Standardized Utilization Ratio Research Articles

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.

Foley Vacation Use to Reduce CAUTI in an ICU

<h3>Background</h3> This project identifies the impact to Catheter Associated Urinary Tract Infection (CAUTI) with the use of a Foley Vacation Algorithm. An increase in CAUTIs was noted in the Intensive Care Unit (ICU) at a Comprehensive Stroke Center. <h3>Methods</h3> This project includes patients admitted to the ICU. The intended target for the Foley vacation algorithm was patients with an indication of "urinary retention." The Foley vacation algorithm was implemented in June 2018. Pre-data was collected starting in January 2018, when the increase in CAUTIs was identified. Post implementation data is through Quarter 3 2019. The hypothesis of the change was that CAUTIs would decrease with implementation of the Foley Vacation Algorithm with an expected decrease in device utilization contributing to a decreased infection risk. The CAUTI definition used was based on NHSN criteria and the outcome data includes a Standardized Infection Ratio (SIR) and Standardized Utilization Ratio (SUR) also defined by NHSN. <h3>Results</h3> After implementation of the Foley Vacation Algorithm in June 2018, the SUR dropped and the ICU has had 2 infections in the first 3 quarters of 2019 as compared to 7 in the same time frame the year prior. The SIR dropped more than half from an average of 2.4 per quarter in 2018 to 1.093 per quarter in 2019. <h3>Conclusions</h3> This project found that utilization of a Foley Vacation Algorithm for patients in the ICU with an indication of "urinary retention" resulted in a decrease in CAUTIs. Utilization of this practice when other CAUTI prevention bundle measures are in place can help decrease utilization and prevent CAUTI in other units or facilities.

Multi-Pronged CAUTI Reduction Strategy

<h3>Background</h3> Catheter associated urinary tract infection (CAUTI) rates were identified as a concern at a large regional medical center (>500 beds). Inpatient chart audits were conducted revealing: nurse initiated indwelling catheter removal protocols inconsistently applied, catheters inserted for urinary retention without supporting documentation, catheters frequently inserted in the emergency department (ED), and inconsistent nursing care documentation. Based on our findings a multi-disciplinary, multi-pronged plan to improve the quality of care related to indwelling catheters and reduce CAUTI was deployed. <h3>Methods</h3> An interdisciplinary team was organized, gap and root-cause analyses were performed. The urinary retention assessment pathway (URAP) was developed to support the nurse initiated indwelling catheter removal protocol. A campaign, Foley Reduction in the ED, was established to reduce initial insertion of indwelling catheters. On the inpatient units, device rounds were implemented to reinforce appropriate nursing practice. An external catheter was made available for female patients. Standardized CAUTI prevention content was provided at orientation as well as annual education for all nursing staff. <h3>Results</h3> Improvements were observed after implementation of the URAP and inpatient device rounds; an emphasis on prevention of insertion of indwelling urinary catheters in the ED; and education regarding proper care and maintenance. A reduction in CAUTI Standardized Infection Ratio from 0.85 in 2018 to 0.662 and a slight decrease in the Standardized Utilization Ratio from 0.931 in 2018 to 0.856 was noted in 2019. <h3>Conclusions</h3> A comprehensive CAUTI prevention strategy for a large regional medical center focusing on clinical education, catheter insertion in the ED, and consistent catheter care and nurse initiated indwelling catheter removal in the inpatient units has led to a reduction of CAUTI and usage of indwelling catheters. While there have been marked improvements, continued monitoring and process improvement will be imperative.

Implementation of External Urine Collection Devices to Decrease the Standardized Utilization Ratio of Indwelling Urinary Catheters

<h3>Background</h3> Catheter associated urinary tract infections (CAUTIs) are one of the most common hospital acquired infections. CAUTIs are associated with numerous complications including increased length of stay. The most significant risk factor for developing a CAUTI is the prolonged use of an indwelling catheter. Our purpose is to determine if the introduction of external urine collection devices for both male and female patients would impact the utilization of indwelling urinary catheters and subsequently, reduce our CAUTI events in our 24-bed Intensive Care Unit (ICU). <h3>Methods</h3> We established our baseline by measuring our urinary catheter utilization rate in our ICU for all 12-months in 2017. In June 2018, a qualitative trial was performed for three weeks for a female external device and then followed by the male external device. Prior to our trial, all team members were educated on the use of the external urine collection systems. Unit based Intensivists were updated on the product trial and encouraged to participate. During the trial, a light duty nurse rounded on each patient with an indwelling catheter to discuss the need for catheter necessity. If the patient required a device, it was advocated to remove the indwelling device and use an external device. Standardized Likert scale evaluations were completed by bedside nursing and nursing assistants during the trial. <h3>Results</h3> Based on the positive trial results, both products were implemented in the ICU and subsequently expanded hospital wide. Our baseline SUR for 2017 was 1.067. In 2018, our SUR decreased by 9.7% to 0.964. To date, our SUR data for January 2019 to October 2019 is 0.736. This is an overall 31% reduction in urinary catheter utilization from our baseline data. <h3>Conclusions</h3> In conjunction with daily conversations regarding catheter necessity, the implementation of external urine collection devices has significantly decreased the SUR on indwelling catheters.

Sustainably reducing device utilization and device-related infections with DeCATHlons, device alternatives, and decision support.

Engagement of frontline staff, along with senior leadership, in competition-style healthcare-associated infection reduction efforts, combined with electronic clinical decision support tools, appeared to reduce antibiotic regimen initiations for urinary tract infections (P = .01). Mean monthly standardized infection and device utilization ratios also decreased (P < .003 and P < .0001, respectively).

Reducing inappropriate urine cultures through a culture standardization program

The objective of this study was to evaluate the impact of a urine culture standardization program that included order indications and urinalysis (U/A) with reflexive culture. The program applied to all adult and pediatric inpatients at an academic medical center; emergency department and ambulatory clinic patients were excluded. The analysis compared outcomes in the pre-implementation (January 2015-May 2016) and post-implementation (July 2016-September 2017) periods. The primary outcomes were urine culture and U/A orders per 1,000 patient days, catheter-associated urinary tract infection (CAUTI) rate per 1,000 catheter days, and urine culture contamination rate per 1,000 patient days. Catheter standardized utilization ratios (SURs) were also examined. The intervention was associated with a significant decrease in urine culture rates by 6.9 cultures per 1,000 patient days (95% CI -4.44, -9.44; P < .0001). The U/A testing rate per 1,000 patient days significantly increased pre-intervention, was not affected acutely by the intervention institution, and significantly decreased post-implementation. The CAUTI rate was not significantly changed by the intervention but did significantly increase post-implementation by 0.2 per 1,000 catheter days (95% CI 0.01, 0.47; P = .04); SURs significantly decreased (0.03; 95% CI -0.003, -0.05; P = .03); and the urine culture contamination rate per month showed no significant change. Sixty-four percent of urine cultures ordered using the reflexive test did not reflex to culture by U/A criteria. A urine culture standardization program led to a significant reduction in urine cultures and did not lead to an increase in U/A testing rates. CAUTI rates increased post-implementation, which may have been confounded by reduced catheter utilization.

1159. Multidisciplinary Leadership Rounds Are Associated with Decreased Urinary Catheter and Central Venous Catheter Device Utilization at a Tertiary Care, Academic Hospital

BackgroundOptimizing use of urinary catheters (UCs) and central venous catheters (CVCs) is crucial to prevent catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), and other complications. Despite education and adoption of catheter removal protocols, indwelling devices not meeting approved indications were still noted.MethodsTwice a week, UC and CVC surveillance rounds were conducted by a team of directors from nursing, vascular access, infection prevention, and hospital epidemiology. Different hospital units were selected each week in random distribution. Rounds emphasized face-to-face discussion with nurses and device observations to identify any removal opportunities and appropriate maintenance. Device utilization was monitored using CDC National Healthcare Safety Network (NHSN) standardized utilization ratio (SUR) and CAUTIs and CLABSIs were monitored using NHSN definitions. Relative ratios of SURs during pre-intervention (pre-INT) and post-intervention (post-INT) time periods for UCs and CVCs were compared using an exact binomial test and mid-P 95% confidence interval (CI). CAUTI and CLABSI rates were compared using Fisher’s exact test using mid-P value.ResultsA baseline time period A of 12 months pre-INT (June 2017-May 2018) was used to compare with the 10-month post-INT time period B (June 2018-March 2019). The UC SURs for periods A and B were 0.813 and 0.696 (Figure 1). The relative ratio shows a post-INT UC SUR that was 85.6% of the pre-INT period (95% CI: 84.1%, 87.2%, P < 0.001). CAUTI rates for periods A and B were not statistically significantly different at 2.276 vs. 2.164/1000 catheter days (P = 0.803). The CVC SURs for periods A and B were 1.244 and 1.081 (Figure 2). The relative ratio shows a post-INT CVC SUR that was 86.9% of the pre-INT period (95% CI: 85.7%, 88.0%, P < 0.001). CLABSI rates for periods A and B were statistically significantly different at 1.27 vs. 0.804/1000 central line days (P = 0.0335).ConclusionLeadership rounds were associated with a significant decrease in utilization of UCs and CVCs. A significant decrease was noted in CLABSI rates but not in CAUTI rates. Multidisciplinary oversight improved adherence to existing policies and should be considered for optimizing device utilization. Disclosures All authors: No reported disclosures.

1174. The Impact of Multidisciplinary Central Line Stewardship Program to Decrease CLABSI Rates and Central Line Utilization Rates in an Academic Urban Medical Center

BackgroundCentral Line-Associated Blood Stream Infections (CLABSI) is a major healthcare dilemma, contributing to increased morbidity, mortality, and costs. We sought to reduce rates of CLABSI and device utilization by implementing a multidisciplinary Central Line Stewardship Program (CLSP).MethodsIn July 2017, the CLSP, multidisciplinary quality improvement project, was implemented at an academic medical center to ensure proper indication for all CVCs in the hospital and removal when no longer indicated. A CLSP team of executive leaders and infection preventionists performed daily rounds on all CVCs to review indications and maintenance. Nursing staff reported all CVCs daily. Information Technology modified the electronic health record to require daily physician documentation of CVC placement and indications, and to suggest alternatives to CVC when possible. In the event of a CLABSI, a root cause analysis was conducted within 72 hours, and feedback was shared with the clinical staff. A retrospective review was conducted 18 months before and after CLSP implementation. As a facility in a state with mandatory reporting of hospital-acquired infections, institutional data were readily available through the National Healthcare Safety Network (NHSN). To compare rates of CLABSI and device utilization pre- and post-CLSP, we reviewed the Incidence Density Rate (IDR), the standardized infection ratio (SIR), and standardized utilization ratio (SUR). Data from the NHSN website were analyzed using statistical tools provided by the NHSN analysis module. Two-tailed significance tests were conducted with α set at 0.05.ResultsPost-CLSP, there was a statistically significant decrease in SIR from 1.99 to 0.885, with risk reduction by 44.3% (P = 0.013, 95% CI 0.226 -0.831). CLABSI IDR per 1000 CVC days declined from 1.84 to 0.886 (P = 0.0213). CVC utilization per 1000 patient-days reduced from 155.08 to 142.35 (P < 0.001). There was also a trend toward fewer PICC line infections post-intervention (17 to 5).ConclusionWith this novel CLSP, we achieved a significant reduction in rates of CLABSI and device utilization, suggesting that a multidisciplinary approach can promote sustainable prevention of line-associated infections through dedicated surveillance of CVC indications and maintenance. Disclosures All authors: No reported disclosures.

1157. GET IT OUT! Nurses and Clinical Quality Improvement Specialists Drive Initiative to Reduce Standardized Utilization Ratios for Indwelling Urinary Catheters in Hospitalized Patients

BackgroundUrinary tract infections (UTIs) account for 34% of all healthcare-associated infections (HAI). Urinary catheters (UC) are placed in 15–25% of hospitalized patients and >75% of HAI UTIs are UC-related. Bacteria introduced via UC can colonize the bladder within 3 days. So, the greatest risk factor for acquiring a catheter-associated urinary tract infection (CAUTI) is prolonged use of indwelling UC. Nursing (RN) staff noted inconsistency with appropriate use of UC and commonly UC remained in place well after their original indication had expired.MethodsAs part of a multi-faceted approach for quality improvement and patient safety, we rolled out an Agency for Healthcare Research and Quality (AHRQ)-based initiative to reduce UC days/Standardized Utilization Ratio (SUR). Daily critical reviews of the indication for UC were conducted by two groups. First, frontline night shift RN staff identified patients who no longer had a valid justification for continued UC. They handed-off the information to day-shift RNs, who recommend removal of UC during daily rounds with the physician teams. A second review was performed by Clinical Quality Improvement Specialists (CQIS) based on defined criteria from our nursing decatheterization protocol. Their discontinue UC recommendations were also sent to the care teams. The critical reviews of UC for CAUTI reduction started with 4 ICUs in August 2018, with additional ICUs added in December, January and March. Monthly UC SURs were trackedResultsFigure 1 shows the number of UCs recommended for removal by RNs vs. CQIS (bars), as well as the percent discordance between RNs and CQIS (line). CQIS identified many more removable UCs than the RNs (888 vs. 256). 211 UC were removed after RN recommendations, and an additional 386 UCs were removed as a result of the CQIS audits. Figure 2 shows the marked corresponding decline in our SUR over this intervention.ConclusionAs more units participated in the initiative, we saw increasing numbers of “discontinue UC” recommendations. Over time there was also a moderate decrease in the discordance between RN and CQIS recommendations for UC removal. CQIS routinely identified many more UCs to be removed compared with RNs, and more than doubled the number of discontinued UC. Notably, the UC SUR markedly improved, decreasing from 0.98 to 0.78. Disclosures All authors: No reported disclosures.

The case for a population standardized infection ratio (SIR): A metric that marries the device SIR to the standardized utilization ratio (SUR).

The device standardized infection ratio (SIR) is used to compare unit and hospital performance for different publicly reported infections. 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 calculated the device SIR (calculated based on actual device days) and population SIR (defined as Σ observed events divided by Σ predicted events based on predicted device days), adjusting for the facility SUR for both central-line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) in 84 hospitals from a single system for calendar years 2016 and 2017. The central-line SUR was 1.02 for 801,172 central-line days, with a device SIR of 0.76 and a population SIR of 0.78, a 1.6% relative increase. On the other hand, the urinary catheter SUR was 0.90 for 757,504 urinary catheter days, with a device SIR of 0.84 and a population SIR of 0.76, a 10.0% relative decrease. The cumulative attributable difference for CAUTI to a target SIR of 1 was -135.4 for the device SIR compared to -203.66 for the population SIR, a 50.8% increase in prevented events. Population SIR accounts for predicted device utilization; thus, it is an attractive metric with which to address overall risk of infection or harm to a patient population. It also reduces the risk of selection bias that may impact the device SIR with interventions to reduce device use.

Reduction in Central Line Associated Bloodstream Infections across a Long-Term Acute Care Hospital System

BACKGROUND Long-term acute care hospitals (LTACHs) have faced challenges with central line associated bloodstream infections (CLABSIs). Central lines are common among patients in this setting, increasing risk for CLABSI. The goal of this research is to determine whether CLABSI reduction initiatives have resulted in a decrease in CLABSI infections. METHODS The LTACH system has 26 hospitals, geographically dispersed across the country. Since 2015, the healthcare system has implemented more consistent reviews of central line necessity, increased education for Infection Preventionists about identifying infections, standardized central line dressing kits, and more robust antimicrobial stewardship committees within each hospital. The hospitals utilize National Healthcare Safety Network to submit identified CLABSIs. CLABSI Standardized Infection Ratios (SIR) and central line Standardized Utilization Ratios (SUR) were reviewed at a system level from 2015 to 2018. RESULTS When comparing 2015 to September 2018, the system has had 145 fewer CLABSI infections identified, an estimated cost savings of $2,672,640. The SIR in 2015 was 1.57, whereas the SIR for 2018 is 1.18, a decrease of 39%. In 2015 the system had 106 more CLABSIs than predicted, whereas in 2018, the system has had 23 more than predicted. In 2018, the system used 63,252 fewer lines when compared to 2015. In 2015, the system used 47,000 more lines than expected, as compared to 9,936 more than expected in 2018. The SUR in 2015 was 1.38 and in 2018 the SUR was 1.10, which indicates a 28% reduction in central line usage. CONCLUSIONS Scrutiny and education on central line usage, in addition? to more education to IPs and standardized dressing change kits have results in significant decreases in infection identified throughout the LTACH system. While the system still has room for improvement in reducing CLABSI, standardization of processes has shown a decrease in CLABSIs and thus better quality care for patients.

Can You Hear Me Now? … Optimized Communication to Reduce Hospital Acquired Central Line Bloodstream Infection

BACKGROUND Effective communication that is timely, accurate, and unambiguous results in improved patient safety. Central venous catheters are the most frequent cause of healthcare-associated bloodstream infections. Central line associated blood stream infection (CLABSI) events increased during FY16. The hospital CLABSI improvement team identified uncoordinated efforts of multiple disciplines simultaneously working on central line bloodstream improvements as a significant root cause for lack of improved CLABSI performance. METHODS A unified communication strategy was created with oversight from the CLABSI committee. Essential communication building blocks included standardized metrics and data display, custom improvement tools and 24/7 access to unit level performance via a “one-stop-shop” team site. Once the team site was implemented, it was used as a regular mode to deliver consistent CLABSI information to all levels of staff and leadership. RESULTS On demand access to metrics and improvement tools enabled stakeholders to have resources available regardless of time, day or shift. Continuous availability to frontline staff created hyperawareness and urgency around CLABSI prevention. Subsequently, staff were engaged and empowered to monitor and act on their own unit's performance. Since implementing the communication strategy there has been a gradual decrease in both Standardized Infection Ratios (SIR) and Standardized Utilization Ratios (SUR). FY17 SIR of 0.80 decreased to 0.72 during FY18 and FY17 SUR of 0.98 decreased to 0.88 during FY18. CONCLUSIONS Effective communication is essential when coordinating any type of sustainable improvements. A multi-pronged communication plan around CLABSI can assist Infection Prevention with a shift towards shared ownership of unit performance.

Methodology to Reduce Healthcare Associated Infections at a Large Multi-Hospital Health System

BACKGROUND In this changing landscape of healthcare, Infection Prevention (IP) programs need to demonstrate their value to their institutions. One way to do this is through the reduction of healthcare associated infections (HAI). This improves patient outcomes and can also provide value through the avoidance of hospital acquired condition (HAC) penalties. METHODS The reduction of HAIs at the system level of a 151-hospital health system became a top priority necessitating a structured approach. Beginning in January 2017, clear expectations of what is submitted to the National Healthcare Safety Network (NHSN) and reporting deadlines were defined. Next, HAI targets were established. Data is accessed from NHSN by the analytics department via Group Administrator rights. Analysis of standardized infection ratios (SIR), standardized utilization ratios (SUR) and Cumulative Attributable Differences (CADS) relative to system targets is conducted. Follow-up with hospitals having the highest CADS begins with a discussion with the IP team. Then, collaboration and feedback with the local team continues and efforts are escalated up to and including the C-suite and may culminate in a site visit if needed. The role and engagement of the Chief Quality Officer (CQO) is critical throughout the process. RESULTS Since establishing this methodology, the HAI outcomes have approved in six of the eight categories. In the past year (October?2017-September 2018) Clostridium difficile reduced 12%, central line associated bloodstream infection (CLABSI) 16%, catheter?associated urinary tract infection (CAUTI) 11%, abdominal hysterectomy surgical site infections (SSI) 46%, colon surgery SSI?19% and hip arthroplasty SSI 15%. In addition, HAC penalties were reduced. CONCLUSIONS This methodology has been very effective in reducing the HAIs across the health system. Also, the feedback from the stakeholders is positive because it results in collaboration and often brings needed attention to an area they have been struggling with.

Finally! an External Female Catheter Device for Women!

BACKGROUND Catheter-associated urinary tract infections (CAUTI) are preventable infections with significant impact on patient outcomes and hospital reimbursement. Per the Center for Disease Control and Epidemiology (CDC), the risk of CAUTI increases 3-7% per day of urinary catheter use. Until recently, no device to replace indwelling urinary catheters in women was adequate for monitoring urine output. Within our 394-bed, acute care hospital, 59% of CAUTIs in 2017-18 occurred in females. Of those, 80% were indicated for urine output monitoring. This project objective was to decrease indwelling urinary catheter use in female patients, thereby reducing risk of CAUTI. METHODS A successful search was conducted to assess the availability of an external female catheter designed to accurately monitor urine output in immobile female patients. A pilot evaluation conducted in the Medical and Critical Care wards resulted in overwhelmingly positive feedback from both healthcare workers and patients. The product accurately monitored urine output, while avoiding skin moisture or breakdown. Contraindications for use included urinary retention, bowel incontinence, skin breakdown and menstruation. The product was approved and implemented on all adult inpatient units in July 2018. Pre-implementation (August 2017-June 2018) and post-implementation (July 2018-October 2018) CAUTI standardized infection ratios (SIR) and urinary catheter standardized utilization ratios (SUR) were calculated and compared using National Healthcare Safety Network (NHSN) analysis tools. All adult inpatient units, except maternal child health, were included in the study. RESULTS Statistically significant decreases in urinary catheter SUR were noted pre- to post-implementation (1.06 to 0.93; p CONCLUSIONS Indwelling catheter utilization was reduced in immobile female patients by offering an external product capable of accurate urine output measurement. Although CAUTI SIR was not decreased, reduced indwelling catheter utilization could lessen the number of CAUTIs in female patients.

The evolution of catheter-associated urinary tract infection (CAUTI): Is it time for more inclusive metrics?

Catheter-associated urinary tract infection (CAUTI) has long been considered a preventable healthcare-associated infection. Many federal agencies, the Centers for Medicare and Medicaid Services (CMS), and public and private healthcare organizations have implemented strategies aimed at preventing CAUTIs. To monitor progress in CAUTI prevention, the National Healthcare Safety Network (NHSN) CAUTI metric has been adopted nationally as the primary outcome measure and has been refined over the past decades. However, this surveillance metric may underestimate infectious and noninfectious catheter harm. We suggest evolving to more inclusive performance metrics to better reflect quality improvement efforts underway in hospitals. The standardized device utilization ratio (SUR) provides a good surrogate for preventable catheter harm. On the other hand, a population-based metric that combines both standardized infection ratio (SIR) and SUR would address both infectious and noninfectious harm, while adjusting for population risk. Finally, electronically captured catheter-associated bacteriuria may contribute essential information on local testing stewardship.

2106. What Metrics Should We Use to Evaluate CAUTI Performance for Inpatient Rehabilitation Units? An Evaluation of a Large, National Healthcare System

BackgroundThe National Healthcare Safety Network (NHSN)’s Targeted Assessment for Prevention (TAP) Strategy is a framework for quality improvement that offers a focused approach to infection prevention. The cumulative attributable difference (CAD) is used as a prioritization metric to identify areas with the highest burden of excess infections. The standardized utilization ratio (SUR) provides risk-adjusted urinary catheter metric beyond traditional device utilization ratios (DUR). We reviewed a TAP Report and SURs for all Inpatient Rehabilitation Facilities (IRF) within a large, national healthcare system.MethodsUsing the NHSN database, we generated a catheter-associated urinary tract infection (CAUTI) TAP Report for all IRFs across the system for calendar year 2017. The standardized infection ratio (SIR) goal was set at 0.75. CAD [observed events − (predicted events multiplied by SIR goal)] was calculated. A 12-month cumulative urinary catheter SUR was also computed in NHSN.ResultsData from 26 IRFs were reviewed. Total CAUTIs ranged from 0 to 5 (median = 0, mean = 0.88). DURs ranged from 3 to 17%; CAD, −0.70 to 4.10; 12-month cumulative SURs, 0.35–2.14. Statistically significant SIRs were only calculated for two IRFs. Several IRFs with 0 infections had SURs > 1, and two IRFs with multiple CAUTIs had an SUR of ≤1 (table).ConclusionCAD is an actionable prioritization metric for infection prevention in health systems and individual facilities. In populations where events are rare, however, the SUR can be an additional metric to reduce device-associated risks. Areas with high CAD/low SUR could be evaluated for other potential causal factors, including device insertion, care/maintenance techniques and accuracy of NHSN definition application.Table.TAP Report, including SURFacility TAP RankCAUTIsDUR %12-Month SURCADSIR15141.854.104.12460.723.40*3381.002.40*4491.122.001.55170.850.80*6150.630.80*7150.670.80*81101.290.70*9160.830.70*101172.140.60*111121.570.50*12070.92-0.10*13030.35-0.10*14060.78-0.20*15060.82-0.20*16030.35-0.20*17070.87-0.20*18081.07-0.20*19050.62-0.30*20070.96-0.30*21070.92-0.30*220101.31-0.30*23070.92-0.30*24070.95-0.40*25040.58-0.40*260121.50-0.70** Not calculated.Disclosures All authors: No reported disclosures.

2158. Introducing the Population Standardized Infection Ratio (SIR): A Metric that Marries the Device SIR to the Standardized Utilization Ratio (SUR)

BackgroundThe device standardized infection ratio (SIR) has been used to compare units’ and hospitals’ performance for different publicly reported infections. Interventions to reduce unnecessary device use may select a higher risk population that is not accounted for in the current risk adjustments, leading to a paradoxical increase in SIR for facilities that may be high performers. The standardized utilization ratio (SUR) adjusts for device use for different units and facilities.MethodsWe calculated the device SIR (calculated based on actual device-days) and population SIR (defined as Σ observed events/ Σ predicted events based on predicted device days) accounting for the facility SUR for both central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) in 84 hospitals from a single system. The observed and predicted events were compiled at the unit-level and aggregated to facility and system-level SIRs for calendar years 2016 and 2017.ResultsThe central line SUR was 1.02 for 801,737 central line-days, with the device SIR of 0.78 and the population SIR of 0.80 (+2.6%, relative increase). On the other hand, the urinary catheter SUR was 0.89 for 758,966 urinary catheter-days, with the device SIR of 0.87 and the population SIR of 0.77 (−11.5%, relative decrease). The cumulative attributable difference for CAUTI with a SIR of 1 was −107 for the device SIR compared with −185 for the population SIR (73% increase in events prevented). Facilities with a wider variation in SUR tended to have a greater difference in device vs. population SIRs (Figures 1 and 2).Figure 1.Population and device SIR difference vs. SUR away from 1 (CLABSI) (SIR difference of zero not shown).Figure 2.Population and device SIR difference vs. SUR away from 1 (CAUTI) (SIR difference of zero not shown).ConclusionPopulation SIR takes into account device utilization, making it an attractive metric to address overall risk of infection or harm to a patient population, and reduces the risk of selection bias that may impact the device SIR with interventions to reduce device use.Disclosures All authors: No reported disclosures.

457. Relationship Between Healthcare Worker (HCW) Perception of Safety and Rates of Healthcare-Associated Infections (HAI) and Hand Hygiene (HH) Compliance

BackgroundMany facilities complete the Agency for Healthcare Research and Quality (AHRQ) patient safety culture survey. Our goal was to evaluate associations between healthcare worker (HCW) responses to AHRQ patient safety culture survey questions and unit performance on healthcare-associated infections (HAI) and hand hygiene compliance.Methods11,257 HCW across 10 acute care hospitals and four rehabilitation facilities completed the 2016 AHRQ patient safety survey. Unit-level standardized infection ratios (SIRs) were calculated for central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) and standardized utilization ratios (SURs) for Foley catheter use. SIRs and SURs <1 met HAI performance goals. Hand-hygiene compliance was captured via secret-shopper methods and ≥75% used as the cut-off for meeting compliance goals. Unit-aggregated survey responses were compared between units that did vs. did not meet SIR, SUR goals for the year, and HH goals for the quarter, prior to survey distribution, using two-sample t-tests.ResultsFewer HCW on low-HH compliance units (i.e., <75%; n = 179 units) responded positively to questions pertaining to overall perception of safety, frequency of events reported, supervisor/manager expectations/actions promoting safety, organization learning, teamwork within units, communication openness, and nonpunitive response to errors, than HCW on high-compliance units (i.e., >75%; n = 69 units; P < 0.05). More HCW on units with CAUTI SIR <1 (n = 40 units) responded positively to supervisor/manager expectations/actions promoting safety, teamwork across units, and hospital handoffs, compared with HCW on units with SIR ≥1 (n = 20; P < 0.05). Fewer HCW on units with Foley SUR <1 (n = 27 units) responded positively to questions on supervisor/manager expectations/actions promoting safety and teamwork within units, than HCW on units with SUR ≥1 (n = 22; P < 0.05). We observed no associations between CLABSI SIR performance and AHRQ safety survey responses.ConclusionHCW perceptions of unit safety culture can be associated with HAI and HH compliance performance. Unit performance/compliance was most commonly associated with supervisor expectations suggesting a key managerial component to promoting safety culture.Disclosures All authors: No reported disclosures.

¿Sirven los estudios de variabilidad geográfica de la práctica para informar la desinversión? Varias cautelas y algunas reflexiones

ObjectiveDisinvestment has been defined as the explicit process of cutting funding, either totally or partially, from health technologies deemed of low-value. Studies of geographic variation in medical practice have been suggested to be useful in guiding decisions on disinvestment, as they may identify unwarranted variations in procedure-rates at the population level. This study aimed to determine the utility of these studies. MethodsWe performed an ecologic study of variations in standardized rates in four «low-value» interventions: proctologic surgery, arthroplasty revision, incisional hernia repair and tonsillectomy. Variation across 199 healthcare areas within the Spanish national health system between 2002 and 2007 was studied by using the extremal quotient (EQ), the empirical Bayes statistic (EB) and the standardized utilization ratio (SUR). ResultsA total of 168,363 proctologic interventions, 41,066 arthroplasty revisions, 222,427 incisional hernia repairs, and 72,724 tonsillectomies were studied. The EQ ranged from a 3-fold variation in proctologic surgery to a 6.5-fold variation in tonsillectomy. The EB figures varied from moderate to high systematic variation: 0.12 in hernia repair and proctology, 0.20 in arthroplasty revision, and 0.30 in tonsillectomy. Twenty-five percent of the healthcare areas showed SUR figures above 1.24 in proctologic interventions, 1.25 in arthroplasty revision, 1.32 in hernia repair and 1.35 in tonsillectomy. ConclusionsThe interventions studied showed moderate to high systematic variation, supporting the usefulness of variation studies in guiding disinvestment policies. Nevertheless, caution should be exercised when evaluating interventions with an uncertain risk-benefit ratio.