Cutting CAUTIs in Critical Care

From the Tucson Medical Center, Tucson, AZ.

Abstract

• Objective: To describe a quality improvement project to reduce catheter-associated urinary tract infections (CAUTIs) in an intensive care unit (ICU).
• Methods: Descriptive report.
• Results: CAUTIs are a common health care–associated infection that results in increased length of stay, patient discomfort, excess health care costs, and sometime mortality. However, many cases of CAUTIs are preventable. To address this problem at our institution, we enrolled in the Hospital Engagement Network (HEN) collaborative for the reduction of CAUTIs, utilizing the Comprehensive Unit-based Safety Program (CUSP) as the platform for our project. This article describes our project implementation, challenges encountered, and the lasting improvement we have achieved at our facility.
• Conclusion: By challenging the ICU culture, providing nursing with alternatives to urinary catheters, and promoting physician engagement, we were able to reduce catheter utilization and CAUTI rates in the ICU.

Hospital-acquired infections (HAIs) are important causes of morbidity and mortality in the United States [1]. Among HAIs, urinary tract infections are the 4th most common, with almost all cases caused by urethral instrumentation [2]. Catheter-associated urinary tract infections (CAUTIs) are associated with an increased hospital length of stay of 2 to 4 days and a cost of $400 million to $500 million annually [3]. As of 2015, the Centers for Medicare and Medicaid Services no longer reimburses hospitals for treating CAUTIs.

CAUTIs are a particular challenge in the intensive care unit (ICU) due to the high urinary catheter utilization rates. In our mixed medical/surgical ICU, the catheter utilization rate was 84% in 2012 and was the setting for the majority of CAUTIs in our hospital. The risk of CAUTI can be reduced by ensuring that catheters are used only when needed and removed as soon as possible; that catheters are placed using proper aseptic technique; and that the closed sterile drainage system is maintained. In 2013 we launched a project to improve our CAUTI rates and enrolled in the Hospital Engagement Network (HEN) collaborative for the reduction of CAUTIs, utilizing the Comprehensive Unit-based Safety Program (CUSP) [4] as the platform for our project. This article describes our project implementation, the challenges we encountered, and the lasting improvement we have achieved.

Setting

Tucson Medical Center is a 600-bed tertiary care hospital, the largest in southern Arizona, with over 1000 independent medical providers. The medical center is a locally governed, nonprofit teaching hospital that has been providing care to the city of Tucson, southern Arizona, southwest New Mexico, and northern Mexico for the past 70 years. There are 2 adult critical care units: a cardiovascular ICU and a mixed medical/surgical ICU. We focused our efforts and interventions on the mixed ICU, a 16-bed unit that includes medical, surgical (neuro, general and vascular), and neurological patient populations that had 19 CAUTIs in 2012, versus 2 CAUTIs in the cardiovascular ICU.

Project

Initial Phase

The first steps in our project were to develop our unit-based team, identify project goals, and review our current nursing practice and processes. First, using the template from the CUSP platform, we assembled a team that consisted of the chief nursing officer (executive sponsor), ICU medical director, nurse manager, infection control manager, infection control nurse, 4 nurse champions (2 two night shift 2 day shift), and a patient care technician.

The second step was to identify a realistic and achievable goal. A goal of a 20% reduction from our current utilization rate was selected. As our catheter utilization rates were consistently above 90%, we aimed to for a rate of less than 70%. In addition, we sought to reduce our CAUTI standardized infection ratio (number of health care–associated infections observed divided by the national predicted number) from 3.875 to less than 1.0.

In reviewing our current nursing practice and processes, we utilized the CUSP data collection tool and adapted it to meet our institutional needs. Figure 1 shows the original CUSP data collection tool, which is organized around 5 key questions about the catheter (eg, Is catheter present? Where it was placed? Why does the patient has a catheter today?) as well as lists appropriate and inappropriate indications. 

To implement the guidelines, we provided education to the nursing staff via emails, placed posters on the unit, and discussed appropriate and inappropriate indications during bedside conversations using the audit tool. As the project continued, these guidelines were reinforced daily when the question “why does your patient have a catheter today?” was posed to the nurses during the audit. Our chief nursing officer supported our implementation efforts by including a CAUTI prevention lecture with her monthly house-wide nursing education series called “lunch and learn.”

We added additional questions to the tool as we learned more about the practices and processes that were currently in use. For example, “accurate measurement of urinary output in the critically ill patient” was the most common reason given by nurses for keeping a catheter in. Upon further questioning, however, the common response was that “the doctor ordered it.” By adding “MD order” to the audit tool, we were able to track actual orders versus nurses falling back on old patterns. This data collection item also provided us the names and groups of physicians to approach and educate on our project goals. Two other helpful items added to the tool related to the catheter seal and stat lock (catheter securement device) placement. The data provided by these questions helped us recognize areas for improvement in nursing practice, supply issues, and the impact of other departments. For example, auditing showed that most of our catheters were placed in the emergency department (ED) and surgery. This gave us an opportunity to reach out to these units to discuss CAUTI reduction strategies. For example, after review of the ED catheter supplies, we discovered that they did not have a closed catheter insertion system with a urometer drainage bag. Therefore, when a patient was transferred to the ICU, the integrity of the urinary collection system had to be broken to place a urometer. Evidence has shown that breaking the integrity of the system increases a patient’s risk for a CAUTI [1]. Once this problem was identified, the ED inventory was changed to include the urometer as part of the closed system urinary insertion kit.

Active Phase

After the implementation phase, the next 15 months were dedicated to daily rounding and bedside auditing, the foundation of our project. Rounding was done by the unit manager or nurse champion and involved talking with the bedside nurse and completing the audit tool. These bedside conversations were an opportunity to review the HICPAC guidelines, identify education needs, and reinforce best practices. During these discussions, the nurses often would identify reasons to remove catheters.

The CAUTI team met monthly to review the previous month’s data, other observed opportunities for improvement, and any patient CAUTI information provided by our infection control nurse liaison. We conducted root cause analysis when CAUTIs developed, in which we reviewed the patient’s chart and sought to identify possible interventions that could have reduced the number of catheter days. Our findings were shared in staff meetings, newsletters, and through quality bulletin boards. We also recognized improved performance. Tokens that could be cashed in at the cafeteria for snacks or drinks were awarded to nurses who removed a urinary catheter. We also organized a celebration on the unit the first time we had 3 months without a CAUTI.