Here we are – six+ months into the era where CMS will no longer pay extra for catheter-associated urinary tract infections (CAUTI’s) – and many hospitals are still struggling to eliminate CAUTI’s.
At the 2009 Annual Scientific Meeting of SHEA (the Society for Healthcare Epidemiology of America) there were several presentations on CAUTI’s as summarized in a Medscape Medical News article. One study by Mark E. Rupp, M.D. and others at the University of Nebraska found the almost a third of Foley catheter days were unnecessary. That is similar to a study done by Raffaele et al in Italy last year. Rupp is quoted in that Medscape article as noting that Foleys are frequently used for “convenience” in incontinent patients. He points out the alternatives to indwelling catheters in the incontinent patient, including diapers, scheduled voiding, intermittent catheterization, and condom catheters. Also in that Medscape article, Dr. Jennifer Meddings from University of Michigan Health System (where many of our previously mentioned studies on bladder bundles were done) notes that new evidence-based guidelines on indwelling catheter use will be forthcoming within months from the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the US Centersfor Disease Control and Prevention. Those guidelines will emphasize that use of indwelling catheters for convenience or incontinence are not indicated.
So why are hospitals still struggling? At multiple hospitals we have found one consistent, recurring theme: the problem areas are the ER and the OR. Most med/surg floors have done a reasonably good job at eliminating or minimizing use of indwelling urinary catheters. However, they keep popping up in patients arriving from either the ER or the OR. Those two areas have historically been sites where Foleys are frequently inserted (note that in the Rupp studies the indication for Foley catheter in 75% of cases was for surgery or postoperative management). They often have legitimate indications in those areas but many times they are inserted almost reflexly.
But we have found one other key and perhaps more important reason for this being a special problem for the ER and OR: these two areas are often not integrated with the rest of the hospital clinical information systems. Many IT vendors sell ER and OR modules separately. So as hospitals have begun implementing the CPOE and EMR systems they either begin on the med/surg units or they have separate ER/OR IT systems that are not integrated with the system installed on the med/surg units. (Yes, we’ll add this to our list of unintended consequences of healthcare IT!).
So what should you do? As in our previous columns, you can either go hi-tech or low-tech. The low-tech solution, you will recall, is simply using a brightly colored sticker that requests a reason for the Foley and/or prompts for a reason for continuation of the Foley. A little more sophisticated sticker would have checkboxes for the legitimate reasons for using a Foley catheter. We actually now recommend that you package your Foley catheters with a card or sticker on the outside that must be filled out prior to opening the Foley tray/package.
But your second solution is more hi-tech. Though many OR and ER areas are not integrated with the HIS, they often do use or interface with the medication ordering system. So the solution is: treat the Foley catheter like a drug! Have it ordered through your CPOE or medication ordering system. That way you can:
Just be careful that you develop carefully the CPOE screens for ordering a Foley in this manner. Test them first in “test” mode before moving to “live”. And, just as you would with any new drug, be observant for any potential unintended consequences.
Most CPOE programs allow the above capabilities in modules other than your medication ordering module. However, the above solution can work well for those settings where other aspects of CPOE are not yet available, such as the OR or ER. There are probably several other non-medications that could be programmed for ordering through the medication ordering module as well.
And don’t forget our other columns on urinary catheter-associated UTI’s:
Rebelo K. Medscape Medical News article: “SHEA 2009: Inappropriate Catheterization Is Common”. March 24, 2009
Raffaele G, Bianco A, Aiello M, Pavia M. Appropriateness of Use of Indwelling Urinary Tract Catheters in Hospitalized Patients in Italy. Infect Control Hosp Epidemiol 2008; 29: 279–281 http://www.journals.uchicago.edu/doi/abs/10.1086/528814?prevSearch=(raffaele)+AND+[journal%3A+iche]