Kathleen S. Hall-Meyer, RN, MBA, CIC Saint Luke s Health System Kansas City, Missouri

Kathleen S. Hall-Meyer, RN, MBA, CIC Saint Luke s Health System Kansas City, Missouri

Nothing to disclose

At the conclusion of this program, the learner will be able to: -Describe how a partnership with your purchasing departments can improve infection prevention activities. -Use purchasing data to support infection prevention data. -Use outcome data to demonstrate value.

Historically, Purchasing focused on price and contracts Product trials did not look at a clinical outcome Infection Prevention might not get involved early in the discussions

Initial value analysis efforts focused on pricing, and standardization Changes in reimbursements and Value Based Purchasing leading to changes in how devices and supplies are purchased

QUALITY COST Value

No Process No formal process Purchases driven by demand, preference Products Committees New Products Teams Focused on review of new products Supplier representative initiate new product entry Purchases driven by requestor Novice Value Analysis Driven by purchasing/supply chain Vendor management (limit access to clinicians) Limited objective non-financial criteria

Value Analysis Intermediate Lead by purchasing and clinicians Objective data is used to reduce variety of products Integration with performance improvement activities Value Analysis Advanced Multidisciplinary team uses clinical, financial and operational data Outcomes data drives decision making (evidence, metrics, protocols) Appropriate use for clinical preference items Value Analysis TRANSFORMATION All levels of care included Clinicians, patients and caregivers collaborate Look at long term outcomes, clinical, financial, and operational data

Faith based, non profit organization 10 hospitals 1Tertiary Care, Academic Medical Center 4 community hospitals 3 Critical Access hospitals 3 Swing bed units 5 retail clinics 10,200 employees 1,365 physicians

Variety of CAUTI reduction Process Improvement Groups (PIGs) mostly driven by Infection Prevention No focused effort to look at utilization of devices No standard processes/polices/protocols/products

Immaculate Catheterization No defined indications for use, no alternatives Wide variations in products, protocols

Practice Variation Product variation Variable Outcome Variable Costs

Wide variety of catheter, drainage devices Practice variation Maintenance variation Some reduction in CAUTI observed, but not truly sustained for more than a few quarters

Clinician preference for antimicrobial catheters drove addition to inventories No review of outcomes following introduction

Number of products aimed at reducing CAUTI implemented with little review of evidence Reactionary implementation of devices/products to reduce infections Reduction in CAUTI observed, but none sustained for more than 4 quarters in smaller hospitals.

Led by purchasing with multi-disciplinary membership Infection Preventionist permanent member Some objective criteria for introducing new products Review of utilization data High volume of new product requests introduced by clinicians Limited standardization Limited data sharing reactionary product implementation Circa 2008-present

Purchase history and issue details can aid in evaluating compliance with best practices Identify opportunities for standardization Identify opportunities to streamline workflow

Use of purchasing data to examine factors related to infection prevention: Non-safety devices Hand hygiene products/surgical scrub solutions Razor purchases Antimicrobial dressing use Implemented hard stops in Materials Management Information System (MMIS) requiring Infection Prevention in-put/review.

Value Analysis Teams chaired by clinicians Multi-disciplinary team with Subject Matter Experts (SMEs) for consultation VAT members in-serviced on scientific literature review, basic statistics, Product additions/changes must be supported by evidence

Data sharing, data from a variety of internal and external sources drives decision making Standardization of policies, procedures/protocols and products throughout the continuum of care Cost of Care and Outcomes reviewed -HAC penalty information shared

Device Utilization Rates reviewed Indications for catheter insertion data retrieved from EMR Foley Cath utilization and indications reviewed at daily Safety Huddles Shoe Leather Surveillance with Infection Prevention

as many as 65% to 70% of CLABSIs and CAUTIs are preventable with current evidence-based interventions Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasona preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32(2):101-114.

Variety of trays/insertion equipment Alternatives to indwelling catheters not readily available. Widespread use of antimicrobial catheters No place in EMR to document on-going indication for catheter Removal protocol not a part of the EMR

Gemba Walk by multidisciplinary team including purchasing to identify defects in process/solicit feedback A-3 Team formed to analyze process, products and outcomes Policies and protocols reviewed and standardized

Initial investigation into catheter alternatives Costs to Standardize Insertion Trays Restricted Access to Antimicrobial Catheters Bladder scanners added Have you ex-foley-ated today?

Community- based, continuum of care Patient/family members/caregivers and clinicians involved Review of clinical, financial and operational information Long Term outcomes data drives decision making Processes, policies, procedures and protocols are aligned Seamless patient access, flow and care coordination Circa 2015-present

Analyzed cost of CAUTI through the continuum SMEs offered in-put Solicited in-put from patient satisfaction surveys (key word search in open ended comments) Solicited in-put from outpatient services, home care, hospice

Collaborate with Nursing Practice Council and Medical Staff Departments - protocol refinement - 3P rounding Alternatives to indwelling catheters Standardized insertion tray with all items needed for aseptic insertion techniques Straight catheter kits available

Standardized Foley Catheter Tray $60,600/yr Alternative to Indwelling catheter for Male pts $25,000/yr Expected acquisition cost increase: $85,600/yr.

Communicated with leadership cost increases Communicated updated protocol and catheter alternative to stakeholders Physician APRNs Wound/Skin Care Teams Nurse Leaders, Educators, Champions Patients Engaged formal and informal leaders to support project.

Indwelling Catheter days decreased by 60% YTD 2016 as compared to same period 2015 Some smaller facilities have had months with no indwelling urinary catheter days Catheter Acquisition costs decreased by $52,502 YTD 2016

$120,000 $ Spend $100,000 $80,000 $60,000 $40,000 $20,000 Q12015 Q2 2015 Q 1 2016 Q 2 2016 $0 Q12015 Q2 2015 Q 1 2016 Q 2 2016

H1 2015 Cath Spend: $189,517 H1 2016 Cath Spend: $137, 015+$ 4,891 (alt Dev.) Cath Device Savings H1 2016: $47,611

% of patients NOT receiving an indwelling catheter increased from 22% to 38% CAUTI decreased from 32/quarter to 3/quarter

Not expecting decrease in acquisition costs Not expecting significant drop in device utilization Many unexpected opportunities for future work identified: -urine specimen ordering practices -urine specimen collection practices - MRI safety with metal clip on drainage bag

Device utilization report at daily safety huddle Opportunities to improve catheter maintenance bundles Opportunities to decrease CVC and PICC Line Utilization identified

Surgical wound management Cesaraian Sections Total Joints Trauma Vasuclar Access PICC Device Utilization Midline Catheter Insertion Program

Randall D. Pierce

Kathleen S. Hall-Meyer, RN, MBA, CIC Saint Luke s Health System kmeyer@saint-lukes.org 816-502-8829 913-707-0229