The national project team is committed to the overall project goals of reducing CAUTI and enhancing the safety culture in participating hospitals. Progress made towards achieving the project's stated goal of CAUTI reduction is encouraging and indicates that focused attention using an effective approach that combines the technical and adaptive aspects of implementation can produce important results.
The project continues to expand with the recent completion of cohort 6 registration and ongoing planning for cohort 7. Although data submission has been challenging, interventions are in place to assist struggling units with this process. Additional interventions are in development for units not reaching the stated project goals. Continued analyses and ongoing data collection efforts will provide a further understanding of the effect of the intervention at a national level. Although progress has been made towards achieving the project's stated goals, substantial work remains, including, but not limited to, the following next steps: increase sample size, increase data submission, target additional interventions, and expand future analyses.
Increase Sample Size
HRET seeks to recruit the remaining States to participate in the final cohort. HRET is encouraging States to enroll as many hospitals as possible, suggesting a minimum of 10 within a State to participate. It is noteworthy that the health care environment has seen a sharp increase in the number of programs addressing health care improvement efforts. This increase has had an impact on all those associated with these efforts, not only our national project team, but also the capacities of State hospital associations and hospitals. HRET remains committed to the national dissemination of the On the CUSP: Stop CAUTI project but recognizes the need to be flexible with the requirements. Therefore, while we strongly encourage a minimum of 10 hospitals per State, we allow participation with fewer hospitals, as needed on a case-by-case determination. In addition, HRET is dedicated to coordinating efforts with CMS, QIO, and HEN CAUTI reduction initiatives through increasing project participation for all hospitals nationwide over the course of the On the CUSP: Stop CAUTI project.
Increase Data Submission
Of the 1,195 registered and active units in the data submission phase of the project (cohorts 1–6), 64 have not submitted any outcome data (5.4 percent). This number has improved through the project cycle as the national project team continues to reach out to units struggling with data submission. Although more units have submitted at least one outcome data point, efforts are ongoing to ensure data submission continues throughout the project life cycle. Outcome data submission rates are lower for the final two post-baseline data collection periods (11 and 14 months after baseline, respectively) compared with baseline and implementation periods. Ongoing efforts to assist units with low data submission include: process development to identify appropriate solutions to increase submission rates (see the 3-I's process explained below under Continuous Improvement); analyses to predict units that may struggle with data submission; working with other improvement initiatives, such as the Partnership for Patients Hospital Engagement Networks providing seamless data measure transfers between projects; eliminating unnecessary data collection requirements by accepting previously completed culture data; and continuing coaching efforts with State leaders to identify ways to increase their States' data submission rates.
Target Additional Interventions
It is important to identify improvement opportunities across all project aspects, including expansion to new health care settings, continuous improvement of project delivery processes, and new training opportunities. These efforts serve to create a wide-ranging package of targeted interventions.
Emergency Department
Always diligent in the pursuit of efforts to achieve best possible outcomes for patients, the NPT in collaboration with ENA and with an endorsement from the American College of Emergency Physicians (ACEP) have developed a new project component, the Emergency Department Improvement Intervention. Although CAUTIs are typically identified following admission to an in-patient setting, more than half of all hospitalized patients are admitted through the ED. Therefore, avoiding placement of unnecessary urinary catheters in the ED may significantly decrease the number of patients with catheters, thereby reducing not only overall catheter utilization during hospitalization, but also subsequent infections. Hence, the ED Improvement Intervention was designed to promote the appropriate use of urinary catheters according to accepted insertion guidelines, provide education and support on proper insertion techniques, and instill a culture of partnership between the ED and in-patient units. Additionally, the intent of the new component is both to expand the reach of the On the CUSP: STOP CAUTI national collaborative to additional areas within the health care setting and to broaden participants' exposure to national experts from the ACEP and the ENA. Recruitment is underway with over 50 EDs participating in the initial cohort.
Continuous Improvement
HRET has developed an integrated project database that allows for continual monitoring of the above categories at national, State, and unit levels. This database captures outcome, process, and cultural measures described above and highlights additional project activities, such as State-level participation rates for onboarding, coaching, and content calls. This database has been a useful tool for easily determining project status across and within States. To complement the project status tracker, HRET has developed a method for evaluating the abilities and needs of the States in order to identify methods that best support State leads and their teams in reaching project goals. The State evaluation process, named the 3-I's process, is a means for Identifying, Investigating, and Intervening (3-I's) with States to support teams' efforts in achieving best possible outcomes for CAUTI reduction. This process consists of, but is not limited to, reviews of the education materials, question-and-answer sessions with team and State leads, and site visits (during which informal qualitative evaluations may take place to understand barriers). In addition, EF support will be available to assist NPT and State partners in monitoring and following up with participating teams. NPT members have also participated in site visits to facilities that would like additional assistance in reducing CAUTI; these site visits have been modeled after the successful approach used in Michigan hospitals.7,8
Training Opportunities
In addition to creating support process for program participants, a specialized training and coaching event was developed for faculty and State hospital association leads. The Interdisciplinary Academy for Coaching and Training (I-ACT) was developed in collaboration with national experts from the University of Michigan and the Society of Hospital Medicine. I-ACT was created as a collaborative and interactive workshop to provide NPT and State leads alike a venue to develop and practice the skills needed to coach interdisciplinary teams through the implementation phase of CAUTI initiative through data collection and sustainability. The skills gained through this workshop were designed to support coaching objectives for individual States and frontline improvement teams, allowing for effective change from a distance. Program objectives were as follows:
- Provide clinical solutions and the latest research updates on complex CAUTI issues and barriers to prevention, such as:
- Morbidly obese patients.
- Spinal cord injury patients with urinary retention.
- Catheter exchange routines.
- Offer a foundational understanding of Just Culture and examples of applications.
- Review implementation challenges and discuss strategies to overcome them.
- Address perspectives of CAUTI multidisciplinary team members, identify "what's in it for them," and develop engagement strategies.
- Provide effective coaching techniques to address challenging issues such as coaching from a distance, assessing organizational culture in a snapshot, and managing difficult personalities.
Overall, about 90 percent of attendees gave "excellent" ratings regarding program satisfaction, importance of the program items, and agreement with program statements. In addition, all presenters were rated highly by attendees. The I-ACT training was well attended and received by all participants, and HRET is strongly encouraged and working on ways to improve, spread, and replicate the program for future faculty and State leads.
Additional training and support is also provided to units that have been identified in the following categories:
- No outcomes data.
- No process data.
- Consistent increases in CAUTI rates post intervention.
- Consistent increase in catheter utilization post intervention.
- Data indicating a dramatic increase in rates and/or catheter days from one period to the next.
Expand Future Analyses and Dissemination of Findings
As participation continues to increase, future analyses will examine the effect of independent, explanatory variables on CAUTI rates. Cohort assignment, the relationship between hospital characteristics and outcome measures, and the effect of multiple units participating within a single hospital (i.e. "nesting") will be analyzed using mixed modeling techniques and allow for random effects. Furthermore, data collection related to the assessment of safety culture is ongoing. Future analyses will also assess unit teamwork and communication within units utilizing the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) and the Team Checkup Tool. In addition to completing robust examinations of the program results, it is important to disseminate broadly the findings of national quality improvement efforts. Therefore, in addition to these important public reports, the NPT has established a manuscript committee, charged with the development and publication of peer-reviewed papers. The NPT is pleased to announce that through this work and the support of AHRQ, one paper has already been accepted for publication and several others are in development.
Resources
Additional information regarding this project can be found online at:
http://www.onthecuspstophai.org/on-the-cuspstop-cauti/
http:/www.catheterout.org/
7. Krein SL, Kowalski C, Harrod M, et al. Barriers to reducing urinary catheter use: A qualitative assessment of a statewide initiative. JAMA Intern Med 2013 May 27;173(10):881-6. PMID: 23529627.
8. Saint S, Greene MT, Kowalski CP, et al. Preventing catheter-associated urinary tract infection in the United States: A national comparative study. JAMA Intern Med 2013 May 27; 173(10):874-9. PMID: 23529579.
