Preventing CAUTI: Engaging Clinicians and Senior Leadership to Implement Change (May 14, 2013)

Paul Tedrick
American Hospital Association - Chicago
May 14, 2013
11:00AM Central Time

Operator: This is a recording for the Paul Tedrick teleconference with AHA - Chicago Tuesday, May 14, 2013 scheduled for 11AM Central Time. Ladies and gentlemen, thank you for your patience in holding. We now have our speakers in conference. Please be aware that each of your lines is in a "listen only" mode. At the conclusion of our speaker's presentations, we will open the floor for questions. Instructions will be given at that time of the procedure to follow if you would like to ask a question. It is now my pleasure to turn this conference over to Mari Franks. You may begin.

Mari Franks: Great. Thank you so much, and good morning and good afternoon, everyone. Welcome to our CAUTI National Content Call. Today's call is titled, "Preventing CAUTI: Engaging Clinicians and Senior Leadership to Implement Change." I want to point out that today's national content call is actually a webinar. So, if you are not logged in to the webinar or the computer portion of today's call and you do not have the link, you can go ahead and email Paul Tedrick at ptedrick@aha.org, and he will go ahead and send you that link. At the time, I am going to have my colleague, Kelly Faulkner, speak to all of your very briefly about our evaluation. Kelly?

Kelly Faulkner: Thank you, Mari. Hello, everyone. I want to just take a few minutes of the time before the content call gets started to announce a CAUTI evaluation examiner. And this to let you know what we're doing with all of the evaluations we ask you to fill out. So, as many of you know, following each of our events, we have a link to an online evaluation or, if it's in person, we hand you a paper form and ask for your feedback. And we want to let you know that we're listening and give this information back to you so you can understand what your hospital teams and peers are saying and identify any issues raised and best practices that come from these evaluations. You will find a link to the upcoming CAUTI evaluation examiner next to the recordings and slides presentations for each content call. And, of course, as always, if you have any questions, feel free to reach out to me, Kelly Faulkner, Mari Franks, or Paul Tedrick and fill out any questions you have on your evaluations as well. So, I wanted to thank Mari for opening it up and Sanjay and Todd for letting me take a couple minutes of their time before the call. Thanks, Mari.

Mari Franks: Sure. Thanks so much, Kelly. And at this time, I am happy to introduce our speakers today. We have both Dr. Sanjay Saint and Dr. Todd Green, who are both members of the On the CUSP: Stop CAUTI National Project Team. Sanjay is George Professor of Internal Medicine at the University of Michigan Medical School, along with the Associate Chief of Staff at Ann Arbor VA Medical Center, and Todd Green is a faculty member at the University of Michigan Medical School. At this time, I am excited to turn over today's call to Dr. Saint.

Sanjay Saint: Thank you, Mari, and thank you all for listening in. Todd and I will be discussing the following topics: First, implementation and CAUTI prevention, CAUTI-engaged physicians and leadership; Todd will then focus on a CAUTI cost calculator that we've been working on for the last several months, and then I'll end with a brief discussion about future directions, and then we can open it up to questions and answers.

So, first in terms of healthcare-associated infection, just some general background and I think this will be familiar to most of you. Importantly, we know that healthcare-associated infection is a common costly and morbid patient safety problem and that the most conservative estimates are that at least 20 percent of episodes could be prevented if evidence-based practices are used. More recent data have revealed that perhaps as much as 70 percent of episodes could be prevented. Unfortunately, preventative practices are variably used across the United States. Some hospitals are doing everything they should be doing to prevent infections; others are doing very few, most are somewhere in between. And infections due to devices, such as urinary catheters or vascular catheters, are especially common and especially preventable. But as all of you know, implementing change within hospitals and within specific units is not for the faint of heart. It can often be very challenging in large part based because of what Peter Drucker, the late great Peter Drucker, who is the father of modern management studies, has written. And that is the hospital is the most complex human organization ever devised. And perhaps because of this complexity, hospitals and health care workers still are struggling with some basic infection prevention activities, such as hand hygiene. In this systematic review of almost 100 studies, the overall medium compliance was 40 percent; low rates in physicians rather than nurses and lower rates before patient contact rather than after patient contact. And given this gap between what should be done and what is done, there has been recent emergence of a new field, and that's known as "implementation science," defined as the scientific study of methods to promote the systematic uptake of research findings into routine practice. One way of conceptualizing implementation is to break it into two silos, both of which are equally important; the technical and the socio-adaptive. The technical will include the specific practices that should be implemented that have been shown in studies to prevent infection; in this particular case, catheter-associated urinary tract infection, the precise definitions and measurement issues. But equally important are the socio-adaptive components of the implementation, which would include the context, the culture, behavior, and dealing with the people issue; engaging frontline clinicians, middle level managers, and senior executives. We'll take these one at a time.

Focusing on urinary tract catheter-associated infection, we know that UTI is a common cause of hospital imparted infection; most of these infections are due to urinary catheters. Depending on the patient population in the study, up to 25 percent of in-patients are catheterized sometime during their stay. And we also know that CAUTI leads to increased morbidity and increased health care costs. Todd will talk a little bit more about the health care costs later in the talk. These are hard outcomes, but what about softer outcomes? What do patients actually think about having a latex or silicone shoe put into their bladder? Well, we asked 100 catheterized VA patients exactly this question, and this is what the Vets told us: 42 percent found the indwelling catheter to be uncomfortable; 48 percent stated that it was painful; 61 percent noted that it restricted their activities of daily living; and 2 Vets provided the type of unsolicited comments that veterans sometimes say, and that is that their catheter hurt a lot. And we were, frankly, not that surprised by the discomfort and pain associated with urinary catheter; that makes sense. But we were struck by the extent to which this commonly used device is put in patients and will restrict their activities of daily living; thereby, preventing them from getting out of bed and getting ready to be discharged. And, therefore, perhaps even leading to other hospital required conditions, such as pressure sore and de-conditioning and falls. So, just as there has been a successful initiative over the last decade or two that has reduced the use of physical or four-point restraints, there is now a successful, reasonably successful, movement towards reducing the use of indwelling catheters, which I don't think it's an overstatement to start thinking of it as a one-point restraint; strategically placed, but essentially tethers patients to the bed.

Focusing on the technical, how can we disrupt the life cycle of a urinary catheter? There are four steps in the life cycle of the catheter; insertion, maintenance, removal, and replacement. And each of these are targets for intervention. The first is preventing unnecessary placement, especially in the Emergency Department, and once the decision is made that a patient really needs a Foley, it should be done using proper aseptic technique. If a Foley catheter is inserted, there should be situational awareness and proper maintenance, keeping the drainage bag below the bladder in order to prevent reflux, and using good hand hygiene whenever manipulation of the drainage bag or the catheter as necessary.

The third part of the life cycle, which has been the initial focus of the national initiative to stop CAUTI, has been prompt catheter removal somehow, whether it's nurse initiated, removal protocol, computerized reminder, written reminder, pre-existing stop orders, whatever it may be, but rather than relying upon the memories of overworked health care workers, we want to systemize this to the extent we can. And then once removed, we should avoid just putting the catheter back in, unless the patient really needs it. Part of the reason the national team focused initially on early catheter removal is because this is where the bulk of data resides in terms of preventing CAUTI. In this meta-analysis published a few years ago by Jennifer Metting and others, they reported that of the 14 studies that have evaluated urinary catheter reminders and stop orders, whether they be written, computerized, or nurse initiated, the pool result was that there was a significant reduction in catheter use of about two and a half days; a significant reduction in infection by about 50 percent. Unfortunately, no evidence of harm. The caveat here, there's only a sub-set of about four studies that looked at harm, which was reinsertion, but in those four studies, there was no significant increase of reinsertion rates. Unfortunately, even though early catheter removal would prevent catheter-associated urinary tract infection as well as non-infectious complications associated with a Foley, a minority of hospitals are using urinary catheter reminders or stop orders. In 2005, it was one in 10; 2009, it was one in five. We have a survey that we sent out a few weeks ago to see if that's changed in 2013, but one of the challenges is: How can we take something like a urinary catheter reminder and spread it across the country? Because it seems like it should be a no-brainer.

So, I'll tell you what we've done first at home, at the Ann Arbor VA, and then across the State of Michigan, because I think there are potentially some lessons that could be helpful as you're in the midst of tackling this important problem in your unit and your hospital. First, in terms of implementing change at home; the Ann Arbor VA is one of about 150 VA hospitals. The VA, as most of you know, is the largest integrated health care system in the United States, and one of the largest integrated health care systems in the world. The VA is also very much focused on systems redesign and quality improvement. What we did is we turned one of our four medicine services into a behavioral laboratory so we could test things out, focusing on nurse/physician communication, for example, to see if it works and then spread it throughout, not just our hospital, but then the other seven hospitals in our region. One of the focus areas was on catheter-associated urinary tract infection prevention, using a nurse initiated reminder, taking advantage of the state of the ER electronic medical record system that the VA has had in place since the mid 1990's. And the key intervention here is that every shift, the nurse documents whether or not the patient has an indwelling catheter and what the appropriate indication is for the indwelling catheter, and the indications were taken from the HICPAC 2009 guideline co-authored by Carolyn Gould and David Pegues and others who are involved in this project. If the patient has a Foley and does not meet an appropriate CDC criteria, then the physician is contacted to see if the urinary catheter can be removed. And what we found over the span of our intervention is that inappropriate indications for Foley's have gone down to less than 5 percent and have remained low for several months. CAUTI rates have decreased by 40 percent after the initiative and this will be published in Infection [Inaudible 00:14:31] Epidemiology in the next several months. We've also done similar work across the State of Michigan that I'll share with you. Specifically, this work has been led to Ross Olmsted, Sam Watson, Chris George, Mohamad Fakih, and others. The Keystone Centers CAUTI initiative has been dubbed the "bladder bundle." And the study period was the four years between 2007 and 2010. There were over 70 hospitals participating in the State of Michigan and, again, the focus was a nurse-led catheter discontinuation protocol, based on the successful work that Mohamad Fakih piloted in his hospital in St. Johns in Detroit, Michigan. And in two papers published over the last couple of years in Archives in Internal Medicine, which is now known as JAM internal medicine, we found that in the State of Michigan, there was a 25 percent relative decrease in catheter usage during this time. The 30 percent relative increase in appropriate catheterization, and then looking at actual CAUTI rates, we partnered with the CDC and the NHSN, and found that CAUTI rates decreased by 25 percent in Michigan hospitals during this time, compared to a decrease of only 6 percent in non-Michigan hospitals, which was a statistically significant greater decrease in Michigan hospitals compared to non-Michigan hospitals. And in data that haven't been published yet but provided to us by the CDC, when continued looking at this data using the standardized infection ratio that this trend has continued in the State of Michigan. The big caveat here is that there's only a relative small number of Michigan hospitals in this data set, and it'll be interesting to see what happens when more hospitals report. What I can tell you, based on our work, both at home as well as in the State of Michigan, and we actually had funding from the NIH to visit the hospitals that were successful, those that struggled, and have also worked with a few hospitals that are trying to improve. There are several lessons. And the first lesson that, hopefully, will have implications for all of you, not just in your CAUTI work, but in your quality improvement work in general is that a key ingredient for success is figuring out how to engage the clinicians in the hospital. And by clinicians, I'm talking about both docs and nurses. And even though my comments will focus primarily on CAUTI, we've used CAUTI really as a portal into which we can view the functioning of a hospital, because how a hospital deals with an endemic kind of low tack, not a very sexy problem, like CAUTI, says quite a bit about how that hospital deals with other similar endemic problems, such as falls, pressure sores, delirium, contrast induced nephropathy; all the types of things that our patients get, but would rather avoid while they're being hospitalized. So, as I discuss some of these lessons, think, both how they can apply to your work in CAUTI, but also beyond.

So, let's focus on the issue of engaging clinicians. And first, we engage clinicians by starting with a plan, and this is the six-point pan; again, it can be modified, and I know many of you have already worked through your own plans. I can tell you the plans that seem to work well at our hospital and others follow this script, and that is: Form a CAUTI prevention team that consists of various key people with one person identified as the team leader. I'll give you a table in a few minutes that shows the roles and responsibilities and examples of the types of individuals to consider. Second, this team should look at the CAUTI policy for the institution. If there is not a CAUTI policy, one should be developed. And the basics should be covered, including when do you use a Foley, what are the indications, and making sure that there will be an availability of condom catheters and bladder scanners, which will, hopefully, help clinicians avoid the use of the Foley. Third, once the CAUTI policy has been approved by the governing bodies of your hospital, usually you pick a unit where to begin, and, hopefully, it'll be a unit that you think will be successful since nothing succeeds like success and you want to have an early success to begin, which will then build momentum. And another thing that would be useful is pick a place where there's a lot of catheters being used. The fourth is that we should anticipate barriers. As I'll get into within CAUTI, nursing resistance is a barrier; physician resistance, patient and family requests for a catheter are barriers, but all can be overcome. Fifth, we should track performance, both process measures, which would include urinary catheter usage as well as rates of appropriate and inappropriate urinary catheter usage as well as outcome measures, actual CAUTI rates. And based upon the performance, we should escalate the intervention as necessary, as I'll get into later on in the talk in terms of when do you do focused reviews or mini root cause analyses? When do you ensure that patients who have catheters inserted are only having those catheters inserted by people who have documented competency in the insertion process. They are both much more time-consuming, but we should have at least given some thoughts to when that's necessary. And then sixth and finally, once there's initial success, at that point, it can be spread to other places, either other units in the hospital, in patient units, the Emergency Department, the Operating Room, or if you're part of one hospital in a larger health system, like so many of us are, to other hospitals in your system.

So, this is the table I briefly mentioned of key roles and responsibilities of the types of people who make the examples to consider and particular roles. I'll go through these very briefly. And this was actually prepared by Sarah Krein and others, who are part of our group here at the University of Michigan, and Sarah's also a member of the National Leadership team. There needs to be a project coordinator or project leader or project manager who puts forward an agenda and keeps people on task and comes with action items and makes sure those things are done. There are many different types of people who can do this. There needs to be a nurse champion for sure. Many different examples of nurse educator, in one hospital; it was very successful, but unit managers, charge nurses, and at our hospital, the Ann Arbor VA, the nurse champion was the staff nurse on the [Inaudible 00:22:18] unit. There should be a physician champion who can engage medical personnel; i.e., doc, hospitalist, hospital epidemiologist, neurologist, and I'll give you some more data about that in a moment. And then someone on the team should be charged with data collection and monitoring it, reporting it. Usually there's someone already doing it, and that person should then be brought on to this team and often that's someone within infection prevention or quality. First, in terms of physicians, and I want to give credit to Dr. Fakih, who prepared several of these following slides, which I've modified.  Speaking as an epidemiologist, I'm going to make some generalizations, and that is physicians play a significant role in shaping the care in the hospital. We tend to be fairly autonomous, and we may not be employed by the hospital; therefore, there may not be a lot of leverage that C suite has over us. And docs are primarily interested in treating illness; that's why we become docs and what we learn in medical school and we're usually not trying to focus on improving safety and preventing harm. That's, fortunately, changing now, but I think, in general, the focus has been on treatment as opposed to prevention. And many physicians are unaware of the safety effort in the hospital, and most have limited time to volunteer for supporting the safety agenda. And, unfortunately, change may not be readily embraced. So, how do we overcome some of these issues? Well, James Rinertson, who is a physician, as well as a former CEO wrote a white paper on this for IHI, which brought up five points. I think they're very appropriate, not just for prevention of CAUTI, but I think for other quality improvement initiatives in which a physician needs to be engaged. And that is we should develop a common purpose, focusing on patient safety, for example, or when talking to hospitalists about efficiency. We should view physicians as partners rather than barriers and identify possible champions early in the process. We should standardize evidence-based processes to the extent we can with the key word here being "evidence-based." Physicians will want to see data to make sure that what the interventions that are being proposed actually have good data behind them, and that authoritative bodies, such as the CDC or professional societies, actually also recommend the use of these practices in their guidelines. And we should provide support for leadership for the efforts of the physician champion, given that that's not extra pay, which is often challenging. In our place, we have a physician champion award in which we give a $200 gift certificate to a physician, front line doc, who has taken a very active role in some of the quality improvement activities at our hospital. Another way of overcoming resistance when dealing with docs is to find a member of the tribe. A chief of staff and a surgeon told us, "Surgeons are very tribal. So, what you need to do, if you have something that you think is a best practice at your hospital, you need to get either the chair of surgery or some reasonable surgeon. If you come in and you're an internist, into a group of surgeons, the first thing we're going to do is we're going to say, "Look, you're not one of us. The way to get buy-in from surgeons is you've got to have a surgeon on your team." This isn't always the case. I think that there are many people who can speak to specialists, not in their own particular area, but I think that if you are meeting resistance, this is an approach to at least consider. And there are many different types of physicians who will support the physician champion, and I'll go through these briefly. So, and this is Mohamad's slide as well, what he's done is that he's listed various specialties and reasons why they may be interested in preventing CAUTI. So, this is a reason why they may then decide to be the physician champion or you can enlist them to help a physician champion. I'll just go through a few of these. ID docs makes a lot of sense, given the importance of CAUTI, and a lot of these patients get treated with antibiotics and antibiotic use and Clostridium difficile infection, of course, are important problems. Hospitalists increasingly are being seen in U.S. hospitals; over about two-thirds or more of you at hospitals have hospitalists and often they are there in order to improve quality, safety, and efficiency for the hospitalized patient. And hospitals, of course, would be very much focused on preventing illness, not just treating it, and can also be helpful in highlighting both the infectious and mechanical complications of the urinary catheter. A urologist makes a lot of sense for obvious reasons, and for geriatricians, a lot of the people who get urinary catheters are the elderly; they're frail, and geriatricians are aware of the issues of reduction of mobility and the types of problems that would then ensue. But in addition to these rehabilitation specialists, intensivists, surgeons, and emergency medicine physicians, all have compelling reasons why they could become the champion or the co-champion or at least supportive of the physician champion as listed on this slide.

Let me turn my attention now to nurses. How do we engage nurses? That's very similar to the five points I've already discussed. We should develop a common purpose, and here the focus is more on safety than efficiency. We should view nurses as partners, not barriers, identify nurse champions early. We should standardize evidence-based processes. I think the keyword here is "standardization," so that we make the right thing to do, the easy thing to do, because workload for nurses will be a big issue, as I'll discuss in a moment. And we should, similar to what I've discussed with physicians, provide support from leadership for the efforts of the nurse champion. Returning to the issue of nurse workload, nursing workload can be an issue, and we've heard this in many of the sites where we visited. One nurse told us, "Convenience, unfortunately, is a high priority, especially with urinary catheters. The workload will be increased if you have to take patients to the bathroom or you have to change their bed a little more often." Nurse buy-in, therefore, is key to success. In fact, while I think having a physician champion is helpful, having a nurse champion is absolutely crucial. Hard to imagine that this would be successful without having an effective and committed nurse champion. As one physician administrator told us, "Because the nurses on the geriatric unit wanted to have their patients regain mobility, they viewed mobility as very important versus the other units where the nurses didn't necessarily feel that was a real goal." So, often the nurses can focus, not jus on CAUTI, but also on mobility or some of the non-infectious problems with putting in a Foley. So, a nurse champion is critically important. And speaking of champions, how do we identify who the right champion is? Well, Laura Damschroeder has published work on this and has discovered that successful champions tend to be intrinsically motivated and enthusiastic about the practices they promote. For example, one champion told us, and this was not a physician, "I have a certain stature in this hospital. People know that I'm very passionate about patient care. So, I get positive reinforcement from them. They're happy to see me because they know that I'm thinking about what's best for the patient." And I suspect that each of you in your respective hospitals and units, you know who the go-to people are. If there was a project, you know who you would want to help kind of lead it from a nursing perspective, even if, for example, the exact topic area is not in their area of expertise. And it's based on who these people are and the type of reputations they've developed. From a physician side, we know who the go-to docs are. I assume that's the case in every discipline within the hospital.

So, we talked about implementation and CAUTI prevention; we then, I spent some time talking about engaging clinicians; I'd now like to talk about leadership engagement, which clearly can help. Within this particular domain of CAUTI, the key senior leaders in preventing CAUTI tend to be the chief nursing officer and the chief medical officer. They'll go by different names in different organizations, but it's basically the top nurse and the top doc. Having said that, other leaders are also important, depending on the hospital. The unit managers and the unit chiefs, service line chiefs, like chief of medicine, chief of surgery, the hospital epidemiologist, and infection prevention also play crucial roles. What we found in our qualitative work where we made phone interviews and site visits of various facilities, some that were doing very well, some not so well, is that there were four key behaviors that effective prevention leaders tended to demonstrate. I'd like to share these with you. And this would be true, not just of C suite members, but also some of the key leaders that I mentioned; mid-level managers and the hospital epidemiologist and the lead infection preventionist as well. First, they tended to cultivate a culture of clinical excellence. They developed a clear vision and they conveyed that to staff. Second, they tended to be inspiring. They motivated and energized followers, and while some were charismatically challenged, they were the type of individual who, through their actions, garnered a great deal of respect from their peers and colleagues, because they did the right thing and people knew that they had the patience; best interest always at the forefront. These are also the type of people who would say that our goal is to be the safest hospital in the country and ask questions when faced with a dilemma, such as, well, if this were my family member, is this what I would want to happen, and, therefore, we should do it for this patient. So, they tended to focus on these kind of transformational approaches to leadership in terms of clinical excellence and being inspirational, but they were also highly transactional and that they were solution-oriented rather than complaining about barriers, and we all face barriers, they focus on overcoming those barriers. And when there was a resistance staff, whether it was a doc, nurse, or someone else, they dealt with that person rather than avoiding having those challenging conversations, and people noticed that they would take some of these tough issues head-on and that they were successful, then again that would build momentum for success. and then fourth, they thought strategically while acting locally. There was a wonderful anecdote from a chief of medicine at a hospital who told us that whenever there was a major committee vote that would come up in the governing body of his particular hospital and it was something that he wanted to put forward, he would always do the politicking ahead of time. He knew he had the votes. If he didn't have the votes and he would talk to the key people. the chief nurse, chief of surgery, a few others, if he didn't have the votes from the key players ahead of time, he wouldn't even bring the issue up until he got the key votes, because he knew that if it went up for a vote and it was unsuccessful, that would set the process back several months and now it would have the allure of failure rather than success. And one important way to engage the leaders at your hospital is by showing them that you have a good plan. Most leaders know the importance of prevention infection, in general, and CAUTI, in particular, so that I think they will be grateful that people have come up with a way to approach it, and that good plan is the one we've already gone over; the six point approach. Another way to engage leaders at your hospital is by showing them that you have a good Plan B. No battle plan ever survives as a war is what general say, and no quality improvement project goes off without a hitch. There's always going to be some changes. And I think it's important as you present your ideas to leaders in order to get their buy-in is to show them that you thought about these things.

And this slide is what our seven hospital regional VA health system, known as the Vizon 11, or VA Integrated Service Network, has done to focus on CAUTI prevention. Tier one are all the things that we think should happen all the time, and that is assessing for the necessity of urinary catheter use, using that nursing template that I showed you, encouraging the use of alternatives to the indwelling catheter, condom catheter, straight catheterization, bladder scanner, using a standard indwelling urinary catheter kit that has a pretty sealed junction and a securement device, using proper insertion technique, follow maintenance and removal approaches, and then measuring CAUTI rates. And if, however, the CAUTI rates go above a certain amount, at that point, you go to Plan B, which is the tier two protocol, which are enhanced practices that are much more time-consuming, where you would assess and then document the competency of health care workers performing the insertion. Of course, it's going to be much more time-consuming, but this is what will be necessary, because perhaps the people who are trained on how to put in the catheter during nursing school may not be doing it correctly now, five, 10, 15, 20 years later. And second, consider root cause analysis or focus review of every CAUTI, or inappropriate catheter use event to identify further improvement opportunities. Re-measure and then see if your rates go back to an acceptable range. A third way to engage leaders is by considering sustainability at the outset. Leaders don't want this to be just a one year, two year project; they will support it and they want this to actually have legs and continue for the foreseeable future. So, I think talking to them about sustainability can be very helpful.

And for the following slides, I'd like to give great credit to Mohamad Fakih and Sarah Krein, since they also gave a recent talk on sustainability, so I'm just going to focus on some of the highlights, because I think it's important to think about this, especially where most of you likely will be, and that's kind of in the midst of your project. So, what is sustainability? Well, it's when desired health benefits are maintained or improved. Innovation, and in this case, it would be CAUTI intervention, but it could also apply to CLABSI prevention or VAT prevention. It loses its separate identity and becomes part of the regular activities of the unit or hospital. It becomes institutionalized. There are three key factors that influence sustainability. We'll take these one at a time.

The first is this integration with existing programs and services. Once the initiative becomes part of the standard of care, either in the hospital or that particular unit, then it becomes institutionalized. You could always change things, based on new evidence, but the bulk of the intervention is part of standard of care. That should always be the goal. And the way this gets done is really trying to rootinize it and integrate it, making sure that it aligns with the organizational goals, that it's part of the regular education and competency. So, for example, if there's a nursing blitz that occurs yearly, having people demonstrate urinary catheter insertion competence is something that could be integrated within that nursing blitz, that it becomes part of the daily routine for nurses and docs, can also be very valuable using either electronic reminders or nursing templates, as I've shown you. And also, it'll be helpful if you could show how the work that you're doing will be synergistic with other initiatives. And right now, there's initiative overload. We're trying to prevent all these different types of hospital acquired conditions as part of the health care engagement networks and other types of programs. And one way of doing this is by saying that we're focusing on the Foley, not just because it will have a beneficial impact on CAUTI, but it also will, hopefully, affect patient discomfort. It will improve issues related to mobility. It'll prevent pressure ulcers. And because of the immobility issues, it will also address falls and amniosomnambulism; two other important hospital acquired conditions.

The second key factor in sustainability is who the project managers and the champions are. These people have already been identified and, hopefully, they keep the effort as a priority by continuing to serve as local experts on this particular area, and, hopefully, will lay it on with other peers, and so they're the CAUTI go-to people, and if there's a success in this project, these are the types of people who would then disseminate the findings, either through conference calls, webinars, posters, and peer review publications.

And then finally, a factor that influences sustainability is periodic evaluation and feedback. And this how we just make sure that people are continuing to be vigilant and mindful about the urinary catheter by giving units point prevalence with or without appropriate use, proper insertion technique audits are done, and maintenance of the urinary catheter audits are don., and then focusing on outcome rates, such as symptomatic infections.

And a final way to engage leaders is to discuss money with them. And for this, I'll turn it over to Todd, who will talk about a cost calculator.

Todd Green: Thank you, Sanjay, and hello, everyone. We all know healthcare-associated infections lead to increased morbodity and mortality and certainly cost. And CAUTI being one of the most common healthcare-associated infections is also deemed reasonably preventable by the Centers for Medicare and Medicaid Services, who in October of 2008 decided to stop reimbursements to hospitals for additional cost caring for patients that developed CAUTI the hospitalization. That has become increasingly important to consider cost in the equation of trying to engage facilities in CAUTI prevention work. So, what we had built, and I'll preface this by saying it was myself and Sanjay as well as Edward Kennedy, who's no longer with us at the University of Michigan and has moved on to his current studies at the University of Pennsylvania. We developed a simple cost calculator that, hopefully, will help motivate hospitals to reduce inappropriate urinary catheter use by providing a tool that estimates both current cost of caring for individuals with CAUTI, but will also yield and project the cost after a hypothetical intervention to prevent these infections. Importantly, we have an online implementation that is available at our website, catheterout.org, and I'll show you come of a couple of snapshots from that interface in a few moments.

To start with the general set-up, we start with four possible events that occur after urinary catheter placement. First is bacteria area. The second, symptomatic urinary tract infection; third, bloodstream infection, and then fourth and finally, catheter removal. So, as part of that, we have five possible patient trajectories. The first one, which is no infection; second, only bacteria area, only symptomatic UTI, only bloodstream infection, and then both symptomatic UTI and bloodstream infection.

The figure here illustrates, there's a bit of a lag in advancing slides here, so one moment. Here we go. Shows the trajectories a little more simplistically, and it should be noted that for trajectories three, four, and five, bacteria must recede all three of those. In terms of developing cost per patient for each of these trajectories, we simply multiple the number of patients experiencing each of those trajectories by relative cost that we get from the literature. There's a couple of simplifying assumptions before we set this up to arrive at current cost; first of which is the cost incurred or not incurred of cost for those trajectories, or this assumption should only bias cost estimates conservatively. The second simplifying assumption that we employ is that symptomatic UTI and BSI costs are added in for patients that have both trajectory five, both count as equal; the sum of patients with just one or the other. So, under these two simplifying assumptions, we can write the equation here and that total CAUTI cost will then be equal to the per patient symptomatic UTI cost multiplied by the number with symptomatic UTI in addition to the per patient bloodstream infection costs multiplied by the number with BSI. And we utilized estimates from some costing techniques that Sanjay had published, which a number of years ago adjusted for inflation, using the general consumer price index, and the per patient cost is about $900 to treat for those with symptomatic UTI, and about $3800 for those with bloodstream infection. So, it should be noted that the number with symptomatic UTI or bloodstream infection equals the total number of patients hospitalized. I'll show later the user to find input in terms of our interface, multiplied by the portion with symptomatic UTI or separately rather with bloodstream infection; Wherein, proportion of those with symptomatic UTI is defined as symptomatic UTI risk among those catheterized with bacteria, which from the literature, is estimated at about 24 percent multiplied by bacteria risk among those catheterized, which the overall risk is about 26 percent; the per day risk amount those patients catheterized has been shown at about 5 percent. Finally, multiplied by the proportion catheterized, which is the second user input that is hospital-specific.

So, that set-up will then get, at the current cost, which I'll show in a moment, but then to get at a post-intervention cost estimation, we looked at interventions that would reduce CAUTI risk through (a) reducing catheter placement. So, in other words, a proportion catheterized. And secondly, reducing the duration, so the mean duration of catheterization per patient. And then the post-intervention risk of bacteria becomes a function of simply the decreased mean duration due to intervention and the pre-intervention risk of bacteria among those catheterized.

So, as you see, as I show you the interface here in a moment, the post-intervention cost will then be characterized as a function of the user specified quantities, which are two, and then quantities are specific to the intervention. One of the interfaces will show that there's a plausible range of that, and the estimates from the literature will show that successful interventions have been shown to lead to 37 percent reductions in the duration as well as 29 percent reductions in catheter placement.

So, this slide here is a snapshot of the interface itself, which is again available at catheterout.org. And, as we go to that, if you navigate to that, you'll see that there's a default page, which I show here, and under the first entry there is the approximate number of annual adult hospital admissions, which is default set to 3,000, and then the percent of adult hospitalized patients with catheter on any given day. So essentially, the point prevalence of urinary catheters, which is defaulted here, as 15 percent. And then submitting that, we get to the output that is shown here below. And on the left, based on those default values, we have current estimated cost of about $42,000, and then again, based on prior interventions that are shown at 37 percent decrease in duration as well as the 29 percent decrease in placement, we show that there is a projected cost after interventions of about $21,000. So, our projected savings of about $21,000 represents the relative reduction of about 51 percent. And on the right side, we've used a delta method to get at the error terms around that, and then using sort of a composite measure of both reducing both duration and placement to get a percent decrease in catheter use. The right side of the graphic here displays a range of potential savings.

The next slide just shows that it's easily modifiable. So, just increasing the number of annual adult hospital admissions to 35,000 and reducing the percent of catheter prevalent to 10 percent. You can see that it has a far greater reach clearly as a number of admissions go up with current costs and then the projected cost after intervention become more substantial, even though the prevalence is lower.

There are a couple of caveats that bear mentioning. First of all, we require users to have input estimates for those two simple points. So, the total number of annual admissions and then catheter prevalence on any given day. Importantly, the projected cost and potential savings do not consider a full range of cost factors. As I noted, the first two trajectories were largely representative of those with either no infection or asymptomatic infection. They're not accounted for. And the cost of intervention to implement that is also not folded in here as our opportunity costs are not as well. But I think despite these limitations, we believe that this tool can help infection control, professional demonstrate the value of CAUTI prevention efforts to key administrators and those in the C suite, particularly at a time when it's becoming increasingly necessary to develop a business case to either initiate new CAUTI prevention interventions or justify the continued support or for ongoing programs.

We have submitted a manuscript based on this work to the Journal of Hospital Medicine, and in that, we have an appendix that sort of lays out the method that supports this. And as far as the interface goes, we're working to modify that a bit so that we can tease out what the potential savings would be, if facilities focused on facility reducing catheter duration or who are more focused on reducing placement so that we could see how that might break down separately rather than as a composite.

Sanjay Saint: All right. Thank you, Todd. Wonderful. I'd like to now to finish up with talking about some future directions by focusing on the issue of a troubleshooting guide. So, again, I suspect the majority of you are right in the midst of your project. You got either early success or you may be having some challenges, and so what we've tried to do is prepare something that could be useful for you to at least start a conversation with your team or do some type of a self-assessment. In terms of background about this is that over the last decade or so, we've been trying to address the fundamental question of why some hospitals in the United States are better than other in preventing infection. Why is it that some hospitals are doing everything they should be doing to prevent three common device associated infections; CAUTI, CLABSI, and VAT, others are doing very few of those types of things. And our work's been funded by various federal agencies where we've done phone interviews and site visits to hospitals across the United States from Maine to California, and we've interviewed people at various levels at the hospital, from CEO to frontline nurse and doc. We completed about 200 formal interviews, and we've also done about a half dozen informal site visits as well, so we're probably interviewed almost 300 people, and we're currently helping people in the European Union do a similar type of study there. But what we can say is that to do this type of qualitative work well, it is a ton of work and it's not practical to go in and visit the 5,000 or so U.S. hospitals to try to figure out what's working well and what isn't. So, what we're piloting now is a new approach to, hopefully, omit the need for site visits that could then be used by sites for self-assessment. And we call this the "CAUTI guide to patient safety" or a "CAUTI GPS," which will be available online once it's nearly finalized so that it would help you identify what's going well, what isn't, and then give you, hopefully, approaches to problems in your own facility, based on what other facilities have done to overcome similar problems.

Let me go through this 10 item troubleshooting guide, and these are really "yes" or "no" questions. If you answer "no" to these, then it would take you then to a link that will give you some guidance of how to overcome these problems. The first is: Do you currently have a well-functioning team focusing on CAUTI prevention? People can decide what "well-functioning" means. We didn't want to define it for folks, but, for example, if you're having trouble at your facility on CAUTI and you give this questionnaire to people on the unit, members of the team, the C suite and you're getting a sense that the perception is that there is not a well-functioning team, that can help you focus your attention.

The second: Do you have a dedicated project manager to coordinate your CAUTI prevention activities?

Third: Do you have an effective nurse champion for your CAUTI prevention activities? I already underscored the importance of having an effective nurse champion.

Fourth: Do bedside nurses assess at least daily whether their catheterized patients still need a urinary catheter? It is a key part of our intervention.

Fifth: Do beside nurses ensure the Foley is removed when no longer needed by contacting the physician or removing the catheter per protocol?

Six: Do you have an effective physician champion for your CAUTI prevention activities?

Seven: Have physicians fully embraced CAUTI prevention activities?

Eight: Has senior leadership fully supported CAUTI prevention activities?

Nine: Do you currently collect CAUTI related data, catheter prevalence, and appropriateness or CAUTI rates in the units in which you are intervening?

And as a follow-up to this, do you feed that information back to the individual units?

And then finally, we end with: Have you experienced any of the following barriers? And if the answer here would be "yes," then it would take you to ways, approaches to overcoming these barriers; substantial nursing resistance, substantial physician resistance, patient and family request for a Foley, and then Foley's commonly being inserted in the Emergency Department without an appropriate indication.

So, what we've done over the last 60 minutes is we've talked about implementation and the emerging field of implementation science going from evidence-based practices into real life can be challenging. We focused our remarks on CAUTI prevention, but, hopefully, much of what we've discussed will go beyond just CAUTI and help you with your other quality improvement activities. This includes the importance of engaging clinicians, both nurses as well as physicians, engaging leaders from the C suite to middle level management. We talked about the CAUTI cost, CAUTI calculator, that you may find useful in providing a business case to your leaders about how much CAUTI may cost your particular hospital. And you should know that we took very conservative estimates of the cost. And then we ended with a discussion of future directions, specifically a self-assessment tool or a CAUTI GPS, something that you could use at your site to engage in conversation if things aren't going as well as you'd like it to go.

So, I'd like to thank you for your attention and we've left almost 15 minutes for questions and discussion.

Mari Franks: Great. Thank you so much, Sanjay and Todd. Chantelle, can you go ahead and open the line up for answer and Q&A?

Operator: Thank you very much. Ladies and gentlemen, at this time we would like to open the floor for questions. If you would like to ask a question, please press "star one" on your touchtone phone now. Questions will be taken in the order in which they are received. If at any time you would like to remove yourself from the questioning queue, please press "star two." Once again, if you would like to ask a question, please press "star one" on your Touchtone phone now. Our first question will come from Kathy Mahoney, Bay State Health.

Kathy Mahoney: Yes hi. I have two questions. The first one is a very quick one. If you could repeat the reference, the reference was given to clinical indications by Gould in 2009. Do you have that full reference available?

Sanjay Saint: Sure, Kathy. It was the HICPAC guidelines, H-I-C-P-A-C, and it's on the CDC website.

Kathy Mahoney: Okay.

Sanjay Saint: And it comes from the National Healthcare Safety Network or NHSN, and it's the 2009 CAUTI prevention guidelines. The first author, last name is Gould, G-O-U-L-D, first name is Carolyn, and then the senior author or last author is David Pegues, as part of our national leadership team. And if you have any trouble finding it, if you just send me an email at saint, S-A-I-N-T, @umich, U-M-I-C-H, .edu, I can send you the link.

Kathy Mahoney: Okay. I think I've seen it once before, but I didn't get the full name in the audio. Thank you very much. I have another question, which is maybe a little bit more involved, and that was: Can you comment on the use of various types of catheters and whether you feel there's a difference? And what you might use? For example, do you use antibiotic impregnated catheters? Do you use silver impregnated latex? Do you use silicone? If you could comment on that.

Sanjay Saint: Yep, sure, Kathy. Yeah, that is more complicated. Let me tell you the evidence behind some of these catheters; some have been subjected to rigorous evaluation, some of them have not. The initial studies with antimicrobial catheters, whether they be silver alloy catheters or nitrogen purizone releasing catheters, and I'm going to lump those together as antimicrobial so that these catheters reduced bacteruia, which is most often asymptomatic, but it was unclear whether or not they reduce the clinically more important outcome, that being symptomatic UTI. And given the excess cost of these catheters, the incremental cost is about $5 or so per tray more than a non-coated comparable catheter. It was recommended that these catheters only be used in patients at very high risk for infection or when CAUTI rates at a particular hospital are not going down despite all the other practices. That, however, I would say changed in November, 2012 when the Lancet published a cluster randomized study of over 20 hospitals in the United Kingdom where hospitals were randomized to silver alloy, nitrogen purizone releasing, or a non-coated catheter. And what they found was that there was no significant difference in symptomatic UTI between the silver alloy group or the non-coated catheter, and the non-coated catheter is teflonized catheter. Between nitrogen purizone releasing versus the non-coated catheter, there was kind of barely statistical significant decrease, but it wasn't a clinically significant decrease per the authors. And, in fact, the makers of the nitrogen purizone releasing catheter after that, they decided to no longer manufacture that catheter and market it in the United States. So, now the recommendation would be to not use antimicrobial catheters unless there's other studies that come out that show a significant difference. In terms of the latex versus silicone question, this is an important question, given the concerns about latex allergy. We, at our place, at the Ann Arbor VA, we actually use a latex catheter, not a silicone catheter. When we tried using the silicone catheter, we have them available for patients who have latex allergies; the issue has not been so much catheter associated urinary tract infection; the issue has been something known as "ridging." When the balloon is deflated and, therefore, the catheter is being removed, for some reason, the balloon doesn't inflate entirely and that it causes some trauma and discomfort at the time of catheter removal and it tends to be seen with the silicone catheters, not the latex catheters. In terms of size, we use a 16 French; we use something where there's a pre-sealed junction, and we also use a securement device primarily to prevent trauma and those types of things. Did that adequately address your question, Kathy?

Kathy Mahoney: Yes, that's great. Thank you so much. That was very helpful.

Sanjay Saint: Sure.

Operator: Thank you. Once again, as a quick reminder, if you would like to ask a question, please press "star one" on your touchtone phone now.

Mari Franks: Great. Thanks, Chantelle. And while we're waiting for a few additional questions, I want to bring your attention to the screen. Again, my colleague, Paul Tedrick, has posted the evaluation for today's content call in the discussion area; in addition, it is on the slide presented at this time.

Operator: Thank you. Again, as a reminder, to ask a question, you may press "star one" on your Touchtone phone now.

Mari Franks: Great. And while we're waiting for other questions, Sanjay or Todd, do you have any additional thoughts or closing comments you want to provide the group before we conclude today's webinar?

Sanjay Saint: Sure, Mari. Let me just kind of just add one other additional piece of information that I didn't have time to go into, and then I'll make some closing comments. And that is this whole issue of alternatives. I mean, Kathy's question about alternative Foley's was an excellent one. One of the alternative devices that could be useful in men are condom catheters, The condom catheters that many of us are familiar with tended to be condom catheters that did not stay one, and so, therefore, there is this reluctance to use those condom catheters. Some of them are these Texas style catheters that have a latex kind of condom style catheter within a Velcro band and, if you do it too tight, it leads to penile ischemia; too loose, it falls off, and it's useless. But increasingly there are condom catheters that come in several different sizes; hopefully, one will actually work. And silicone, see-through, so you can see the patient's meatus every day in order to avoid abrasions. The adhesive device is part of the condom catheter and it can stay on, even under moist conditions. So, it's something that should be considered, given that there is some evidence that condom catheters, when used in appropriate patients, specifically, men who do not have bladder output obstruction, leads to decreased infections as well as improved satisfaction. Men tend to prefer the condom catheter to the indwelling catheter. So, that's one area to kind of consider. I guess the final thing I would say is perhaps the most important part of this initiative is ensuring that every day, preferably every shift, that the bedside nurse is mindful about the fact, does this patient still need a Foley. if the patient still needs the Foley, then it should remain because there's many indications for a Foley. But if it's there initially for appropriate reasons, and this could be true whether it's in ICU, a step down, post-surgical, or on a regular med. surg. floor, but no longer during that shift really needs to be in place. At that point, that's kind of they key decision point when the nurse should either take it upon himself or herself and remove the catheter, provided that there is a nurse initiated discontinuation protocol at that particular hospital, or contact the physician to ask for it to be removed. I think that really is kind of the fundamental core of what we're trying to do.

Mari Franks: Thank you, Sanjay. Operator, do we have any questions in the queue?

Operator: At this time, we have no further questions.

Mari Franks: Great. Thank you. And with that, Todd or Sanjay, do you have any additional closing comments for today's participants?

 Sanjay Saint: Thank you for your time.

Todd Green: None for me. Thank you.

Mari Franks: Terrific. Thank you, everyone. And we look forward to speaking with you next month, and please don't forget to complete today's evaluation. Your feedback is very important to us. Have a wonderful afternoon and big thanks to both Todd and Sanjay for their time today. Take care, everyone.

Operator: Thank you very much. Ladies and gentlemen, at this time, this conference is now concluded. You may disconnect your phone lines and have a great rest of the week. Thank you.