Catheter-associated urinary tract infection (UTI) is a common device-associated infection in the United States and one of the most common health care–associated infections worldwide. Preventing health care–associated infection in general, and catheter-associated UTI in particular, has emerged as a priority in the United States, with government agencies taking a lead role. The Agency for Healthcare Research and Quality, along with the Health Research and Educational Trust (the research and education affiliate of the American Hospital Association) and its partners, launched a nationwide effort to implement the Comprehensive Unit-based Safety Program (CUSP) to reduce catheter-associated UTIs in U.S. hospitals. Saint et al. report the results from the first four of nine cohorts of hospital units in the June 2, 2016, issue of the New England Journal of Medicine.
In this study of an educational program to prevent catheter-associated urinary tract infection, implemented in more than 10% of U.S. acute care hospitals, both catheter use and catheter-associated UTI rates were significantly decreased in the non-ICU setting. A new Original Article summarizes.
Q: To what extent is catheter-associated urinary tract infection preventable?
A: Up to 69% of catheter-associated UTIs are considered to be avoidable, provided that recommended infection-prevention practices are implemented.
Q: How much success have efforts beginning in 2009 had in reducing the rate of catheter-associated UTI in acute care hospitals?
A: Catheter-associated UTI was the first hospital-acquired complication chosen by the Centers for Medicare and Medicaid Services in 2008 as the basis for denial of additional payment to hospitals. In 2009, the Department of Health and Human Services released the “National Action Plan to Prevent Health Care–Associated Infections: Road Map to Elimination,” which provided strategic guidance for preventing infections in acute care hospitals. The goal was to reduce the rates of catheter-associated UTI by 25% by 2013. Despite these efforts, national data indicate that the incidence of catheter-associated UTI increased by 6% from 2009 to 2013.
Morning Report Questions
Q: What kinds of interventions might contribute to a decrease in catheter-associated UTI in acute care hospitals?
A: In the Comprehensive Unit-based Safety Program, key interventions were as follows: conducting a daily assessment of the presence and necessity of an indwelling urinary catheter; avoiding the use of an indwelling urinary catheter by considering alternative urine collection methods, such as intermittent straight catheterization; and emphasizing the importance of aseptic technique during insertion of a catheter and proper maintenance after insertion. Additional recommended interventions were as follows: providing feedback to the units’ nurses and physicians on catheter use and catheter-associated UTI rates and providing training to address any identified gaps in knowledge about urinary management processes (i.e., proper insertion and maintenance of indwelling urinary catheters, use of alternative urine collection methods, and prevention of infectious and noninfectious consequences of urinary catheter use). Education on the prevention of catheter-associated UTI was provided to participating units through in-person meetings, coaching calls, and webinars. In addition, monthly national content calls were conducted, during which experts provided education on both technical and socioadaptive aspects of catheter-associated UTI prevention. The leaders also led monthly coaching calls with the participating units in the leader’s state to review data trends, discuss unit-specific issues, and share best practices in the prevention of catheter-associated UTI.
Table 1. Program Recommendations and Examples of Interventions.
Figure 1. Study Timeline.
Q: Did the interventions in the Comprehensive Unit-based Safety Program reduce rates of catheter-associated UTI?
A: Saint et al. found that a collaborative effort focusing on both technical and socioadaptive interventions can reduce catheter-associated UTI rates in the non-intensive care unit (ICU) setting. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). In an adjusted analysis, the rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Reductions occurred mainly in non-ICUs, where catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). The rates did not change significantly in the ICUs.
Table 3. Multivariable-Regression Estimates of Changes in Catheter-Associated UTI Rates, According to Unit Type.
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