The Joint Commission Update for Infection Control
Bye, bye UTIs: Joint Commission and CMS putting heat on, but this mission is possible
How one hospital slashed infection rates and saved a cool $115,000
The Joint Commission and other national infection prevention groups made a point to include catheter-related urinary tract infections (CA-UTIs) — traditionally considered a relatively benign adverse event — in a recently issued compendium targeting the major health care-associated infections (HAIs).1 Moreover, The Joint Commission announced that the condensed, actionable recommendations on UTIs and the other infections may become required as accreditation standards by 2010.
But the real game changer on UTI prevention came a bit earlier when the Centers for Medicare & Medicaid Services (CMS) announced effective October 2008 that it would halt payment on additional costs generated by UTIs and two other infections (mediastinitis, catheter-related vascular infections). With both The Joint Commission and CMS now focusing on prevention of UTIs — an infection once considered such a low priority that it has been dubbed the "Rodney Dangerfield" of HAIs — what type of approach does the infection preventionist need to accomplish this task?
First, dare we say, give the UTI the respect it warrants in terms of patient safety. If nothing else, for sheer numbers. UTIs are the most common hospital-acquired infection, and 80% of those infections are attributable to an indwelling urethral catheter.2 Twelve to 16% of hospital inpatients will have a urinary catheter at some time during their hospital stay. Urinary tract infection is the most important adverse outcome of urinary catheter use, with bacteremia and even sepsis occurring in a small proportion of infected patients. Morbidity attributable to any single episode of catheterization is limited, but the high frequency of catheter use in hospitalized patients means that the cumulative burden of CA-UTIs is immense. Complications include patient discomfort, prolonged length of stay, increased cost, and spikes in patient morbidity and even mortality.
Yet surprisingly, a study published last year found that urinary catheters — a well-established risk of infection if not removed as soon as possible — are not even monitored at a large number of hospitals.3 In a particularly striking finding, one-third of hospitals surveyed did not even conduct any type of UTI surveillance. However, among the two-thirds of the hospitals that do UTI surveillance — a proportion expected to rise sharply under CMS and Joint Commission prodding — is the University of Pittsburgh Medical Center (UPMC) St. Margaret. Noticing an increase in CA-UTIs in 2006 — well before the CMS mandate — UPMS St. Margaret's infection prevention team began developing a comprehensive UTI prevention program that continues to produce some striking results.
"We had one [recent] month where we only had one catheter-associated UTI," says Barbara Jordan, RN, MSN, CCRN, clinical director of infection control and regulatory compliance. "We double-checked everything and it was true. Now, we have not maintained that level of one, but we are still doing a really good job of keeping the rates down."
It is estimated UTIs cost from $1,000 to $4,000 depending upon the symptoms, infecting pathogen (i.e., drug-resistant vs. susceptible), antibiotic therapy, and additional length of stay.4 The prevention program at St. Margaret decreased the number of CA-UTIs from 113 in 2006 to 67 in 2007, a decrease of 46 infections. That resulted in an estimated annual savings of $115,000 if you price out the average UTI at $2,500. Now that preventing UTIs is a prime directive from both the CMS and The Joint Commission, Jordan's program can certainly guide other IPs in adopting similar strategies.
The keys to the program include:
- improving insertion technique and catheter management through mandatory education of staff;
- utilizing electronic health record technology;
- reducing urinary (Foley) catheter usage and decreasing urinary catheter device days (dwell time);
- implementing improved catheter product technology (i.e., silver alloy, hydrogel-coated catheters).
But before we get to the nuts and bolts of the UTI prevention plan designed by Jordan and infection prevention colleagues such as Susan DiNucci, RN, BSN, it is worth noting the core values that drive the program and similar efforts at the medical center.
"My philosophy and the philosophy of St. Margaret, the CEO and the board are, 'Yes we do have to meet these regulatory needs but we have to do what's right for the patient," Jordan says. "Keep the patient centric and you're going to do the right thing. Of course, this really helps with CMS in reducing these infections, but I don't know that we are going to totally eliminate them. But through this initiative, we have reduced our CA-UTIs."
One of the basic tools used in the program is an observation form to assess urinary catheter management, which is used to assess both appropriate placement and handling. (See form.)
"We observed how the catheters were being managed and actual insertions of catheters," she says. "Then we tried to figure out how can we reduce the days that they're in. We attacked that first. We provided education to the staff on proper care of patients with urinary catheters, then we focused on reducing the dwell time."
Indeed, it is well established in the literature that the sooner you can get an unnecessary urinary catheter out of a patient, the less likely they are to develop an infection. "We're fortunate to have electronic health records so we were able to capture what patients had catheters in," Jordan says. "This report would print out every day on the nursing unit, and we had a report in infection control. The charge nurse would take that and talk with the physicians and see about getting the catheters out."
As part of the tracking process, daily assessment of urinary catheter necessity involves identifying one of the following criteria for insertion and assessment for insertion and retention of the catheter. "If the physician insists on keeping it in, then that's fine — it is documented," she says. If one of the following does not apply, the physician must be notified regarding a possible order to discontinue the catheter:
- bladder irrigation;
- close monitoring of urine output in critically ill patient;
- Comfort Measures Only care;
- nonurologic surgery less than 24 hours ago;
- Stage III or IV sacral/perineal pressure ulcer;
- surgical/trauma indications in perineal area;
- urinary retention;
- urologic surgery.
A vital component of the center's program was housewide implementation of silver-coated catheters, which have been shown to reduce UTIs. The silver coating's antimicrobial properties help prevent biofilm formation and adhesion of microbes on the catheter. However, cost analysis revealed the silver devices were roughly twice as much as a conventional catheter. The argument was successfully made that prevented infections would pay for the more expensive devices, Jordan notes.
"We opted to go housewide with those rather than restricting the specific patient populations," she explains. "For example, we know there are surgical patients that will just have a urinary catheter in overnight. We could have said they can just set up a regular catheter, but we wanted to make this as simple as possible."
With the program up and running, Jordan looked for key target areas to reduce placement of unnecessary catheters. The emergency department was a prime target. "We created insertion criteria for the emergency department because we saw that nurses were putting catheters in based on no science really. It was just a past practice." (See ED catheter insertion form.) The criteria were established in consultation with the ED clinicians and then an ongoing education process began.
"We made it as easy as possible and got the ED nurses to teach this form to the urinary catheter insertion trainees," Jordan says. "The nurses use it and [we] pick them up every month and review them. Again, with a lot of staff education, we are reducing the insertion of catheters. Our next step — and we just had discussions this past week — is [to include] the OR. We have opportunities there to reduce usage of urinary catheters."
Surprisingly enough, some patients want urinary catheters — and may resist removal — to avoid the pain and hassle of moving about to urinate. "It's hard when your patients are hurting after surgery to make them get up and things like that, but again we have to look at when we can transition them to using an alternative means — a urinal or a condom cath," she says. "That's where the necessity criteria come in, but if we can avoid putting them in [in the first place] all the better. That has worked with the emergency department and we are exploring that with ambulatory surgery and our pre-op areas. "
Ongoing education and specific feedback to health care workers are necessary to keep the program effective and robust. "We break it down by inpatient unit," Jordan says. "So if they can see we had three CA-UTIs in our surgical unit, [they ask] what's going on? It's the staff that are taking care of the patients that make the difference. We have developed a culture here where we are going to seek out opportunities for improvement."
- Society for Healthcare Epidemiology of America. Compendium of Strategies to Prevent Healthcare Associated Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol; October 2008 supplement available online at: www.shea-online.org.
- Lo E, Nicolle L, Classen D, et al. SHEA/IDSA Practice recommendation strategies to prevent catheter-associated urinary tract infections in acute care hospitals. lnfect Control Hosp Epidemiol 2008; 29:S41-S50.
- Saint S, Kowalski CP, Kaufman SR. Preventing hospital-acquired urinary tract infection in the United States: A national study. Clin Infect Dis 2008; 46:243-250.
- Wald HL, Kramer AM. Nonpayment for harms resulting from medical care. JAMA 2007; 298(23):2,782-2,784.