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Introducing the No Preventable Harms campaign: Creating the safest health care system in the world, starting with catheter-associated urinary tract infection prevention

      Highlights

      • We describe a regional campaign to reduce hospital-acquired conditions.
      • Catheter-associated urinary tract infection (CAUTI) prevention was the first focus.
      • CAUTI rates significantly declined in nonintensive care units after the initiative.
      • Qualitative evaluation provided several themes for improving regional initiatives.
      • A regional collaborative appears to be a useful strategy for reducing patient harms.

      Background

      Endemic health care-associated safety problems, including health care-associated infection, account for substantial morbidity and mortality. We outline a regional No Preventable Harms campaign to reduce these safety problems and describe the initial results from the first initiative focusing on catheter-associated urinary tract infection (CAUTI) prevention.

      Methods

      We formed a think tank composed of multidisciplinary experts from within a 7-hospital Midwestern Veterans Affairs network to identify hospital-acquired conditions that had strong evidence on how to prevent the harm and outcome data that could be easily collected to evaluate improvement efforts. The first initiative of this campaign focused on CAUTI prevention. Quantitative data on CAUTI rates and qualitative data from site visit interviews were used to evaluate the initiative.

      Results

      Quantitative data showed a significant reduction in CAUTI rates per 1,000 catheter days for nonintensive care units across the region (2.4 preinitiative and 0.8 postinitiative; P = .001), but no improvement in the intensive care unit rate (1.4 preinitiative and 2.1 postinitiative; P = .16). Themes that emerged from our qualitative data highlight the need for considering local context and the importance of communication when developing and implementing regional initiatives.

      Conclusions

      A regional collaborative can be a valuable strategy for addressing important endemic patient safety problems.

      Key Words

      The Institute of Medicine's seminal report on patient safety, To Err Is Human,
      led to widespread efforts to improve the safety of patients; yet, much work remains. Patient safety hazards range from rare, but catastrophic “never events”

      Agency for Healthcare Research and Quality Patient Safety Network. Patient Safety Primer: Never Events. 2010. Available from: http://www.psnet.ahrq.gov/primer.aspx?primerID=3. Accessed March 30, 2012.

      such as operating on the wrong patient or amputating the wrong limb to less newsworthy problems that occur every day in hospitals around the world such as developing delirium or a pressure ulcer. These endemic health care-associated safety problems, which include health care-associated infection, account for far greater morbidity and mortality than “never events.” Although efforts addressing safety have increased in recent years, the absence of a framework for identifying and prioritizing interventions has limited our ability to demonstrate progress in patient safety.
      • Pronovost P.J.
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      Recognizing this, a translational research framework for reducing preventable harm—ranging from discovery to implementation and evaluation—has been proposed.
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      Coordinated and structured approaches organized at the health system,
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      The quality ‘journey’ at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year–and aim to do even better.
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      Legacy Health's ‘Big Aims’ initiative to improve patient safety reduced rates of infection and mortality among patients.
      regional,
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      How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care.
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      and national
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      Preventing bloodstream infections: a measurable national success story in quality improvement.
      levels have demonstrated significant reductions in preventable deaths, health care-associated infection, and costs. These successes, marked by leadership support, clearly stated goals, organization-wide cooperative efforts, and transparency of results, offer promising insights into how the national goals of reducing preventable patient harm can be achieved.
      Serving almost 9 million veterans each year, the Veterans Healthcare Administration (VHA) is the largest integrated health care system in the United States,

      U.S. Department of Veterans Affairs. Veterans Health Administration: Providing Health Care for Veterans. 2014. Available from: http://www.va.gov/health/. Accessed March 24, 2014.

      and 1 of the largest in the world. A broad spectrum of services is available to veterans, including primary, acute medical, surgical, psychiatric, rehabilitative, and long-term care. The VHA, which manages 150 hospitals, more than 800 community-based outpatient clinics, and 135 nursing home care units, is organized into 21 regional networks called Veterans Integrated Service Networks (VISNs).

      U.S. Department of Veterans Affairs. About VA: VA History. 2014. Available from: http://www.va.gov/about_va/vahistory.asp. Accessed March 24, 2014.

      Each VISN coordinates the activities of the medical facilities in its region to better meet veterans' health care needs.
      One such regional network, VISN 11, which includes 7 acute care hospitals and 29 community-based outpatient clinics located in central Illinois, Indiana, Michigan, and northwest Ohio, engaged in a campaign to aggressively enhance veteran safety by addressing harms in the acute care setting. This initiative is called the No Preventable Harms campaign and is led by regional leadership. Our objective is to describe the overall campaign and provide preliminary results of the first initiative. Our overarching purpose is to provide guidance to infection control professionals who work as part of larger health care systems and are involved in implementing best practices to prevent infection. Given the movement in the United States of health care increasingly being delivered as part of accountable care organizations,
      • Berwick D.M.
      Launching accountable care organizations–the proposed rule for the Medicare Shared Savings Program.
      such guidance may be useful to enhance the safety of hospitalized patients.

      Methods

      Overview of the No Preventable Harms campaign

      During March 2011 the regional leadership formed a think tank, which was tasked with developing initiatives to help keep veteran patients safe. A multidisciplinary team of patient safety experts was recruited from the 7 regional hospitals. The explicit goal was to create the safest health care system in the world, 1 region at a time beginning with VISN 11. At the first meeting, the regional director led the think tank in a discussion to identify the scope and objectives of the No Preventable Harms campaign (Table 1).
      Table 1No Preventable Harms campaign think tank's scope and goals
      Questions discussed during think tank formationDecisions
      What are the harms we'd like to prevent?Common, important harms, ideally where outcome data is already being collected, to minimize burden to hospitals
      Where do we get the evidence and practices?Published peer-reviewed literature and ideally a successful pilot study at 1 of 7 regional hospitals
      Ownership to look at evidence and practices?Membership of the think tank and/or ad hoc experts from regional hospitals
      Definition of scope (inpatient, outpatient, long-term care)?Initial focus will be inpatient care, specifically preventing hospital-acquired conditions
      Determination of overarching strategy?Go slow and ensure initial success
      How will we know it is working?Set up evaluation plan with each initiative, minimizing data collection burden. Compare results with other Veterans Affairs hospitals that are not participating in the initiative
      The think tank decided to initially focus on the acute care setting because data for evaluation was already being collected and reported to the Department of Veterans Affairs (VA) Inpatient Evaluation Center (IPEC),
      • Render M.L.
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      • Sales A.E.
      • Deddens J.
      • et al.
      Infrastructure for quality transformation: measurement and reporting in veterans administration intensive care units.
      a national quality improvement program that electronically collects data from VA computer databases and through facility reports to monitor evidence-based practices. To accomplish this, the think tank adopted the following principles:
      • 1.
        The harm should be a hospital-acquired condition that health care workers within the region would likely consider important to prevent;
      • 2.
        There should be data that are currently being collected (eg, IPEC data) to evaluate the incidence of the harm or include data collection as part of the intervention (a so-called measure-vention);
        • Maynard G.
        • Stein J.
        Designing and implementing effective venous thromboembolism prevention protocols: lessons from collaborative efforts.
      • 3.
        The evidence to prevent the harm must be strong and come from the peer-reviewed literature ideally coupled with pilot implementation at a VA (or non-VA) hospital with proven success;
      • 4.
        Explicit guidance should be available to the hospitals on how to implement changes and how to ramp-up efforts if they are not achieving the goal reductions in the complication; and
      • 5.
        The campaign initiatives would be evaluated using both quantitative and qualitative assessment, and lead to changes in the initiative and future initiatives as necessary.
      Based on these criteria, the think tank identified patient harms with strong evidence for prevention strategies, such as health care-associated infection,
      • Magill S.S.
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      • Beldavs Z.G.
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      Multistate point-prevalence survey of health care-associated infections.
      given the clinical and economic consequences of each episode. Next, initiatives were identified to prevent these harms that had been successful at either a single medical center or a group of hospitals. Finally, programs were developed to promote spread of these initiatives throughout the entire region, focusing on a single complication at a time.

      Catheter-associated urinary tract infection (CAUTI) prevention

      The first harm chosen to be addressed throughout the region as part of the No Preventable Harms campaign was CAUTI. We chose CAUTI for several reasons. Approximately 25% of hospitalized patients have an indwelling urinary catheter at any given time,
      • Gokula R.R.
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      • Smith M.A.
      Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital.
      and CAUTI accounts for approximately one-third of all device-related infections.
      • Magill S.S.
      • Edwards J.R.
      • Bamberg W.
      • Beldavs Z.G.
      • Dumyati G.
      • Kainer M.A.
      • et al.
      Multistate point-prevalence survey of health care-associated infections.
      In addition, use of urinary catheters can increase patient risk for noninfectious complications, such as urethral stricture.
      • Hollingsworth J.M.
      • Rogers M.A.
      • Krein S.L.
      • Hickner A.
      • Kuhn L.
      • Cheng A.
      • et al.
      Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis.
      Given the ubiquity of urinary devices,
      • Schuur J.D.
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      • Hou P.C.
      Urinary catheter Use and appropriateness in U.S. Emergency departments, 1995-2010.
      potential consequences for patients,
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      • Cheng A.
      • et al.
      Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis.
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      and growing costs to hospitals,
      • Jarvis W.R.
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      • Saint S.
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      safe urinary catheter use should be a priority. Yet CAUTI has proven difficult to reduce. Studies have shown that urinary catheter use is inappropriate in at least one-third of the days that patients are catheterized.
      • Jain P.
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      • David A.
      • Smith L.G.
      Overuse of the indwelling urinary tract catheter in hospitalized medical patients.
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      • Jones S.R.
      • Morthland V.H.
      Nosocomial urinary tract infection: a prospective evaluation of 108 catheterized patients.
      Physicians commonly forget about, or were never aware of the presence of the catheter, contributing to prolonged catheterization.
      • Saint S.
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      • Bernstein M.L.
      • Patel U.D.
      • Zemencuk J.K.
      • et al.
      Are physicians aware of which of their patients have indwelling urinary catheters?.
      Evidence suggests that avoiding unnecessary initial placement, as well as the use of urinary catheter reminders and stop-orders to promote prompt removal of unneeded catheters can help reduce CAUTI.
      • Knoll B.M.
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      • et al.
      Reduction of inappropriate urinary catheter use at a Veterans Affairs hospital through a multifaceted quality improvement project.
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      • Saint S.
      Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review.
      The region-wide CAUTI initiative was heavily based on a successful intervention that involved a nurse-initiated urinary catheter removal protocol to promote timely catheter removal and was initially developed and pilot-tested at the VA Ann Arbor Healthcare System.
      • Miller B.L.
      • Krein S.L.
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      • Zawol D.
      • Lyons A.
      • et al.
      A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center.
      An electronic medical record nursing template was developed to assist with daily assessments for the presence of and appropriateness of urinary catheters based on the Centers for Disease Control and Prevention guidelines.

      Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. 2009. Available from: http://www.cdc.gov/hicpac/cauti/002_cauti_toc.html. Accessed April 23, 2014.

      The template also prompts nurses to contact physicians for a removal order when the catheter is no longer indicated. Standardized closed-system catheter kits were purchased to help prevent the introduction of bacteria into the system. At the VA Ann Arbor Healthcare System there was a sizable decrease in the CAUTI rate after the introduction of the CAUTI Prevention Program, from 13.1 infections per 10,000 patient days before the intervention to 8.0 per 10,000 patient days after the intervention (39% decrease; P = .04). The proportion of inappropriate catheters—based on point prevalence studies—also decreased substantially after the intervention, from 13.3% to 2.3% (P = .06).
      • Miller B.L.
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      • Lyons A.
      • et al.
      A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center.
      We took a stepwise approach to addressing CAUTI in the other 6 hospitals of VISN 11. The first step, reviewing CAUTI rates across the region, led to the conclusion that the region-wide CAUTI rate was well above the collaborative target rate of 2 CAUTI per 1,000 catheter days (admittedly with some variability among hospitals). This benchmark was based on the median national rate reported by the National Healthcare Safety Network (NHSN), stratified by type of unit (intensive care unit [ICU] or ward).
      • Dudeck M.A.
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      • et al.
      National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module.
      Step 2 involved identifying which urinary products each hospital was using. This required a survey of each hospital and, in some cases, a conversation with the infection preventionist or other personnel at each hospital to identify exactly what products were being used. For CAUTI prevention, such queries focused on the exact type of Foley catheter and whether an antimicrobial urinary catheter was being used, the type of condom catheter used in men, and whether portable bladder ultrasound scanners were available at the facility. There was also great variability in the processes of care, including the brands and types of urinary catheters and trays carried by each facility. For example, in many facilities the catheters were packaged separate from the insertion tray, which included the drainage bag and tubing, and were thereby not considered closed drainage systems. Additionally, some facilities were using antimicrobial catheters for all insertions despite these catheters often being more costly and recently were found to not significantly reduce CAUTI when compared with noncoated catheters.
      • Pickard R.
      • Lam T.
      • MacLennan G.
      • Starr K.
      • Kilonzo M.
      • McPherson G.
      • et al.
      Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial.
      Step 3 entailed the regional network office providing guidance to each hospital about the standard practices recommended to prevent CAUTI as well as additional interventions that should be used if rates were higher than the agreed upon benchmark, as described in more detail in the next section.

      Two-tiered approach to CAUTI prevention

      The No Preventable Harms CAUTI initiative utilized a 2-tiered approach for CAUTI prevention (Fig 1). Tier 1 practices are to be used by all facilities and include daily monitoring for continued catheter use and use of a standardized catheter kit. The regional network office worked through the contracting procedures to allow each facility to purchase the recommended standardized closed-system Foley catheter insertion kits. These kits include directions for use, a list of the Centers for Disease Control and Prevention indications for urinary catheter use, an insertion checklist, maintenance checklist, and patient education. The supply processing department at each facility was advised to remove all kits that were no longer recommended for use as well as individual urinary catheters from their stock, such as antimicrobial urinary catheters that were no longer recommended based on the evidence.
      • Pickard R.
      • Lam T.
      • MacLennan G.
      • Starr K.
      • Kilonzo M.
      • McPherson G.
      • et al.
      Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial.
      Each facility was also provided with the electronic nursing template for monitoring urinary catheter presence and indications for use that had been pilot-tested at the VA Ann Arbor Healthcare System. When a catheter is present but deemed not appropriate, nurses are prompted to contact a physician to discuss removal of the catheter.
      Figure thumbnail gr1
      Fig 1No Preventable Harms campaign 2-tiered approach to catheter-associated urinary tract (CAUTI) prevention. BDOC, bed-days of care; ICU, intensive care unit; VISN, Veterans Integrated Service Network.
      Facilities were asked to report the number of CAUTIs each month. Evaluation was performed using both the NHSN rate of CAUTI per 1,000 catheter days, as well as a population-based measure of CAUTI per 10,000 bed days of care.
      • Fakih M.G.
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      • et al.
      Introducing a population-based outcome measure to evaluate the effect of interventions to reduce catheter-associated urinary tract infection.
      If a facility's average CAUTI rate for a 6-month period exceeded both of the assigned thresholds, the facility was encouraged to proceed to the more time-intensive Tier 2 activities, which included documenting insertion competency and performing a focused review or root cause analysis of all CAUTI events (Fig 1).

      Qualitative outcomes

      Qualitative research is well suited for answering how facilities implement infection prevention initiatives, factors that may hinder the process, and how knowledge gained from implementation of 1 initiative can subsequently inform those that follow.
      • Forman J.
      • Creswell J.W.
      • Damschroder L.
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      As part of the evaluation of the program, several team members (SS, SK, KF, MH, and EG) conducted facility site visits to better understand how the No Preventable Harms campaign was implemented. A total of 46 interviews across 6 facilities were conducted focusing on where each site was in the process, barriers they encountered, and decisions they made in response to those barriers. Our goal of the interviews was 2-fold. First, we wanted to provide immediate feedback to regional leadership about how the process was going and what, if any, additional support and resources were needed to help with implementation. Second, we intended to use our findings to inform future initiatives.
      Given the timeframe for the interviews and need for immediate feedback to regional leadership, we chose a rapid analysis approach to analyze our data,
      • Beebe J.
      Basic concepts and techniques of rapid appraisal.
      which entails developing domains, coding the transcripts with these domains, and then writing summaries of the data. Two team members (MH and EG) read the transcripts and summarized the findings focusing on the factors that impeded implementation and, given each site's experience, the feedback they would provide regional leadership to improve the implementation process. The summary findings were then discussed by team members and verified. The evaluation of the No Preventable Harms CAUTI initiative was approved by the VA Ann Arbor institutional review board.

      Results

      Using IPEC data, we compared regional CAUTI rates per 1,000 catheter days for the 27 months before (October 2010-December 2012) and 15 months after the initiative (January 2013-March 2014). The average preintervention CAUTI rate per 1,000 catheter days was 2.4 in non-ICUs and 1.4 in ICUs. That rate decreased to 0.8 CAUTI per 1,000 catheter days (P = .001) in the non-ICUs, but increased to 2.1 CAUTI per 1,000 catheter days in the ICUs (P = .16) after the start of the CAUTI initiative (Fig 2 A & B). As demonstrated in Figure 3, the CAUTI rate per 1,000 catheter days was elevated during the initial 6 months of the program, but then decreased by 55% in non-ICU units to 0.56 (P = .10) and 76% in the ICU to 0.93 (P < .001) in the next 9 months of the program.
      Figure thumbnail gr2
      Fig 2Catheter-associated urinary tract infection (CAUTI) rate per 1,000 catheter days in (A) nonintensive care units (ICU) and (B) ICU units. Time period reported by quarter year, October 2010-March 2014.
      Figure thumbnail gr3
      Fig 3Catheter-associated urinary tract infection (CAUTI) rate per 1,000 catheter days by month after implementation of a CAUTI initiative. ICU, intensive care unit.

      Qualitative evaluation

      Some of our major opportunities for improvement (Table 2) consisted of the role local context and communication had in the implementation process. For example, the diversity across sites with respect to patients and services, with some providing less acute and more long-term care, suggested a need for more flexibility and room for individualization given the local context. Some sites also expressed a desire for increased communication from the regional network and for the opportunity to provide more input as the initiatives are developed and disseminated. Feedback from the site visit team to regional leadership on initiative development and implementation highlighted what support and resources could assist with implementation of future initiatives.
      Table 2Feedback to regional network from site visits
      Opportunity for improvementExample quote(s)
      Consider local policies and procedures“I think it's a good idea to take into consideration local policies and procedures about changes in documentation.”
      Allow the initiative to be individualized according to site/unit“Make room for the ability of that team on the ground to individualize or personalize their model because there are some significant differences.”

      “I think there's definitely a need for flexibility. We have to consider the uniqueness of the patient populations in each facility…”
      One initiative at a time/provide time between initiatives“I think if they didn't do so many at one time, that might help.”

      “The first thing, give us a break, let us breathe in between…give us time to adjust and settle into the new changes.”
      Make sure all stakeholders are involved in initial conversations and have input“…if we are going to kind of agree to things as a VISN, it might be better to everyone get together and kind of talk face to face.”

      “A really good [clinical applications coordinator]…they've got their thoughts together and they're looking at [it] system-level…”
      Be clear about who should be involved at the local level (eg, champions and a project manager). Involve all affected staff“Rolling out a new program you need a work group of all your process owners or it's going to fail.”

      “You need frontline staff, they're the ones out there doing the work…”

      “Yeah that's what we need [a project manager]. We don't have that.”

      “At each institution there has to be a physician and a nursing champion…”

      Discussion

      We describe a regional patient safety collaborative of 7 hospitals that are part of the national VHA in which we first addressed the issue of CAUTI. The VHA's organization into 21 regional networks makes it an especially successful model to enhance patient safety and decrease preventable harms. Rather than responding as individual hospitals, the collaborative effort of a VISN-wide initiative capitalizes on centralized and consistent expertise, greater bargaining and purchasing power, onsite coaching, and an ability to share experiences between various sites. Indeed, the VHA's infrastructure lends itself to national spread once the best practice and implementation strategy has been identified through this regional work. We are currently partnering with the VA National Center for Patient Safety on a national CAUTI collaborative within the VHA.
      Such an evidence-based model to ensure patient safety can help inform the patient safety work in other countries that have integrated health systems, such as England, Italy, Thailand, Japan, and others. Through some of our work in such countries
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      we recognize the important roles national and regional culture plays in implementation as recently described by Borg;
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      thus, any collaborative in these venues should ideally also be based on local and regional work before widespread dissemination. Our initial focus on CAUTI parallels the decision made by the Centers for Medicare and Medicaid Services to choose CAUTI as the first hospital-acquired condition chosen for nonpayment during 2008.
      • Saint S.
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      Thus far, the No Preventable Harms campaign appears to have decreased CAUTI rates in non-ICU settings, a phenomenon also being observed outside of VHA. Specifically, a federally funded national collaborative of nearly 1,000 non-VHA hospitals
      • Fakih M.G.
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      had similar findings to our VHA project: Preliminary results indicate non-ICUs have decreased their CAUTI rates by 25%, whereas the rate in ICUs has increased by 5%.

      Health Research & Educational Trust. Eliminating CAUTI: A National Patient Safety Imperative: Interim Data Report on the National On the CUSP: Stop CAUTI Project. Agency for Healthcare Research and Quality (AHRQ); July 2013. Available from: http://www.ahrq.gov/professionals/quality-patient-safety/cusp/using-cusp-prevention/cauti-interim/index.html. Accessed May 28, 2014.

      The reason that ICUs have lagged in CAUTI prevention remains unclear but could, in part, be related to the culture in many ICUs in which Foley catheters are considered standard care.
      A key strength of our study is the coupling of quantitative results with site visits that yielded important qualitative findings that will be used to inform future initiatives within the No Preventable Harms campaign as well as spreading CAUTI prevention throughout VHA. We found that sites were willing to provide advice for how to better implement regional initiatives, especially improved communication between the regional network office and individual facilities beginning at the development stages. Specifically, almost all interview participants mentioned communication as a factor that needed improving. Communication related to such things as explanations for why the sites were being asked to implement this initiative, why a new documentation template was needed, why a specific catheter product had been chosen, and who was going to be the onsite coordinator and initiative leader.
      In addition to collecting data, the site visit team was able to provide advice to the facilities regarding any implementation issues they were encountering. This included technical guidance—providing a bladder scanner protocol, answering questions related to use of condom catheters, and discussing application of the NHSN surveillance definition—and socioadaptive advice such as providing recommendations for additional members of the local CAUTI prevention team and strategies to promote physician and nurse engagement.
      Because CAUTI prevention includes both technical and socio-adaptive components, qualitative evaluation—site visits in particular—is especially informative and often necessary to fully understand hospital-specific challenges and thus make recommendations for improvement. In terms of spreading the CAUTI initiative throughout the VHA or other large health care networks, site visits are not practical. We recommend that individual facilities conduct self-assessments to help identify potential challenges and strategies for improvement. A recently developed CAUTI Guide to Patient Safety
      • Saint S.
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      • Harrod M.
      • Krein S.L.
      Introducing a catheter-associated urinary tract infection (CAUTI) prevention guide to patient safety (GPS).
      might be a helpful tool for this purpose. The CAUTI Guide to Patient Safety,
      • Saint S.
      • Gaies E.
      • Fowler K.E.
      • Harrod M.
      • Krein S.L.
      Introducing a catheter-associated urinary tract infection (CAUTI) prevention guide to patient safety (GPS).
      which is based on lessons learned from other hospitals' CAUTI improvement efforts, consists of a brief assessment process followed by feedback, including possible solutions to specific issues.

      Conclusions

      We found that a regional collaborative that includes a multidisciplinary advisory group can address important endemic patient safety problems such as CAUTI. In the future, we plan to tackle other hospital-acquired conditions such as central line-associated bloodstream infection, sepsis, medication reconciliation during hospital discharge, antimicrobial overuse, and CAUTI in long-term-care settings. Such a collaborative will leverage the creativity of individual facilities and the coordinating power of a large regional network.

      Acknowledgments

      The authors thank the members of the VISN 11 No Preventable Harms campaign, including Michael Finegan, Paul Bockelman, Alan Pawlow, Susan Honaker, Mimi Kokoska, Karen Arthur, Robin Hemphill, Danielle Hoover, Beth King, Sandra Hart, Tisha Crowder-Martin, Sandeep Vijan, Jack Iwashyna, Anne Sales, Sorabh Dhar, Cynthia Paterson, Jill Benns, Wasfy Hamad, Justin Peters, Rose Reyburn, Dana Spradlin, Aleksandra Radovanovich, Margaret Freundl, and Tamra Pierce.

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