Keystone provides keys to preventing UTIs

'Bladder bundle' team includes ICPs

The Michigan Health & Hospital Association's Keystone Center for Patient Safety & Quality has created a "bladder bundle" of measures to prevent urinary tract infections. Some of the key recommendations for implementation of the bundle are summarized as follows:

• Step 1: Identify and enlist a nurse champion to lead this bundle. The nurse champion could be a case manager, nurse coordinator, clinical nurse specialist. The major focus of this bundle is on processes of care with an emphasis on continual assessment and removal of the catheter as soon as possible — especially those for which there is no clear indication. The underlying reasons are that:

i) Over 80% of hospital-associated UTIs are caused by an indwelling urinary catheter;

ii) Studies that have looked at indications for catheters in place have found that only about 46% are appropriate;

iii) The insertion, care, and maintenance of the indwelling catheter falls entirely on the nursing staff.

• Step 2: Identify and organize the bladder bundle team. This likely will include nurse(s), physician(s) (consider a hospitalist if available or other medical director), education coordinator, infection control professional, patient care assistants, performance improvement coordinator, social worker, etc.

• Step 3: Identify the unit(s) targeted for implementation of the bladder bundle.

i) Obtain urinary catheter utilization data from your facility's purchasing department to determine which units are high volume.

ii) It may be more challenging to get buy-in from ICU personnel even though utilization of catheter is likely high. Consider instead an inpatient medicine, surgery or even a progressive care unit. If the facility has a limited number of beds this may require enrolling the entire medical/surgical unit.

• Step 4: Baseline assessment: Structure and crude frequency of positive urine cultures.

i) In collaboration with your facility's ICP ask the microbiology laboratory or key contact with the laboratory your facility uses to create a report that provides:

a. All urine cultures that were positive more than 48 hours after the patient's date of admission

b. If possible, see if this can be sorted by unit, frequency, pathogen, and cumulative susceptibility profile for all of these positive cultures.

• Step 5: Point prevalence study of appropriateness of urinary catheterization —

A) Baseline Point Prevalence: If unit-specific catheter utilization data are not readily available, do a single day point prevalence survey of all medical/surgical inpatient units to determine which have the highest utilization of urinary catheters.

B) Identify target unit(s)

C) Collect pre-intervention phase: Baseline data (e.g. assess 5 days/week 1)

a. If possible, have target unit begin collecting urinary catheter days, e.g., on each day, tabulate total number of patients with an indwelling urinary catheter on a device utilization log.

b. Calculate unnecessary catheterization rate

c. Calculate proportion of unnecessary catheters.

d. Provide training on prevention of catheter-related UTIs to personnel, including list of appropriate indications for catheter utilization.

e. Report baseline findings to personnel

D) Intervention Phase (weeks 2 & 3):

a. Convene daily patient rounds, aka "catheter patrol."

b. During rounds, assess patients for presence of a catheter and if present documentation in chart on reason(s) for insertion and unit where inserted.

c. Implement RN-based discontinuation protocol (if physician leadership for involved unit approves protocol) or reminders to patient's physician if use is not appropriate.

d. Recollect catheter utilization ratio, unnecessary catheter utilization rate, and proportion of unnecessary catheters.

e. Report findings periodically to personnel.

E) Post-Intervention Phase (weeks 4-7): No specific intervention; continue to collect weekly indicators and report findings to personnel.

F) Post-Intervention Phase (week 8): Collect data to assess the effect of the intervention, compare results over the project phases, & report findings to personnel.

a. Ask laboratory to provide a repeated uro-pathogen distribution report. Have ICP analyze this for any notable changes and report findings.