SummaryVHA Pennsylvania, a regional office of VHA, Inc., sponsored and coordinated a 1-year collaborative among 21 hospitals focused on urinary tract infection prevention. Each participating hospital defined its own performance goals and developed specific strategies to achieve them. Strategies generally fell into four categories, including daily physician/nurse review of criteria for catheter use, use of equipment to prevent infection, clinician and patient/family education, and data analysis of specific cases. VHA Pennsylvania staff supported the process through data display/performance reporting; coaching; and assistance in sharing best practices, resources, and tools. The program reduced urinary tract infections by 32 percent and the number of days that patients had catheters in place by 5 percent, leading to significant cost savings; some participants achieved larger reductions in infections and catheter use.Moderate: The evidence consists of pre- and post-implementation comparisons of urinary tract infections (UTIs) and the number of days patients had catheters in place, along with estimates of the number of prevented infections and associated cost savings.
Developing OrganizationsVHA Inc.; VHA Pennsylvania
VHA Pennsylvania is located in Pittsburgh, PA. The VHA national office is located in Irving, TX, and employs a clinical improvement services team that supports the efforts of regional offices to provide a comprehensive clinical improvement program to members.
Date First Implemented2008
Problem AddressedUTIs are the most common hospital-acquired infection,1 with extended catheter use being a primary cause of infection. Although effective strategies to prevent catheter-related UTIs exist, many hospitals and long-term care facilities do not implement them consistently or in a coordinated fashion.
- Common but preventable: UTIs account for almost 40 percent of all hospital-acquired infections, affecting approximately 600,000 inpatients annually. Most UTIs (between 66 and 86 percent) are associated with catheterization.1 The Centers for Medicare & Medicaid Services stopped reimbursing for treatment of hospital-acquired UTIs and other "preventable complications" in October 2008,2 making prevention a major focus for hospitals around the country.
- Extended catheter use as major preventable cause of infection: Catheters are warranted for a specific set of bladder-related problems (e.g., urinary tract obstruction and neurogenic bladder, a condition in which the bladder does not empty properly due to neurological dysfunction), but they should remain in place only as long as indications persist.3 However, in many hospitals, catheters may not be removed promptly, even if the patient's condition has resolved. Other common, catheter-related problems—such as nonsterile insertion and removal, poor catheter securement, and improper placement of drainage bags—also increase the risk of catheter-associated infection.
Description of the Innovative ActivityVHA Pennsylvania sponsored and coordinated a 1-year collaborative, spanning between June 2008 and June 2009, among 21 hospitals focused on UTI prevention. Each participating hospital defined its own performance goals and developed specific strategies to achieve them. Strategies generally fell into four categories, including daily physician/nurse review of criteria for catheter use, use of equipment to prevent infection, clinician and patient/family education, and data analysis of specific cases. VHA Pennsylvania staff supported the process through data display/performance reporting; coaching; and assistance in sharing best practices, resources, and tools. Key program components included the following:
- Hospital-developed goals and strategies: Each participating hospital developed a specific, aggressive goal for reducing UTIs, with target reductions ranging from 10 to 50 percent. Each hospital then developed customized strategies designed to achieve its goal; an example of the approach taken by three representative hospitals follows:
- Jefferson Regional Medical Center: Jefferson Regional Medical Center in Pittsburgh implemented more than 20 activities to prevent UTIs, including a physician order sheet that prompts daily review of criteria for continued catheter use, a protocol for urinalysis and culture collection, a patient/family education pamphlet describing the indication for and care of a catheter, hospital-wide clinician education, and mandatory demonstration of competency with respect to catheter care and insertion.4
- Reading Hospital and Medical Center: Reading Hospital and Medical Center in West Reading, PA, implemented a protocol that specifies the circumstances in which nurses can remove catheters without physician order, a survey to identify barriers to catheter removal, a comprehensive staff education program that addressed misconceptions and emphasized the importance of catheter removal and the need to keep the bag below the patient's bladder, leadership rounding focused on UTI prevention and other quality outcomes, and use of stickers on urine bags that indicate catheter insertion date and other critical information.4 A UTI Prevention Team meets monthly and reviews all UTI cases to ensure that the protocol for early removal was followed. The physician champion follows up with physician-specific quality of care issues regarding catheter use. Furthermore, in 2010 the team facilitated the integration of the UTI prevention strategies (protocol information, prompts for urine specimen collection, catheter removal) into the hospital's automated clinical documentation system. For example, the reason the indwelling urinary catheter was not removed is a required field if the urinary protocol score met the criteria for removal and the catheter was not removed. In addition, best practices for catheter care (securing device, maintaining a closed system, indications for insertion) were added to the clinical documentation system to ensure appropriate care and documentation. A preformatted progress note was created to ensure the inclusion of the appropriate indications for insertion.
- Jameson Memorial Hospital: Jameson Memorial Hospital in New Castle, PA, implemented several interventions to help prevent UTIs, such as hospital-wide education for all departments that have interaction with patients, daily review of criteria (physician and nurse), consistent use of drainage bag covers and clips, and publication of a "Potty Press" staff newsletter. As of 2011, hospital has continued its prevention measures including avoidance of inserting a Foley catheter and appropriate care of the catheter and the drainage system. The hospital has developed a "Follow the Foley" tool to help clinicians monitor the care of the Foley catheter, and the daily assessment for removal has gone through multiple revisions. The form serves as a reminder to staff and physicians to assess the need for the catheter and to remove it as soon as possible. The removal of the catheter by postoperative day 2 for surgical patients has been a driving force in the implementation of the new "Follow the Foley" form; the hospital has set 2 days as the goal for Foley catheter removal in medical patients as well.
- Common strategies: Participating hospitals adopted some or all of the following strategies—daily review of catheter use criteria, use of equipment to reduce infection risk, education, and data analysis.
- Daily review of criteria: A strict set of criteria directs catheter use at many participating hospitals, with a daily review to ensure each patient meets the criteria. Patients generally qualify for a catheter if one of the following applies: urinary obstruction, recent urologic surgery, pressure ulcers caused or exacerbated by incontinence, neurogenic bladder, or a care plan that requires an accurate measure of urinary output. Hospitals typically incorporate these criteria into a tool, such as a form, checklist, or sticker, with nurses and/or physicians reviewing the criteria on a daily basis. At least one criterion must be present to justify continued catheter use; in these cases, physicians must formally confirm the order for continued catheter placement.
- Specialized equipment to reduce UTI risk: Participating hospitals considered the use of specialized equipment that could reduce UTI incidence. VHA Pennsylvania assisted with equipment purchases requested by the hospitals but did not recommend certain brands. Examples of equipment used by participating hospitals include the following:
- Securement devices: Participating hospitals use devices that secure the catheter to the patient's leg, thus reducing the risk that patient movements will cause the catheter to move, potentially allowing bacteria to enter the urinary tract and cause an infection.
- Bladder scanner: Catheters are indicated in patients who cannot empty their bladders due to a variety of conditions. Some participating hospitals use a bladder scanner to perform an ultrasound and determine the fullness of the bladder (and thus the need for a catheter) in patients who report symptoms of bladder fullness.
- Items to secure drainage bag: Some participating hospitals use hooks, bag covers, and other devices to secure and protect the urine drainage bag. These items keep the drainage bag below the level of the patient's bladder (to ensure that urine does not travel back into the bladder), while also preventing the bag from touching the floor or a wheelchair wheel, thus ensuring the bag remains clean and uncontaminated.
- Silver-alloy catheter: A silver alloy catheter has a special coating that makes it resistant to bacterial colonization; 13 of the 21 participating hospitals use this type of catheter, with the rest using traditional catheters.
- Training and education: Participating hospitals engaged in various efforts to educate and train clinicians on appropriate catheter use, with common approaches outlined below:
- Customized, departmental training: All departments within each participating hospital received customized education about UTI prevention. For example, Jameson Hospice of Lawrence County conducted comprehensive staff training and created job-specific training sheets to ensure that staff members understood how to prevent UTIs and to identify risk factors (e.g., a tube or bag that is touching the floor).4
- Catheter placement/removal competency testing: Some nursing departments within participating hospitals adopted the use of periodic testing to ensure nurse competence in catheter placement and removal, often using simulation.
- Educational publications: Participating hospitals typically include information about UTI prevention in publications. For example, Jameson Memorial Hospital in New Castle developed a bimonthly newsletter specifically focused on UTI prevention and performance4; other hospitals embed UTI education and information in hospital-wide publications or via streaming automation.
- Patient/family education: Patient and family members typically receive education in oral and/or written form. Some hospitals, including Jefferson Regional Medical Center in Pittsburgh, distribute patient-specific pamphlets.4
- Data analysis: Infection control staff at each hospital reviewed a monthly list of UTI patients and identified common causes of infection, which, in turn, allowed for one-on-one staff education when appropriate and/or the development and adoption of system-wide approaches to reducing UTIs.
- VHA support: VHA Pennsylvania supported participating hospitals during the 1-year initiative by providing data analysis and benchmarking reports; coaching; and assistance in sharing best practices, tools, and other resources, as outlined below:
- Data analysis and benchmarking reports to stimulate quality improvement: VHA Pennsylvania collected and shared infection data across participants, thus allowing them to benchmark their own performance against similar-sized hospitals.
- Coaching: The director of performance improvement at VHA Pennsylvania provided monthly coaching to hospital teams over the telephone and through onsite meetings.
- Sharing of best practices and resources: VHA Pennsylvania hosted quarterly conference calls for participants to share best practices on UTI prevention. During these calls, VHA representatives encouraged participants to post any useful tools, forms, protocols, policies, or other resources on the VHA Web site, thus allowing participants to adopt these resources (adapting them to local needs as necessary) rather than "reinventing the wheel."
Context of the InnovationVHA, Inc., is a national health care provider network that is headquartered in Irving, TX, with 16 regional offices around the United States. These offices work with hospitals and health systems on a variety of issues, including supply chain management and clinical performance improvement. VHA Pennsylvania, located in Pittsburgh, currently serves 25 hospitals and health systems in the state. Performance improvement executives within these member institutions drive the selection of collaborative initiatives, typically focusing on topics related to regulatory requirements or reimbursement. VHA Pennsylvania has historically worked with members on prevention of hospital-acquired infections, including ventilator-associated pneumonia and central line bloodstream infections; addressing UTI prevention represented a natural next step, and, consequently, this topic became the focus of clinical improvement efforts for the 2008 to 2009 year.
ResultsThe program reduced UTIs by 32 percent and the number of days that patients had catheters in place by 5 percent, leading to significant cost savings; some participants achieved larger reductions in infections and catheter use.
Moderate: The evidence consists of pre- and post-implementation comparisons of urinary tract infections (UTIs) and the number of days patients had catheters in place, along with estimates of the number of prevented infections and associated cost savings.
- Fewer UTIs and catheter days: Between June 2008 and June 2009, participating hospitals reduced UTIs by 32 percent and the number of inpatient days in which catheters were used by 5 percent. Most participating hospitals (15 of 21) achieved their stated goal with respect to UTI reduction.
- Lower costs: The 32-percent reduction in UTIs translated into a total of 44 avoided infections, which yielded an estimated cost savings of $26,500 (assuming each infection costs $600 to cover antibiotics and an additional inpatient day). These figures were derived from calculations of participating hospitals that analyzed their costs associated with UTIs.
- Larger reductions at some hospitals4: Although individual hospital results varied, some participants achieved larger reductions in UTIs and catheter days. For example, Jefferson Regional Medical Center cut UTIs in half and reduced catheter days by 15 percent. Jameson Memorial Hospital also reduced UTI rates by 50 percent and reduced catheter days by 23 percent, and Reading Hospital and Medical Center experienced a 28-percent decline in catheter use days and lowered its infection rate to less than one catheter-associated UTI per 1,000 catheter days. Hospitals that achieved better initial results started earlier with the application of change ideas and tended to reach their goals sooner, whereas others continued to work toward and achieved their goals after the formal end of the yearlong collaborative. Information provided in March 2011 indicates that Reading Hospital had a catheter-associated UTI rate of 1.01 per 1,000 catheter days in 2010; Jefferson Regional Medical Center reduced its UTIs from 166 in 2007 to 23 in 2009 and 24 in 2010; and Jameson Hospital had a UTI rate of 0.37 per 1,000 catheter days in 2010.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Engaging senior leadership support: In early 2008, at a VHA Pennsylvania board meeting, member hospital chief executive officers (CEOs) were informed of the upcoming VHA collaborative to reduce UTIs. By providing data on various clinical improvement initiatives and activities that were a priority for hospital leaders, VHA was able to obtain participation endorsement by the CEOs. Each participating hospital CEO signed an agreement to support the program and was provided with periodic updates regarding participant progress. The chief nursing officers were also informed of the opportunity and endorsed participation as well. Some even participated on their hospital teams that worked to reduce UTIs.
- Submission of baseline data: Each participating hospital submitted baseline UTI data to VHA Pennsylvania.
- Distribution of best practices: VHA, Inc., distributed three "leading practice blueprints" describing best practices for UTI prevention used by organizations that have been successful in reducing infections.
- Gap assessment: Participating hospitals performed a formal gap assessment to determine how their own practices differed from the leading practices laid out in the blueprints, with the goal of identifying opportunities for improvement. VHA Pennsylvania's director of performance improvement traveled to each hospital to assist with this process.
- One-day training: Teams from each participating hospital (typically including an infection control practitioner, a performance improvement representative, and a staff nurse) participated in a 1-day meeting held at the VHA Pennsylvania office. At this session, VHA national office staff delivered a specially developed training program designed to teach the teams how to identify, develop, adopt, and adapt strategies to prevent catheter-associated UTIs.
Resources Used and Skills Needed
- Staffing: The program required no new staff, as program development and implementation were integrated into the daily responsibilities of existing staff.
- Costs: Costs incurred by each hospital varied, depending, for example, on what new equipment was purchased and how much time staff spent developing and implementing quality improvement strategies.
Funding SourcesVHA Pennsylvania; VHA Inc.
VHA membership fees covered the cost of their participation, whereas participating hospitals bore the costs of developing and implementing the various strategies.
Tools and Other ResourcesThe Centers for Disease Control and Prevention (CDC) guideline for preventing catheter-associated UTI is available at http://www.guideline.gov/content.aspx?id=15519&search=%23%237596.
A guideline from the Infectious Diseases Society of America, entitled "Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals," is available at http://www.guideline.gov/summary/summary.aspx?doc_id=13394&nbr=006805&string=urinary+AND+tract+AND+infection.
Getting Started with This Innovation
- Ensure CEO support: Engage hospital leaders by sharing data documenting the prevalence and costs of hospital-acquired UTIs.
- Involve all departments from the outset: Including every department in program planning will help to secure the support of all staff who come into contact with patients having a catheter.
- Tailor education to needs of each department: Staff members need to understand how to recognize risk factors for UTI and what they can do to prevent infection on a daily basis.
- Ask frontline staff to identify barriers to UTI prevention: Practical information about barriers to UTI prevention can support the development of process improvements, strategies, and tools to reduce infection.
- Train all nurses on catheter insertion and removal: Do not assume that experienced nurses know how to properly insert and remove a catheter. Train all staff regardless of how long they have been practicing.
- Consider multidisciplinary rounding: Having nurses and physicians review the need for continued catheter use on a daily basis can lead to more informed decisions.
Sustaining This Innovation
- Collect and share data on program impact: Collect and share data to encourage ongoing improvement and to maintain the support of senior leaders.
Contact the InnovatorMark Tino
Vice President, Performance Improvement
VHA Mid-Atlantic region
Innovator DisclosuresMr. Tino has not indicated whether he have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesHospitals in Pennsylvania Prevent Urinary Tract Infections, Nursezone.com. Available at: http://www.nursezone.com/nursing-news-events/more-news/Hospitals-in-Pennsylvania-Prevent-Urinary-Tract-Infections_29810.aspx
Rosenthal MB. Nonpayment for performance? Medicare's new reimbursement rule. N Engl J Med. 2007;357:1573-5. [PubMed]
4 Hospitals in Pennsylvania prevent urinary tract infections, Nursezone.com. Available at: http://www.nursezone.com/nursing-news-events/more-news/Hospitals-in-Pennsylvania-Prevent-Urinary-Tract-Infections_29810.aspx
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Original publication: February 03, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: May 08, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 02, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.