Hello, and welcome to the session, Stop the Landslide, Gaining Ground on Reducing Catheter-Associated Infections in the Intensive Care Unit. I'd like to introduce you to the speakers. My name is Kathleen Vollmann, and I'm a critical care clinical nurse specialist, educator, and consultant. And I've published and lectured nationally and internationally on a variety of critical care topics. I'm a subject matter expert for the Society of Critical Care Medicine on the CAUTI and CLABSI initiative for AHRQ, and also for the American Hospital Association on infection reduction, pressure injury reduction, sepsis, and culture of safety. Our next speaker, Pat Poza, who will be talking about CAUTI reduction strategies, is the quality and patient safety director for the adult hospitals at Michigan Medicine. Her prior role was a quality excellence leader for St. Joe Mercy Health System in Southeastern Michigan, leading various initiatives to reduce HACS, improve patient outcomes for critically ill patients, and reduce readmissions. She's very interested in sepsis and critical care. She serves on the advisory board for the Sepsis Alliance, and she has presented and published on HACS, sepsis, and other critical care topics. She also is a subject matter expert for the Society of Critical Care Medicine on CAUTI and CLABSI reduction for the AHRQ project. Dr. Will Miles is our third speaker, and he is going to be focusing on CLABSI reduction strategies. Dr. Miles is a director of the Surgical Critical Care Outreach and co-medical director of the Neurosurgical ICU at the University of North Carolina School of Medicine, their Charlotte campus. Will has published book chapters and over 500 articles and abstracts on infections and trauma. He's involved in the reduction of CAUTI and CLABSI rates for high-acuity surgical and neurosurgical ICUs, and also serves as a Society of Critical Care Medicine subject matter expert for the AHRQ initiative for CAUTI and CLABSI reduction in the intensive care unit. So we've got quite a lineup to provide some excellent information and evidence-based practices to help you in your journey. These are the overall objectives for the session. My objective will be to apply lessons learned during the pandemic to reboot quality initiatives to reduce hospital-acquired infections. Pat Pose's objective will be to analyze clinical indications for catheter placement and the use of alternatives to reduce urinary tract infections. And Dr. Miles' objective is to identify and detail evidence-based practices that go beyond guidelines in reducing central line-associated bloodstream infections in high-acuity ICUs. I wanted to put the web address for the AHRQ CAUTI and CLABSI prevention strategies in the ICU. There are a whole host of resources, and one of my favorite resources are the Make It Work tip sheets, things that we learned through these six cohorts to help teams overcoming certain hurdles in their initiatives. So I hope you have an opportunity to check it out. So I'm going to go ahead and get started, and my talk is called System Derailment, Getting Your Catheter-Related Quality Improvement Initiatives Back on Track. My disclosures, I'm a consultant on the Speaker Bureau for Stryker SAGE, Baxter Healthcare, and Botero Medical. We were doing pretty good on this CAUTI and CLABSI thing before the pandemic hit in most of our ICUs around the country, but there was a significant impact. This was a study that looked at the first three months of the pandemic compared to a similar period in 2019, looking at about 3,000 hospitals and about 13,000 inpatient units. And what did they find? Well, you can see that there was an overall 28% increase in the SIR. Device utilization increased a little. ICU SIR increase was significantly higher at 39% versus 13% for the wards. It happened in all shapes of hospitals and sizes and bed sizes. And interesting, don't know why, but the SIR rate was highest in the upper northeast region. In that study, they looked at qualitative feedback from the clinicians of rationale for why they believed the increase was happening. And what they talked about and what you've all experienced is the shortage of PPE that occurred during that. The staffing changes. In the beginning of the pandemic, it was a lot of non-ICU clinicians coming in to help, so may not be aware of the policies and processes that occurred. And later on, travelers reduced frequency of contact with the patient, therefore less bathing, alteration in line care. In the beginning of the pandemic, our lines were outside the room, pumps in the hallway, a lot less scrubbing the hub for compliance. A lot of our patients were upside down in the prone position, so line and dressing integrity was much more difficult to maintain. There were a lot more blood draws off the lines versus poking because of the exposure components. And also, some of our quality improvement rounding reduced during that time, and we had significant competing priorities happening. Some other things, overall pandemic fatigue, trying to reconcile the rapidly changing and conflicting guidance that occurred during that time, and also the increased workload that took place across the board. Now, this gives us additional data, moves us into the 2020 quarter three and quarter four, and you can see that initial increase that took place in terms of CLABSI, 27%, ranging and sustaining at about a 46%, 47% increase. CAUTI, we didn't have much of an increase in the beginning, but there was an increase that took place in the later quarters. And even though we're not focusing on this here, I want you to notice the VAE increase that took place, significant across those three quarters. Now, this was just published, giving us the data from year two or 2021. So, you can look at some of the preliminary data from the third quarter of 2021 in comparison to the third quarter of 2019, and you can look at those quarters as we go. You saw the increase, we had a drop in quarter two, but then it went back up in quarter three, and that parallels with what was happening in our ICU units. And you can see when we look at the overall increase, it was about an SIR of 1.03 compared to 2019 of 0.69. And you're looking at an SIR CAUTI of 0.8. It was 0.7 in 2019, so not as large of an increase. But I do, again, want to point out VAE was significant, 1.6 from 0.9 in 2019. And there is an associated cost, both clinically and financially. The clinical cost for every 1,000 in-hospital CLABSI cases, there are 150 excess deaths. And for CAUTI, for every 1,000 in-hospital CAUTI cases, there are in excess 36 deaths. And when we look at the financials associated with this, you're looking at about a $14,000 increase per CAUTI and about a $48,000 increase for CLABSI. One of the challenges we face with all our quality initiatives are system shocks. And probably the biggest shock we had to our system was the pandemic. But the ones that we routinely live with is leadership turnover, which can derail a process, financial constraints. We're experiencing those right now and had them all throughout the pandemic. EMR change, anytime you mess with anybody's documentation, that creates a challenge on the other things that are happening within the environment. And staffing turnover and shortages and onboarding is a huge issue right now, creating a lot of challenges in the environment for cementing processes to ensure that new groups coming in know what's going on in the environment. And then system mergers can also be a shock to our system. But even with system shocks, you can be successful. So it's really about resetting our culture. Florence Nightingale wrote this in 1859. It may seem a strange principle to enunciate that the very first requirement in a hospital is to do the sick no harm. So there's no question that our connective purpose is to do the right thing for the patient, prevent harm from taking place so that they can recover from their illness and thrive and function. And so getting that teamwork back is an important component. And so in a study that looked at the sixth cohort of the AHRQ initiative that I told you about in reducing ICUs that had higher levels of CAUTI and CLABSI, they had a pause during their initiative because of COVID. And so this group was different than the other five cohorts. So they interviewed them to identify themes that help them maintain and improve during COVID. And what they said is one of the themes was that they had already had CAUTI and CLABSI teams, policies and practices in place before the pandemic. And they felt that that really helped. That the teams had flexibility with regards to policies and procedures and implementation. And they were also able to maintain consistent buy-in and engagement for the HAI strategies, not only from the care teams, but also from the top leadership. And the last thing is one of the themes was that they learned from other units as a part of this initiative, whether they were in their own hospital or from outside where they were able to share ideas, which helped them sustain the improvement. So what teamwork strategies that were learned through the pandemic will help get your team back on track? Well, creative communication strategies. There were a lot of those that happened during the pandemic. Think about maintaining those. Faster development and approval of practice changes. How many of you whipped up a prone positioning protocol relatively quickly and got it passed and started educating and implementing? Yeah. So let's maintain that quicker process. Resiliency practices, both at the individual and organizational level, to help us stay both physically and emotionally strong through these processes. Managing change on the quick so that change doesn't take the two and a half years. And sometimes the concept of just do it. And one of the groups that I spoke with, they really said that there was a nimbleness that we didn't believe that we had. So we have to rebuild as we rebuild our teams. We have to ensure their psychological safety presence that I, as a person practicing in the environment, I can show you who I am without consequences or fear of negative consequences. If I'm a leader, I need to be present, transparent, and role model behavior. And I need to be positive and communicate effectively. We have to work at restoring trust, creating those learning environments where team members feel comfortable in expressing their opinion and also putting out solutions and focusing on our purpose. So some key team and culture work to re-engage is if you don't have a quality multidisciplinary group that meets once a month, create one that focuses on your quality and place CAUTI and CLABSI as permanent agenda items on the initiative. Consider revising goals of the work that you're on based on the current state because we're in a different current state than we were before the pandemic. Creating plans for re-engagement of staff post-COVID as well as re-engagement of physicians and our champions. So in re-engagement plan for nursing staff, key drivers to that engagement is really a staff member's ability to learn and grow in their work setting, a positive work culture that they trust in their leaders. So you're seeing themes here, and then I have a voice that can be heard. So how do I make that happen? Do it in small steps. Reconnect us, reconnect with the purpose. If you have shared governance, re-establish your shared governance at the unit level. Foster team work and communication at point of care. Do education at point of care as well. Ensure that recognition is taking place individual as well as unit. Point of care, learn from a defect, and I'll talk to you about that in a second. And again, reiterating this non-punitive response to errors. Strategies to engage providers. Find a passionate physician champion. It's great if they also serve as the medical director. Share data with physicians and providers on how the team can improve and discuss strategies at those team meetings. Engage physicians and providers specifically during those multidisciplinary rounds focused on not do we still need the catheter, but are we using the catheter to treat urine output on an hourly basis, something like that? Or does this patient still meet the criteria for the central line? And when the teams are having difficulties with a physician or provider, the champion will then go and facilitate a conversation and help everybody to get on the same page. Other strategies to engage providers, and you'll find some of these on the make it work tip sheet. Confirm all physicians receive individualized and pure reports of current data. So they get very specific data related to the lines that they've inserted or the catheters they've cared for and also culturing practices. Review current policies and evidence-based practices to make sure there's buy-in from the whole team. And have your physicians and providers participate in the learn from a defect analysis as a part of the learning journey. So when we look at it all together, share unit-specific data, you can see driving it with data with frontline physician and the safety committee. Refresh expectations on clinical practice and documentation. Refresh any unit-based improvement practices if the huddle went away. Start using the huddle again, unit-based council meetings, and learn from a defect. And I'll talk about that. And continue to measure and make data-driven decisions. One of the things that we've discovered as part of our learning journey is oftentimes staff, because this data comes in percentages and it comes a month later, that they aren't connecting it to the human being that's being harmed. And so it's not necessarily seen as a harm. So how do I address that? The way is to do an immediate huddle from a learn from a defect for both CAUTI and CLABSI. And these tools are available on the AHRQ website. And what that is, is the infection preventionist usually knows with about 80% certainty by about 48 to 72 hours that it's likely going to be an infection. They call up to the unit. The unit then goes right to the bedside and does an immediate learn from a defect. They develop an action plan. And then that information gets incorporated into the next 24-hour shift huddles. So everyone is aware that a harm occurred. And lastly, I'm going to reiterate again the importance of driving performance with data. Audits on insertion and maintenance practices specific to your areas of challenge, early and late infections so that you understand whether it is insertion or maintenance, and then display of a data and not in a graft. Do it where it has meaning because I got to tell you, if I have CLABSI, it's been 200 days since my last infection and that goes down to zero, I'm going to start asking questions. Thank you for the time that you spent with me. And Pat Posa will be talking about urine or you're out, controlling the flood of CAUTIs in your high acuity ICU. And Dr. Will Miles will be talking, it's still the wild, wild west, corralling CLABSI reduction in high acuity ICUs. Thank you and have a great day.

catheter-associated infections

intensive care unit

reducing infections

teamwork

data-driven decision-making