In our January 8, 2008 Patient Safety Tip of the Week “ ” we noted a study by Sanjay Saint, M.D. and colleagues at the University of Michigan (Saint 2008) showing that 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and only 9% used catheter reminders.
In 2008 CMS implemented its plan to stop payment for various hospital-acquired infections (HAI’s), including catheter-associated urinary tract infections (CAUTI’s). It would be anticipated that most hospitals would have adopted best practices to reduce their CAUTI rates as well as the rates of other HAI’s. So Saint and colleagues (Krein 2011) did another nationwide survey to see how practices changed since that time. They found that most hospitals had put an increased priority on avoiding CLABSI, VAP and CAUTI. But, whereas most hospitals had implemented multiple practices to prevent CLABSI and VAP, only one CAUTI prevention practice was used by at least 50% of hospitals. They also note that CLABSI and VAP rates nationwide have declined but CAUTI rates have not.
They note that for CLABSI and VAP there have been “bundles” of recommended best practices and large collaboratives focusing on reducing these complications but such have been scant for CAUTI. They also feel that the CMS payment rule probably has had little impact on the rates.
The system you put in place should have both a pre-emptive component and a surveillance component. The pre-emptive component can be either low-tech or hi-tech. The simple colored sticker alert shown in our January 8, 2008 Patient Safety Tip of the Week “ ” has given way to computerized physician order entry (CPOE) order entry screens that request indication and expected duration any time someone orders a Foley catheter. Adding lines for indication and duration to standardized order sets or pre-printed order sheets can also be effective. Alternatives to Foley catheters may include condom catheters in males or intermittent catheterization and use of portable bladder scanners may reduce the need for any kind of catheter in the first place.
The second component of your system is the surveillance component. That means assessing all patients with urinary catheters to see if they still need them. We routinely look for unnecessary catheters during patient safety “walk rounds” and so should you. However, you need a system in place so they are looked for on a daily basis. Make this activity a “checklist” item on nursing rounds or teaching rounds. Also, if your hospital uses a barcode system to track inventory, adapt that system to alert you to every patient to whom a catheter was attached. Educating your patients to question why they need or still need a catheter should be part of your patient-oriented patient safety program.
And, of course, good nursing care for those catheters that are indicated is also crucial.
Be sure to include monitoring and measuring in your QI activities because the initial Hawthorne effect of implementing such a system often fades with time. Posters and screensavers about preventing CAUTI’s may generate some enthusiasm for your program early on but you need more to ensure durability of your program long-term. Feedback and celebrating success are important in that regard.
Saint S, Kowalski CP, Kaufman SR, et al. Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study. Clinical Infectious Diseases 2008; 46: 243–250
Krein SL, Kowalski CP, Hofer TP, Saint S. Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 200 Gen Intern Med 2011; published online December 6, 2011