In your role as Unit Medical Director, you regularly meet with nursing leadership for 6-West. Today, they bring to your attention several cases from the last month: a 67-year old female admitted for severe pneumonia who initially rapidly improved on antibiotics, but then developed a new fever and was found to have a urinary tract infection; an 83-year old male admitted for elective hip replacement who became obtunded and hypotensive on hospital day 3, and was found to have a urinary tract infection; and a 77-year old male with heart failure on a furosemide drip who this morning was found to have a new leukocytosis that was preliminarily being attributed to a urinary tract infection. All of them had urinary catheters in place prior to and at the time of their diagnoses. One nurse states, “I think we could have prevented these events. How can we work together to decrease the risk of CAUTI for all our patients?”
Catheter associated urinary tract infection (CAUTI) affects about 2 million patients per year. Its mechanism of infection is understood, the technical means to prevent it are known, and it remains a high-profile topic of national concern. Despite this, recent data from the Centers for Disease Control and Prevention indicate that between 2009 and 2012 the US national CAUTI rate actually rose by 3%. This week’s NEJM contains a study that informs our efforts to minimize CAUTI.
Saint et al. report on a partnership between The Agency for Healthcare Research and Quality and the American Hospital Association known as Comprehensive Unit-based Safety Program (CUSP) to Reduce CAUTI. This effort was launched nationally with the goal of implementing best practices to prevent CAUTI at United States Hospitals. Since 2011, nine cohorts of hospital units have been recruited. Participating units agreed to form local teams focused on CAUTI prevention, collect and share relevant data, and participate in ongoing interventions. Interventions included technical/educational (e.g. appropriate use, aseptic insertion, proper maintenance, and timely removal of catheters) as well as “socio-adaptive”, a term the authors use to describe aspects related to the challenges of improvement implementation. Beyond this, local teams were empowered to tailor CAUTI prevention initiatives to meet their unique situations and needs. Ongoing mentorship was provided by project leadership.
Saint et al. now present data on the CAUTI rate and the proportion of patients with indwelling catheters collected from CUSP to Reduce CAUTI’s first 4 cohorts between March 2011 and November 2013. In the 926 analyzed hospital units, study authors found that adjusted CAUTI rates significantly decreased from 2.4 to 2.05 per 1,000 urinary catheter-days. During this time, catheter utilization rate also significantly decreased from 20.1% to 18.8%. On subgroup analysis, authors found that these effects were predominantly driven by non-ICU units. In fact, in the subset of ICU units, there was neither a significant change in the rate of catheter utilization nor in the CAUTI rate.
At this point, you may be asking yourself, So what? We’ve known for a long time that appropriate use, aseptic insertion, proper maintenance, and timely removal of catheters can help prevent CAUTI. How is this news? The significance of CUSP to Reduce CAUTI relates to its focus on teams, communication, problem solving, and implementation mentoring to achieve change in clinical practice. As patient safety expert Dr. Lucien Leape commented in NEJM in 2014, “The key is recognizing that changing practice is not a technical problem… but a social problem of human behavior and interaction.” CUSP to Reduce CAUTI succeeds by addressing both the technical as well as the social.
While providing us with hope for attainable change in preventing CAUTI in the non-ICU setting, Saint et al. do leave us wondering about the future of CAUTI prevention efforts in the ICU. In an accompanying editorial, Dr. Susan Huang of UC Irvine School of Medicine draws attention to several factors, both patient-specific and general, that may have complicated CAUTI reduction efforts for critically ill patients in this study. Among them, ICU patients may require longer use of catheters (and a resulting increased risk for CAUTI) as a direct result of their critical illness. There may also be an inappropriate perceived need for longer use of catheters in this population, a potential social barrier to catheter discontinuation. Lastly, successive changes to the definition of CAUTI may have resulted in increased rates of CAUTI beginning in 2012, and decreased rates beginning in 2015. For the data presented by Saint et al. (collected between 2011 and 2013) this may have underestimated the benefits of CUSP to Reduce CAUTI.
Recognizing the importance of CAUTI prevention, you organize a team of interested nurses, patient care technicians, resident and attending physicians, and administrators. You engage hospital leadership and contact other units in your hospital who have lower CAUTI rates than yours. While several members of the group are developing a nursing-driven catheter discontinuation protocol, you begin to think about what social barriers to change might exist to this intervention.
Have you participated in a CAUTI prevention project on your unit? What barriers to change did you face?
Don’t miss the NEJM Quick Take video summary on this study:
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Joshua Allen-Dicker, MD, MPH
Josh is an Instructor in Medicine and Hospitalist at Beth Israel Deaconess Medical Center in Boston, MA. He completed his residency in internal medicine at Beth Israel Deaconess Medical Center, medical degree at NYU School of Medicine, and MPH at Harvard School of Public Health.