Standardized Utilization Ratio Research Articles

Implementation of a multi-modal intervention adopting new technologies, clinical services, and feedback improves catheter-associated urinary tract infections

ABSTRACT Objectives Catheter-associated urinary tract infections (CAUTI) are a significant cause of morbidity and financial burden to healthcare systems. The aim of this study was to develop and implement a program designed to reduce Foley catheter use days and associated CAUTI rates. Methods A retrospective evaluation of a multi-modal program aimed toward reducing Foley catheter use days and associated CAUTI rates across the Indiana University Health (IUH) system was conducted. IUH is comprised of 16 hospitals and 2,703 available beds. The program included the adoption of new technologies with evidence-based clinical training materials based on change management and feedback from clinicians. National Healthcare Safety Network Standardized Infection Ratio (SIR), Standardized Utilization Ratio (SUR), and Incidence Density Ratio (IDR) rates were assessed. Results Implementation of the multi-modal program resulted in a significant reduction in SIR, SUR, and IDR in the post-implementation compared to the baseline periods. Conclusions Through CAUTI bundle workflow assessments, education, and interventions designed to standardize practice variation, the program was successfully implemented and resulted in a significant decrease in Foley Catheter use days, and associated CAUTI rates.

Innovative Approaches to Monitor Central Line Associated Bloodstream Infections (CLABSIs) Bundle Efficacy in Intensive Care Unit (ICU): Role of Device Standardized Infection Rate (dSIR) and Standardized Utilization Ratio (SUR)-An Italian Experience.

In several settings, the COVID-19 pandemic determined a negative impact on the occurrence of healthcare-associated infection, particularly for on central lines associated bloodstream infections (CLABSI). In our setting, we observed a significant increase in CLABSI in our intensive care unit (ICU) during 2020 and 2021 vs. 2018 to 2019. A refresher training activity on central venous catheter (CVC) management bundles was carried out in September-October 2021 for the ICU health staff. We assessed the impact of bundle implementation by means of standardized indicators, such as the Device Utilization Ratio (DUR), in this case, the Central Line Utilization Ratio, the Standardized Utilization Ratio (SUR), and the device Standardized Infection Ratio (dSIR). Standardized ratios for device use and infection ratio were computed using data from 2018 and 2019 as expectation data. After bundle implementation, we observed a significant reduction of dSIR (p < 0.001), which dropped from 3.23 and 2.99 in the 2020-2021 biennium to 1.11 in 2022 (CLABSI in the first quarter only); no more CLABSI were observed afterwards. Standardized ratios proved helpful in identify increasing trends of CLABSI in the ICU and monitoring the impact of a simple effective tool, i.e., training on and implementation of a bundle for CVC management.

Investigating potential drivers of increased central-line–associated bloodstream infections during the SARS-CoV-2 omicron-variant surge

Background: Central-line–associated bloodstream infection (CLABSI) rates increased nationally during COVID-19, the drivers of which are still being characterized in the literature. CLABSI rates doubled during the SARS-CoV-2 omicron-variant surge at our rural academic medical center. We sought to identify potential drivers of CLABSIs by comparing period- and patient-specific characteristics of this COVID-19 surge to a historical control period. Methods: We defined the study period as the time of highest COVID-19 burden at our hospital (July 2021–June 2022) and the control period as the previous 2 years (July 2019–June 2021). We compared NHSN CLABSI standardized infection ratios (SIRs), central-line standardized utilization ratios (SURs), completion of practice evaluation tools (PETs) for monitoring of central-line bundle compliance, and proportions of traveling nurses. We performed chart reviews to determine patient-specific characteristics of NHSN CLABSIs during these periods, including demographics, comorbidities, central-line characteristics and care, and microbiology. Results: The CLABSI SIR was significantly higher during the study period than the control period (0.89 vs 0.52; P = .03); the SUR was significantly higher during the study period (1.08 vs 1.02; P &lt; .01); the PET completion per 100 central-line days was significantly lower during the study period (23.0 vs 31.5; P &lt; .01); and the proportion of traveling nurses was significantly higher during the study period (0.20 vs 0.08; P &lt; .01) (Fig. 1). Patients with NHSN CLABSIs during the study period were more likely to have a history of COVID-19 (27% vs 3%; P = .01) and were more likely to receive a higher level of care (60% vs 27%; P = .02). During the study period, more patients had multilumen catheters (87% vs 61%; P = .04). The type of catheter, catheter care (ie, dressing changes and chlorhexidine bathing), catheter duration before CLABSI, and associated microbiology were similar between the study and control periods (Table 1). Conclusions: During the SARS-CoV-2 omicron-variant surge, the increase in CLABSIs at our hospital was significantly associated with increased central-line utilization, decreased PET completion, and increased proportion of traveling nurses. Critical illness and multilumen catheters were significant patient-specific factors that differed between CLABSIs from the study and control periods. We did not observe differences in catheter type, duration, or catheter care. Our study highlights key modifiable risk factors for CLABSI reduction. These findings may be surrogates for other difficult-to-measure challenges related to the culture of safety during a global pandemic, such as staff education related to infection prevention and daily review of central-line necessity.Disclosures: None

2031. Role of Urine Culture Hard Stop in Reducing Catheter-associated Urinary Tract Infections

Abstract Background Catheter-associated urinary tract infection (CAUTI) is one of the most commonly reported healthcare associated infections (HAI) reported to the National Healthcare Safety Network (NHSN). However, asymptomatic bacteriuria is common in patients with indwelling urinary catheters (IUC), and inappropriate culturing leads to overdiagnosis in colonized patients, unnecessary antibiotics and increased resistance. We evaluated the effectiveness of an electronic medical record (EMR) “hard stop” in reducing inappropriate urine cultures (UC) and its impact on CAUTI rates. Methods This was a pre-post quasi-experimental retrospective study comparing CAUTI rate per 1000 catheter days, UC order rate per 1000 patient days, Standardized Utilization Ratio (SUR) and Standardized Infection Ratio (SIR) in the pre-intervention period (January 2019-December 2020) to the intervention period (April 2021-March 2022) in Southeast Michigan. In March 2021, we implemented a hard stop in Epic® that fired 24 hours after admission in patients with IUC &amp;gt;1 calendar day and until 4 days after IUC removal. The Medical Director of Infection Prevention and Control had the ability to override the hard stop when indicated after reviewing the case upon provider request; education was provided in real-time. We prospectively monitored outcomes, including pyelonephritis and/or bacteremia within 3 days and readmission for sepsis within 30 days in patients UC was deemed unnecessary. Results CAUTI rate was 0.52 in the pre-intervention period and 0.09 in the post-intervention period, an 83% reduction (Figure 1). Rate of UC performed was 0.283 in the pre-intervention period and 0.218 in the post-intervention period, a 23% reduction. SUR decreased from 0.809 to 0.716, an 11% reduction (95% CI, 0.875-0.894, p&amp;lt; 0.001). SIR decreased from 0.392 to 0.135, a 66% reduction (95% CI, 0.154-0.0689, p=0.0015). Post-intervention, there were 44 override requests that were denied with no adverse patient outcomes. Conclusion Urine culture stewardship, utilizing an electronic hard stop, was effective in reducing inappropriate UC orders, SIR and SUR in patients with IUC without causing patient harm. This strategy combined with real-time education can significantly reduce CAUTI rates. Disclosures All Authors: No reported disclosures.

Implementation of Standardized Catheter Cleansing Cloths at an Inpatient Rehab Facility

<h3>Background</h3> A higher than expected number of catheter-associated urinary tract infections (CAUTIs) was occurring at an inpatient rehab facility (IRF). Patients at IRFs often have indwelling urinary catheters (IUCs) for medical conditions like neurogenic bladder or urinary retention conditions. It is essential to provide consistent care and maintenance of IUCs for patients with long-term or chronic urinary catheters to prevent infection. Variability exists in the frequency, procedure, and availability of products for catheter care. <h3>Methods</h3> The quality improvement project, using lean methodology, took place over a six-month period at a 38 bed IRF to include patients with an IUC. The catheter cleansing cloths were used daily and as needed on patients with an IUC. The improvement project assessed if the daily use of the catheter cleansing cloths reduced the incidence of CAUTI at an IRF. A daily tracking tool was developed to monitor catheter device utilization and record daily documentation of urinary catheter care with the designated cleansing cloths. <h3>Results</h3> In the 12 months prior to the implementation of the catheter cleansing cloths, the IRF had seven CAUTIs. In the six months since the start of using the cloths, the IRF had zero CAUTIs. The Standardized Utilization Ratio (SUR) for the IRF in the six months prior to implementing daily device monitoring was 1.458. In the first six months of daily device monitoring, the SUR was 1.014. <h3>Conclusions</h3> The quality improvement project revealed a standardized process for daily catheter care is associated with a reduction in CAUTI. This project also notes an association between the daily monitoring of IUC devices and a reduction in catheter device utilization. Using catheter cleansing cloths for daily catheter care may be a great resource to provide consistent and predicable care for patients with IUCs.

770. Impact of COVID-19 Pandemic on Central Line-associated Bloodstream Infections in Metropolitan Detroit

BackgroundRecent publications suggest that central line-associated bloodstream infection (CLABSI) rates have increased in US hospitals during the COVID-19 pandemic. The objective of this study was to evaluate the impact of COVID-19 pandemic on CLABSIs.MethodsThis was a retrospective cross-sectional study comparing CLABSI rate per 1,000 central line (CL) days, blood culture (BC) utilization rate per 1,000 CL days, CL utilization rate per 1,000 patient days, Standardized Infection Ratio (SIR) and Standardized Utilization Ratio (SUR) in the pre-COVID-19 period from January 1, 2019 to December 31, 2019 to the COVID-19 period from April 1, 2020 to March 31, 2021 at an 877-bed tertiary care hospital in Detroit, Michigan. CLABSI, and BC and CL utilization rate were extracted from the electronic medical record (Epic™ Bugsy). SIR and SUR data were extracted from National Healthcare Safety Network (NHSN).ResultsThe average CLABSI rate per 1,000 CL days increased 24% from 1.66 to 2.06. Twenty percent of patients were hospitalized for COVID-19. The BC utilization rate per 1,000 CL days decreased from 0.43 to 0.32 with a 26% reduction. However, CL utilization increased by 28% from 0.25 to 0.32 (Figure 1). However, CLABSIs due to common commensals decreased from 13.8% to 10.9%. The SIR increased significantly from 1.055 to 1.795 (P-value 0.008), resulting in a 70% increase. The overall SUR also increased from 0.900 to 0.988 (P-value < 0.001). Figure 2 is a control chart of the CLABSI rate from July 2019 to April 2021. Figure 1. CLABSI, blood culture utilization and central line utilization rates pre-and during COVID-19 pandemic Figure 2. CLABSI control chart pre-and during COVID-19 pandemicConclusionDuring the COVID-19 pandemic, there was a significant increase in CL utilization, CLABSI rate, SIR and SUR likely due to higher acuity in COVID-19 patients despite a decrease in BC orders. Disclosures All Authors: No reported disclosures

779. COVID-19 Pandemic and Catheter-associated Urinary Tract Infection Trends

BackgroundIt has been postulated that the COVID-19 pandemic would increase the overall catheter-associated urinary tract infections (CAUTI) risk in part due to higher acuity, increased indwelling urinary catheter (IUC) utilization, longer length of stay, changes in infection prevention practices due to staffing shortages. However, reported data are limited. The goal of this study was to evaluate the impact of the COVID-19 pandemic on our CAUTI rates. MethodsThis was a retrospective cross-sectional study comparing CAUTI rate per 1,000 indwelling urinary catheter (IUC) days, urine culture (UC) utilization rate per 1,000 IUC days, IUC utilization rate per 1,000 patient days, Standardized Infection Ratio (SIR) and Standardized Utilization Ratio (SUR) in the pre-COVID-19 period from January 1, 2019 to December 31, 2019 to the COVID-19 period from April 1, 2020 to March 31, 2021 at an 877-bed tertiary care hospital in Detroit, Michigan. CAUTI, UC utilization and IUC utilization rate were extracted from the electronic medical record (Epic™ Bugsy). SIR and SUR data were extracted from National Healthcare Safety Network (NHSN).ResultsThe average CAUTI rate per 1,000 IUC days decreased from 0.99 pre-COVID-19 to 0.64 during COVID-19, yielding a 35% reduction. The UC order rate per 1,000 IUC days decreased from 19.19 to 18.83 with only 2% reduction. However, IUC utilization rate increased by 55% from 0.184 to 0.286. The SIR decreased from 0.483 to 0.337 with a 30% reduction, although this was not statistically significant ((P-value 0.283). The overall SUR decreased significantly from 0.806 to 0.762 (P-value < 0.001). Figure 2 is a control chart of the CAUTI rate from July 2019 to April 2021. Figure 1. CAUTI, indwelling urinary catheter and urine culture utilization rates pre-and during COVID-19 pandemic. Figure 2. CAUTI control chart pre-and during COVID-19 pandemic.ConclusionAlthough the IUC utilization increased during the COVID-19 pandemic, CAUTI rate, SIR and SUR decreased and UC orders remained unchanged. Thus, the pandemic did not have a negative impact on our CAUTI rates.Disclosures All Authors: No reported disclosures

MP55-17 REDUCING FOLEY CATHETER USAGE IN A PEDIATRIC HOSPITAL USING A BEHAVIORAL NUDGE

You have accessJournal of UrologyPediatric Urology V (MP55)1 Sep 2021MP55-17 REDUCING FOLEY CATHETER USAGE IN A PEDIATRIC HOSPITAL USING A BEHAVIORAL NUDGE Daniel Pelzman, Marc Colaco, Omar Ayyash, and Glenn Cannon Daniel PelzmanDaniel Pelzman More articles by this author , Marc ColacoMarc Colaco More articles by this author , Omar AyyashOmar Ayyash More articles by this author , and Glenn CannonGlenn Cannon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002085.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Catheter-associated urinary tract infections (CAUTI) prolong hospitalizations and increase healthcare costs. The rates of infection are monitored by the Joint Commission and the Centers for Disease Control. As a result, many adult hospitals have instituted policies to reduce their CAUTI rate, but similar efforts have not been well-studied in pediatric hospitals. We sought to investigate whether behavioral modifications including catheter teaching and a daily rounding checklist could reduce unnecessary catheter usage in a 313-bed tertiary-care pediatric hospital. METHODS: Prospectively collected data of urinary catheter utilization at a single pediatric-only hospital from Jan 2015-Dec 2019 were analyzed. In May 2017, hospital-wide mandatory workshops were performed and a nursing-driven daily checklist to assess for catheter necessity was implemented. Pre- and post-intervention catheter utilization rates were compared using the standardized utilization ratio, which is a CDC-developed quality measure of catheter usage defined as total catheter days per total patient days. The intervention was implemented during a seven-month run-in period (May-Dec 2017), which was omitted from analysis. RESULTS: A total of 455,534 patient-days were available for analysis between January 2015 and December 2019. Overall CAUTI rate decreased from 0.13/1000 patient-days to 0.04/1000 patient-days. Hospital-wide catheter utilization decreased from 9.8% (95% confidence interval (CI) [9.4% - 10.3%]) pre-intervention to 3.5% (95% CI [3.3% - 3.8%], p < 0.01) post-intervention (Figure 1). These changes were most pronounced in critical care units where utilization dropped from 35.0% (95% CI [33.5% – 36.4%]) to 12.8% (95% CI [11.6% - 14.1%], p < 0.01). Standardized utilization ratios in the critical care units fell from 2.09 (95% CI [2.00 – 2.19]) to 0.76 (95% CI [0.69 – 0.84], p < 0.01). CONCLUSIONS: Catheter teaching and institution of a daily rounding checklist successfully reduced monthly urethral catheter utilization as measured by catheter usage rates and standardized utilization ratio in a pediatric hospital. Widespread adoption of these protocols may decrease unnecessary catheter usage and catheter-associated morbidity. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e966-e966 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Pelzman More articles by this author Marc Colaco More articles by this author Omar Ayyash More articles by this author Glenn Cannon More articles by this author Expand All Advertisement Loading ...

Comparison of metrics used to track central-line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) across a regional network.

The paradoxical relationship between standardized infection ratio and standardized utilization ratio for catheter-associated urinary tract infections (CAUTIs) in contrast to central-line-associated bloodstream infections (CLABSIs), in addition to CAUTI definition challenges, incentivizes hospitals to focus their prevention efforts on urine culture stewardship rather than catheter avoidance and care.

Effectiveness of a Multidisciplinary Team-Approach on Central-Line–Associated Bloodstream Infections

Background: Although there has been a significant reduction in central-line–associated bloodstream infection (CLABSI) rates in the past decade with the implementation of evidence-based practices, an estimated 30,100 CLABSI occur each year in acute-care facilities. CLABSIs are associated with increased length of stay, cost, morbidity, and mortality, and they are preventable. In this study, we assessed the impact of a multidisciplinary team approach on CLABSI rates at a 319-bed teaching hospital in northwestern Ohio. Methods: In this before-and-after retrospective study, we compared the CLABSI rate per 1,000 central-line days, standardized infection ratio (SIR), and standardized utilization ratio (SUR) in the preintervention period (January 1, 2016, to December 31, 2018) to those of the intervention period (January 1, 2019, to December 31, 2020). Despite hospital-wide nursing education focusing on central-line maintenance in 2017, our SIR and SUR remained above the national benchmark. Starting in August 2018, we began to focus on insertion practices and physician education. An infection preventionist observed resident central-line insertion training and noted that there was no emphasis on infection prevention measures. There was a best practice knowledge gap. Thus, the indications for central-line use were updated, the insertion checklist was standardized, and the vascular access policy was revised to limit femoral and internal jugular vein use. Infection prevention training was provided to all providers involved in central-line insertions. Nurses were tasked with observing insertion of every central line and stopping the procedure if there is was an observed break in sterile technique. A central-line report listing indications and duration was developed and was sent to the nursing directors who assessed daily need with providers and prompted removal of unnecessary lines. The infection prevention medical director provided CLABSI prevention education to providers. Results: The CLABSI rate per 1,000 central-line days decreased from 0.90 in the preintervention period to 0.34 in the postintervention period, resulting in a 62% reduction in CLABSI rate. The SIR decreased from 0.886 to 0.323 (p-value &lt;0.05), yielding a 64% reduction. The SUR also decreased from 1.156 to 0.874 (p-value &lt;0.001) with a 24% reduction. Conclusion: A multidisciplinary team-approach with emphasis on standardized insertion checklist to ensure adherence to sterile technique and prompt removal of unnecessary central lines, and physician insertion training focusing on IP practices may potentially reduce CLABSI rates.Funding: NoDisclosures: None

Intentional Leadership Rounds: A Proactive Approach to CAUTI Reduction

Background Catheter-associated urinary tract infections (CAUTI) are the most common preventable hospital-acquired infection. Our facility's rate of CAUTI was above the risk adjusted expected rate. Using intentional leadership rounds, we sought to reduce indwelling urinary catheter (IUC) utilization and thus reduce CAUTI events. Methods Using the Plan-Do-Study-Act model and a Pareto tool for data collection, intentional leader rounds were completed by an Infection Prevention (IP) nurse on two 20-bed medical-surgical units (Neuro-Oncology and Surgical). Units were identified using the National Healthcare Safety Network (NHSN) targeted assessment for prevention (TAP) strategy as units with excess burden of CAUTIs. An IP nurse rounded with nurse providers on each of these units daily (Monday – Friday) for five months, interacting with the nurse to determine if the indication for the IUC was appropriate, if care and maintenance were completed, and if the catheter could be removed or an external catheter placed. The standardized utilization ratio (SUR) was used to determine a decrease in catheter utilization and the standardized infection ratio (SIR) was used to track CAUTIs over time. Results After five months of leadership rounding on Neuro-Oncology and Surgical, the SUR decreased 22% and 12% respectively on each of these units. There were no additional CAUTI events identified during this time frame. Observations from leader rounds identified collaboration between IP and staff nurses to discover barriers on the units and engaged staff in problem-solving. In addition, sustained change was facilitated through the building of interpersonal relationships between IP and the bedside nurse. Conclusions Urinary device utilization was reduced on each unit and there were no additional CAUTI events identified. Integrating leader rounds as an added strategy to reduce CAUTIs connects leaders with clinical staff. Intentional leader rounding along with evidence-based practices to reduce preventable infections and patient harm should be integrated as a proactive overall prevention strategy.

573 A Novel Nursing Approach in Reducing Catheter-Associated Urinary Tract Infections in a Regional Burn Center

Abstract Introduction Catheter-associated urinary tract infections (CAUTI) adversely affect more than 30% of patients in critical care hospital settings. Considered one of the most prevalent of nosocomial infections, CAUTI are linked to extended hospital stays, rising health care costs, and increased morbidity and mortality. CAUTI are attributed to prolonged catheter use, contaminated catheter insertion, and improper care and maintenance. Adhering to infection control guidelines is essential in preventing CAUTI in healthcare institutions. To illustrate, nearly 380,000 CAUTIs could be prevented and 9,000 lives saved, annually, with the prevention of CAUTI (Centers for Disease Control and Prevention, 2019). Methods Over the last nine months, our burn team has been working to reduce the CAUTI Standardized Infection Ratio (SIR) and Standardized Utilization Ratio (SUR) in the Burn Center. Efforts to facilitate this reduction include the education of nurses and providers on the indications for placement, replacement, and removal of indwelling urinary catheters. We also developed and assigned a PowerPoint presentation and post-assessment to staff members to educate and measure their understanding of the proper care for patients with urinary catheters in place. The hospital facility’s protocol was revised to reflect the specific needs and alternatives for urinary catheters in our burn patient population. The new burn specific protocol now serves as a guideline for the multidisciplinary team during daily rounds to reduce the risk of CAUTI in the Burn Center. Charge Nurses continue regular audits. Results The SIR benchmark for 2019 was 0.774. The SIR for the Burn Center in the third quarter of 2019 was incalculable because the predicted number was less than one. The SIR for the fourth quarter of 2019 was 0.913. The SUR benchmark for 2019 was 1. The SUR for the Burn Center in the third and fourth quarters of 2019 were 1.035 and 1.150, respectively. This data indicated the need for a comprehensive plan for improvement. Following the implementation of our team’s comprehensive improvement plan, the SIR and number of infections for the first quarter of 2020 was zero, which is below the SIR benchmark 0.727 for 2020. The improvement plan we instituted also reduced the SUR to 0.897 for the first quarter of 2020, compared to the benchmark of one for 2020. The SUR rate for the second quarter was 1.118. Conclusions Instituting this simple nurse-driven protocol has resulted in a noteworthy improvement in patient outcomes. Achieving benchmark goals remains a significant priority to our burn center team as we continue to see the progress and health benefits of fostering the safest care environment for our patients, while remaining financially responsible to our institution.

Rates of Ventilator Associated Pneumonia in Saudi Ministry of Health Hospitals; A Two-year Multi-Center Study

BACKGROUND: Although the rates of ventilator associated pneumonia (VAP) have been estimated in Saudi Arabia, however national surveillance data for VAP has never been reported earlier. OBJECTIVES: To estimate VAP rates and ventilator utilization ratios in 105 Ministry of health (MOH) hospitals and to benchmark them with International Standards. METHODS: It was a prospective surveillance study in 15 different types of intensive care units (ICUs) between January 2018 and December 2019. The data were entered into the health electronic surveillance network (HESN) program. The methods of US National Healthcare Safety Network (NHSN) and the Gulf Cooperation Council (GCC) center for infection control were used. RESULTS: During two years of surveillance covering 1,469,658 patient-days and 569,961 ventilator-days, a total 1,694 VAP events were identified. The overall MOH VAP rate was 2.97 (95% confidence 2.83-3.11) per 1000 ventilator-days and the overall ventilator utilization ratio was 0.39 (95% confidence 0.387- 0.389). VAP rates were highest in adult medical (4.40), pediatric cardiothoracic (3.64), and adult medical surgical ICUs (3.61). VAP standardized infection ratio across all types of ICUs in MOH hospitals were 29% lower than GCC hospitals, 78% lower than International Nosocomial Infection Control Consortium (INICC) hospitals, and 191% higher than NHSN hospitals. Ventilator standardized utilization ratio in all types of ICUs in MOH hospitals were 19% lower than GCC hospitals, 32% higher than INICC hospitals, and 50% higher than NHSN hospitals. CONCLUSIONS: Using huge standardized data, the current report can serve as a unique national VAP benchmark, fostering a culture of competitiveness between the hospitals and regions.

Improving Care for Critical Care Patients by Strategic Alignment of Quality Goals With a Physician Financial Incentive Model.

The passage of the Affordable Care Act has ignited a shift from the pay-for-performance model to value-based care with a particular relevance in critical care settings. Provider incentive programs are widely considered as a means to reward providers based on the achievement of preset quality metrics. This article aims to demonstrate the effects of a provider incentive program in the critical care delivery system in a large academic center in the Northeastern United States. This article describes the results of a retrospective analysis of a performance-driven quality improvement initiative at a critical care facility of an academic medical center using a quasi-experimental pre-/posttest design. A set of quality measures was selected as outcome metrics. Selection criteria for the process measures are as follows: (i) the metric goals should be influenced by the physician's input to a large degree; (ii) the measure must be transparent and accessible within the hospital-wide data reporting system; (iii) the metric that required group effort and interdisciplinary collaboration to achieve; and (iv) the measure must directly affect patient outcome. The outcome metrics are central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), standardized infection ratio (SIR), Foley catheter and central line utilization standardized utilization ratio (SUR), hand hygiene compliance, and adherence to respiratory recovery pathway goals. These metrics were tracked from for 3 years with success defined as achieving set benchmarks for each metric. The average CLABSI SIR and CAUTI SIR across all intensive care units (ICUs) decreased by 44% (P = .05) and 87% (P = .02) over 3 years as well as the central line and Foley catheter utilization falling by 41% and 30%, respectively. Hand hygiene compliance in the ICUs improved for the same period by 27 percentage points, as did compliance with the respiratory recovery pathway program by 4 percentage points. The use of a physician-driven financial incentive model in a critical care setting measured by outcome metrics dependent on physician input is successful with rigorous implementation and careful evaluation.

Comparison of Metrics Used to Track CLABSIs and CAUTIs Across a Regional Network

Background: The standardized infection ratio (SIR) is the nationally adopted metric used to track and compare catheter-associated urinary tract infections (CAUTIs) and central-line– associated bloodstream infections (CLABSIs). Despite its widespread use, the SIR may not be suitable for all settings and may not capture all catheter harm. Our objective was to look at the correlation between SIR and device use for CAUTIs and CLABSIs across community hospitals in a regional network. Methods: We compared SIR and SUR (standardized utilization ratio) for CAUTIs and CLABSIs across 43 hospitals in the Duke Infection Control Outreach Network (DICON) using a scatter plot and calculated an R2 value. Hospitals were stratified into large (&gt;70,000 patient days), medium (30,000–70,000 patient days), and small hospitals (&lt;30,000 patient days) based on DICON’s benchmarking for community hospitals. Results: We reviewed 24 small, 11 medium, and 8 large hospitals within DICON. Scatter plots for comparison of SIRs and SURs for CLABSIs and CAUTIs across our network hospitals are shown in Figs. 1 and 2. We detected a weak positive overall correlation between SIR and SUR for CLABSIs (0.33; R2 = 0.11), but no correlation between SIR and SUR for CAUTIs (−0.07; R2 = 0.00). Of 15 hospitals with SUR &gt;1, 7 reported SIR &lt;1 for CLABSIs, whereas 10 of 13 hospitals with SUR &gt;1 reported SIR &lt;1 for CAUTIs. Smaller hospitals showed a better correlation for CLABSI SIR and SUR (0.37) compared to medium and large hospitals (0.19 and 0.22, respectively). Conversely, smaller hospitals showed no correlation between CAUTI SIR and SUR, whereas medium and larger hospitals showed a negative correlation (−0.31 and −0.39, respectively). Conclusions: Our data reveal a weak positive correlation between SIR and SUR for CLABSIs, suggesting that central line use impacts CLABSI SIR to some extent. However, we detected no correlation between SIR and SUR for CAUTIs in smaller hospitals and a negative correlation for medium and large hospitals. Some hospitals with low CAUTI SIRs might actually have higher device use, and vice versa. Therefore, the SIR alone does not adequately reflect preventable harm related to urinary catheters. Public reporting of SIR may incentivize hospitals to focus more on urine culture stewardship rather than reducing device utilization.Funding: NoneDisclosures: None

Population Standardized Infection Ratio (pSIR): A More Meaningful Reflection of Performance With Reduction in Device Use

Background: Interventions to reduce unnecessary device use may select a higher-risk population, leading to a paradoxical increase in SIR for some high-performing facilities. The standardized utilization ratio (SUR) adjusts for device use for different units and facilities. We evaluated the performance of a population SIR (pSIR) metric compared to device SIR (dSIR) in the situations of increased, decreased, and no change in SUR for a large system. Methods: We evaluated hospitals that had a reduction, increase, and no substantial change (±5% relative change) in their SUR in FY2019 (July 2018–June 2019) compared to baseline FY2017 (July 2016–June 2017). The dSIR (defined as Σ observed events divided by Σ predicted events based on actual device days) and pSIR (defined as Σ observed events divided by Σ predicted events based on predicted device days). We calculated the cumulative attributable difference (CAD) for catheter-associated urinary tract infections (CAUTIs) for the same facilities based on dSIR and pSIR. Results: Overall, the system SUR dropped from 0.92 in 2017 to 0.85 in 2019 (7.3% decrease). Of the 48 hospitals included, 25 (52%) exhibited a drop, 13 (27%) exhibited an increase, and 10 (21%) had no change in SUR during 2019. For hospitals in which SUR decreased, the dSIR decreased by 15.9% from 0.88 to 0.74, and the pSIR decreased by 32.3% from 0.85 to 0.58 (Table 1). In 2019, the CAD for CAUTI to a target SIR of 1 was 133 for the dSIR compared to 181 for the pSIR, and 36% more events were avoided. Conclusions: The traditional SIR (dSIR) underestimated improvements in infection rates compared to the pSIR because it failed to account for reduced device utilization associated with infection prevention interventions. The pSIR accounts for overall risk of infection associated with device exposure in a population and better reflects the efficacy of prevention efforts compared to dSIR. The pSIR should be considered in situations in which interventions have led to substantial reductions in device use.Funding: NoneDisclosures: None

Amidst the CAUTI Metrics Hurley Burly, a Sustained SURly Success Adaptable for Reducing Other Nosocomial Infections

Background: Surveillance metrics for catheter-associated urinary tract infections (CAUTIs) are subject to ongoing debate and refinement to best capture infectious catheter-related harm (ICRH) and noninfectious catheter-related harm (NCRH). Indwelling urinary catheters cause 5 times more NCRH than ICRH. The commonly used standardized infection ratio (SIR) does not fully capture NCRH nor the impact of prevention efforts in all settings. Alternatively, device utilization rates and ratios (DUR) do not reflect differences in other factors that may describe levels of device use. DUR lose comparability over time and across settings and can mask truly effective interventions by selecting for a higher risk group of catheterized patients. Experts now advocate use of the standardized utilization ratio (SUR). We sought to implement a multidimensional intervention to reduce exposure risk, CAUTI, and NCRH across a 5-hospital healthcare system, totaling 1,692 acute-care beds. Methods: The intervention comprised the following elements: (1) an interactive educational campaign comprising one-on-one engagements between infection preventionists and frontline providers, encouraging the use of female external urinary collection devices and male custom-fitted condom catheters, rewarding overall participation, device utilization, hand hygiene, and CAUTI rates; (2) educational emails to all staff from top executives; (3) increasing the urinalysis reflex to culture threshold from &gt;5 to ≥10 WBCs; and (4) clinical decision support (CDS) for ordering urine cultures for patients with indwelling catheters and for encouraging Foley catheter alternatives and catheter removal. Monthly, quality department representatives discuss unit level DURs with managers, who then discuss patient-level device use at daily huddles with physicians and advanced practice providers. Significance was determined using the 2-tailed t test. The results are listed in Table 1. Discussion: One year after the intervention, use of device alternatives increased 5-fold, CDS-driven ordering predominated, and the SIR and SUR remained significantly decreased. These successes are especially notable because , a ventricular-assist device program was launched in the postintervention period. By the end of the study, the program became the second-busiest of its type in the United States, resulting in a group of patients at high risk of device use and infection in the postintervention period, but absent in the preintervention period. numerous reports of effective interventions for reducing CAUTI have been published, we found no large studies using the SUR as the main metric. The limitations of this study include the lack of a population SIR and data pertaining to catheter-related bacteriuria and antibiotic usage. However, this approach is easily customizable to any infection, device, and diagnostic test.Disclosures: NoneFunding: None

Catheter-Associated Urinary Tract Infections (CAUTIs) Reduction: A Multidisciplinary Approach

Background: CAUTIs remain one of the most common hospital-acquired infections (HAIs) accounting for prolonged hospital stay and increased healthcare costs. According to the NHSN, the standardized infection ratio (SIR) at our institution was 1.6 compared to national average of 0.84 in 2018. We highlight the interventions implemented in our institution to prevent CAUTIs. These interventions have shown a reduction in the rate of CAUTIs, the SIR, Foley catheter days, and institutional cost. Methods: In addition to standard CAUTI prevention practices, we hypothesized that we could decrease CAUTIs through the daily implementation of specific practices. We developed a comprehensive interdisciplinary team which included the staff or charge registered nurse (RN), the unit manager, an infection preventionist, an advanced practice registered nurse (APRN), a pharmacist with an antimicrobial focus, and a physician from the infectious disease department who would conduct daily rounds on different units in the institution for education and assessment of catheter indications. A detailed review and analysis of the urine culture orders for patients with a Foley catheter was performed. A nurse-driven Foley catheter removal protocol before urine culture collection was initiated. We implemented a Foley catheter bundle that has guidelines for Foley insertion, best practice competency, and urinary catheter best practice algorithm and advocated alternative use of male or female external catheter. We educated physicians about ordering a reflexive urine analysis test followed by urine culture instead of testing either individually after removal of a Foley catheter. Lastly, we performed a root-cause analysis on all reported CAUTIs. These policies were implemented in a 435-bed tertiary-care center in November 2018, and we present data from 1-year before and after the interventions. Results: At our institution, we had 71 CAUTIs, with an SIR of 1.6, a standardized utilization ratio (SUR) of 0.92, 27,621 Foley days, and institutional cost of $979,303 compared to 40 CAUTIs with an SIR of 1, an SUR of 0.88, 24,193 Foley days, and institutional cost $537,927 after implementing our interventions. Conclusions: CAUTIs can be reduced by implementing specific measures that include infection control team rounds, nurse-driven protocol, and the use of Foley catheter bundles. Measures should be undertaken to prioritize these practices as part of a protocol. We advocate further studies to evaluate these measures. Education programs for healthcare professionals concerning CAUTIs and its complications can be implemented to carry out the prevention methods efficiently.Funding: NoneDisclosures: None

Care Bundles for Preventing Device Related Infections: Just Focus on These 6 Things

Background: Centralizing healthcare associated infection (HAI) data for 21 hospitals across several states facilitates a big picture assessment of monthly enterprise performance along with evaluation of practice, policy, and products. Variation in prevention practices has made it difficult to identify areas of focus and created confusion when attempting to standardize prevention tactics for central-line and urinary catheter care. Lack of consistent practice audits have made it difficult to evaluate actual practice. For these reasons, we performed a gap analysis to understand the current state. Methods: Gap assessment tools were developed to assess infection prevention practices for central lines and indwelling urinary catheters. Survey questions were developed with a comment option to collect qualitative data. The 2014 Compendium of Strategies to Prevent Healthcare-Associated Infection in Acute-care Hospitals was utilized as the reference point. This document facilitates the translation of essential information into clinical practice, thus providing the rationale and level of evidence needed for discussion groups. Completion occurred with various key stakeholders within each hospital. One survey per hospital was compiled. Results: All hospitals completed the survey with key themes emerging and supported by observational data. Findings included variation with education, chlorhexidine bathing, types of dressings, and compliance with alcohol port protectors. Gaps identified with urinary catheter care included confusion surrounding catheter care, breaches in seals, and optimizing alternatives to catheterization. Rather than segment solutions for identified gaps, care bundles were developed to provide focus, to facilitate evidence-based practice, and to create standard work-around clinical audits that consisted of going to the patient rather than the electronic health record. Care bundles provided the 6 items to focus on and for which to create policy and standardize products. Conclusions: Care-bundle implementation initially created resistance from clinicians and many questions regarding actual practice. The design of the tool was deliberate in that audit language, the metric, and the “why” were included and served as a medium to discuss the evidence and immediate feedback for practice. Pareto charts were posted on unit performance boards. It became evident that compliance with prevention tactics was not consistent. Although number of infections or outcome data did not appreciably decrease, standardized utilization ratio was reduced by 11% for each device after 3 quarters. Process measures from bundle audits continue to improve, as do observational data, and these are part of focused discussions at quality forums. A culture change has occurred as process measures and evidence-based practice has become a priority.Funding: NoneDisclosures: None

Using the NHSN Tap Report and Standardized Utilization Ratio to Decrease Urinary Catheter Utilization

<h3>Background</h3> Our facility had the highest urinary catheter standardized utilization ratio (SUR) in our hospital system, which consists of nine acute care hospitals in Nebraska and Iowa. Using the NHSN Tap report and SUR, we were able to focus on the specific unit with the highest SUR's, which was the 29-bed orthopedic medical surgical unit. <h3>Methods</h3> We completed a chart review of IUC's in place on this unit, and were able to determine that a majority of the usage was related to orthopedic surgical patients. After completing a literature review for best practices for utilizing and removing IUC in this patient population, we updated the orthopedic order sets to use alternative urinary collection methods, such as a external female catheter or urinal, prior to inserting a IUC. Orthopedic surgeons allowed removal of the urinary catheter in certain cases in the operating room or post-anesthesia care unit before the patient was transferred to the inpatient units, or did not insert a IUC during the procedure. <h3>Results</h3> During our initial chart audit in October and November 2018, our orthopedic surgeons completed 117 procedures in that time from and 67% of these cases included patients that were admitted to the orthopedic unit was a foley catheter. In September and October 2019, our orthopedic surgeons completed 90 procedures in that time from and 30% of these cases were patients that were admitted to the orthopedic unit was a foley catheter. This was a 37% improvement in IUC utilization in this patient population. <h3>Conclusions</h3> Overall, our interventions had drastically improve our indwelling urinary catheter SUR on our orthopedic medical surgical unit and have helped us to decrease the risk for catheter-associated urinary tract infections for our patients at our facility.