Catheter-Associated UTIs: Measurements Matter

William R. Jarvis, MD


September 22, 2011


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Recently, there have been several reports on calculation of the catheter-associated urinary tract infection (UTI) rate and what denominator to use. The traditional denominator used in the US Centers for Disease Control's (CDC) National Healthcare Safety Network is catheter-days. However, several reports have suggested that after quality improvement interventions were implemented, that denominator has not worked very well. This is particularly important because catheter-associated UTIs account for about 40% of all healthcare-associated infections and about 13,000 deaths each year.

Because of increased length of stay and cost, the Centers for Medicare & Medicaid Services (CMS) modified the rules for reimbursement, effective October 2008, in which they would no longer provide increased reimbursement for higher costs associated with inpatient acquisition of a catheter-associated UTI. A number of interventions have been implemented; most famous perhaps is the Keystone Center bladder bundle. [1] If you look at that bundle, 3 of the 5 elements target decreased use of urinary catheters.

An interesting study by Wright and colleagues, [2] published in Infection Control & Hospital Epidemiology in July of this year, initiated a quality improvement program. Activities included physician orders for placement or continued use of a urinary catheter that was present on admission; daily nursing evaluation of patients for the need or potential discontinuation of the catheter; a physician reminder that required renewal with a rationale every 48 hours; and targeted education in high-use areas, particularly emergency departments, for unnecessary urinary catheterization. The study authors collected catheter-associated UTI data for several years. The background rate, from July 2007 to June 2008, was the first time period.

They then embarked on their educational program in July and August 2008, which they called the Catheter Associated Quality Improvement program. They did this at 3 hospitals, in a large number of nursing units, and in a very large number of patients. The intervention period was time period 2, from September 2008 to October 2009. The device utilization decreased from 0.36 to 0.28, and this was statistically significant at the .001 level. The duration of catheterization also decreased from 3.29 to 3.19 days and was statistically significant. UTIs per catheterized patient did not significantly decrease (2.56 vs 2.63). Of interest, the catheter-associated UTI rate when measured per 10,000 patient-days decreased by 18% and was statistically significant (28.2-23.2). In contrast, when the denominator of 1000 catheter-days was used -- this has been the traditional surveillance method -- the catheter-associated UTI rate did not decrease (7.79 vs 8.28).

This illustrates an increasing problem with denominators. With central line-associated bloodstream infections, we have discussed the need to consider the number of catheters or even the number of lumens in the denominator. Now we have the catheter utilization rate or device-days showing that when you have a quality improvement program -- you decrease catheter-associated UTIs in general and decrease the use of devices with the traditional methodology -- no significant difference is found. This is something that we are going to have to grapple with in the future because if you improve with your quality improvement program, you would like to be able to document that through a validated evidence-based statistic. This is going to lead all of us to look at what interventions we implement and how we measure the effectiveness of those interventions in the future.


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