Catheter-associated urinary tract infection (CAUTI) represents a significant proportion of healthcare-associated infections (HAIs). The US Department of Health and Human Services issued a plan to reduce HAIs with a target 25% reduction of CAUTI by 2013. Michigan's successful collaborative to reduce unnecessary use of urinary catheters and CAUTI was based on a partnership between diverse hospitals, the state hospital association (SHA), and academic medical centers. Taking the lessons learned from Michigan, we are now spreading this work throughout the 50 states. This national spread leverages the expertise of different groups and organizations for the unified goal of reducing catheter-related harm. The key components of the project are,

  1. centralized coordination of the effort and dissemination of information to SHAs and hospitals,
  2. data collection based on established definitions and approaches,
  3. ocused guidance on the technical practices that will prevent CAUTI,
  4. emphasis on understanding the socioadaptive aspects (both the general, unit-wide issues and CAUTI-specific challenges), and
  5. partnering with specialty organizations and governmental agencies who have expertise in the relevant subject area.

The work may serve in the future as a model for other large improvement efforts to address other hospital-acquired conditions, such as venous thromboembolism and falls. 

Written by:
Fakih MG, George C, Edson BS, Goeschel CA, Saint S Are you the author?
St. John Hospital and Medical Center, Detroit, Michigan

Reference: Infect Control Hosp Epidemiol. 2013 Oct;34(10):1048-54.
doi: 10.1086/673149

PubMed Abstract 
PMID: 24018921

Healthcare-associated infections are common, costly, and potentially deadly. However, effective prevention strategies are underutilized, particularly for catheter-associated urinary tract infection (CAUTI), one of the most common healthcare-associated infections. Further, since 2008, the Centers for Medicare and Medicaid Services no longer reimburses hospitals for the additional costs of caring for patients who develop CAUTI during hospitalization. Given the resulting payment pressures on hospitals stemming from this decision, it is important to factor in cost implications when attempting to encourage decision makers to support infection prevention measures. To this end, we present a simple tool (with easy-to-use online implementation) that hospitals can use to estimate hospital costs due to CAUTI, both before and after an intervention, to reduce inappropriate urinary catheterization. Using previously published cost and risk estimates, we show that an intervention yielding clinically feasible reductions in catheter use can lead to an estimated 50% reduction in CAUTI-related costs. Our tool is meant to complement the Society of Hospital Medicine's Choosing Wisely campaign, which highlights avoiding placement or continued use of nonindicated urinary catheters as a key area for improving decision making and quality of care while decreasing costs.

Written by:
Kennedy EH, Greene MT, Saint S Are you the author?
VA Center for Clinical Management Research, Ann Arbor VA Health Services Research and Development Center of Excellence, Ann Arbor, Michigan; Patient Safety Enhancement Program, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan; Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania.

Reference: J Hosp Med. 2013 Sep;8(9):519-22
doi: 10.1002/jhm.2079

PubMed Abstract
PMID: 24038833

Background: The National Healthcare Safety Network (NHSN) definition for catheter-associated urinary tract infection (CAUTI) is used to evaluate improvements in CAUTI prevention efforts. We assessed whether clinician practice was reflective of the NHSN definition.

Methods: We evaluated all adult inpatients hospitalized between July 2010 and June 2011, with a first positive urine culture > 48 hours of admission obtained while catheterized or within 48 hours of catheter discontinuation. Data comprised patients' signs, symptoms, and diagnostic tests; clinician's diagnosis; and the impression of the infectious diseases (ID) consultant. The clinician's practice was compared with the NHSN definition and the ID consultant's impression.

Results: Antibiotics were initiated by clinicians to treat CAUTI in 216 of 387 (55.8%) cases, with 119 of 387 (30.7%) fitting the NHSN CAUTI definition, and 63 of 211 (29.9%) considered by ID to have a CAUTI. The sensitivity, specificity, and positive and negative predictive values of a clinician diagnosis of CAUTI were 62.2%, 47%, 34.3%, and 73.7% when compared with NHSN CAUTI definition (n = 387) and 100%, 57.4%, 50%, and 100% when compared with the ID consultant evaluation (n = 211), respectively. The positive predictive value of the NHSN CAUTI definition was 35.1% when compared with the ID consultant's impression (n = 211).

Conclusion: NHSN CAUTI definition did not reflect clinician or ID consultant practices. Our findings reflect the differences between surveillance definitions and clinical practice. 

Written by:
Al-Qas Hanna F, Sambirska O, Iyer S, Szpunar S, Fakih MG Are you the author?
Department of Medicine, St John Hospital and Medical Center, Detroit, MI

Reference: Am J Infect Control. 2013 Sep 5 (Epub ahead of print)
doi: 10.1016/j.ajic.2013.05.024

PubMed Abstract
PMID: 24011555

Background: Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use.

Methods: To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interventions prompting UC removal by reminders or stop orders. A narrative review summarises other CAUTI prevention strategies including aseptic insertion, catheter maintenance, antimicrobial UCs, and bladder bundle implementation.

Results: 30 studies were identified and summarised with interventions to prompt removal of UCs, with potential for inclusion in the meta-analyses. By meta-analysis (11 studies), the rate of CAUTI (episodes per 1000 catheter-days) was reduced by 53% (rate ratio 0.47; 95% CI 0.30 to 0.64, p < 0.001) using a reminder or stop order, with five studies also including interventions to decrease initial UC placement. The pooled (nine studies) standardised mean difference (SMD) in catheterisation duration (days) was -1.06 overall (p=0.065) including a statistically significant decrease in stop-order studies (SMD -0.37; p < 0.001) but not in reminder studies (SMD, -1.54; p=0.071). No significant harm from catheter removal strategies is supported. Limited research is available regarding the impact of UC insertion and maintenance technique. A recent randomised controlled trial indicates antimicrobial catheters provide no significant benefit in preventing symptomatic CAUTIs.

Conclusions: UC reminders and stop orders appear to reduce CAUTI rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing UC use involves changing well-established habits.

Written by:
Meddings J, Rogers MA, Krein SL, Fakih MG, Olmsted RN, Saint S Are you the author?
Department of Internal Medicine, University of Michigan Medical School, , Ann Arbor, Michigan, USA

Reference: BMJ Qual Saf. 2013 Sep 27 (Epub ahead of print)
doi: 10.1136/bmjqs-2012-001774

PubMed Abstract
PMID: 24077850

Interdisciplinary team (IDT) rounds were initiated in the intensive care unit (ICU) in June 2010. All catheters were identified by location, duration, and indication. Catheters with no indication were removed. Data were collected retrospectively on catheter days and associated infections in a 20-month period before and after intervention with an aggregate of 19 207 ICU days before and 23 576 ICU days after institution of rounds. Results showed a statistically significant decrease in the number of indwelling urinary catheter (IUC) days (5304 vs 4541 days, P = .05) and catheter-associated urinary tract infection rates (4.71 vs 1.98 infections/1000 ICU days, P < .05). Central line days statistically increased after IDT rounds (3986 vs 4305 days, P < .05) but the catheter-related bloodstream infection rate trended down (3.5 vs 1.6 infections/1000 ICU days, P = .62). This analysis suggests that IDT rounds may have an impact on reducing the number of IUC days and associated infections.

Written by:
Arora N, Patel K, Engell CA, Larosa JA Are you the author?
Newark Beth Israel Medical Center, Newark, NJ

Reference: Am J Med Qual. 2013 Sep 4. (Epub ahead of print)
doi: 10.1177/1062860613500519

PubMed Abstract
PMID: 24006027

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