CAUTI Prevention: Simple Measures Work Best

Norra MacReady

May 30, 2013

In 2008, as part of an aggressive effort to reduce the rate of healthcare-associated infections (HAIs), the Centers for Medicare and Medicaid Services (CMS) declared it would no longer cover the extra costs incurred in caring for patients who developed certain infections while hospitalized.

Catheter-associated urinary tract infections (CAUTIs) were among the earliest targets: They are some of the most common HAIs in United States hospitals, yet are considered reasonably preventable by the CMS. Now a new study article, published in the May 27 issue of JAMA Internal Medicine suggests that their incidence can be reduced by a bundle of simple best practices.

Effect of Best Practices

In 2007 the Keystone Center for Patient Safety, part of the Michigan Health and Hospital Association, launched a statewide initiative to reduced CAUTI called the Keystone Bladder Bundle Initiative. "This initiative consisted of the following key practices to reduce CAUTI: urinary catheter reminders or removal prompts and nurse-initiated urinary catheter discontinuation protocols, alternatives to indwelling urinary catheterization, portable bladder ultrasound monitoring, and insertion care and maintenance," write Sanjay Saint, MD, MPH, from the Veterans Administration Ann Arbor Health System and the Department of Internal Medicine, University of Michigan Medical School, and colleagues.

To assess the effect of the Keystone Bladder Bundle Initiative, Dr. Saint and colleagues sent surveys to infection preventionists at all the nonfederal general medical and surgical hospitals with at least 50 beds in Michigan and at a random sampling of hospitals throughout the United States. The survey, sent in 2009, included questions about the hospital's infection control and prevention programs and the frequency with which the hospital employed specific CAUTI prevention measures. The authors also collaborated with the Centers for Disease Control and Prevention and the Michigan Department of Community Health to determine standardized infection ratios (SIRs) for each state, calculated by dividing the number of observed infections for a given population by the expected number of infections for that population. SIR "is a practical risk-adjustment statistic for comparing HAI rates," the authors explain.

The researchers received responses from 103 (79%) of Michigan hospitals, but 25 of those institutions had fewer than 50 beds and were excluded from the study. Of 566 non-Michigan hospitals that received surveys, the investigators included 392 (69%) in the analysis. They found that 94% of the Michigan hospitals were participating in collaborative efforts to reduce HAIs, including the Keystone Bladder Bundle Initiative, compared with 67% of the hospitals outside Michigan (P < .001). Sixty percent of Michigan hospitals reported that they routinely monitored duration and/or discontinuation of urinary catheters compared with 39% of the non-Michigan hospitals (P < .001). However, 79% of the non-Michigan hospitals had an established surveillance system for monitoring urinary tract infection rates compared with 59% in Michigan (P < .001). Compared with hospitals outside Michigan, the odds ratio that a Michigan hospital would use a portable bladder ultrasound scanner was 2.02 (95% confidence interval [CI], 1.18 - 3.43). In addition, the odds ratio of using urinary catheter reminders or stop orders, or allowing nurses to decide whether to discontinue catheter use, was 2.19 for Michigan hospitals compared with non-Michigan settings (95% CI, 1.24 - 3.86).

Nationwide, the number of observed CAUTIs in 2010, derived from 1062 hospitals, was 9845 compared with an expected rate of 10,456, for a SIR of 0.94 (95% CI, 0.92 - 0.96). For Michigan, the observed and expected values, obtained from 24 hospitals, were 150 and 201, respectively, for a SIR of 0.75 (95% CI, 0.63 - 0.87). "These estimates suggest that CAUTI rates in Michigan hospitals decreased by approximately 25% from 2009 to 2010, while CAUTI rates in hospitals in the rest of the United States (aggregated) decreased by approximately 6% during the same period," the authors report.

Bundle Barriers

In a separate article published in the same issue of the journal, the same investigators examined the barriers to implementation of the initiatives. Lead author Sarah L. Krein, RN, PhD, from the Center for Clinical Management Research, Veterans Affairs Health Services Research & Development, Veterans Affairs Ann Arbor Healthcare System, and colleagues chose 12 of the participating Michigan hospitals for a closer study of what did and did not work. The study consisted of semistructured telephone interviews with selected hospital staff members plus site visits at 3 of the hospitals. The researchers identified 3 basic barriers to implementation of CAUTI prevention measures:

  • Difficulty with nurse and physician engagement: Both nurses and physicians often viewed CAUTIs as less serious than other types of HAIs, and many hospitals lacked physicians who would champion the initiatives. Strategies to overcome these barriers included identification of specific champions on the nursing and physician staff and review of the benefits of early catheter removal, as well as the potentially serious consequences of CAUTIs.

  • Patient and family requests for indwelling catheters: Family members and even patients themselves often expressed preference for catheters, citing convenience or fears of incontinence. The authors recommend education on the risks of CAUTIs and their implications to overcome this barrier..

  • Catheter insertion in the emergency department (ED): ED staff often would insert urinary catheters to collect specimens or because they thought that was the floor nurses' preference even when it was not medically necessary. They urge more education on appropriate indications and monitoring of catheter use in the ED.

Most CAUTIs Preventable

In an accompanying comment, Paul S. Pottinger, MD, states that "it has been estimated that 65% to 70% of CAUTI may be preventable with current evidence-based best practices." Those best practices are "deceptively simple," writes Dr. Pottinger, from the Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle. "Perhaps CAUTI's greatest challenge is posed by its very innocuousness. As epidemics go, it is mostly silent." He concludes, "Admitting we have a problem must surely be the first step toward a solution. Acting on that knowledge is a responsibility we all share."

This project was supported in part by the Blue Cross Blue Shield of Michigan Foundation and the National Institute of Nursing Research. Dr. Saint has received numerous honoraria and speaking fees from academic medical centers, hospitals, group-purchasing organizations, specialty societies, state-based hospital associations, and nonprofit foundations for lectures about CAUTI and implementation science. Another author is employed by the Michigan Health and Hospital Association. Dr. Pottinger has disclosed no relevant financial relationships.

JAMA Intern Med. 2013;173:874-879, 881-886, 879-880. Saint abstract, Krein abstract, Comment extract

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