Joint Initiative Lays Groundwork for ICU CAUTI Reduction Nationwide

2016 - 2 April - SCCM’s Quality Improvement Initiatives
William S. Miles, MD, FACS, FCCM; Diane Byrum, RN, MSN, CCRN, CCNS, FCCM
Learn about SCCM’s efforts to combat CAUTIs and CLABSIs.

In September 2014, the Health Research & Educational Trust (HRET) of the American Hospital Association (AHA) entered the last year of its contract with the Agency for Healthcare Research and Quality (AHRQ), which funded the national initiative “On the CUSP: Stop CAUTI.” Because catheter-associated urinary tract infection (CAUTI) rates did not decline to desired levels in the intensive care unit (ICU) setting nationally, ICUs were the focus of the last HRET cohort, Cohort 9. HRET and AHA engaged with Lori Harmon, RRT, MBA, director of quality with the Society of Critical Care Medicine (SCCM), the Michigan Hospital Association and the New Jersey Hospital Association to recruit ICUs across the country. SCCM’s Cohort 9 enrolled ICUs in multiple states: Virginia, North Carolina, South Carolina, Georgia, and two ICUs in California. HRET engaged state hospital associations to work with ICU clinical leadership in the states to recruit at least 10 hospitals in each state for a nine-month urinary catheter (UC) utilization and CAUTI reduction project that ran from December 2014 through August 2015.

The SCCM Cohort 9 project leaders were Dr. William Miles, MD, FACS, FCCM, Director of Surgical Critical Care Outreach at Carolinas Medical Center, Charlotte, NC, USA, and Diane Byrum, RN, MSN, CCRN, CCNS, FCCM, clinical nurse specialist and manager of quality implementation programs at SCCM. The approach for this fast-track CAUTI project was to partner state hospital associations with a physician/clinical nurse specialist (CNS) dyad in each state for ICU recruitment. A mixture of ICUs was targeted to join the project, based either on increased UC use/CAUTI rate (low performers) or decreased UC use/CAUTI rates (high performers).

Educational Opportunities
SCCM’s 44th Critical Care Congress hosted a CAUTI Boot Camp to initiate the project, allowing enrolled ICUs, as well as other Congress participants, to network and ask questions. National experts presented evidence-based practices for reducing CAUTIs and Comprehensive Unit-Based Safety Program (CUSP) concepts and tools. A total of eight educational content calls were held monthly, focusing on both evidence-based technical and socioadaptive interventions to reduce UC use/CAUTIs and improve safety culture in the ICU.

Topics included forming effective ICU teams (physician and nurse champions), Healthcare Infection Control Practices Advisory Committee guidelines and appropriate indications for catheter use, daily UC necessity rounds, UC alternatives, UC maintenance, UC insertion proficiency, two-person insertion teams, nurse-driven removal protocols and an acute urinary retention protocol, reduction and elimination of pan cultures. The National Healthcare Safety Network CAUTI definitions with case scenarios to improve understanding and application of definition criteria, strict definition and limited use of hourly urine output assessment, using data to drive performance, use of a CUSP safety model, reward and recognition of practices that decrease UC use, and CAUTIs were utilized to increase sustainability.

Monthly coaching calls reinforced content from monthly content calls. These calls were conducted by Dr. Miles and Diane and provided an opportunity for ICU teams to ask questions, review progress data and engage in peer learning by discussing successes and challenges. Each state hospital association held a statewide educational event at which all the state-enrolled hospitals’ CAUTI teams could meet, network and discuss CAUTI prevention content and solutions for sustainability. Each hospital prepared a Team Checkup, sharing successes and barriers to success. In addition, 15 site visits were conducted by physician/CNS dyads to delve deeper into specific hospital barriers. 

Each ICU submitted baseline and monthly National Healthcare Safety Network data, and progress was tracked. The aggregate UC utilization rate and CAUTI data (state, cohort and national comparisons) were shared on coaching calls and statewide meetings. The final data for the project have not been released by AHRQ. The monthly aggregate data reporting allowed the physician/CNS dyad to see a snapshot of progress. It was impressive to see that the patient safety initiatives embedded into the missions of SCCM, AHA and HRET were being implemented. UC utilization and CAUTI rates appeared to be trending toward reduction. The mission, multiprofessional makeup and SCCM’s direction provided the necessary jump start and foundation for this important CAUTI project in critical care.

Starting in September 2015, SCCM has partnered again with AHA, HRET, AHRQ and the Centers for Disease Control and Prevention with a multi-state and multi-organizational collaborative project to improve outcomes of hospital-acquired infections in hospitals that have higher-than-expected rates of CAUTIs and central-line-associated bloodstream infections (CLABSIs). The project is titled “AHRQ Safety Program for ICUs: CLABSI/CAUTI,” and enlists specialists from all over the United States to assist in developing needs assessments, curricula and content, as well as problem solving and process improvement for the enrolled ICUs. SCCM has been asked to partner with these organizations to lend its expertise in quality improvement and multiprofessional process implementation. The project co-leaders are William S. Miles, MD, FACS, FCCM, and Julia D. Burgess, MSN, RN, ACNS-BC, CCRN-CMC, clinical nurse specialist. The project concludes in March 2017, with reporting to be completed at the end of the 18 months.