What’s New in the Patient Safety World
November 2012
CAUTI Conundrum
Data was recently
published regarding the impact of implementation of CMS’ nonpayment policy for
hospital-acquired conditions in 2008 (Lee 2012). The
authors concluded that the financial disincentive did not lead to lower rates
of certain hospital-acquired conditions. Rates for these complications were
already declining prior to CMS’ implementation of its reimbursement policy.
Specifically, for CLABSI’s there had been a significant 4.8% decline per
quarter prior to implementation and 4.7% afterward. For CAUTI’s the
preimplementation decline was 3.9% per quarter and only 0.9% per quarter
afterward.
There are many
possible explanations for the slowing of the decline in CAUTI rates. Yes, there
may have been some game playing and undoubtedly many patients were getting
urinalyses and urine cultures on admission to demonstrate that the UTI was
already present on admission. That, of course, means a whole lot of patients
also likely received unnecessary treatment for asymptomatic bacteruria. But we
think that it simply reflects that we were already targeting CAUTI’s long
before CMS implemented their policy.
We have long focused
on preventing CAUTI’s (see the list below of our multiple prior CAUTI columns)
and many organizations had preventive programs in place well before 2008
(though Sanjay Saint and others have noted previously the absence of good
programs and practices in many hospitals).
But, to complicate
matters, Owen et al. (Owen 2012)
recently reviewed the relationship between compliance with SCIP measure Inf-9
and CAUTI rates. SCIP Inf-9 is the measure for discontinuation of indwelling
urinary catheters within 48 hours in patients undergoing surgery. They found
that compliance with SCIP Inf-9 increased substantially over time, reaching
about 90%, but that there was no correlation with improved monthly UTI rates.
In their analysis they found that CAUTI rates were actually very low in
patients in whom the catheter was removed in less than 48 hours. However, most
of the UTI’s occurred in patients “exempted” from the measure. In fact, the
odds ratio of developing a postoperative UTI was 8 times higher for patients
exempted from SCIP Inf-9. While there are a number of reasons a surgeon can
specify to qualify for such exemptions, the most common one in this study was
presence of an epidural catheter.
The authors conclude
that the high rate of CAUTI’s in “exempt” patients actually supports
continuation of the SCIP Inf-9 measure but that the exemptions need to be
modified.
While there are
undoubtedly some surgeons (and some CFO’s!) who will use these studies to call
for elimination of the SCIP Inf-9 measure, we think that continued focus on
preventing CAUTI’s is still of great importance from both a patient quality
perspective and healthcare cost perspective.
When we implement
“evidence-based” quality pay-for-performance metrics we sometimes find out
later that the evidence was not so strong and we often get unintended
consequences. Remember the metric of antibiotics within 4 hours of arrival in
the ER for pneumonia patients? That led to numerous patients who turned out not
to have pneumonia getting unnecessary antibiotics. It would be interesting to
see how many patients got unnecessary antibiotics for asymptomatic bacteruria
because of the CMS nonpayment policy for CAUTI’s. If the latter rate is high
that might be a reason to change the metric. But continued focus to avoid
CAUTI’s is the right thing to do regardless of whether nonpayment policies are
in effect or not.
But surgeons may not
be the only ones paying less attention to CAUTI prevention. Another new study
has found that a surprising lack of attention to CAUTI prevention policies and
procedures in many ICU’s (Conway
2012). Less than a quarter of ICU’s responding to a survey had policies
regarding use of bladder ultrasound or condom catheters. Even fewer used
catheter removal reminders or nurse-initiated catheter removal protocols.
Ironically, smaller hospitals generally did better than large hospitals in
adopting at least one CAUTI prevention strategy.
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”
References:
Lee GM, Kleinman K,
Soumerai SB, et al. Effect of Nonpayment for Preventable Infections in U.S.
Hospitals. N Engl J Med 2012; 367: 1428-1437
http://www.nejm.org/doi/full/10.1056/NEJMsa1202419
Rachel M. Owen RM,
Perez SD, Bornstein WA, Sweeney JF. Impact of Surgical Care Improvement Project
Inf-9 on Postoperative Urinary Tract InfectionsDo Exemptions Interfere With
Quality Patient Care? Arch Surg. 2012; 147(10): 946-953
http://archsurg.jamanetwork.com/article.aspx?articleid=1380450
Conway LJ,
Pogorzelska M, Larson E, Stone PW.
Adoption of policies to prevent catheter-associated urinary tract
infections in United States intensive care units. Amer J Inf Control
2012; 40(8): 705-710, October 2012
http://www.ajicjournal.org/article/S0196-6553%2811%2901256-9/abstract
Print “PDF
version”
http://www.patientsafetysolutions.com/