Patient Safety Tip
of the Week
April 3, 2018 Cost of a CAUTI
Some of our earliest
columns on the cost of complications (see our Patient Safety Tips of the Week
for August 21, 2007 “Costly
Complications About to Become Costlier” and January 22, 2008 “More
on the Cost of Complications”) noted wide variation in the “attributable”
costs of CAUTI’s (catheter-associated urinary tract infections).
A new systematic
review emphasizes that the attributable costs of CAUTI’s are very dependent
upon the nature of the patient population and location of services (Hollenbeak
2018). From that review the
authors note the attributable costs of a CAUTI were: $876 (inpatient cost to
the hospital for additional diagnostic tests and medications); $1,764
(inpatient cost to Medicare for non-intensive care unit [ICU] patients); $7,670
(inpatient and outpatient costs to Medicare); $8,398 (inpatient cost to the
hospital for pediatric patients); and $10,197 (inpatient cost to Medicare for
ICU patients).
That review is
timely since there were also recent studies on CAUTI’s in the latter two
circumstances (ICU’s and pediatric populations).
Mullin and
colleagues (Mullin
2017) assembled a project team
composed of all critical care disciplines to address an institutional
goal of decreasing CAUTI’s. Interventions implemented between year 1 and year 2
included protocols recommended by the CDC for placement, maintenance, and
removal of catheters. Also, leaders from all critical care disciplines agreed
to align routine culturing practice with American College of Critical Care Medicine
(ACCCM) and Infectious Disease Society of America (IDSA) guidelines for
evaluating a fever in a critically ill patient. Following implementation, the CAUTI
rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. Device
utilization ratio was 0.7 in 2013 and 0.68 in 2014. Hospital-acquired
bloodstream infection rates per 1,000 patient days also decreased from 2.8 in
2013 to 2.4 in 2014. The authors attributed success to the multifaceted and
collaborative approach but also singled out stewardship of culturing as
a key component of their success.
The role of cranberry products in prevention
or treatment of urinary tract infections has been controversial, with some
studies showing benefit and others showing no benefit. But one study in a
heterogeneous ICU population (Sorour 2016) showed that the addition of
cranberry-containing products and antimicrobial meatal care may further reduce
incidence of CAUTI when added to standard recommendations.
A previous study
showed that implementation of a quality improvement prevention bundle can
significantly reduce CAUTI rates in children (Davis
2014). The four elements in their
prevention bundle were:
- placing an indwelling urinary catheter only when there was an
approved indication for its usage
- inserting urinary catheters using aseptic technique and an insertion
checklist
- maintaining urinary catheters based on principles of asepsis and
positioning the patient and collection device to assist in urine drainage
- reviewing urinary catheter necessity daily and removing promptly
when the indications are no longer met.
Implementation was
associated with a 50% reduction in the mean monthly CAUTI rate, from 5.41 to
2.49 per 1000 catheter-days. Most patients with CAUTIs were female (75%),
received care in the pediatric or cardiac ICUs (70%), and had at least 1
complex chronic condition (98%). Nearly 90% of patients who developed a CAUTI
had a recognized indication for initial catheter placement.
But, of course, CAUTI’s are a concern not just in ICU
populations but also non-ICU populations. One other intervention merits noting
since it uses one of our favorite tools, the “huddle” (see our December
9, 2008 Patient Safety Tip of the Week “Huddles
in Healthcare”). A recent Health Leaders Media article (O’Brien
2018) highlighted work done at St. Anthony Hospital in Chicago. They used a
daily interdisciplinary safety huddle (DISH) to focus on central venous catheters
and indwelling urinary catheters. Their DISH huddle is “a 15-minute meeting
held in the morning to incorporate participation from a swath of hospital
employees ranging from security to nurse managers, emergency services, and
infection control”. They also instituted a policy for nurse managers to report
catheter usage, while an infection control practitioner reviewed indications,
duration, and plans for device removal. Any barriers to catheter removal were
required to be addressed within 24 hours. After DISH was implemented, they had a
significant decrease in central venous and indwelling urinary catheter use in
non-ICU settings. They attributed these declining device utilization
rates as key to a 90% reduction in HAI’s, which resulted in a cost savings of
nearly $500,000.
The Hollenbeak study did not
address the cost of CAUTI’s in the other setting where CAUTI’s remain
significant - long-term care (LTC). But
it’s worth noting the “AHRQ Toolkit Designed to Reduce Urinary Tract Infections
in Long-Term Care” (AHRQ
2017). The toolkit is based on the experiences of more than 450 long-term
care facilities across the country that participated in an AHRQ-funded project
and reported significant CAUTI rate reductions. The toolkit uses strategies
from AHRQ's Comprehensive Unit-based Safety Program (CUSP) and includes behavior
change elements that promote leadership involvement, improvement in safety
culture, teamwork, and communication, and sustainability.
Our other columns on
urinary catheter-associated UTI’s:
- May 8,
2007 Tip of the Week “Doctor,
when do I get this red rubber hose removed?”
- January
8, 2008 Tip of the Week “Urinary
Catheter-Associated Infections”
- April 2008 What’s New in the
Patient Safety World column “More
on Nosocomial UTI’s”
- June
24, 2008 Tip of the Week “Urinary
Catheter-Related UTI’s: Bladder Bundles”
- April
21, 2009 Tip of the Week “Still
Futzing with Foleys?”
- June
9, 2009 Tip of the Week “CDC
Update to the Guideline for Prevention of CAUTI”
- March 2010 “IDSA
CAUTI Guidelines”
- February
2011 What’s New in the Patient Safety World column “Catheters
Not Needed in C-Sections?”
- January 2012 “CAUTI’s
Still Get No Respect”
- May 2012 “Foley
Catheter Hazards”
- November 2012 “CAUTI
Conundrum”
- December 18, 2012 “Unintended
Consequences of the CAUTI Measure?”
- January 2013 “Silver-Coated
Urinary Catheters Don’t Reduce CAUTI’s”
- June 2013 “Barriers
to CAUTI Prevention”
- November 2013 “Further
Reducing Urinary Catheter Use”
- June 2014 “Updated
HAI Prevention Guidelines from SHEA/IDSA”
- June 30, 2015 “What
Are Appropriate Indications for Urinary Catheters?”
- December 2015 “CAUTI
Prevention Tools”
- July 2016 “Holy
Moly, My Patient has a FOLEY!”
- December 2016 “The
Joint Commission NPSG for CAUTI’s”
References:
Hollenbeak CS, Schilling AL. The
attributable cost of catheter-associated urinary tract infections in the United
States: A systematic review. Am J Infect Control 2018; Published online:
February 22, 2018
http://www.ajicjournal.org/article/S0196-6553(18)30036-1/fulltext
Mullin KM, Kovacs CS, Fatica C, et
al. A Multifaceted Approach to Reduction of Catheter-Associated Urinary Tract
Infections in the Intensive Care Unit with an Emphasis on “Stewardship of
Culturing”. Infect Control Hosp Epidemiol 2017; 38(2): 186-188
Sorour K, Nuzzo E, Tuttle M, et
al. Addition of bacitracin and cranberry to standard Foley care reduces
catheter-associated urinary tract infections. Canadian Journal of Infection
Control 2016; 31(3): 166-168 Fall 2016
http://ipac-canada.org/photos/custom/CJIC/Vol31no3.pdf
Davis KF, Colebaugh AM, Eithun BL, et al. Reducing Catheter-Associated Urinary
Tract Infections: A Quality-Improvement Initiative. Pediatrics 2014; published
online August 11, 2014
http://pediatrics.aappublications.org/content/early/2014/08/06/peds.2013-3470
O’Brien J. Fewer Catheters, Fewer Infections: Reducing HAIs
Through a 'Hospital-wide Huddle'. Health Leaders Media 2018; February 19, 2018
AHRQ (Agency for Healthcare Research and Quality). Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities.
AHRQ March 2017
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