Although many healthcare leaders applaud the attention CMS is bringing to this deadly condition, some are finding the highly prescriptive measures too constricting.
This article first appeared in the April 2016 issue of HealthLeaders magazine.
In the wake of the October 2015 release of the Centers for Medicare & Medicaid Services' sepsis management bundle, health systems are reviewing their sepsis identification and treatment approaches. And although many healthcare leaders applaud the attention CMS is bringing to this deadly condition, some are finding the highly prescriptive measures too constricting.
"The CMS bundle takes a little bit of the art of medicine out of the hands of the physician," says Nirav G. Shah, MD, FCCP, and director of the pulmonary and critical care fellowship program at the University of Maryland Medical Center, the flagship academic medical center of the 12-hospital University of Maryland Medical System.
Shah has closely studied sepsis and shared his expertise by discussing this topic as part of his grand rounds at his hospital and surrounding hospitals in Baltimore.
He supports the intent of the CMS bundle, though, which is to create a sense of urgency to address the condition.
Sepsis, according to the Centers for Disease Control and Prevention, is the body's overwhelming and life-threatening response to an infection, which can lead to tissue damage, organ failure, and death. There are more than 1 million cases of sepsis each year, and it kills more than 258,000 Americans annually. Sepsis is the primary cause of death from infection and is one of the leading causes of death in intensive care units.
CMS' sepsis management bundle concentrates heavily on treatment and reporting for the first three and six hours—time frames known to be critical in controlling the outcome. Researchers have found that each hour of delay in administering antibiotics results in an average decrease in survival of 7.6%.
Closely aligned with bundles from the Surviving Sepsis Campaign and the National Quality Forum, the CMS bundle requires detailed reporting on diagnosis, fluids, antibiotics, monitoring, outcomes, and more.
Craig Coopersmith, MD, FACS, FCCM, and associate director for the Emory Critical Care Center at Emory University School of Medicine, calls the agency's prescriptive bundle "absolutely fantastic" because it promotes "earlier recognition and earlier treatment."
If healthcare systems follow the bundle, "they will save thousands of lives," he says, adding that mortality isn't the only issue with sepsis; speed in diagnosis and treatment is also essential to avoid long-term cognitive issues, lengthy hospital stays, and readmissions.
"The medical profession is actually recognizing that sepsis exists and that it is a medical emergency on par with heart attacks, strokes, and gunshot wounds," says Coopersmith, who sees a tremendous number of patients with sepsis who come into the intensive care unit from the emergency department and the patient floors at Emory University Hospital, a part of the Emory Healthcare Network, the Atlanta-based network that includes six hospitals, 200 provider locations, and 1,800 physicians.
A member of the steering committee of the Surviving Sepsis Campaign and immediate past president of the Society of Critical Care Medicine, Coopersmith says what Emory faces in terms of sepsis is "representative of every medical center around the world."
But as some healthcare leaders, including the University of Maryland Medical Center's Shah, dig deeper into the CMS bundle, they are finding the measures to be too prescriptive and somewhat at odds with their existing sepsis protocols.
For instance, ahead of the CMS bundle, many at the University of Maryland Medical Center used PlasmaLyte as its preferred fluid to administer to sepsis patients. The CMS bundle, however, prescribes normal saline or Lactated Ringer's solution.
"If we don't use those specific solutions, then we don't meet the CMS checklist and it will impact reporting," Shah says. Not following the bundle to the letter also could affect reimbursement if that follows the reporting measures.
Shah says that while using the CMS core measures doesn't impact care, the stringent nature "leaves a bad taste" with physicians.
He says he worries that the trigger for the CMS bundle—systemic inflammatory response syndrome (SIRS)—is not always sepsis and, therefore, broad-spectrum antibiotics might not be the appropriate response. There has to be room, he says, for physicians to make the sepsis diagnosis.
To help support the monitoring and reporting aspects of the sepsis bundle and to evoke early goal-directed therapy, the University of Maryland Medical Center implemented a critical care consult service that operates from 7 a.m. to 5 p.m. If a patient is thought to be septic, the medical staff can page the consult service and an attending physician, fellow, and other skilled clinicians will assess the situation.
"They determine the patient's acute needs, such as whether they require a line for fluids, antibiotics, or vasopressors, and they can start the order set with the pharmacy," Shah says. The consult service also can coordinate with the intensive care unit to ensure proper transition of care, if necessary.
"Sepsis is certainly difficult to diagnose, but we are doing a better job of getting patients plugged into treatment as fast as possible," Shah says.
The power of automation
At South Nassau Communities Hospital, a 455-bed acute care facility in Oceanside, New York, the patient population is older and, therefore, at higher risk for sepsis, according to Ruth Ragusa, RN, senior vice president for quality and care management.
She has found the biggest challenge with sepsis is identification. "When anyone comes in with a fever, elevated heart rate, and other SIRS criteria, there could be many different reasons," she says.
The hospital has programmed algorithms into the electronic medical record system that help alert physicians to certain sepsis cues. "Rather than having to rely on their memory, the EMR offers prompts to alert physicians when they should consider the diagnosis to be sepsis," she says.
Once the diagnosis is made, then the EMR system helps set the CMS bundle protocol in motion, prompting medical teams on each element of the bundle, down to how much, how often, and the type of fluid to administer. The EMR also can automatically bring up the order sets necessary for the bundle.
Sepsis has been on South Nassau Communities Hospital's radar for the past five or six years, but it wasn't until recently that protocols moved from paper to the EMR. When the CMS bundle came out, Ragusa says the hospital was already in substantial compliance with its protocols.
Also, the hospital already was tracking sepsis and reporting on it because of the 2013 New York state law passed in the wake of the 2012 sepsis death of 12-year-old Rory Staunton.
"Everyone is tracking sepsis and reporting on the same measures and steps in the protocol. Each quarter, the state health department sends a report not only on how we're doing but how we're doing against other hospitals in the state," she says.
To hasten care to sepsis patients, the hospital recently adopted several new measures, including embedding phlebotomists in the ED at all times to shorten the turnaround time on necessary blood cultures.
The sooner medical teams get lab results, the sooner patients can move from broad-spectrum to targeted antibiotics, providing good stewardship of these medications. Medical teams also now put two lines into a septic patient instead of one to expedite the delivery of fluids and antibiotics.
Ragusa says hospital staff continues to train on sepsis signs and symptoms to ensure everyone is on the same page and providing timely treatment.
Getting resourceful
At Beaumont Health System's Beaumont Hospital–Royal Oak campus, a tertiary care center with 1,070 beds in Royal Oak, Michigan, having the CMS core measures integrated into the EMR system will assist in fulfilling bundle requirements. However, Paul Bozyk, MD, assistant director of the medical ICU, says physicians still must carefully assess each patient to ensure the core measures match the necessary level of care.
"The CMS core measures are very prescriptive in what they want to see documented," he says. "But many of the things they want documented are binary without a need to explain that's an appropriate next step."
Like Shah, Bozyk says the CMS bundle "leaves little to no room for clinical decision-making."
For instance, if an elderly patient with severe systolic dysfunction were to present as septic, CMS would expect the provider to administer a full fluid treatment. On such a patient, though, the prescribed 30ccs per kilogram may be harmful. Bozyk says his institution's physicians are aware that missing elements on the bundle means the hospital doesn't get credit for treatment and could impact the publicly reported measurement.
"The best physicians may take a hit on CMS measures," he says, emphasizing that the health system must back them up. Physicians must be empowered by the health system to overrule EMR protocol alerts and determine if patients are sick for other reasons, such as complications due to COPD or end-stage renal failure, Bozyk says.
"We can't always assume that SIRS presentation is sepsis," he says. Conversely, it should be clear that just because the core measures have been fulfilled, it doesn't mean the source of infection has been addressed, he says.
Bozyk also is concerned about the ability of health systems to follow the six-hour bundle outside of the critical care units. "Sepsis protocols can be tricky on a medical floor. If you can get fluids, antibiotics, and lactic acid measurements, then you've checked the boxes on the three-hour bundle. But they might not have the resources to handle the six-hour bundle, which requires more intensive care," he says.
At Beaumont, if a noncritical care patient is thought to be septic, nurses can contact a rapid response team to quickly assess patient status and determine if he or she needs to be moved to the medical ICU for close monitoring.
A smaller hospital, he says, might not have layered resources like a rapid response team and, therefore, could wind up with poor scores on reported core measures.
"The resources the bundle requires are significant," he says. Core measures should be based on guidelines without controversy and stick to areas of consensus. "The intention is correct, but the methodology is flawed."
University of Maryland Medical Center's Shah says he has contacted CMS about some of the specifics in the bundle and the organization has agreed to review his concerns, but not until later this year.
Healthcare system leaders are finding that prolonged multipronged efforts can lead to reduced infection rates, though some experts caution about the potential for unintended consequences.
This article first appeared in the March 2016 issue of HealthLeaders Magazine.
Kerri Scanlon, RN, MSN, knows how important prevention of catheter-associated urinary tract infections is because, at age 20, she acquired one postsurgery.
“I was young and able to fight it off, but an 80-year-old patient with no reserves can’t fight off a CAUTI,” says Scanlon, chief nursing officer at North Shore University Hospital, an 812-staffed-bed teaching hospital in Manhasset, New York, and deputy chief nurse executive for the hospital’s parent system, Northwell Health, a 21-hospital network based in Great Neck, New York.
Today Scanlon champions efforts in her hospital and the health system overall to slash CAUTI rates. CAUTIs occur when germs—usually bacteria—enter the urinary tract through the urinary catheter and cause infection, according to the Centers for Disease Control and Prevention. Such infections have been associated with increased morbidity, mortality, healthcare costs, and length of stay.
In 2008, the Centers for Medicare & Medicaid Services announced Medicare’s nonpayment policy for the additional care required as a result of hospital-acquired conditions, including CAUTIs, and have instituted a rigorous reporting protocol.
Scanlon says that in addition to patient health, which is of primary concern, CAUTI infections put at risk a portion of Northwell’s $9.5 million CMS payment bundle, which includes CAUTIs.
In 2015, the health system’s executive leadership committed to its initiative to improve CAUTI rates and felt it was so important that the effort was tied to executive compensation as its model quality indicator. “Linking CAUTI performance to compensation showed a level of commitment, that this was a priority,” she says.
Scanlon and the CAUTI team set in place an aggressive goal to decrease incidence of CAUTIs by 25%, as well to increase and sustain compliance for catheter care and removal. Their baseline: The hospital’s 2012 standardized infection ratio of 1.7 against CMS’ threshold of 0.85 or less. The SIR compares the number of infections in a facility or state to the number of infections that would be expected to have occurred based on previous years of reported data (national baseline).
As part of the CAUTI project, Scanlon and her team identified 188 employee champions in critical care areas, including nursing assistants, nurses, and advanced practice providers; reeducated the staff and patient transporters on insertion practices; and evaluated aseptic techniques such as perineal care.
They instituted four key prevention techniques from the Agency for Healthcare Research and Quality (AHRQ): pause and validate the need for Foleys before insertion; involve a second person during insertion to facilitate aseptic technique; evaluate continued need daily; and empower the nursing staff to discontinue catheter use as soon as possible.
The pause rule helped staff to figure out if alternative methods for measuring urine intake and output—including bladder screeners/scanners, condom catheters, female and male urinals, and straight intermittent catheterization—could avoid the risk of an indwelling catheter.
Scanlon and other leadership closely followed—and continue to follow—the hospital’s progress through a unit-level and hospital-based dashboard that shows how many Foleys are inserted daily, how long they’ve been in, and any potential CAUTIs. An interdisciplinary root cause analysis team meets monthly to review CAUTI incidents and uncover breaches in protocol and resolve them.
These comprehensive changes have resulted in dramatic improvement. Foley days decreased 22.5% from 2012 to 2015, with a 73% reduction in critical care CAUTIs. And the hospital’s CMS SIR is now 0.57, which is better than the 0.85 threshold. The hospital estimates CAUTI reductions saved $522,000 between 2012 and 2015. The CAUTI project has now been extended to noncritical care units as well.
As a health system, Northwell Health decreased Foley days 24%, reduced CAUTIs 60% with an estimated cost savings of $2,561,000 from 2012 to 2015. The system SIR is 0.74, which is better than the CMS threshold.
“When we started the CAUTI project at the hospital, we had 82 patients with infections in our critical care environment; we are now at the end of 2015 at 20 patients with a CAUTI. We are saving lives,” Scanlon says, adding Northwell as a whole has seen significant improvements with CAUTI incidence.
A collaborative approach
Russell N. Olmsted, MPH, CIC, director of infection prevention and control at Michigan-based Trinity Health, an integrated delivery network with 85 acute care hospitals in 22 states, was a member of the team that developed AHRQ's CAUTI prevention tools, including those used by North Shore University Hospital.
Trinity participated in AHRQ's nationwide “On the CUSP: Stop CAUTI” program, which included 1,200 hospitals in 42 states and ran from 2011 to August 2015. The collaborative focused on the acute care setting, aiming to make decreased CAUTI rates sustainable in the long term by fostering a culture of safety.
In addition to a 7% drop in the use of catheters, the collaborative’s participating hospitals reported a 32% drop in their CAUTI rates, what Olmsted calls “pretty impressive.”
A key component of the program, he says, was to study catheter use in emergency departments. Not only did the collaborative study the initial need for a Foley in the ED, but also what happens when the patient gets transferred to the ICU or patient floor.
“When patients move from the emergency department to inpatient, we want emergency teams to assess whether the patient still needs the device. If not, then we want them to discontinue it before transporting,” Olmsted says. Doing so directly impacts the potential for CAUTIs to arise.
At Trinity, Olmsted says CAUTIs have been on the radar for quite some time and are included in the monthly systemwide measurement scorecard. While some hospitals perform better than the CMS recommended rate, others have missed the target at times, he says, drawing attention to the need for CAUTI prevention.
Olmsted says a change across the healthcare system is the elevation of nurse input on Foley removal. “Catheters are a nurse-centered device and, therefore, they should be empowered to remove it,” he says. Trinity’s executives have made this shift clear so that nurses feel supported and won’t be critiqued by other clinicians.
The health system also is in the process of integrating the American Nurses Association’s CAUTI Prevention Tool into its EMR system, but have found it challenging, as the system has numerous EMR programs. “We have a workgroup trying to incorporate logic from the ANA tool across Epic, Cerner, and other platforms,” he says.
Olmsted expects a larger shift in the healthcare industry away from the thought that “catheters are innocuous.” People now recognize, he says, that catheters “carry significant risk.” In addition to potential for infections, catheters can keep a patient bedridden, which can lead them to experience deconditioning of muscles and delirium. “The longer a patient lies around, the more challenging it is for clinicians to get them back up and normal,” he says.
The first 48 hours
Cheryl Christ-Libertin, DNP, RN-BC, NE-BC, CPNP-PC, is evidence-based practice coordinator at Akron Children’s Hospital in Ohio, which has nearly 800,000 patient visits each year to the hospital’s two campuses and network of locations. She learned through her organization’s CAUTI prevention project that the length of time the catheter is in place is the strongest predictor for CAUTI.
In 2012, she and the hospital’s infection control manager started a pilot study in the burn unit. Using the six-step Rosswurm and Larrabee model to develop evidence-based guidelines for implementing the prevention bundle, the pilot study reported significant results for 2013, including reducing catheter days by about 75% and reducing infection incidence by more than 90%. The unit also was able to sustain a CAUTI rate of zero for all of 2015, according to Christ-Libertin.
The team used the study’s outcomes to springboard elsewhere in the organization and to find opportunities for impactful change. For instance, they found the diaper wipes did not have antimicrobial agents so nurses now start with a diaper wipe and then do a peri wipe. They also realized through their pilot that more than 50% of catheters were placed in the operating room, so the operating room staff applied the bundles appropriately.
Akron Children’s Hospital joined the Ohio Children’s Hospitals’ Solutions for Patient Safety Collaborative, which includes more than 80 children’s hospitals and is focused on reducing harm by preventing readmissions, serious safety events, and 10 specific hospital-acquired conditions, including CAUTI. Between 2015 and 2016, the collaborative aims to reduce hospital-acquired conditions such as CAUTI by 40%.
Christ-Libertin says it is a hospital’s responsibility to be a good steward of antibiotics and, therefore, avoid infections that could require their usage. “We don’t want to contribute to antibiotic resistance,” she says.
In addition to implementing prevention techniques similar to North Shore University Hospital, Akron Children’s Hospital has online modules that address each of these areas, and peer practice groups that help improve clinicians’ catheter skills. To ensure that everyone who deals with catheters is up to date on best practices, catheter care is built into the hospital’s graduate resident education program and taught to parents, who sometimes have to catheterize their children. “We’ve also integrated catheter reviews into the team rounding process so each day the risk/benefit of a patient’s catheter can be weighed,” Christ-Libertin says.
The hospital, having now achieved a 70% reduction in catheter days in the ICU, is turning its attention to general units and is currently gathering data for a baseline.
The right windmill?
As many hospitals target resources toward CAUTI to ensure patient safety and CMS payment, Michael Edmond, MD, MPH, MPA, the chief quality officer and associate chief medical officer at the University of Iowa Hospitals and Clinics, a 730-bed facility that annually admits 32,000 patients for in-patient hospital care, calls CAUTI “a distraction” that is diverting resources away from other higher-impact prevention activities.
CAUTIs, he says, “have low preventability, high levels of misclassification, low impact because significant morbidity is uncommon and death is rare, and a high opportunity cost.”
He cites a 2013 JAMA Internal Medicine study that although CAUTI was more common than CLABSI, another HAI, the cost per infection was significantly lower, accounting for only $0.03 billion annually for CAUTI vs. $1.85 billion for CLABSI. And hospitals spent $110 on SSIs for every $1 spent on CAUTI.
Edmond says that while the mortality rate of secondary bloodstream infections from CAUTIs is notable at 11%, the actual risk of getting a secondary bloodstream infection from CAUTI is relatively low, with Baylor University finding that 1.6% of patients with CAUTIs acquire a secondary bloodstream infection and the University of Wisconsin reporting 0.4%.
Edmond uses the Stop CAUTI Project’s Comprehensive Unit-based Safety Program model to determine that a 900-bed hospital with 49,000 catheter days per year would avoid only one additional secondary bloodstream infection every five years and one additional death every 50 years.
Removing catheters too soon can lead to other issues, he says, such as patient falls as they walk to the bathroom, and the need for more nursing resources on the patient floors. “You can’t look at CAUTIs in isolation; prevention can have adverse unintended consequences.”
Leaders are finding that multipronged efforts can lead to reduced infection rates, though some experts caution about the potential for unintended consequences.
This article first appeared in the March 2016 issue of HealthLeaders magazine.
Kerri Scanlon, RN, MSN, knows how important prevention of catheter-associated urinary tract infections is because, at age 20, she acquired one postsurgery.
"I was young and able to fight it off, but an 80-year-old patient with no reserves can't fight off a CAUTI," says Scanlon, chief nursing officer at North Shore University Hospital, an 812-staffed-bed teaching hospital in Manhasset, New York, and deputy chief nurse executive for the hospital's parent system, Northwell Health, a 21-hospital network based in Great Neck, New York.
Today Scanlon champions efforts in her hospital and the health system overall to slash CAUTI rates. CAUTIs occur when germs—usually bacteria—enter the urinary tract through the urinary catheter and cause infection, according to the Centers for Disease Control and Prevention. Such infections have been associated with increased morbidity, mortality, healthcare costs, and length of stay.
Leaders are finding that multipronged efforts can lead to reduced infection rates, though some experts caution about the potential for unintended consequences.
This article first appeared in the March 2016 issue of HealthLeaders Magazine.
Kerri Scanlon, RN, MSN, knows how important prevention of catheter-associated urinary tract infections is because, at age 20, she acquired one postsurgery.
"I was young and able to fight it off, but an 80-year-old patient with no reserves can't fight off a CAUTI," says Scanlon, chief nursing officer at North Shore University Hospital, an 812-staffed-bed teaching hospital in Manhasset, New York, and deputy chief nurse executive for the hospital's parent system, Northwell Health, a 21-hospital network based in Great Neck, New York.
Today Scanlon champions efforts in her hospital and the health system overall to slash CAUTI rates. CAUTIs occur when germs—usually bacteria—enter the urinary tract through the urinary catheter and cause infection, according to the Centers for Disease Control and Prevention. Such infections have been associated with increased morbidity, mortality, healthcare costs, and length of stay.
In 2008, the Centers for Medicare & Medicaid Services announced Medicare's nonpayment policy for the additional care required as a result of hospital-acquired conditions, including CAUTIs, and have instituted a rigorous reporting protocol.
Scanlon says that in addition to patient health, which is of primary concern, CAUTI infections put at risk a portion of Northwell's $9.5 million CMS payment bundle, which includes CAUTIs.
In 2015, the health system's executive leadership committed to its initiative to improve CAUTI rates and felt it was so important that the effort was tied to executive compensation as its model quality indicator. "Linking CAUTI performance to compensation showed a level of commitment, that this was a priority," she says.
Scanlon and the CAUTI team set in place an aggressive goal to decrease incidence of CAUTIs by 25%, as well to increase and sustain compliance for catheter care and removal. Their baseline: The hospital's 2012 standardized infection ratio of 1.7 against CMS' threshold of 0.85 or less. The SIR compares the number of infections in a facility or state to the number of infections that would be expected to have occurred based on previous years of reported data (national baseline).
As part of the CAUTI project, Scanlon and her team identified 188 employee champions in critical care areas, including nursing assistants, nurses, and advanced practice providers; reeducated the staff and patient transporters on insertion practices; and evaluated aseptic techniques such as perineal care.
They instituted four key prevention techniques from the Association for Professionals in Infection Control and Epidemiology (APIC): pause and validate the need for Foleys before insertion; involve a second person during insertion to facilitate aseptic technique; evaluate continued need daily; and empower the nursing staff to discontinue catheter use as soon as possible.
The pause rule helped staff to figure out if alternative methods for measuring urine intake and output—including bladder screeners/scanners, condom catheters, female and male urinals, and straight intermittent catheterization—could avoid the risk of an indwelling catheter.
Scanlon and other leadership closely followed—and continue to follow—the hospital's progress through a unit-level and hospital-based dashboard that shows how many Foleys are inserted daily, how long they've been in, and any potential CAUTIs. An interdisciplinary root cause analysis team meets monthly to review CAUTI incidents and uncover breaches in protocol and resolve them.
These comprehensive changes have resulted in dramatic improvement. Foley days decreased 22.5% from 2012 to 2015, with a 73% reduction in critical care CAUTIs. And the hospital's CMS SIR is now 0.57, which is better than the 0.85 threshold. The hospital estimates CAUTI reductions saved $522,000 between 2012 and 2015. The CAUTI project has now been extended to noncritical care units as well.
As a health system, Northwell Health decreased Foley days 24%, reduced CAUTIs 60% with an estimated cost savings of $2,561,000 from 2012 to 2015. The system SIR is 0.74, which is better than the CMS threshold.
"When we started the CAUTI project at the hospital, we had 82 patients with infections in our critical care environment; we are now at the end of 2015 at 20 patients with a CAUTI. We are saving lives," Scanlon says, adding Northwell as a whole has seen significant improvements with CAUTI incidence.
A collaborative approach
Russell N. Olmsted, MPH, CIC, director of infection prevention and control at Michigan-based Trinity Health, an integrated delivery network with 85 acute care hospitals in 22 states, was a member of the team that developed APIC's CAUTI prevention tools, including those used by North Shore University Hospital.
Trinity participated in APIC's nationwide "On the CUSP: Stop CAUTI" program, which included 1,200 hospitals in 42 states and ran from 2011 to August 2015. The collaborative focused on the acute care setting, aiming to make decreased CAUTI rates sustainable in the long term by fostering a culture of safety.
In addition to a 7% drop in the use of catheters, the collaborative's participating hospitals reported a 32% drop in their CAUTI rates, what Olmsted calls "pretty impressive."
A key component of the program, he says, was to study catheter use in emergency departments. Not only did the collaborative study the initial need for a Foley in the ED, but also what happens when the patient gets transferred to the ICU or patient floor.
"When patients move from the emergency department to inpatient, we want emergency teams to assess whether the patient still needs the device. If not, then we want them to discontinue it before transporting," Olmsted says. Doing so directly impacts the potential for CAUTIs to arise.
At Trinity, Olmsted says CAUTIs have been on the radar for quite some time and are included in the monthly systemwide measurement scorecard. While some hospitals perform better than the CMS recommended rate, others have missed the target at times, he says, drawing attention to the need for CAUTI prevention.
Olmsted says a change across the healthcare system is the elevation of nurse input on Foley removal. "Catheters are a nurse-centered device and, therefore, they should be empowered to remove it," he says. Trinity's executives have made this shift clear so that nurses feel supported and won't be critiqued by other clinicians.
The health system also is in the process of integrating the American Nurses Association's CAUTI Prevention Tool into its EMR system, but have found it challenging, as the system has numerous EMR programs. "We have a workgroup trying to incorporate logic from the ANA tool across Epic, Cerner, and other platforms," he says.
Olmsted expects a larger shift in the healthcare industry away from the thought that "catheters are innocuous." People now recognize, he says, that catheters "carry significant risk." In addition to potential for infections, catheters can keep a patient bedridden, which can lead them to experience deconditioning of muscles and delirium. "The longer a patient lies around, the more challenging it is for clinicians to get them back up and normal," he says.
The first 48 hours
Cheryl Christ-Libertin, DNP, RN-BC, NE-BC, CPNP-PC, is evidence-based practice coordinator at Akron Children's Hospital in Ohio, which has nearly 800,000 patient visits each year to the hospital's two campuses and network of locations. She learned through her organization's CAUTI prevention project that the length of time the catheter is in place is the strongest predictor for CAUTI.
In 2012, she and the hospital's infection control manager started a pilot study in the burn unit. Using the six-step Rosswurm and Larrabee model to develop evidence-based guidelines for implementing the prevention bundle, the pilot study reported significant results for 2013, including reducing catheter days by about 75% and reducing infection incidence by more than 90%. The unit also was able to sustain a CAUTI rate of zero for all of 2015, according to Christ-Libertin.
The team used the study's outcomes to springboard elsewhere in the organization and to find opportunities for impactful change. For instance, they found the diaper wipes did not have antimicrobial agents so nurses now start with a diaper wipe and then do a peri wipe. They also realized through their pilot that more than 50% of catheters were placed in the operating room, so the operating room staff applied the bundles appropriately.
Akron Children's Hospital joined the Ohio Children's Hospitals' Solutions for Patient Safety Collaborative, which includes more than 80 children's hospitals and is focused on reducing harm by preventing readmissions, serious safety events, and 10 specific hospital-acquired conditions, including CAUTI. Between 2015 and 2016, the collaborative aims to reduce hospital-acquired conditions such as CAUTI by 40%.
Christ-Libertin says it is a hospital's responsibility to be a good steward of antibiotics and, therefore, avoid infections that could require their usage. "We don't want to contribute to antibiotic resistance," she says.
In addition to implementing prevention techniques similar to North Shore University Hospital, Akron Children's Hospital has online modules that address each of these areas, and peer practice groups that help improve clinicians' catheter skills. To ensure that everyone who deals with catheters is up to date on best practices, catheter care is built into the hospital's graduate resident education program and taught to parents, who sometimes have to catheterize their children. "We've also integrated catheter reviews into the team rounding process so each day the risk/benefit of a patient's catheter can be weighed," Christ-Libertin says.
The hospital, having now achieved a 70% reduction in catheter days in the ICU, is turning its attention to general units and is currently gathering data for a baseline.
The right windmill?
As many hospitals target resources toward CAUTI to ensure patient safety and CMS payment, Michael Edmond, MD, MPH, MPA, the chief quality officer and associate chief medical officer at the University of Iowa Hospitals and Clinics, a 730-bed facility that annually admits 32,000 patients for in-patient hospital care, calls CAUTI "a distraction" that is diverting resources away from other higher-impact prevention activities.
CAUTIs, he says, "have low preventability, high levels of misclassification, low impact because significant morbidity is uncommon and death is rare, and a high opportunity cost."
He cites a 2013 JAMA Internal Medicine study that although CAUTI was more common than CLABSI, another HAI, the cost per infection was significantly lower, accounting for only $0.03 billion annually for CAUTI vs. $1.85 billion for CLABSI. And hospitals spent $110 on SSIs for every $1 spent on CAUTI.
Edmond says that while the mortality rate of secondary bloodstream infections from CAUTIs is notable at 11%, the actual risk of getting a secondary bloodstream infection from CAUTI is relatively low, with Baylor University finding that 1.6% of patients with CAUTIs acquire a secondary bloodstream infection and the University of Wisconsin reporting 0.4%.
Edmond uses the Stop CAUTI Project's Comprehensive Unit-based Safety Program model to determine that a 900-bed hospital with 49,000 catheter days per year would avoid only one additional secondary bloodstream infection every five years and one additional death every 50 years.
Removing catheters too soon can lead to other issues, he says, such as patient falls as they walk to the bathroom, and the need for more nursing resources on the patient floors. "You can't look at CAUTIs in isolation; prevention can have adverse unintended consequences."
Sandra Gittlen is a contributing writer for HealthLeaders Media.
There is no apparent relationship between the cost of a cancer drug and how effective it is, and physicians and patients must consider such decision factors at the point of care, says the CMO of the American Society of Clinical Oncologists.
This article first appeared in the January/February 2016 issue of HealthLeaders magazine.
As the healthcare industry strives to control costs, oncologists and other quality leaders are feeling strain related to the high-priced pharmaceuticals and other expenses associated with cancer care. The challenge is to ensure quality of cancer care when cost considerations could influence the treatment plan.
"There's no question that the costs to treat cancer have been rising. And they will continue to rise for a variety of factors, not the least of which is a trend toward combining drugs for more effective treatment," says J. Leonard Lichtenfeld, MD, MACP, deputy chief medical officer for the American Cancer Society.
For example, the U.S. Food and Drug Administration last year approved the use of Bristol-Myers Squibb's Yervoy and Opdivo for the treatment of advanced melanoma. The manufacturer expects the combination will cost more than $250,000 per patient in the first year of treatment, according to the Wall Street Journal.
PROs provide objective information about where a patient is in the disease process compared to the larger population and whether the patient is a candidate for certain procedures.
This article first appeared in the December 2015 issue of HealthLeaders magazine.
Even as the healthcare industry emphasizes patient-centered care and patient engagement, and health systems hire chief experience officers, one of the strongest elements of this strategy remains unrealized by many provider organizations: patient-reported outcomes.
Patient-reported outcomes, as defined by the National Quality Forum, are "any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else."
For areas such as orthopedics, cancer, and HIV, the direct input of the patient is essential for proper diagnosis and treatment. But patient-reported outcomes have not had substantial adoption, in part because integration with most electronic health systems is kludgy, and providers have not figured out how to blend PROs into the workflow of their daily practice.
"I do not believe that there has been a resistance to physicians using PROs," says David Ayers, MD, director of the Orthopedic Center of Excellence at UMass Memorial Health Care. "Traditionally, PROs have been used in research and have been well accepted and validated. But the use of PROs in office practice has been slowed by the lack of integration into patient flow in the clinical setting.
"Trying to do patient-reported outcomes on your own with pen and paper is very difficult. You need them to be computerized and available on Internet-based platforms so information can be immediately analyzed, scored, and utilized," he says.
Ayers is passionate about the need for widespread use of PROs in orthopedics, and their ability to improve quality. PROs provide objective information about where a patient is in the disease process compared to the larger population and whether the patient is a candidate for joint replacement surgery, he says.
Five years ago, Ayers, who also is chair of the Orthopedics and Physical Rehabilitation department at the University of Massachusetts Medical School, helped obtain a $12 million grant from the Agency for Healthcare Research and Quality to develop an orthopedic joint replacement registry. FORCE-TJR, which stands for Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement, is an independent data collection, analysis, and reporting system used to guide best practices in total joint replacement surgical practices.
"FORCE-TJR has developed an integrated way to collect PROs in the office setting in an efficient and patient- and staff-friendly way."
The registry, available in 26 states, has collected data from more than 25,000 patients. Patients are questioned about their pain and function levels using the standard SF-36 form and a joint-specific questionnaire before surgery and at regular intervals post-surgery.
Surgeons can access the data to see how they stack up against their peers across the country in the management of patient pain and function levels as well as implant successes/failures.
"FORCE-TJR has developed an integrated way to collect PROs in the office setting in an efficient and patient- and staff-friendly way," Ayers says. "In addition, FORCE-TJR can provide members with electronic-based platforms to collect and score the PROs in real time so that the PROs' scores can be used for shared decision-making and thus can be an important part of clinical practice."
At his practice, Ayers has patients submit PROs via a registry app on a tablet just before an exam. The app analyzes the data and delivers a score that Ayers can share with a patient during the exam and use to help determine the need for a knee or hip replacement. The results show patients how they are tracking over time and put their case in perspective. "Data from the FORCE-TJR is remarkably consistent in patient self-reported pain and function scores across surgeons before total joint replacement," he says, which enables him to trust the analytics.
The PRO-based score also opens the door to engage the patient in shared decision making. "Using validated tools facilitates the information from the patient through his or her history and physical exams that the clinician has to help the patient and the doctor make decisions and gauge their progress," he says. For instance, if a patient scores 55 and the median is 50, then he or she is likely not a candidate for surgery. "We're not just relying on our clinical impression anymore."
Patients who are candidates for surgery typically have severe pain and significant physical limitations so that their physical function score is roughly two standard deviations below the mean, Ayers explains. When using the SF-36, the mean physical function score is 50 and one standard deviation is 10 points. Patients and surgeons typically, through shared decision-making, choose elective joint replacement when scores are around 30 to 33 points.
As PROs find a foothold in orthopedics, Ethan Basch, MD, MSc, director of the Cancer Outcomes Research Program at the University of North Carolina at Chapel Hill, says he is hoping a similar trajectory will occur in oncology.
"There can be a real downside to the treatments I recommend, and I want to understand how other patients have experienced it," Basch says, adding firmly that "patient-reported outcomes should be a key part of every clinical trial in oncology."
In addition to improving drug development, PROs also enable insight for symptom management by individual doctors and nurses as well as quality assessment among practices. "Symptoms such as pain are hugely under-detected and undertreated [in oncology]," he says. "Until we systematically collect this information from our patients, we will be limited in our ability to optimally manage patients' symptoms."
Basch says individual oncology clinics, hospitals, and practices are starting to use PROs, but mostly piecemeal. He would like to see usage standardized, easily interfaced via plug-ins to EHR systems, and available via the Web, mobile devices, and interactive voice response phone systems. Also, patients and doctors should be able to access data via patient portals. "EHR vendors today have rudimentary patient-reported outcomes platforms, but the information is hard to find, hard to use, and not part of the workflow. That has to improve," he says.
That day will come, he says, when PROs become a quality metric that is an expectation for reimbursement. "It is my hope that it will be done well and systematically," Basch says.
Albert Wu, MD, MPH, FACP, a professor and director of the Center for Health Services and Outcomes Research at the Johns Hopkins Bloomberg School of Public Health, also says he believes that PROs will be widely adopted. After all, he has seen tremendous change in acceptance of PROs since he first started working with them in 1987.
Back then, he championed the introduction of PROs as part of HIV clinical drug trials in San Diego and San Francisco as a way to monitor patient response to quality of life, symptoms, and adherence to protocols.
Today, he has extended his PRO expertise to cancer and kidney disease, as well as other conditions such as asthma.
"There really is an overall growing acceptance that outcomes from a patient's perspective through patient-reported outcomes are the best and most convenient way to get perspective into research and then into practice," Wu says.
Standards are being worked on. As an example, he points to PROMIS (Patient Reported Outcome Measurement Information System), the National Institutes of Health's assessment system for self-reported health that provides clinicians and researchers with "efficient, precise, valid, and responsive adult- and child-reported measures of health and well-being," according to the project's website.
Even those Wu refers to as conservative forces regulators who require data collected and reported on paper will be convinced to move to the electronic world soon, he predicts.
Wu says he believes a link to reimbursements such as offering a certain dollar amount for each PRO collected could drive greater adoption of the practice of collecting and using the information.
