Healthcare-associated infections (HAIs) are a major threat to patient safety. They can be serious and even deadly to the patient, yet they are often preventable. According to the World Health Organization, HAIs are the most frequent adverse event in healthcare delivery worldwide.1 In addition to the harm they can do to patients, healthcare organizations may be penalized financially for these infections by the Centers for Medicare and Medicaid Services (CMS) and other payers due to non-payment. HAIs account for nearly $45 billion in direct hospital costs.2 Recent studies, however, suggest that by implementing existing prevention practices up to a 70% reduction in certain HAIs can be achieved. The financial benefit of using these prevention practices is estimated to be $25 billion to $31.5 billion in medical cost savings.3
HAIs generally include central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), select surgical site infections (SSI s), hospital-onset Clostridium difficile infections (C. difficile) and hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (bloodstream infections). The setting where these infections occur is not limited to hospitals – also included are ambulatory outpatient care centers, long-term care facilities and same-day surgery centers.
The power of data is evident in the statistics available to the public through the National Healthcare Safety Network (NHSN), a national HAI tracking system. Over 14,500 healthcare facilities participate by reporting HAIs to this database, which is the largest in the U.S. Progress has clearly been made in reducing the number of these HAIs. The most recent NHSN National HAI Progress Report includes data supporting this improvement.
The NHSN’s National HAI Progress Report shows:
- A 46% decrease in CLABSIs between 2008 and 2013
- A 19% decrease in SSI s related to the 10 select procedures tracked in the report between 2008 and 2013
- A 6% increase in CAUTIs between 2009 and 2013 (although initial data from 2014 seem to indicate that these infections have started to decrease)
- An 8% decrease in hospital-onset MRSA bacteremia between 2011 and 2013
- A 10% decrease in hospital-onset difficile infections between 2011 and 20134
Opportunities for additional improvements with CAUTIs exist
As noted above, one of the more elusive HAIs to improve is CAUTI. The literature about CAUTIs is abundant with numerous toolkits available to guide reducing these infections. Key strategies center on indications for catheter placement and reducing inappropriate urinary catheter use, catheter insertion by appropriately trained individuals using aseptic techniques and sterile equipment, maintaining a closed drainage system with unobstructed flow, limiting the length of time the catheter is in place to 24 hours or less and consistently carrying out proper hand hygiene.5 While the trend for CAUTIs is now more favorable, patient care management interventions warrant robust analysis of “bundles” and isolated strategies, as well as teamwork and communication issues, which may be barriers to further reducing these infections.
A recent systematic review and meta-analysis of CAUTI-minimizing interventions was published by Meddings, et al. One of their key summary points reported that “catheter reminders or stop orders reduced the rate of CAUTI by 53%. An updated literature review identified many recent interventions with reminders or stop orders reducing CAUTI rates and/or urinary catheter use.”6 Realistically, the practicality of implementing alerts and stop orders to further reduce CAUTIs may be inhibited depending on the culture of the unit and leadership’s participation in the initiative.
Teamwork and communication
The use of alerts or reminders, stop orders and protocols for nurse-directed removal of unnecessary catheters have shown success in further reducing CAUTIs. To be successful with these strategies, however, it is important to understand the safety culture of the unit where the initiative is being implemented. Consider the following comments from three nurses working in different care settings around the country:
- First perspective – “A section of charting was added so nurses can chart the reason the catheter is still in place. An order set was created for physicians to fill out daily. The order set consists of a list of reasons the catheter needs to be continued. One problem that continued to occur was nurses were not removing catheters if physicians did not renew the order. The nurses were in fear of being wrong about the removal, and this led to catheters being in place longer than 24 hours when it was not necessary. On the physicians’ side, they were failing to renew orders and catheters were being removed that should not have been, resulting in reinsertion of catheters. With nurses not removing catheters that did not have orders to renew, physicians not renewing orders and catheters being reinserted, the number of CAUTIs did not seem to be decreasing. Nurses and physicians were re-educated on the process and their responsibilities. A prompt was added to the charting system for nurses to ensure the order was renewed, and physicians received prompts daily when logging into the patient’s chart, requiring them to renew the catheter order or discontinue it. With these prompts and daily reminders we have seen an overall decrease in CAUTIs in our unit.”7
- Second perspective – “The most difficult aspect of the new CAUTI protocol was getting the nurses and physicians on the same page. Our nurses were told to remove the catheters if the order wasn’t renewed within 24 hours. Our physicians were neglecting to write the renewal orders. Nurses were either discontinuing the catheters on their own, or having to call the physicians to remind them. Even though the physicians were told it was their responsibility to write the renewals, they weren’t doing so and they began defaulting to telephone orders when nurses who were considerate enough to remind them made the call. It wasn’t until leaders stepped in and no longer allowed renewal orders to be given over the phone did physicians start to remember that daily renewal orders needed to be renewed daily. When physicians began having to return to the facility after leaving for the day just to write renewal orders, the CAUTI protocol became successful.”8
- Third perspective (summarizing leadership opportunities to implement change) – “…if we are getting to the point of reward and punishment to implement change, we are missing something bigger. Why isn’t everyone on the same page? Is everyone receiving the same training or data presentation? Is there something preventing open lines of communication before a catheter is removed? Is it possible to implement daily multidisciplinary rounds to include nurses, doctors, techs, etc. where everyone can discuss the plan and interventions for the day? It can’t possibly be pleasant for patients to have catheters inserted and removed just because of a communication issue among staff.”9
Impressive progress has been made in reducing HAIs. As demonstrated above, more than clinical strategies are needed. The importance of teamwork and communication cannot be understated, and must always be considered when new initiatives are presented and compliance is expected.
Implementing a teamwork and communication training program such as TeamSTEPPS® is one approach to consider. This evidence-based leadership system “provides higher-quality, safer patient care by producing highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes for patients; increasing team awareness and clarifying team roles and responsibilities; resolving conflicts and improving information sharing; and eliminating barriers to quality and safety.”10 By teaching individuals how to be good team members, they learn to share their mental model, use standardized language and close-loop communicate. Teams that care for patients have briefs, huddle and debrief to evaluate what went well with a procedure or treatment plan, what they could improve and what they might do differently the next time. These teamwork activities lead to improved care and improved outcomes for patients.
The business case
While the case for improving patient safety should speak for itself, those on the front lines often have to make the business case to advance patient safety initiatives. Significant work was done by Kennedy, et al. in the development of a tool estimating customized hospital costs of CAUTIs. The authors note that their “tool can help infection control professionals demonstrate the values of CAUTI prevention efforts to key administrators, particularly at a time where it has become increasingly necessary to develop a business case to initiate new interventions or justify the continued support for ongoing programs.”11 The CAUTI Cost Calculator12 estimates a hospital’s current cost of CAUTIs, and can also be used to project costs after a hypothetical intervention is implemented.
With seven years under our belt since CMS implemented nonpayment for certain hospital-acquired conditions, it is evident that significant strides have been made in reducing HAIs. Safety collaboratives around the country continue to use the best available evidence to further improve care, identify the most successful strategies to use and support the work being done in hospitals every day. Teamwork and communication training continues to be implemented on a unit level and across healthcare systems, further embedding patient safety strategies at the point of care. We still have work to do, but the future is bright.
This content was originally published in the HRMR October issue
Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM
Healthcare Risk Management and Patient Safety Consultant
Resources available to address CAUTIs and antibiotic resistance
- CAUTI Prevention Toolkit: http://www.cdc.gov/HAI/ca_uti/...
- On the CUSP: Stop CAUTI: http://www.onthecuspstophai.or...
- Institute for Healthcare Improvement: How-to Guide: Prevent Catheter-Associated Urinary Tract Infection: http://www.ihi.org/resources/P...
- CDC Vital Signs – Making Healthcare Safer: Stop Spread Antibiotic Resistance, found at: http://www.cdc.gov/vitalsigns/... (accessed August 28, 2015)
- World Health Organization. Healthcare Associated Infections Fact Sheet. http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf.
- The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. 2009. US Centers for Disease Control and Prevention. http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf.
- Healthpeople.gov. Healthcare Associated Infections. http://www.healthypeople.gov/2020/topics-objectives/topic/healthcare-associated-infections.
- CDC HAI Progress Report. http://www.cdc.gov/hai/progress-report/index.html, accessed August 31, 2015.
- CAUTI Prevention Toolkit. http://www.cdc.gov/HAI/ca_uti/uti.html.
- Meddings, J., Rogers, M., Krein, S., Fakih, M., Olmsted, R. and Saint, S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. 2013. BMJ Quality Safety. doi:10.1136/bmjqs-2012-001774. http://qualitysafety.bmj.com/c...
- Discussion Board Communication, K.E., June 2015.
- Discussion Board Communication, K.M., June 2015.
- Discussion Board Communication, A.F., June 2015.
- About TeamSTEPPS®. http://www.ahrq.gov/profession...
- Kennedy, E., Greene, M.T., Saint, S. Estimating hospital costs of catheter-associated urinary tract infection. 2013. Journal of Hospital Medicine, 8(9), 519-522. doi: 10.1002/jhm.2079. http://www.ncbi.nlm.nih.gov/pm...