Tar­get­ing the ED to re­duce uri­nary catheter in­fec­tions

Modern Healthcare - - BEST - By Mau­reen McKin­ney

In 2012, officials at As­cen­sion Health no­ticed that catheter-as­so­ci­ated uri­nary tract in­fec­tion rates across the 101-hos­pi­tal sys­tem were about even with na­tional rates. They dis­cov­ered the op­por­tu­nity for im­prove­ment when they ex­am­ined bench­mark­ing data af­ter St. Louis-based As­cen­sion was named a hos­pi­tal en­gage­ment net­work un­der the fed­eral Part­ner­ship for Pa­tients safety ini­tia­tive.

“We were able to zero in on some­thing that we re­ally thought was pre­ventable,” said Ann Hen­drich, As­cen­sion Health’s chief qual­ity, safety and nurs­ing of­fi­cer.

Catheter-as­so­ci­ated UTIs are the most com­mon type of health­care-as­so­ci­ated in­fec­tion in hos­pi­tals, ac­count­ing for more than 30% of in­fec­tions re­ported to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion’s on­line in­fec­tion sur­veil­lance sys­tem. Such in­fec­tions cost the U.S. health­care sys­tem more than half a bil­lion dol­lars and lead to more than 8,000 deaths an­nu­ally, ac­cord­ing to fed­eral data.

Ef­forts to re­duce these in­fec­tions typ­i­cally fo­cus on re­mov­ing catheters as soon as pos­si­ble. But Dr. Mo­hamad Fakih, As­cen­sion Health’s na­tional in­fec­tious dis­ease physi­cian leader, said con­cen­trat­ing on ap­pro­pri­ate catheter use in the emer­gency de­part­ment helps avoid plac­ing uri­nary catheters in the first place. “Oth­ers say, ‘Let’s get rid of it quickly.’ We say, ‘Let’s stop be­fore we even put it in,’” he said.

The ED is a log­i­cal place to start be­cause it’s the en­try point to the hos­pi­tal, of­ten ad­mit­ting more than half of pa­tients, and it’s of­ten the place where uri­nary catheters are placed, said Russ Olmsted, direc­tor of in­fec­tion pre­ven­tion and con­trol ser­vices at St. Joseph Mercy Hos­pi­tal, Yp­si­lanti, Mich., and past pres­i­dent of the As­so­ci­a­tion for Pro­fes­sion­als in In­fec­tion Con­trol and Epi­demi­ol­ogy.

Begin­ning in June 2012, Fakih led a six-month im­prove­ment project at 18 As­cen­sion Health hos­pi­tal EDs, in­clud­ing 673-bed St. John Hos­pi­tal and Med­i­cal Cen­ter, Detroit, where he serves as med­i­cal direc­tor of in­fec­tion pre­ven­tion and con­trol.

Fakih and his team drafted clear guide­lines for uri­nary-catheter use, cus­tom­ized for ED pa­tients. For in­stance, catheters were deemed ap­pro­pri­ate for pa­tients with uri­nary ob­struc­tion or hip frac­tures, and for pa­tients who were sched­uled for cer­tain sur­gi­cal pro­ce­dures. But they were cat­e­go­rized as in­ap­pro­pri­ate for in­con­ti­nent pa­tients and pa­tients with de­men­tia. They also named a physi­cian and nurse cham­pion at each site and tasked them with pro­mot­ing the project, ex­plain­ing the clin­i­cal ben­e­fits and as­sist­ing with staff ed­u­ca­tion.

The project was based on a suc­cess­ful pilot at St. John Hos­pi­tal in 2007 and 2008, which showed a sig­nif­i­cant drop in ED uri­nary-catheter uti­liza­tion af­ter the in­tro­duc­tion of well-de­fined guide­lines and physi­cian ed­u­ca­tion.

“Be­fore, it was just the norm to put a catheter in, and now it’s def­i­nitely not,” said Ar­lene Boestler, St. John Hos­pi­tal’s clin­i­cal nurse man­ager and nurse cham­pion for the project. She said the hos­pi­tal em­bed­ded the cri­te­ria into the elec­tronic health-record sys­tem so the in­di­ca­tions au­to­mat­i­cally pop up when nurses chart a catheter.

“We’re now at a point where it’s just part of the cul­ture,” said Dr. Mar­garita Pena, med­i­cal direc­tor for the hos­pi­tal’s clin­i­cal de­ci­sion unit and the physi­cian cham­pion for the pro­gram.

New uri­nary-catheter place­ments fell more than 30% across the 18 par­tic­i­pat­ing hos­pi­tal EDs dur­ing the ini­tia­tive, from 9.1% at the base­line to 6.1%, ac­cord­ing to re­sults pub­lished in June in the An­nals of Emer­gency Medicine. The per­cent­age of ap­pro­pri­ate catheter place­ments—those that met the guide­lines—jumped from 74% to 91%.

The project faced some chal­lenges, in­clud­ing un­even progress among par­tic­i­pat­ing hos­pi­tals and some dif­fi­culty get­ting sites to sub­mit data in a timely man­ner. For the most part, though, the process went smoothly, Fakih said. He stressed that catheters not only bring in­fec­tion risk, but also limit pa­tients’ mo­bil­ity and are gen­er­ally un­pleas­ant. “Avoid­ing un­nec­es­sary ones ad­dresses all of those is­sues,” Fakih said.

A na­tional ef­fort funded by the Agency for Health­care Re­search and Qual­ity to pre­vent catheter-as­so­ci­ated UTIs, called “On the CUSP: STOP CAUTI,” has in­te­grated As­cen­sion Health’s ap­proach into its pro­gram. It’s now in use in more than 200 EDs, Fakih said.

Olmsted said he has im­ple­mented the pro­gram at St. Joseph Mercy Hos­pi­tal and seen good re­sults. “My col­leagues at As­cen­sion have done a great job of iden­ti­fy­ing a key area of en­try— the ED—and get­ting folks to ask, ‘Do we re­ally need this catheter?’”

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