Hospitals have made strides toward eliminating health care-associated infections (HAIs) since the Department of Health and Human Services declared it a national priority in 2009. But the most recent national progress report contains a notable exception to a generally positive trend: Catheter-associated urinary tract infections, or CAUTIs, rose by 6% between 2009 and 2013.
Experts acknowledge that making a dent in CAUTIs has proven to be more complicated than lowering other HAIs, like central line bloodstream infections or surgical site infections. Those rates fell by 46% and 19%, respectively, from 2009 to 2013, according to the CDC's “National and State Healthcare-Associated Infections Progress Report” published in January.
Progress on CAUTIs is possible, they say, but there's no silver bullet.
“Everyone is interested in preventing CAUTI, but it's not sexy and it's not easy,” said Sanjay Saint, MD, MPH, FACP, chief of medicine at VA Ann Arbor Healthcare System in Ann Arbor, Mich., who is on the leadership team of On the CUSP: Stop CAUTI, a program funded by the Agency for Healthcare Research and Quality (AHRQ) that works with hospitals to implement the Comprehensive Unit-based Safety Program (CUSP).
“Clinicians tend to gravitate toward following evidence-based best practices, but with CAUTI you also have to change people's behavior because the best way to prevent CAUTI is by not using a Foley catheter at all, or removing one when it's no longer needed,” he said.
Preliminary results for participants in On the CUSP suggest that it is possible to make a significant dent in CAUTI rates by implementing best practices in catheter management. As of 2013, hospitals that had participated in the program for at least 14 months were able to reduce CAUTI rates by an average of 16%. The project is aiming for an overall 25% reduction.
Approximately one-quarter of hospital inpatients have catheters inserted at some point during their stay, but many are placed inappropriately, said Dr. Saint. That puts patients at risk for CAUTI and other secondary harms that are largely preventable.
“Besides CAUTI, urinary catheters can lead to bloodstream infections when bacteria transmigrate from the bladder into the bloodstream, which can then lead to sepsis, ICU transfer, and possible death,” he said. “And catheters function as a 1-point restraint that tethers patients to their beds, preventing them from carrying out the activities of daily living like getting to the toilet and doing physical therapy, which could lead to other hospital-acquired conditions like deep vein thrombosis, pressure sores, and falls.”
Preventing CAUTI and downstream harms requires sustained effort by administrators and clinician leaders to change the way people think about catheter management, said Jennifer Meddings, MD, ACP Member, an assistant professor of internal medicine at the University of Michigan Health System in Ann Arbor who has published papers on CAUTI interventions.
“Changing behavior is not necessarily financially expensive in terms of materials to purchase but tends to be resource-intensive with respect to the time and attention required to implement and evaluate processes to change clinician behavior to reduce unnecessary urinary catheter use,” she said. “You have to work closely with individual units in order to understand the barriers and challenges to getting catheters out—just putting in a protocol and mandating it doesn't work.”
While CAUTIs are one of the most common types of HAIs, the rates may have been overblown in the past due to misclassification, said Michael Edmond, MD, MPH, FACP, chief quality officer and associate chief medical officer at the University of Iowa Hospitals and Clinics in Iowa City.
However, that may change under a new definition of CAUTI published in January by the CDC's National Healthcare Safety Network (NHSN), which tracks HAIs at hospitals nationwide.
“One of the big problems with tracking CAUTIs was that patients with Candida in the urine were being classified as having CAUTI, but in almost all cases these were not true infections,” said Dr. Edmond. “The new definition means that those cases will no longer be included, which could have a big impact on the numbers.”
According to NHSN, yeast is no longer a pathogen for diagnosing CAUTI and does not qualify as a positive urine culture for purposes of UTI surveillance. The change is significant, said Dr. Edmond, because in some hospitals almost 40% of CAUTI cases are diagnosed based on Candida in the urine, even though most patients are otherwise asymptomatic.
Even with that change, misdiagnosis may still occur because fever, one of the prominent signs in the definition of CAUTI, is common to other conditions, said Mohamad Fakih, MD, MPH, FACP, medical director of infection prevention and control at St. John Hospital and Medical Center in Detroit, Mich. Hospitals' rates of CAUTI can depend on their frequency of culturing, especially in the intensive care units, he added.
Overestimates of CAUTIs have major financial implications since hospitals with the most unfavorable CAUTI rates are at risk for penalties based on CMS's Hospital Acquired Condition (HAC) program.
Dr. Fakih, who is also on the leadership team of On the CUSP, and others have suggested changes to the way the CDC tracks CAUTI rates, which are currently calculated using a standardized infection ratio of actual to expected events. Rather than only tracking infections, they want to incorporate quality measurements that reflect hospitals' efforts to prevent or reduce their use of catheters.
“We should be looking at this as a patient-focused safety issue related to device use,” he said. “Appropriate use of the catheter is more reflective of a hospital's efforts to reduce the risk of infections [than the standardized infection ratio].”
Changing the culture
Preventing CAUTIs requires a “multi-pronged approach,” said Brian Koll, MD, FACP, executive director of infection prevention and control for Mount Sinai Health System in in New York City. At one of the health system's hospitals, Mount Sinai Beth Israel, the CAUTI prevention program began in the ED.
“The ED is where the majority of patients start,” said Dr. Koll, who oversees 7 facilities. “If you can prevent Foley catheters from being placed in the ED, there is a very good chance that those patients will not have one when they're transferred to the medical-surgical unit.”
The hospital created unit-specific physician-nurse dyads with responsibility for monitoring appropriate indications for catheter insertion and ensuring earliest possible removal. The effort to avoid infection in patients who have catheters includes physicians, nurses, physician assistants, nurse practitioners, and other health care workers such as transporters and radiology technicians, who monitor appropriate handling of the catheter bag when patients are moved from one area of the hospital to another.
For patients without catheters, nurses perform hourly rounds to help patients to the bathroom if needed, while nurses specializing in wound care help monitor for and prevent skin breakdown due to soiled or wet bedding. For those with catheters, continued need is assessed daily and maintenance practices are monitored. To reinforce the importance of such efforts, the hospital holds monthly unit-based and hospital-wide educational forums where individual units are recognized for achieving low rates of catheter use.
Last year, the hospital met its goals of reducing device utilization by 10% and lowering the CAUTI rate by 30% to 0.5 per 1,000 catheter-days. One key to success was having top leadership support the plan, said Dr. Koll.
“We created a quality leadership council made up of the chief medical officers, chief nursing officers, and presidents of each of our hospitals who are ultimately held accountable for our results,” he said. “Everyone has to play a role but we are depending on senior leadership to be the driving and supporting force.”
To help nurses at the bedside, leaders should provide education about alternative strategies for measuring urinary output or managing incontinence, said Dr. Meddings. Some nursing homes, under pressure to lower catheter use to meet quality assessments, can serve as a model of how to proceed.
“Nursing homes have put more resources into incontinence management to minimize urinary catheter use,” she said. “Their strategies go beyond turning the patient to using different types of incontinence garments, barrier creams, prompted voiding, adjusting medications to avoid accidents, and using behavioral interventions.” Nursing homes have also invested in dedicated clinical personnel focused on optimizing incontinence care plans, she noted.
One of the most effective ways to reduce catheterization is to remind clinicians that a catheter is in place, said Dr. Meddings. Interventions might include a daily checklist or verbal/written reminder to assess continued catheter need, a sticker reminder on the patient's chart or catheter bag, or an electronic reminder that a catheter is still in place. Some hospitals go further by implementing stop orders that require the clinician to remove the catheter order after a certain time period if it no longer meets criteria.
In a meta-analysis of 11 studies that used reminders or stop orders, published in BMJ Quality and Safety in September 2013, Dr. Meddings and colleagues found that such interventions reduced CAUTI episodes per 1,000 catheter days by 53% (P<0.001).
“Drastically reducing catheter use means changing your default thinking process,” said Dr. Meddings. “Instead of thinking ‘The patient needs to keep the catheter until I know they don't need it,’ you think ‘Let's take out the catheter unless we clearly know a reason why we shouldn't’.”
Costs vs. benefits
Despite the prevalence of CAUTI, some experts question whether putting extensive resources into prevention is justified. They argue that efforts to reduce other HAIs, such as central line-associated bloodstream infections (CLABSIs), often yield a greater bang for the buck.
“In the big picture, CAUTIs are relatively low-impact infections, but we are spending a lot of energy on them,” said Dr. Edmond. “In a perfect world, we want to avoid every infection, but we are working with finite resources and should be putting our time and effort into preventing infections that have the most impact.”
In a presentation at ID Week 2014, Dr. Edmond cited data showing that large-scale prevention efforts sponsored by AHRQ to reduce CLABSI resulted in an 82% rate reduction over 14 to 18 months, compared with 16% for CAUTI.
He also pointed to a study, published in JAMA Internal Medicine in December 2013, showing that the cost per infection for CAUTI is much lower than for other HAIs—$896 per infection compared with $45,814 for CLABSI and $40,144 for ventilator-associated pneumonia (VAP), for example.
However, others contend that while preventing CAUTIs may not result in the same magnitude of cost savings as preventing CLABSI or VAP, in terms of lowering length of stay and reducing morbidity and mortality, reducing catheters has far-reaching effects.
A study published in the Sept. 13, 2013, Annals of Internal Medicine, for example, concluded that catheters are associated with many noninfectious complications that are at least as frequent as but far less documented than CAUTIs. In addition to minor complications, such as urine leakage, short-term catheterization was associated with urethral strictures in 3.4% of patients and with gross hematuria in 13.5% of patients with spinal cord injuries, according to the analysis of 37 studies.
It's important to take a broad view of CAUTI prevention, said Dr. Saint. Many HAI interventions overlap and should be viewed together as a way to foster a culture of patient safety.
“How a hospital deals with preventing CAUTIs is a nice window into how it functions,” said Dr. Saint. “It says a lot about how the hospital handles other endemic problems, such as pressure sores, falls, and delirium.”
You have to look beyond the numbers when weighing the costs and benefits of CAUTI prevention, added Dr. Fakih.
“If we think about CAUTI narrowly in terms of costs, it might seem trivial, but it becomes a huge issue when we think about it as a surrogate for other problems,” he said. “If I put a catheter in place when it is not needed, besides CAUTI, it can lead to trauma, discomfort, immobility, and inappropriate antibiotic use. We need to think about this as a device safety issue.”