A new study from the researchers leading the highly successful Keystone initiative in Michigan to prevent catheter-associated UTI’s (CAUTI’s) has identified barriers to implementation of best practices to prevent CAUTI’s (Krein 2013). They used survey data and structured interviews in a sampling of participating hospitals to assess barriers encountered. Some of the barriers are well-known and anticipated but others are more surprising.
The least surprising, but most significant, barrier is lack of buy-in from physicians and nurses. Many physicians and nurses simply did not appreciate the invasive nature and potential seriousness of CAUTI’s. Convenience for nurses was also mentioned frequently. Some noted conflicting patient safety goals, often speculating that an indwelling catheter would keep patients from going to the bathroom, during which they might encounter a fall (ironically, falls might actually be more common in patients with indwelling catheters). Potential strategies to deal with these barriers include having a nurse “champion” and doing hourly rounds where attention to toileting activities is included. Hospitals have struggled with identifying physician “champions”, which can really help, but all noted that at least having some support from the medical staff was important.
A second barrier relates to ER insertion of urinary catheters. Many hospitals have had reasonable success at reducing urinary catheter insertion on their med-surg units and ICU’s. However, urinary catheters often get inserted in the OR or in the ER. The Krein paper notes many of the reasons that catheters get inserted in the ER, some not surprising but others somewhat unexpected. Those reasons not surprising were catheter insertion to get urine specimens and insertions for conveniences since bathroom facilities are often not readily accessible in ER’s. The busy nature of an ER is also a factor. But a somewhat surprising reason was the pereception that they were doing the nursing staff on the hospital floors a favor by inserting the catheters. The primary strategy here was working with the ER leadership to educate all staff on the importance of avoiding catheters that are not medically necessary. One factor they did not mention but that we see frequently is the lack of IT interoperability between the ER and the rest of the hospital. While some of our interventions have required a physician to order the catheter in CPOE and include an indication, those capabilities are often not present in the ER. A low-tech intervention might be simply having the physician specify the indication on paper before the catheter is removed from its packaging.
The surprising barrier was patient and family requests for urinary catheters. We would not have anticipated this and neither did the researchers. Educating the patient and family about all the adverse effects of catheters (see our May 2012 What’s New in the Patient Safety World column “Foley Catheter Hazards”), not just CAUTI’s, is the suggested intervention. It’s important for the physicians to understand these as well since many of the requests from patients and families to keep indwelling catheters go through the physician.
A companion study by the Michigan group (Saint 2013) looked at CAUTI rates in those hospitals participating in the Michigan Keystone Bladder Bundel Initiative compared to the rest of US hospitals. The Michigan hospitals were more likely to participate in collaboratives, more likely to use ultrasound bladder scanners, and more likely to use stop orders or nurse-initiated discontinuation. More frequent use of the preventive practices in Michigan hospitals led to a 25% reduction in CAUTI’s compared to only a 6% reduction over the same timeframe in the rest of the US.
And yet another recent study, presented as an abstract, showed that hospitalizations due to urinary catheters have been increasing over the past decade (Colli 2013). Analyzing national HCUP data, they found that hospitalizations due to indwelling urinary catheters increased from 11,742 in 2001 to 40,429 in 2010 and the corresponding national bill increased from $175 million to $1.3 billion for these. The majority of these patients had UTI’s but septicemia rates almost doubled.
Some of the same issues identified in acute hospitals by Krein et al. probably are also factors in continuation of catheter use after discharge, whether that discharge is to a nursing home or rehab facility or the patient’s home. Continuously asking whether the catheter is still necessary should be a regular part of the patient’s care. For example, some stroke patients may develop urinary retention acutely but in the majority that changes over time. It may be replaced by urinary incontinence as an uninhibited neurogenic bladder or reflex neurogenic bladder evolves but that incontinence is better managed by other methods (eg. condom catheters in males, pads in females, etc.). Even those who continue with urinary retention or develop detrusor-sphincter dyssynergia might be managed by alternative means (eg. intermittent catheterization). Clearly, individualization of management is needed but if you don’t ask whether the catheter is still needed no one will discontinue it.
Our other columns on urinary catheter-associated UTI’s:
Krein SL, Kowalski CP, Harrod M, Forman J, Saint S. Barriers to Reducing Urinary Catheter Use: A Qualitative Assessment of a Statewide Initiative. JAMA Intern Med 2013; 173(10): 881-886
Saint S, Greene MT, Kowalski CP, et al. Preventing Catheter-Associated Urinary Tract Infection in the United States. A National Comparative Study. JAMA Intern Med 2013; 173(10): 874-879
Colli J, Walls K, Dunn E, et al. Abstract 138: Hospitalizations due to indwelling urinary catheters, 2001-2010. American Urological Association (AUA) 2013 Annual Scientific Meeting. Abstract 138. Presented May 5, 2013
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