Research has shown that urinary catheter-associated urinary tract infections (UTIs) are among the most common healthcare–associated infections both in the United States and throughout the world. Studies indicate that up to 69% of urinary catheter-associated UTIs are avoidable if clinicians use recommended infection-prevention practices when managing patients. According to current guidelines, several strategies are recommended to prevent these infections. These include using the devices appropriately, aseptic insertion, proper maintenance, and timely removal of indwelling urinary catheters in addition to using established practices, such as hand hygiene.
In addition to the technical aspects of prevention, there has been a focus on instituting behavioral and cultural changes to further improve quality of care, according to Sanjay Saint, MD, MPH. “Preventing catheter-associated UTIs has emerged as a priority in the United States,” he says. Catheter-associated UTI was the first hospital-acquired complication chosen by CMS in 2008 as the basis for denial of additional payment to hospitals. Since that time, more initiatives have been launched to provide strategic guidance for preventing infections in acute care hospitals. Despite these efforts, national data indicate that the incidence of catheter-associated UTI increased by 6% from 2009 to 2013.
A Nationwide Initiative
Recently, the AHRQ and several other partners launched a nationwide effort to implement the Comprehensive Unit-Based Safety Program to reduce catheter-associated UTIs in ICUs as well as non-ICUs. “This effort involved an explicit focus on the technical and socioadaptive aspects of preventing catheter-associated UTIs,” says Dr. Saint. He and his colleagues recently published the results from the first four of nine cohorts of hospital units in the New England Journal of Medicine.
The program disseminated primary and secondary recommendations to sponsor organizations and hospitals (Table), collected data, and offered guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: at baseline (3 months), during implementation (2 months), and through long-term sustainability (12 months). “This was a large study in that data were obtained from 926 units in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico,” says Dr. Saint. Nearly 60% of the units were non-ICUs while about 40% were ICUs.
According to the findings, the unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1,000 catheter-days after initiating the intervention. In an adjusted analysis, the rates of catheter-associated UTIs decreased from 2.40 to 2.05 infections per 1,000 catheter-days. Among non-ICUs, catheter use decreased significantly and catheter-associated UTI rates dropped from 2.28 to 1.54 infections per 1,000 catheter-days. “Overall, we saw a reduction in catheter-associated UTI rates of about 32% in non-ICUs,” Dr. Saint says. He adds, however, that catheter use and catheter-associated UTI rates were largely unchanged in ICUs.
“Our data show that a collaborative effort focusing on both technical and socioadaptive interventions can reduce catheter-associated UTI rates in non-ICU settings,” says Dr. Saint. “When we add this data to what has been learned from that of local and regional level investigations, we have better guidance on how to scale up the intervention to benefit the nation.” Dr. Saint adds that his study group also used the results of previous qualitative studies to guide their implementation efforts.
Non-ICUs benefited from participating in the program but ICUs did not experience the same benefits. This dichotomy between ICUs and non-ICUs has also been seen in studies using CDC surveillance data. Dr. Saint says the reasons are unclear as to why ICUs have been less successful than non-ICUs in preventing catheter-associated UTIs.
“It’s possible that clinicians believe patients who are sick enough to warrant being admitted to the ICU require close monitoring of urine output, which is an appropriate criterion for indwelling urinary catheters,” Dr. Saint says. The higher catheter-associated UTI rate in ICUs could also be related to the fact that fevers occur frequently in critically ill patients. This could lead clinicians to couple routine culturing of various body fluids, including urine, to identify possible sources of infection. Given the findings observed in the study and the CDC criteria for catheter-associated UTI, patients in ICUs may meet the surveillance definition of catheter-associated UTIs more frequently than patients in non-ICUs.
According to Dr. Saint, a key take home message for all clinicians is that the national prevention program used in the study appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. “Our national collaborative program used both technical and cultural interventions that led to a decrease in rates of catheter-associated UTIs in non-ICUs,” he says. “There is no ‘silver bullet’ approach that will work for all hospitals, but developing and maintaining a culture of excellence is critical to further reducing the burden of these infections.” He notes that the next step, which is currently underway, is to conduct a similar collaborative effort in long-term care settings, for which preventive data are more limited.
Saint S, Green MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374-2111-2119. Available at: http://www.nejm.org/doi/full/10.1056/NEJMoa1504906?query=featured_home#t=article.
Saint S, Greene MT, Kowalski CP, Watson SR, Hofer TP, Krein SL. Preventing catheter-associated urinary tract infection in the United States: a national comparative study. JAMA Intern Med. 2013;173:874-879.
Saint S, Olmsted RN, Fakih MG, et al. Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle. Jt Comm J Qual Patient Saf. 2009;35:449-455.
Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:625-663.
Saint S. Hand washing stops infections, so why do health care workers skip it? The Conversation.
May 17, 2016. Available at: http://theconversation.com/hand-washing-stops-infections-so-why-do-health-care-workers-skip-it-58763. For more on this, go to https://www.youtube.com/watch?v=U3MtvvNjUR4.