cauti prevention in a vha nursing home cohort 821
Additionally, studies suggest that knowledge about device care as well as antimicrobial stewardship may be lacking in both community-based and VHA nursing homes.7–9 Recently, a large-scale collaborative initiative, the Agency
for Healthcare Research and Quality (AHRQ) Safety Program for Long-term Care:Healthcare-Associated Infections (HAIs)/ catheter-associated UTI (CAUTI), was shown to reduce CAUTI rates across a large group of community-based nursing homes.10,11 The collaborative focused on professional development related to urinary catheter utilization, catheter care and maintenance, infection prevention, and antimicrobial stewardship as well as promoting resident safety culture, team building, and leadership engagement. Given the success of the program in the community nursing home setting, coupled with the similar success of national efforts to reduce CAUTI on medical-surgical units,12,13 we sought to evaluate the effectiveness of the program among VHA nursing homes. The VHAis a large integrated healthcare system, with a robust infection prevention infrastructure, and a system-wide CAUTI prevention initiative was implemented in 2011.14,15 Thus, this evaluation provides important information about the potential utility of large-scale collaborative efforts for facilities with an already heightened focus on infection prevention and more ready access to infection prevention resources.
methods Study Setting
A nationwide cohort of 63 of 133 VHA nursing homes voluntarily enrolled in the “AHRQ Safety Program for Long- Term Care: HAIs/CAUTI” as part of a group of nursing homes that began the 12-month program in June 2015. At the start of this program, the VHA already had quality improvement efforts in place to prevent healthcare-associated infections, including CAUTI, in VHA nursing homes. These efforts, which originally targeted intensive care units starting in 2006, consisted of national teleconference calls, the dissemination of toolkitswith criteria for defining infections, goal setting, senior leadership support, and site mentoring. The primary focus of the VHA program was on catheter insertion, including having an insertion order and indication for insertion, use of alter- natives, aseptic insertion technique, and use of securement devices. The collection and reporting of catheter days and number of infections was also an important part of this initiative. These activities were facilitated through use of a web-based tool, managed by the VHA Inpatient Evaluation Center, and in 2011 reporting of CAUTI was required for all VHA settings, including nursing homes.15 The VA Ann Arbor Health System, University of Michigan
and Health Research and Educational Trust institutional review boards reviewed the study and determined that it did not meet the regulatory definition of research involving human subjects.
AHRQ Safety Program Intervention
The intervention of interest for this analysis was the AHRQ Safety Programfor Long-TermCare, which has been previously described.10,16 Briefly, the program used a collaborative approach to enhance adoption of infection prevention practices in nursing homes with a specific focus on reducing CAUTI. The program included education about infection prevention prac- tices (eg, reducing catheter utilization and improving catheter care and maintenance) as well as strategies for promoting resi- dent safety culture, team building, and leadership engagement, which were provided through a series of virtual learning sessions, coaching calls, and webinars. This part of the program included learning sessions alongwithmonthly contentwebinars and coaching calls led by an organizational lead and national project team faculty. Nursing home teams also had access to an implementation guide and other tools and resources via a program website or their organizational lead. Like the prior VHA initiative, the AHRQ program focused on appropriate indications for catheter insertion and regular assessment of catheter need. However, while the 2011 VHA initiative was aimed at both acute-care and long-term care settings, the AHRQ program was designed specifically for nursing homes, and it included incontinence care planning and assessing for CAUTI in nonverbal patients. The AHRQ program also provided specific content on antimicrobial stewardship in long-term care and the appropriate use of urine cultures.
Study Outcomes and Data Collection
The primary outcome was the CAUTI rate as defined by the CDCNationalHealthcare SafetyNetwork (NHSN): the number of CAUTIs meeting long-term care surveillance criteria divided by the number of catheter days and multiplied by 1,000 (in accordance with the CDC NHSN protocol for tracking infections in long-term care facilities, January 2015).17 Secondary outcomes included catheter utilization and appro- priate urine testing. Catheter utilization was defined as the number of catheter days divided by the number of resident days, multiplied by 100 and reported as a percentage. Urine testing was defined as the number of urine culture orders for all resi- dentswhile in the facility divided by the number of resident days and multiplied by 1,000. Participating VHA nursing homes collected data on the number ofCAUTIs, catheter days, resident days, and urine culture orders for each month of the program. These data were entered into a system maintained by the VHA NationalCenter for Patient Safety for subsequent extraction and analysis. In addition, as part of program start-up each facility was asked to complete a needs assessment questionnaire, which included questions about general facility characteristics and infection prevention resources.14
Statistical Analysis
Nursing home characteristics, process data, and outcome data were assessed using descriptive statistics. We used multilevel
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