Targeted Assessment For Prevention Research Articles

Abstract TP85: A Collaborative Approach In The Reduction Of Hospital Acquired Infections In A Neuroscience ICU

Intro: HAIs such as catheter associated urinary tract infections (CAUTIs) and central line associated bloodstream infections (CLABSIs) increase morbidity, mortality, healthcare cost, and account for a significant burden of patient harm. We describe efforts between nursing, Infection Prevention (IP), and clinicians in the reduction of HAI-CAUTIs and HAI-CLABSIs on a neuroscience intensive care unit (NeuroICU) in an academic acute care hospital. Methods: Using the Centers for Disease Control and Prevention’s (CDC) Targeted Assessment for Prevention (TAP) framework [Target, Assess, Prevent], IP identified the Neuro-ICU as having an excess burden of HAI-CAUTIs and HAI-CLABSIs and facilitated interdisciplinary engagement. In partnership, nursing, IP, and Neuro-ICU clinicians, developed action plans focused on foley catheter (FC) and central line (CL) utilization, FC bundle compliance, FC maintenance competency validation, and training on central line maintenance. Monthly meetings to discuss progress and identify barriers were performed. Neuro-ICU clinicians and nurse managers performed device rounds twice a day to discuss device necessity utilizing a nurse-driven protocol, and verified FC and CL removal. This project used the CDC’s National Healthcare Safety Network (NHSN) healthcare-associated infection (HAI) tracking system to compute standardized infection ratios, HAI events, FC utilization, and CL utilization. CLABSI and CAUTI bundle compliance were evaluated using an electronic audit tool. Staff competency validation and education attendance were tracked. The project period was from September 2020-July 2021 for CAUTI and January 2021-July 2021 for CLABSI. Results: HAI-CAUTI events decreased from 6 to 1, the standardized infection ratio (SIR) reduced from 3.003 to 0.593, and the FC utilization ratio decreased from 0.36 to 0.31 from October 2019- August 2020 to September 2020-July 2021. HAI-CLABSI events decreased from 1 to 0, CL utilization ratio decreased from 3.31 to 2.81 from June 2020- December 2020 to January 2021- July 2021. Conclusions: These results suggest that an interdisciplinary approach and robust IP practices may be an effective approach to improving patient safety and reducing patient harm.

Making a C-DIFFerence: Implementation of a prevention collaborative to reduce hospital-onset Clostridioides difficile infection rates.

To assist hospitals in reducing Clostridioides difficile infections (CDI), the Centers for Disease Control and Prevention (CDC) implemented a collaborative using the CDC CDI prevention strategies and the Targeted Assessment for Prevention (TAP) Strategy as foundational frameworks. Acute-care hospitals. We invited 400 hospitals with the highest cumulative attributable differences (CADs) to the 12-month collaborative, with monthly webinars, coaching calls, and deployment of the CDC CDI TAP facility assessments. Infection prevention barriers, gaps identified, and interventions implemented were qualitatively coded by categorizing them to respective CDI prevention strategies. Standardized infection ratios (SIRs) were reviewed to measure outcomes. Overall, 76 hospitals participated, most often reporting CDI testing as their greatest barrier to achieving reduction (61%). In total, 5,673 TAP assessments were collected across 46 (61%) hospitals. Most hospitals (98%) identified at least 1 gap related to testing and at least 1 gap related to infrastructure to support prevention. Among 14 follow-up hospitals, 64% implemented interventions related to infrastructure to support prevention (eg, establishing champions, reviewing individual CDIs) and 86% implemented testing interventions (eg, 2-step testing, testing algorithms). The SIR decrease between the pre-collaborative and post-collaborative periods was significant among participants (16.7%; P < .001) but less than that among nonparticipants (25.1%; P < .001). This article describes gaps identified and interventions implemented during a comprehensive CDI prevention collaborative in targeted hospitals, highlighting potential future areas of focus for CDI prevention efforts as well as reported challenges and barriers to prevention of one of the most common healthcare-associated infections affecting hospitals and patients nationwide.

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.

Targeted Assessment for Prevention: A Statewide Collaborative

Background: Infection preventionists (IPs) are the backbone of the quality and safety matrix of their organizations. Tools to help locate potential gaps can provide unique viewpoints from frontline staff. The CDC provides a Targeted Assessment for Prevention (TAP) strategy that identifies vulnerabilities in the prevention of healthcare-associated infection (HAIs). Methods: A statewide quality improvement organization, partnering with the CDC TAP team, administered TAP facility assessments for catheter-associated urinary tract infection (CAUTI), central-line–associated bloodstream infection (CLABSI), and Clostridioides difficile infection (CDI) to a collaborative of 15 acute-care and 2 long-term acute hospitals. More than 800 respondents filled out surveys based on their individualized perceptions of infection prevention practices. Results: The survey results yielded the following lagging indicators: lack of awareness of nursing and physician champions, need for competency-based training of clinical equipment, and feedback on device utilization. At the hospital system level, one improvement team focused on CDI, uncovered leading and lagging areas in general infrastructure, antibiotic stewardship, early detection and appropriate testing, contact precautions, and environmental cleaning. To culminate the TAP collaborative, the cohort of organizations, supported by interdisciplinary teams, participated in a full-day TAP workshop in which they reviewed detailed analyses of their HAI data and assessment results, shared best practices for infection prevention and planned for specific improvement projects using the plan-do-study-act model. Conclusions: Results of a statewide analysis of HAI prevention data and opportunities at a local level were reviewed. The TAP strategy can be used to target opportunities for improvement, to assess gaps in practice, and to develop and implement interventions for improving outcomes. Healthcare facilities and quality improvement organizations can drive infection prevention actions.Funding: NoneDisclosures: None

Targeted Assessment for Prevention Facility Assessments: The Most Common CAUTI and CLABSI Infection Prevention Gaps

Background: The Targeted Assessment for Prevention (TAP) strategy is a quality improvement framework created by the Centers for Disease Control and Prevention (CDC) to facilitate the reduction of healthcare-associated infections (HAIs). TAP facility assessments are a component of the TAP strategy and are completed by staff across the facility to help identify perceptions of and target infection prevention gaps. We have described the gaps most commonly reported by facilities completing TAP facility assessments for catheter-associated urinary tract infections (CAUTIs) and central-line–associated bloodstream infections (CLABSIs). Methods: TAP CAUTI and CLABSI assessments were completed by acute-care facilities across the nation, with CDC technical assistance, from December 2014 to August 2019. Similar questions across 2 versions of CAUTI assessments and 3 versions of CLABSI assessments were combined. Analysis was limited to facilities with ≥10 assessments. Infection prevention gaps were defined as ≥33% respondents answering Unknown, ≥33% respondents answering “no,” or ≥50% of respondents answering “no” and “unknown” or “never” and “rarely” “sometimes” “unknown.” The analysis was completed at the facility level, and the gaps most commonly reported across facilities were identified. Results: In total, 1,942 CAUTI assessments from 42 facilities in 12 states and 1,623 CLABSI assessments from 29 facilities in 11 states were included for analysis. The mean numbers of assessments per facility were 46.2 for CAUTIs and 56.0 for CLABSIs. Across both CAUTIs and CLABSIs, commonly reported perceptions about infection prevention gaps included lack of physician and nurse champions for prevention activities, failure to conduct competency assessments, and inconsistency in select device insertion practices (Fig. 1). For CAUTIs, lack of practices to facilitate timely removal of urinary catheters were also commonly reported, with one-third of facilities reporting inconsistency in use of alerts for catheter removal, 78.6% reporting lack of physician response to these alerts, and 90.5% reporting deficiencies in removing unnecessary catheters in the postanesthesia care unit. For CLABSIs, 79.3% of facilities reported failure to replace central lines within 48 hours after emergent insertion, and 62.1% reported that feedback was not provided to staff on central-line device utilization ratios. Conclusion: For both assessments, absence of CAUTI and CLABSI prevention champions, failure to conduct competency assessments, and inconsistency in performing device insertion practices were commonly reported across facilities. These common gaps have and will continue to inform the development of tools and resources to improve infection prevention practices as well as help to better target the implementation of interventions.Funding: NoneDisclosures: None

Extending the Use of Healthcare-Associated Infections and Antibiotic Use and Resistance Surveillance Data

Background: The CDC National Healthcare Safety Network (NHSN) is the nation’s most widely used healthcare-associated infection (HAI) and antibiotic use and resistance (AUR) surveillance system. More than 22,000 healthcare facilities report data to the NHSN. The NHSN data are used by facilities, the CDC, health departments, the CMS, among other organizations and agencies. In 2017, the CDC updated the NHSN Agreement to Participate and Consent (Agreement), completed by facilities, broadening health department access to NHSN data and extending eligibility for data use agreements (DUAs) to local and territorial health departments. DUAs enable access to NHSN data reported by facilities in the health department’s jurisdiction and have been available to state health departments since 2011. The updated agreement also enables the CDC to provide NHSN data to health departments for targeted prevention projects outbreak investigations and responses. Methods: We reviewed the current NHSN DUA inventory to assess the extent to which health departments use the NHSN’s new data access provisions and used semistructured interviews with health department staff, conducted via emails, phone, and in person conversations, to identify and describe their NHSN data uses. Results: As of late 2019, the NHSN has DUAs with health departments in 17 states, 7 local health departments (including municipalities and counties), and 1 US territory. The NHSN also has received requests from 2 state health departments for data supporting HAI prevention projects. Health departments with DUAs described improved relationships with facilities in their jurisdictions because of new opportunities to offer NHSN data analysis assistance to facilities. One local health department analyzed their NHSN carbapenem-resistant Enterobacteriaceae (CRE) data to identify (1) facilities in its jurisdiction with comparatively high CRE infection burden and (2) geographic areas to target for a CRE isolate submission program. Outreach to facilities with high CRE burden led to enrollment of 15 clinical laboratories into a voluntary isolate submission program to analyze CRE isolates for additional characterization. Examples of health departments’ use of data for action include: notifying facilities with high standardized infection ratios (SIRs) and sharing Targeted Assessment for Prevention (TAP) reports. Conclusions: The NHSN’s role as a shared surveillance resource has expanded in multiple public health jurisdictions as a result of new data access provisions. Health departments are using NHSN data in their programmatic responses to HAI and AR challenges. New access to NHSN data is enabling public health jurisdictions to assess problems and opportunities, provide guidance for prevention projects, and support program evaluations.Funding: NoneDisclosures: None

1162. An Evaluation of Metrics for Catheter-Associated Urinary Tract Infections (CAUTIs): A Statewide Comparison

BackgroundThe Standardized Infection Ratio (SIR) is a metric used to gauge catheter-associated urinary tract infection (CAUTI) prevention, both locally and nationally. The device utilization ratio (DUR) is a process metric that captures catheter harm. More recently, the cumulative attributable difference (CAD) was introduced, which identifies the number of excess infections that need to be prevented to reach the desired goal. Our objective was to evaluate these metrics across all acute care hospitals in Connecticut (CT) by facility size.MethodsA CAUTI Targeted Assessment for Prevention (TAP) Report for acute care hospitals across CT was generated from 1/1/2018 to December 31/2018, using the National Healthcare Safety Network (NHSN) database. CAUTI events, SIR, DUR, and CAD were compared across all hospitals. The SIR goal of 0.75 was used to calculate the CAD. Hospitals were stratified into large ( >425 beds), medium (250 to 424 beds), and small ( <249 beds) based on the Healthcare Cost and Utilization Project NIS Description of Data Elements, Agency for Healthcare Research and Quality for urban hospitals in the northeast region.ResultsA comparison of CAUTI metrics for 29 acute care hospitals across CT is shown in Table 1. Median SIR and DUR were 0.97, 1.02, 0.77, and 22%, 14%, 14.5% for large, medium and small hospitals, respectively. Of the 20 small hospitals, SIR could not be calculated for 5 hospitals, while 2 hospitals had an SIR = 0, as they had no reported infections. Median CAD for large, medium and small hospitals was 6.17, 1.3 and 0.25, respectively. Of note, 40% of small hospitals (J – CC, as in Table 1) had a negative CAD. Interestingly, 5 of these 8 hospitals with a negative CAD had a DUR higher than 16%.ConclusionBased on CT hospital data, metrics like CAD and SIR may be more suitable for larger hospitals or hospitals with higher CAUTI events, whereas DUR may be a more useful metric for smaller hospitals or hospitals with rare events. Hospitals with high SIR and low DUR may represent a population with high-risk catheter use, poor catheter care or higher rates of urine culturing. On the other hand, hospitals with high DUR and low SIR may represent low-risk populations, better catheter care practices or lower rates of urine culturing. Ultimately, we need a combination of metrics to measure preventable catheter harm. DisclosuresLouise Dembry, MD, MS, MBA, ReadyDock: Consultant, Stock options.

The Centers for Disease Control and Prevention STRIVE Initiative: Construction of a National Program to Reduce Health Care-Associated Infections at the Local Level.

The Centers for Disease Control and Prevention STRIVE Initiative: Construction of a National Program to Reduce Health Care-Associated Infections at the Local Level.

Quantitative Results of a National Intervention to Prevent Hospital-Acquired Catheter-Associated Urinary Tract Infection: A Pre-Post Observational Study.

Many hospitals struggle to prevent catheter-associated urinary tract infection (CAUTI). To evaluate the effect of a multimodal initiative on CAUTI in hospitals with high burden of health care-associated infection (HAI). Prospective, national, nonrandomized, clustered, externally facilitated, pre-post observational quality improvement initiative, for 3 cohorts active between November 2016 and May 2018. Acute care, long-term acute care, and critical access hospitals, including intensive care and non-intensive care wards. Target hospitals had a high burden of Clostridioides difficile infection plus central line-associated bloodstream infection, CAUTI, or hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection, defined as cumulative attributable differences above the first tertile in the Targeted Assessment for Prevention (TAP) strategy. Some additional nonrecruited hospitals also joined. Multimodal intervention, including Practice Change Assessment tool to identify infection prevention and control (IPC) and HAI prevention gaps; Web-based, on-demand modules involving onboarding, foundational IPC practices, HAI-specific 2-tiered approach to prioritize and implement interventions, and TAP resources; monthly webinars; state partner-led in-person meetings; and feedback. State partners made site visits to at least 50% of their enrolled hospitals, to support self-assessments and coach. Rates of CAUTI and urinary catheter device utilization ratio. Of 387 participating hospitals from 23 states and the District of Columbia, 361 provided CAUTI data. Over the study period, the unadjusted CAUTI rate was low and relatively stable, decreasing slightly from 1.12 to 1.04 CAUTIs per 1000 catheter-days. Catheter utilization decreased from 21.46 to 19.83 catheter-days per 100 patient-days from the pre- to the postintervention period. The intervention period was brief, with no assessment of fidelity. Baseline CAUTI rates were low. Patient characteristics were not assessed. This multimodal intervention yielded no substantial improvements in CAUTI or urinary catheter utilization. Centers for Disease Control and Prevention.

CAUTIon With Our Patients: The Development and Implementation of a CAUTI Tracer Program

BACKGROUND The most common hospital acquired infection is catheter associated urinary tract infection (CAUTI). Approximately 75% of urinary tract infections acquired in the hospital are associated with urinary catheters. CAUTI increases the length of stay by two days and incurs unnecessary costs to the patient. Our nosocomial CAUTI SIR (Standardized infection ratio) in 2017 was 1.161 which is above the Center for Medicare and Medicaid services Hospital Value- Based Purchasing (CMS VBP) benchmark of 0.822. The purpose of this project is to reduce nosocomial CAUTI SIR and to increase catheter bundle compliance. METHODS We utilized a multidisciplinary approach partnering with our corporate Infection Preventionist. We performed a gap analysis using the Targeted Assessment for Prevention (TAP) report to identify our units with opportunities for improvement. We built a CAUTI tracer tool that can be utilized to measure compliance of catheter care and a report can be generated for analysis. A tip sheet was developed and education was provided on all of the bundle components including alternatives for external urinary devices. For sustainment we engaged senior leadership and the units identified with opportunities were required to perform daily catheter care audits until CAUTI free for four months. RESULTS After the process changes were initiated in quarter 1 2018, the hospital acquired CAUTI SIR started to show a steady decline. The 2018 quality year January through September CAUTI SIR is at 0.883 which is a 28% reduction from 2017. With the implementation of the tracer tool, bundle compliance was observed to increase from 80% to 95%. CONCLUSIONS Initiation of the education tip sheet and the CAUTI tracer tool were successful interventions in reducing hospital acquired CAUTI's. Support from both corporate and entity leadership has proven to be effective towards deployment, reduction and sustainment.

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.

531. Reducing Inappropriate Hospital-Acquired Clostridium difficile Diagnoses

Background Clostridium difficile infection (CDI) rates suddenly increased 30%, coincident with adoption of a new electronic medical record (EMR) and a reduction in our Environmental Services (ES) workforce. A Targeted Assessment for Prevention (TAP) report suggested we had the greatest opportunity for improvement among Massachusetts hospitals. Senior leadership identified CDI as an institutional top priority.MethodsWe prospectively measured CDI rates, using CDC criteria. A multidisciplinary team applied root cause analysis to each case; many represented repetitive testing or did not meet criteria for clinically significant disease. We reviewed, revised, and reinforced already robust efforts regarding hand hygiene, environmental cleaning and disinfection, antimicrobial stewardship, and test ordering behaviors. We revised C. difficile testing guidelines in accord with IDSA/SHEA Guidelines and leveraged EMR orders to help providers test more appropriately. Limit testing to patients with ≥3 unformed stools/day. Exclude testing within 24 hours of laxative use. Lab rejects specimens within 7 days after negative result and within 28 days after positive result; orders expire after 48 hours. We compared monthly ES staffing (FTEs/1,000 patient-days) and CDI rates, using linear regression.Results C. difficile testing decreased 47%, from 358 to 188 tests per month (Figure 1). CDI rates decreased 39% in 1 year (from 141 to 83), reducing the rate of infection below expected (Figure 2). Despite improvement, 40–60% of CDI testing still occurs during laxative use. ES staffing rates were associated with 5.2% of CDI rate changes (P < 0.05); adequate staffing reduced CDI rates 44% (Figure 3).ConclusionImplementation of a new EMR brought to light over-diagnosis of hospital-acquired CDI, resulting in unnecessary isolation and treatment of patients without significant illness. Inadequate ES staffing correlates with increased CDI rates. These factors also contribute to vulnerability to CMS Hospital-Acquired Condition (HAC) penalties. Revising laboratory testing and laxative EMR orders is laborious but significantly reduces inappropriate testing. It is essential to have senior leadership endorsement to marshal quality improvement and EMR resources.Figure 1.Figure 2.Figure 3.Disclosures All authors: No reported disclosures.

Catheter Associated Urinary Tract Infection (CAUTI) Targeted Assessment for Prevention (TAP) Effective Practices

Catheter Associated Urinary Tract Infection (CAUTI) Targeted Assessment for Prevention (TAP) Effective Practices

Reduction of Clostridium difficile (C diff) Cases Using a Targeted Assessment for Prevention (TAP) Strategy in the Department of Veterans Affairs (VA) Healthcare System.

Reduction of Clostridium difficile (C diff) Cases Using a Targeted Assessment for Prevention (TAP) Strategy in the Department of Veterans Affairs (VA) Healthcare System.

Evaluating Veterans Affairs (VA) Acute Care Facilities for Clostridium difficile Infections (CDIs) Using a Targeted Assessment for Prevention (TAP) Strategy

Evaluating Veterans Affairs (VA) Acute Care Facilities for Clostridium difficile Infections (CDIs) Using a Targeted Assessment for Prevention (TAP) Strategy