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Kim Roberts

Infection Control Manager

OCH Regional Medical Center

CAUTI: Lessons Learned from the HAC Penalty

April 14, 2015

CAUTI: Lessons learned from the HAC penalty

“Did you hear the news…?!”

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I hope others will learn from our experience with the HAC penalty. Our story began like this…

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HAC Penalty Calculation • Domain 1 Score •  Jul 2011 - Jun 2013 •  Patient Safety Indicator

(PSI 90) composite measures (8 items): v  Pressure ulcer v  Iatrogenic pneumothorax v  CVC-related bloodstream infection v  Postoperative hip fracture v  Perioperative pulmonary embolism

or DVT v  Postoperative sepsis v  Postoperative wound dehiscence v  Accidental puncture or laceration

Our score was 3

Weighted at 35% of overall HAC score.

• Domain 2 Score •  Jan 2012 - Dec 2013

•  CLABSI v This score calculated for any ICU with >1.0 “expected” infections. v We had less than 1 “expected” infection, so this data was not used.

•  CAUTI v  This score calculated for any ICU with >1.0 “expected” infections v  We had 1.747 expected infections. v  Since we didn’t have a CLABSI score, the CAUTI score counted for the entire Domain 2 score.

Our score was 10 Weighted at 65% of overall HAC score.

HAC Penalty Calculation •  Hospital data was ranked into performance “deciles” •  Scores of 1-10, based on which decile you fall into

v  Lower scores are better •  Domain 1 (35% of overall score). Our score was 3 •  Domain 2 (65% of overall score). Our score was 10 •  Hospitals received penalty if overall HAC score > 7

v  Our combined score was 7.55 (see below)

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Statistical Power Would 1 fewer infection have changed our score on Domain 2? CMS used a ratio of actual vs. "expected" infections. # actual CAUTI / # expected CAUTI 5 / 1.747 = 2.862 4 / 1.747 = 2.290 The 10th performance decile included scores between 2.013 to 6.000 Even after subtracting one infection, our CAUTI score was in the 10th decile. The 9th performance decile included scores between 1.564 to 2.013 What would the number have been with 2 fewer infections? 3 / 1.747 = 1.717 With a score of 9 on Domain 2 (weighted at 65% of total HAC score), and the score of 3 on Domain 1 (weighted at 35%), it would put us below the magic number 7 that CMS set as the threshold for the penalty. HAC Penalty Formula: (Domain 1 Score * Domain 1 weight) + (Domain 2 Score * Domain 2 weight) = Total HAC Score Our score was calculated as: (3 * 0.35) + (10 * 0.65) = 7.55 We were penalized because this score was > 7

The lesson learned was that we needed 2 fewer CAUTI infections during 2012-2013 to avoid the HAC penalty: (3 * 0.35) + (9 * 0.65) = 6.9 That’s less than the threshold for the penalty (less than 7)

Device Days The ITS department developed an automated

system to help record the # of inpatients on each unit, and the # of devices in use at same time every day:

•  ICU •  Inpatient Medical Ward •  Inpatient Surgical Ward •  Postpartum / Pediatric Ward

Can do weekly sampling method if average # device days > 75 per month

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Culture Surveillance

•  The Infection Control department reviews all culture reports.

• When we identify a positive urine culture, we check whether the UTI was present-on-admission (POA), and whether the infection meets the HAI or CAUTI definitions, per NHSN.

• We track what types of organisms are causing CAUTIs at our facility (next slide) à

CAUTI  organisms

20%

20%

40%

20%

Proteus  vulgaris

Providencia  stuartii  andKlebsiella  oxytocaE.  coli

MRSA

Culture Surveillance

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CAUTI Prevention • Foley assessments

v Observe and evaluate nurses performing Foley catheter insertions

v Product evaluation: ü What types of catheters are in use at our

facility, what features do nurses prefer, talk to staff about their catheter experiences

ü Compare various catheter trays ü Ask other facilities what products they are

using. Get advice and recommendations.

Foley Insertion Assessment Table  1:    Foley  Inser0on  Steps  per  Direc0ons  for  Use  (DFU)              Correct  Incorrect

  Opens  CSR  wrap  to  form  sterile  field  (STEP  1)    63%  38% Places  underpad  plas@c  side  down  (STEP  2)    38%  63% Dons  (sterile)  cuffed  gloves  (STEP  3)    75%  25% Places  fenestrated  drape  (STEP  4)      0%  100% Pours  cleansing  solu@on  onto  three  prep  balls  (STEP  5)  100%  0% Opens  catheter  lubrica@ng  jelly  (STEP  6)    100%  0% Removes  top  tray  (STEP  7)      63%  38% Opens  plas@c  sheath  surrounding  the  catheter  (STEP  8)  100%  0%  Lubricates  the  catheter  (STEP  9)      100%  0% Prepares  pa@ent  with  saturated  prep  balls  using  forceps  (STEP  10)  100%  0% Proceeds  with  catheteriza@on  in  usual  manner  (STEP  11)  88%  13% Inserts  @p  of  water  filled  syringe  into  valve  (STEP  12)    100%  0%  Inflates  balloon  with    en@re  amount  of  water  (STEP  13)  100%  0%

 

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Risk Factors for CAUTI

• Having a Foley catheter and/or keeping the catheter in place longer than necessary

•  Improper Foley insertion technique •  Lack of adequate peri-care •  Improper catheter maintenance

v Some risk include: bag above level of bladder, putting drainage bag on floor, dependent loops in catheter tubing, not washing hands before handling catheter tubing or bag

•  Patient acuity & other medical problems v Renal failure, CVA, diabetes, heart disease, MDRO

colonization, altered mental status, nutritional status, etc.

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All  Years  Combined  CAUTI

0

1

2Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Date

Num

ber  C

AUTI

Device  Utilization

Expected  CAUTI

Actual  CAUTI

CAUTI  originally  reported  to  NHSN  in  October  2013  was  removed  after  further  chart  review  determined  the  UTI  was  present-­‐‑on-­‐‑admission.  

Key Lessons Learned

• Know how your data is being collected and evaluated. BE A STATISTICAL GEEK.

• Know how your data is being used by CMS. •  Verify best-practices & staff knowledge. •  Check for consistent performance. •  Share significant data with medical staff,

front-line clinical staff, and administration. COMMUNICATE & COLLABORATE

•  Be proactive. Don’t be the “last to know.” Get ahead of the story. Have your talking points ready!

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We learned some valuable lessons. If I could go back in time… this is how I wish the conversation had started.

NHSN Definitions

•  http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf (modified April 2015)

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Some CAUTI Resources

•  APIC Guide to Preventing CAUTI: http://apic.org/Resource_/EliminationGuideForm/6473ab9b-e75c-457a-8d0f-d57d32bc242b/File/APIC_CAUTI_web_0603.pdf

•  CDC CAUTI Toolkit: http://www.cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf

•  Targeted Assessment for Prevention (TAP): http://www.cdc.gov/hai/prevent/tap.html

•  On the CUSP: Stop CAUTI http://www.onthecuspstophai.org/on-the-cuspstop-cauti/

Feel free to contact me about CAUTI

Kim Roberts Infection Control Manager

OCH Regional Medical Center Starkville, Mississippi

(662) 615-2820 kroberts@och.org

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Thank You

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For more information contact your state’s QIN-QIO representative:

This material was presented on behalf of atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. 15.SS.MS.02.001E