Urinary tract infection is one of the most common healthcare-associated infections (HAIs) in long-term care residents, and residents with indwelling urinary catheters are at increased risk. Pennsylvania facilities reported 1,079 catheter-associated urinary tract infections (CAUTIs) in 2015. CAUTI places long-term care residents at risk for sepsis and hospitalization, and the use of antibiotics to treat CAUTI can lead to the growth of drug-resistant organisms. Bacteria can enter the urinary system through external or internal surfaces of a urinary catheter. The Pennsylvania Patient Safety Authority participated in the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Long-Term Care: HAIs/CAUTI project to promote safety by reducing the incidence of CAUTI. The project used evidence-based practices to prevent CAUTI and provided methods for facilities to sustain and enhance safety. Despite an insignificant reduction in catheter utilization, the use of process improvement tools and educational offerings in the project was associated with an encouraging reduction in CAUTI at participating Pennsylvania facilities. These facilities were invited to participate in a survey to assess the success of the project and the value of the process improvement tools provided.
Annually in the United States, between 1 million and 3 million healthcare-associated infections (HAIs) occur in long-term care (LTC) residents, with urinary tract infections being one of the most common.1,2 In 2015, Pennsylvania LTC facilities reported 1,079 catheter-associated urinary tract infections (CAUTIs) to the Pennsylvania Patient Safety Reporting System (PA-PSRS).3 Residents who develop a CAUTI are at risk of developing sepsis and requiring hospitalization.1-3 In addition to improving care for individual residents, reducing CAUTI in LTC also helps reduce antibiotic use that can lead to the development of drug-resistant organisms.1,2,4,5
Many factors contribute to the development of a urinary tract infection (UTI), such as advanced age, female gender, or anatomic or medical conditions causing urinary obstruction.3,4 Healthcare-acquired UTIs are frequently associated with the use of an indwelling urinary catheter; CAUTIs are associated with indwelling urinary catheters inserted through the urethra. (Infections that may be associated with suprapubic catheters or straight catheters for intermittent catheterization are not defined as CAUTIs.) Insertion technique, duration of catheter use, catheter care, and resident susceptibility influence the risk of developing a CAUTI.4,5 Bacteria can enter the urinary tract through the external or internal surfaces of the catheter. External entry can occur from contamination caused by poor aseptic technique during insertion, colonization of the external surface through creation of a biofilm, or from capillary action.4 Internal entry can occur from urine reflux into the bladder from the drainage bag; failure to maintain a closed, sterile drainage system; or damage to the bladder mucosa, which facilitates biofilm formation.5-8
The Pennsylvania Patient Safety Authority participated in a national project led by the Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association, and funded by the Agency for Healthcare Research and Quality (AHRQ). It was called the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI. Pennsylvania was part of HRETs Cohort 2, which ran from November 2014 through December 2015 and consisted of nine states. The Authority was the organizational lead for participants in Pennsylvania and was responsible for identifying and recruiting facilities to participate in the project. Further, the Authority worked with the facilities to form teams and set individual CAUTI reduction goals, monitored facility involvement in educational offerings and data submission, and analyzed submitted data. As an organizational lead, the Authority was tasked with enrolling at least 15 facilities in the project, which was offered to all LTC facilities in Pennsylvania. To assist with recruitment, Authority analysts queried PA-PSRS for reports of events that occurred from April 1, 2014, through May 31, 2014, to obtain LTC CAUTI rates. Fifteen Pennsylvania facilities completed the project.
Goals of the Project
HRET goals were as follows:
Additional Authority goals were as follows:
Increase implementation of evidence-based CAUTI-prevention process measures
Increase collaboration among individual LTC facilities and between facilities and the Authority
Work with individual facilities to develop facility-based CAUTI reduction goals
The project had data requirements and time commitments. The facilities were encouraged to convene a process improvement team to work on the project. Each facility administrator signed a commitment letter of participation, acknowledging that the facility would comply with the requirements of the project, including the following:
At least one team member attends the five onboarding webinars, four training modules, and the monthly content and coaching calls
At least one team member attends the three in-person learning sessions
Data collection and submission requirements are complied with
Monthly team safety meetings are held to review CAUTI outcome, process, teamwork, and communication data
Project improvement tools are learned and implemented
At the end of the project, 10 of the 15 facilities completed an online survey to measure the effectiveness of the project activities. Survey results are presented in the companion Pennsylvania Patient Safety Advisory article, Evaluating the Effect of Infection Control Practices on Reducing CAUTIs in Pennsylvania Long-Term Care Facilities.
The CAUTI project used several methods to engage the participants and improve practice, including on-site visits, coaching support, educational sessions, and process improvement tools.
Authority infection prevention analysts visited each of the participating facilities in March and April 2015 to meet with the CAUTI teams. All staff at the participating facilities were given the opportunity to complete the Culture of Safety survey. The survey assesses staff perception of resident safety in the facility. Educational materials and process improvement tools were given to the teams along with encouragement and support. Data reports and the facility Culture of Safety survey results were reviewed with each team. The facilities were taught how to use their Culture of Safety survey results to develop action plans to address their own identified issues and how to use the skills assessments to identify areas of need of education resources. The visits allowed Authority analysts to work directly with the facility team to answer questions and provide education and support.
Coaching support was provided to all participating facilities through monthly coaching calls, monthly newsletters, and individual communication via telephone and email. Facilities were encouraged to participate in the monthly calls. The coaching calls reviewed current Pennsylvania project facility data, highlighted facility successes, and provided education on identified areas of need such as antibiotic stewardship or the correct application of infection criteria. The monthly newsletter provided information on upcoming educational webinars, reviewed data-entry requirements and deadlines, and highlighted facility successes.
In-person learning sessions were held in August 2014, April 2015, and October 2015. The goals of the sessions were to facilitate collaboration among the facilities and to provide education on basic infection prevention, antibiotic stewardship, and the use of the process improvement tools. Facilities identified as having engaged teams or who had implemented effective processes during the on-site visits were invited to share their stories with the other participants.
Process Improvement Tools
Process improvement tools were provided to the participating facilities along with training on how to use them in their facilities. The process improvement tools provided were the Culture of Safety survey, Skill questionnaires for licensed and unlicensed staff, the Team Communication Guide, Learn from Defects tool, T.E.A.M.S mnemonic infographic, and C.A.U.T.I. mnemonic infographic.9
Culture of Safety survey. This survey assessed staff perception of the following:
Overall perceptions on resident safety
Feedback and communication about Incidents
Supervisor/manager expectation and actions promoting resident safety
Management support for resident safety
Training and skills
Compliance with procedures
Nonpunitive response to mistakes
All staff were provided the opportunity to complete the survey. The anonymous survey was administered early in the project and again at its end. The survey assesses and measures conditions that can lead to resident harm, identifies strengths and areas for improvement, and raises staff awareness of the importance of resident safety. The two main areas the survey strives to assess are the staff perception of resident safety in the facility and whether they would recommend the facility to friends as a safe home for their family.
Skill questionnaires. The skills questionnaires for licensed staff and certified nursing assistants were given early in the project and again at its end. They do the following:
Assess staff knowledge of the principles of CAUTI prevention (the staff education on CAUTI-prevention principles was provided in the onboarding webinar)
Identify areas of need, to target educational needs
Assess the effectiveness of the provided education
Team Communication Guide. The guide is a three-section tool that evaluates facility progress in instituting the T.E.A.M.S. intervention and CAUTI reduction strategies and in overcoming barriers to team progress. It is used as follows:
Provides quarterly assessment
Measures process improvement
Evaluates compliance with best practice process measures
Identifies opportunities for improvement
Assists in directing educational resources
Learn from Defects. This tool identifies the factors that contribute to a safety event or situation. It is used as follows:
Helps review a safety event or situation that the facility does not want to happen again
Helps plan the next steps to be taken to prevent the event from happening again
Identifies ways to learn from the event
C.A.U.T.I. intervention. The C.A.U.T.I. mnemonic provides evidenced-based interventions to reduce CAUTI. It focuses on reducing unnecessary catheter use and using best practices for catheter insertion and maintenance care. The mnemonic components include five prevention and control strategies: Catheter removal, Aseptic insertion, Use regular assessments, Training for catheter care, and Incontinence care planning.
Information on the prevention and control measures is presented in the companion Advisory article, Evaluating the Effect of Infection Control Practices on Reducing CAUTIs in Pennsylvania Long-Term Care Facilities.
T.E.A.M.S intervention. The T.E.A.M.S. mnemonic provides specific interventions to promote a culture of safety. The mnemonic includes five team- and culture-building strategies: Team formation, Excellent communication, Assessment of what’s working, Meeting monthly, and Sustaining efforts.
Facilities submitted into an online collaborative database (CDS) the number of CAUTIs, the number of urinary catheter devices, and the number of resident days monthly, from November 2014 through October 2015. This data was collated by staff at HRET and entered into the CDS. The participating facilities could access their own facility’s reports and the Pennsylvania aggregate data on safety culture, CAUTI rates, and device use rates. HRET provided the information on slides to be used within the facility. The facilities were encouraged to share this information with administration, staff, the facility medical director, and medical staff and to review the information at the Quality Assurance Process Improvement (QAPI) meetings.
All of the participating facilities were visited by the Authority infection prevention analysts.
A total of 11 monthly coaching calls were held. Calls were not held the months of the in-person sessions. Participation in the calls decreased over the course of the project: The first coaching call had 80% facility participation and the last coaching call had 27% facility participation.
Of the 15 facilities, 12 (80%) participated in the first in-person learning session, 10 (67%) participated in the second session, and 6 (40%) participated in the final session.
Process Improvement Findings
Seventy-nine percent of staff (2,268 of 2,863) completed the initial Culture of Safety survey: The areas identified as opportunities for improvement were nonpunitive responses to mistakes, improving staffing levels, and enhancing communication openness. Ninety percent of the surveyed staff believe their facility is safe for residents and 96% would recommend their facility to friends as a safe place for family members.
Skills questionnaires: Comparing the second skills questionnaire to the initial results showed an increase in staff knowledge of team building, CAUTI definitions, resident safety culture, hand hygiene, antibiotic stewardship, and epidemiology, surveillance, and reporting. Staff knowledge of antibiotic stewardship had the greatest increase, from 65% to 78%. Decreases were noted in staff knowledge of equipment and environmental training, standard and transmission-based precautions, and case studies to identify CAUTI.
Team Communication Guide: The barriers identified by the guide concerned lack of administrative involvement. Some facilities documented few meetings between the administrative champion and the CAUTI team or low participation in safety rounds.
For the 12-month period, the 15 participating Pennsylvania facilities reported a significant reduction (54%) in CAUTIs and a modest reduction (3%) in catheter use. See Figures 1 and 2.Figure 1. CAUTI Rate of Participating Pennsylvania Nursing Homes
Source: CAUTI events reported by participating facilities to the Health Research & Educational Trust Comprehensive Data System from November 1, 2014, though Octover 31, 2015.
CAUTI, Catheter-associated urinary tract infection. Figure 2. Catheter-Use Rate of Participating Pennsylvania Nursing Homes
Source: Catheter device use data reported by participating facilities to the Health Research & Educational Trust Comprehensive Data System from November 1, 2014, through October 31, 2015.
The project was successful in reducing CAUTI rates in the participating facilities despite minimal reduction in catheter use. The small reduction in catheter use can be attributed to the resident population at some of the facilities enrolled in the project who required chronic indwelling catheters, such as residents with spinal cord injuries or other physiological issues resulting in neurogenic bladders, without volitional bladder control. Indications for an indwelling catheter include acute urinary retention or bladder outlet obstruction, sacral or perineal wound healing in incontinent patients, and end-of-life care. When catheters cannot be removed, it is important to follow best practices for catheter care and maintenance. Project results suggest that improved catheter maintenance awareness and technical skills may result in decreased incidents of CAUTI, even in populations for whom long-term indwelling catheters are indicated. The decrease in staff knowledge of basic infection prevention practices noted on the skills questionnaire could be due to the frequent staff turnover observed in the participating facilities.
The participating facilities increased their knowledge of infection prevention and safety, became more proficient in using screening criteria and data collection, and became more adept at data analysis. The facilities perceived the on-site visits from the infection prevention analysts to be helpful. The project also raised awareness of the Authority by developing relationships between the facilities and the infection prevention analysts.
Facilities in this project, which used evidence-based infection prevention practices, data analysis, and caregiver education, decreased the incidence of CAUTI among their residents despite minimal decrease in catheter use. Adopting best practices for catheter insertion and maintenance are key in reducing CAUTI in residents for whom an indwelling catheter is necessary. The use of process improvement tools can greatly enhance resident care by identifying opportunities for improvement, providing visual reminders of appropriate care, and improving staff knowledge of infection prevention and control.
Christina M. Hunt, MBA, MSN, RN, HCM, CPPS, Director of Collaborative Programs at the Pennsylvania Patient Safety Authority, provided insight and guidance as the project coordinator. Sharon Bradley, RN, CIC, Senior Infection Prevention Analyst at the Pennsylvania Patient Safety Authority, assisted in running the collaborative, developed educational offerings, and provided clinical expertise and guidance as the lead clinical expert for the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI project.
Schweon S, Burdsall D, Hanchett M, Hilley S, Greene D, Kenneley I, Marx J, Rosenbaum P. Infection preventionist’s guide to long-term care. Arlington (VA): Association for Professionals in Infection Control and Epidemiology; 2013: 99-101.
Greene L, Marx J, Oriola S. Guide to the elimination of catheter-associated urinary tract infections (CAUTIs). Arlington (VA): Association for Professionals in Infection Control and Epidemiology; 2008: 8-15.
Hooten T, Bradley S, Cardenas D, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE; Infectious Diseases Society of America. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines. Clin Infect Dis 2010 Mar 1; 50(5):625-63.
Carr H. Catheter-associated urinary tract infections in adults: prevention through care and technology. Infection Control Today 1998;2(8):26-9. Also available: http://www.infectioncontroltoday.com
Donlan R. Biofilms and device-associated infections. Emerg Infect Dis 2001 March-April;7(2):277.
Biofilms. Chapter 70. In: Grota P, et al. (eds). 2014 APIC Text of Infection Control and Epidemiology, 4th ed. Arlington (VA): Association for Professionals in Infection Control and Epidemiology; 2014.