 Inpatient and Home Healthcare:
Pay-for-Reporting
• Reduction of payment for hospitals and Home Health
Agencies not submitting data regarding specified
quality measures
• Medicare Home Health Compare and Hospital Compare
 www.medicare.gov
 Resource link
• More measures continue to be added

Improve clinical quality, patient safety and efficiency of care

Reduce adverse events

Encourage patient-centered care

Avoid unnecessary costs

Stimulate investment in systems to improve quality and
efficiency

Make performance results transparent and understandable
for consumer empowerment
National Health Safety Network
(NHSN)

State reporting to CDC initially was voluntary, and not
standardized

2005 - NHSN Reporting System was launched
• Standard in HAI surveillance
• Open enrollment to all types of healthcare facilities in the US

2008 – CMS disallows payment for certain Hospital Acquired
Conditions (HAC) such as:
• CAUTI
• Staph Aureaus bloodstream infections
• Serious bedsores, objects left in pt, blood incompatibility, and air
embolism
• Surgical Site Infections (SSI)
Patient Safety Component
Patient Safety
Component
Device
Associated
Model - DA
Central Line
Associated BSI
- CLABSI
Ventilator
Associated
Pneumonia VAP
Catheter
Associated
UTI - CAUTI
Procedure
Associated
Model - PA
Dialysis
Incident - DI
Surgical Site
Infection - SSI
Post-procedure
Pneumonia PPP
*Reporting will be publically accessible through
www.hospitalcompare.hhs.gov
Medication
Associated
Model - MA
Antibiotic Use
and Resistance
- AUR
The NHSN uses the information reported to produce
comprehensive rates used for hospital comparison.
•It is very important that the data is collected using exactly the
same definitions each time.



CAUTI: UTI that occurs in a patient who had an indwelling
urethral catheter in place within 48 hours prior to specimen
collection.
Transfer Rule: If the UTI develops in a patient within 48 hours
of discharge from a location, the discharging location is
indicated
NHSN definitions: Reportable CAUTI
http://www.cdc.gov/nhsn/index.html
• Six specific definitions
• Four are associated with the patient that had an indwelling urinary
catheter at the time of specimen collection, removed within 48 hours
prior to specimen collection, and the patient who did not have an IUC
• Two definitions for patients < 1 year of age
The new 2012 National Patient Safety Goal (NPSG)

Founded in 1951 it is the oldest and largest standardssetting and accrediting body in healthcare
• Evaluates and accredits >19,000 health care organizations and
programs in the US
Governed by a Board of Commissioners
 Accreditation

• Earned by an entire health care organization

Certification
• Earned by programs or services based within or associated with
an accredited health care organization i.e. diabetes, heart
disease, cancer, and more

2002 – Established to help organizations address specific
areas of patient safety concerns
• Patient Safety Advisory Group determines the highest priority
safety issues and how to address them
• Elements of Performance

2004 - Aligned with the CDC and endorsed by CMS to
standardize common measures

Public website – www.qualitycheck.org

Approval of one new NPSG
NPSG.07.06.01 – Implement evidence-based practices to prevent
indwelling catheter-associated urinary tract infections (CAUTI)
• Evidence-based guidelines
 2008 SHEA Compendium of Strategies
 2009 HICPAC/CDC Guideline
• Phase-in period
 TJC Survey will ensure planning and preparation for full
implementation in 2013
•This goal is not applicable to
•pediatric populations
Prevention Interventions and Control Practices

APIC – Association for Professionals in Infection Control and
Epidemiology
• 2008 Guide to the Elimination of CAUTIs

SHEA – Society for Healthcare Epidemiology of America
• 2008 Strategies to Prevent HAI in Acute Care Hospitals

CDC/HICPAC – Healthcare Infection Control Practices Advisory
Committee
• 2009 Guideline for the Prevention of Catheter-associated Urinary Tract
Infections

IDSA – Infectious Diseases Society of America
• 2009 Strategies to Reduce the Risk of CAUTI

IHI – Institute for Healthcare Improvement
• 2011 How-to Guide: Prevent Catheter-associated Urinary Tract Infections
Identify the Problem of CAUTI
1.
•
Prevalence and Burden
Risk Assessment
2.
•
Baseline data to determine patients at highest risk
Surveillance
3.
•
Monitoring and data collection
Strategies to Prevent CAUTI
4.
•
Policies, procedures, education, and feedback
Implementation of Best Practices
5.
•
ABC Bundle, protocols, and techniques
Basic Infection Prevention
and Antimicrobial
Stewardship
1.
•
•
•
•
3.
4.
•
•
•
•
Programs, Policies and Protocols
Systems and Strategies
Prevalence of Urinary Tract
Infections
2.
Complications of IUCs
Endogenous pathogens
Contaminated equipment
Environmental
Long-term IUC
Pathogenesis
6.
•
•
•
Risk factors
Bacteriuria
Urinary Catheter Use in
Healthcare settings
UTI Pathogens
5.
Extraluminal
Intraluminal
Biofilms
Diagnosis of CAUTI
7.
•
Specimen collection
Existing organizational program
1.
•
What systems are in place?
Population at risk
2.
•
Point prevalence survey
Baseline outcome data
3.
•
•
•
Examine CAUTI utilizing pathology reports
Assess location, frequency and prevalence
Use NHSN definitions
4.
Financial impact
5.
Multidisciplinary Team
Surveillance for CAUTI is a dynamic and essential way
to turn data into useful information to drive interventions!

Elements of Surveillance
1.
2.
3.
4.
5.
6.
7.
8.
Assessment of the population
Identification of those at greatest risk
Determination of observation time
period
Choice of surveillance methodology
Monitoring for outcomes
Collection of data
Analysis of data
Display and distribution of findings

Clear and Consistent

Document UTIs, assess risk factors, and monitor procedures
and practices

Device utilization ratio (NHSN)
• Numerator – number of events
• Denominator – number or event-related catheter days or patient days
• Monthly assessment

Incidence – new cases in a given time period

Prevalence – number of cases at a particular point in time
divided by the total population being studied

Plan: Monthly rate of CAUTI in MICU for one year

Criteria: NHSN criteria for CAUTI

Data collection: Active surveillance of MICU patients

Numerator: Number of new CAUTI per month

Denominator: number of IUC days in MICU

Calculation of Incidence rate:
• CAUTI RATE = Number of new CAUTI
X 1000
 Number of catheter days
• 2 UTI/702 catheter days = .002847 X 1000 = 2.8 per 1000 IUC days
*As of 02/2012 - Zero CAUTI
A.
* Adherence to a sterile, continually closed system has been
the cornerstone of CAUTI prevention
Appropriate Infrastructure
1.
2.
3.
4.
5.
Surveillance
B.
1.
2.
3.
C.
Written guidelines for UC use, insertion and maintenance
Only trained, dedicated personnel insert UCs
Necessary supplies for aseptic technique
Documentation system
Resources to support surveillance
Risk assessment and identification of patient units
Standardized criteria
Appropriate and valid
Education and Training
D. Appropriate Technique for IUC Insertion
•
•
•
•
•
Indications for insertion
Alternatives
Hand hygiene
Aseptic technique and sterile equipment/kit
Smallest size catheter
E. Appropriate Management of IUCs
•
•
•
•
•
•
•
Proper securement
Sterile closed system
Appropriate sample collection
Unobstructed urine flow
Empty the bag regularly
Keep the bag below the level of the bladder
Routine perineal hygiene after insertion
F. Accountability
•
•
•
Executive level support
Management
Direct healthcare providers
Remove Unnecessary IUCs
1.
•
•
Assess the need for an IUC daily
Physician reminder systems – EMR, written, daily rounds reminder
Automatic stop orders
2.
•
Requires renewal of the order for continuation
Nurse-driven protocols
3.
•
•
May be part of an algorithm
Independent of a physician order
* Postoperative Urinary
Catheter removed on POD 1
or POD 2
4.
Surgical patients – SCIP – 9 Core Measure Indicator
5.
Bladder scanners
6.
Anti-microbial coated catheters
A septic insertion and proper maintenance
B ladder ultrasound may avoid IUC
C ondom or intermittent catheterization in appropriate patients
D o not use IUC unless necessary
E arly removal of catheters
using reminders or stop orders
Create your own acronym for
a Bundle that would work in
your organization

Culture of Patient Safety
• Information and education
• Foundation for surveillance
• Involvement can make a difference

Assemble a Team
• Oversee the process
• Be the driving force
“If you only have a hammer,
you tend to see every problem
as a nail.”
-- A. Maslow
• Partner with nursing, case management, infection prevention, and
physicians

Implement Teamwork and Communication
• Use tools for improvement
• Identify opportunities and barriers

Identify and Learn for Defects
• What happened and why
• What can be done to reduce risk

Engage Senior Executive
• Bridge the gap
• Help remove barriers
• Implement improvement efforts
• Everyone is accountable for efforts to reduce risks to patients
No of CAUTI/Patient Days*1000
1.6
1.4
No of CAUTI/Month
18
1.37
16.4
43.3% Reduction
16
14
1.2
12
1
0.77
0.8
9.3
10
8
0.6
6
0.4
4
0.2
2
0
0
Preintervention
Postintervention
Preintervention
Postintervention

Catheter bundle implemented with a decrease
in CAUTI > 83% in 5 years
• St. Joseph Regional Medical Center, Lewiston, ID



In one month # of CAUTI dropped from 8 to 2
As of 1/30/12 no UTIs for 403 days
Intervention provided a 98.87% decrease in UTI over 4 years
• Tacoma General, Mary Bridge Children’s, Allenmore and Good Samaritan Hospitals, Tacoma, WA

Bringing about cultural change is difficult but achievable

CAUTI rates can be reduced by a multidisciplinary approach

Review evidence-based resources

Implement recommended practices

Ensure that evidence-based practices are adhered to and embraced
by all members of the team

Continuous education and feedback will bring success

Evaluate and re-evaluate your own facility

Do NOT give up the fight to Aim for Zero on CAUTI reduction!!
Finally, the “other” catheter
is getting the attention it
deserves!
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
APIC 2008 Guide to the elimination of Catheter-associated Urinary Tract Infections
A Brief History of Report Cards by John Steen
Centers for Medicare and Medicaid Services, Roadmap for Implementing Value Driven
Healthcare in the traditional Medicare Fee-for-Service Program
The CMS. www.cms.hhs.gov
Healthcare Associated Infections: States and Public Reporting. ww.extendingthecure.org
Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention
of Catheter-associated Urinary Tract Infections 2009.
Infection control and Hospital Epidemiology. SHEA Position Paper 2008. Strategies to
Prevent Catheter-associated Urinary Tract Infections in Acute Care Hospitals
Infectious Disease Society of America 2009 International Clinical Practice Guidelines.
Diagnosis, Prevention, and Treatment of Catheter-associated Urinary Tract Infection in
Adults
Institute of Medicine. To Err is Human Series: Building a Safer Health System & to Delay is
Deadly.
Jeffers, T.W., The GOAL: Elimination of Catheter Associated Urinary Tract Infections.
Online webinar slide retrieval. August 2011
The Joint Commission. www.jointcommission.org. 2012 Hospital National Patient Safety
Goals
Mourad,M., Auerbach,A., Improving Use of the “Other” Catheter. Archive of Internal
Medicine. Vol 172 (no. 3) Feb. 13,2012.
The Recovery Act. Whitehouse.gov/Recovery
Responsible Reform for the Middle Class. The Patient Protection and Affordable Care
Act
The Center for Disease Control and Prevention. www.cdc.gov/nhsn