Maureen Bucci, BSN, RN, CCDS

Maureen Bucci is a Senior Healthcare Consultant for Panacea Healthcare Solutions where she performs clinical documentation and quality chart audits that focus on identifying missed opportunities to obtain an accurate and complete record for each patient. Maureen has 20+ years of experience in Emergency / Critical Care Nursing, Quality Management and Process Improvement, and Clinical Documentation Improvement. She is a Registered Nurse and a Certified Clinical Documentation Specialist (ACDIS).

Everyone take a breath! 2015 has come to an end, and although the healthcare profession in 2016 will continue to be challenged, our focus remains on getting the job done. We are better educated and have gained practical experience in implementing ICD-10. We are also making great efforts to problem-solve the high-priority outcome quality measures that threaten reimbursement, quality scores, and to some degree, the credibility of healthcare facilities.  

In the past two editions of VBPmonitor.com’s e-news, Rachel Mack (RN, MSN, CCDS, CDIP) provided a brief synopsis of outcome measures as defined by The Agency for Healthcare Research and Quality (AHRQ) (http://www.qualitymeasures.ahrq.gov/tutorial/HealthOutcomeMeasure.aspx), with a focus on central line-associated bloodstream infections (CLABSIs). Laurie Hilyard (RN, MSN, CCDS) discussed a new outcome measure for 2016: surgical site infections (SSIs). Moving forward in this series of potentially preventable conditions is the equally important outcome measure of catheter-associated urinary tract infections (CAUTIs).

What is an Outcome Measure?

 Simply stated, outcome measures are the specific complications that develop subsequent to admission and negatively impact a patient’s state of health. These are often preventable conditions incurred as a direct result of the care provided.

How Are Outcome Measures Reported?

The National Healthcare Safety Network (NHSN)) is an Internet-based system that facilitates the collection and use of data, adherence to preventative practices, analysis of data trends, and monitoring of hospital-acquired infection reporting to the Centers for Medicare & Medicaid Services (CMS). The NHSN patient safety component monitors events associated with devices, antimicrobials used during care, and multi-drug resistant organisms; CAUTI, CLABSI, and SSI fall under this module, and instructions and standardized surveillance methods and definitions can be found on the NHSN website at http://www.cdc.gov/nhsn.

 For information regarding reporting, see the Centers for Disease Control and Prevention (CDC) website at http://www.cdc.gov/nhsn/pdfs/pscmanual/1psc_overviewcurrent.pdf.

CAUTIs

Urinary tract infections (UTIs) account for more than 15 percent of infections reported by acute-care hospitals according to the CDC, and they can lead to complications that are potentially debilitating and life-threatening to the patient.

It’s understandable that CMS has included CAUTIs as an outcome measure due to the sheer volume of urinary catheters utilized in hospital settings, combined with the high potential of infection. Likewise, very established guidelines exist regarding the prevention of these UTIs, and as part of the hospital-acquired condition (HAC) reduction program, reimbursement is withheld as a penalty when facilities fail to prevent this type of infection. Ultimately, these outcome measures provide the opportunity for facilities to be rewarded for exceptional quality care, and the opportunity to identify and remediate where protocols and practices fail.

There are very specific rules and definitions when associating a UTI to an indwelling catheter, and attention to all qualifying criterion is required in making that determination (“in and out” catheterization is excluded, regardless of type of “straight” catheter used):

CAUTI (Must meet Nos. 1, 2, and 3)

1.  The patient has an indwelling urinary catheter in place for the entire day on the date of event (recognition of a UTI), and for greater than two days

  • Date of device insertion is day 1
  • Indwelling catheter in place on date of event or day before
  • Indwelling catheter removed; date of event for UTI is day of discontinuation or the day after.

    2.  At least ONE of following: (Fever being three days before or three days after the first positive diagnostic test)
  • Fever (38.0 C or higher)
  • Suprapubic pain
  • Costovertebral angle pain
  • Urgency, frequency
  • Dysuria

    3.  Positive urine culture (with no more than two specimens)

*The above criteria include catheters that have been removed on the day of or the day before the date of event.

Non-CAUTI (Must meet Nos. 1, 2, and 3)

  • The patient had a indwelling catheter but not greater than two days, or the patient did not have a catheter on date of event or the day before
  • Fever, suprapubic tenderness, frequency, urgency, dysuria, costovertebral pain
  • Positive urine culture

Please note that the aforementioned criteria have been simplified, and certain scenarios may become more complex. As part of self-education and achieving better understanding, please visit the CDC’s CAUTI website for more information or any clarification: http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf.

CDIs and Quality

The role of the clinical documentation specialist (CDIS) is becoming more encompassing in light of the Patient Protection and Affordable Care Act (PPACA), and this has necessitated an elevated understanding of the quality aspects that are pressing in healthcare. CAUTI can be identified in hospital complication reports (as well as other filtered reports), and some quality departments are working in tandem with CDISs to clarify physician documentation, leading to under- and over-reporting complications. Querying for clarification of specific core measures and quality indicators may not only impact the resulting MS-DRG and quality score, but may also support other quality measures, such as those abstracted for specialty accreditations such as a stroke centers.

CDI and CAUTIs

The importance of establishing present-on-arrival or present-on-admission (POA) conditions is never undervalued, and this is particularly important when there is infection related to a device. Very specific guidelines indicate that when a patient is admitted with a device such as a urinary catheter together with UTI, a definitive physician statement of causation must be made before it can be coded as such; the association can never be assumed. A UTI that is directly associated to an existing indwelling catheter that is present on admission is a complication of the device but is not a hospital-acquired condition (HAC). In other words, the hospital will not be penalized for something it didn’t cause.

Likewise, the existence of an indwelling catheter and UTI after admission must meet the very specific criterion to meet the definition of CAUTI. The CDI specialist should evaluate these aspects when a CAUTI is or is not documented by a physician:

  • Does the patient exhibit the necessary criteria specified for a CAUTI event? (Remember, date of insertion, timing of positive urine culture, and date of onset of symptoms)
    • No positive urine culture: No CAUTI, despite symptoms

Conclusion

Years ago the impending reduction program was a thorn in the side of healthcare. Now many believe that, despite having been incentivized to perform at a higher level for reasons outside of their control, it is ultimately a good thing. The proof is in the data, and through diligent CAUTI prevention practices, hospital-acquired infection rates are lower, patients are safer, and the inpatient population has experienced better health outcomes because of these measures. Moving forward in 2016, CDIs are being challenged to continue their education, self-motivation, and understanding of current and future quality measures so that documentation opportunities are not lost.

About the Author

Maureen Bucci is a senior healthcare consultant for Panacea Healthcare Solutions, where she performs clinical documentation and quality chart audits that focus on identifying missed opportunities to obtain an accurate and complete record for each patient. Maureen has more than 20 years of experience in emergency/critical care nursing, quality management and process improvement, and clinical documentation improvement. She is a registered nurse and a certified clinical documentation specialist (ACDIS).

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