The Use of an Indwelling Catheter Protocol to Reduce ...

The Use of an Indwelling Catheter Protocol to Reduce Rates of Postoperative Urinary Tract Infections AFFAN UMER, MD, DAVID S. SHAPIRO, MD, CHRIS HUGHES, MD, CYNTHIA ROSS-RICHARDSON, RN, AND SCOTT ELLNER, DO, MPH

ABSTRACT – Background: Catheter-associated urinary tract infections (CAUTI) have been associated with increases in morbidity and mortality as well as increased costs of hospitalization. At our institution, we implemented a protocol for indwelling catheter use, maintenance, and removal based on Center for Medicare and Medicaid Services (CMS) guidelines, in efforts to reduce CAUTI rates. Methods: A hospital committee of quality stewards focused on several measures which included staff education, modification of existing systems to ensure compliance, and auditing of patient care areas for catheter utilization before implementation of the protocol. Pre- and postintervention postoperative cohorts were then identified through American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) for prevalence of CAUTI. Data were collected through chart review and postdischarge patient interviews. AFFAN UMER, MD, Research Scientist, Department of Surgery, Saint Francis Hospital and Medical Center, Hartford; DAVID S. SHAPIRO, MD, Chief, Surgical Critical Care, Chair, Medical Staff Oversight Group, Saint Francis Hospital and Medical Center, Hartford, University of Connecticut Health Center, Farmington; CHRIS HUGHES, MD, MPH, Chief Resident, Department of Surgery, Saint Francis Hospital and Medical Center, Hartford, University of Connecticut Health Center, Farmington; CYNTHIA ROSS-RICHARDSON, RN, NSQIP Surgical Clinical Analyst, Department of Surgery, The Hospital of Central Connecticut, New Britain; SCOTT ELLNER, DO, MPH, President, Saint Francis Medical Group, Vice Chairman, Department of Surgery, Director of Surgical Quality, Saint Francis Hospital and Medical Center, Hartford. Corresponding author: AFFAN UMER, MD, affan.umer.83@ gmail.com

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Results: A total of 3873 patients were identified between September 2007 and December 2010. Thirtysix patients (2.6%) were diagnosed with a CAUTI in the preintervention group (N = 1404) compared to 38 (1.5%) patients who were diagnosed with a CAUTI in the postintervention group (N = 2469). There was a 1.1% decrease in CAUTI rate after protocol implementation (P < .028). This reduction in rates resulted in annual estimated savings of $81,840 to $320,540 annually. Conclusion: A simple, multifaceted approach consisting of staff education and changing existing processes to reflect best care practices has the potential to significantly reduce the incidence of postoperative CAUTI. Key words: CAUTI , postoperative urinary retention, straight catheterization, indwelling urinary catheter, bladder scanner, general surgery complication

Introduction rinary tract infections (UTI) account for approximately 40% of hospital-acquired infections. The majority of hospital-acquired UTIs are associated with the use of indwelling urinary catheters (IUC), termed catheter-associated urinary tract infections.1,2 The risk of bacterial colonization of the urinary tract increases by approximately 5% every day after 48 hours of catheterization. Infection rates vary between 10% and 25% among those patients who are colonized.3 The most successful hospital-based measures for reducing CAUTI rates have been those which reduce the frequency and duration of catheter placement.3–5

U

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Figure 2. Indwelling Urinary Catheter Protocol 1. Indwelling urinary catheters will be inserted only when necessary. 2. When ordering an indwelling urinary catheter, the physician or APP (Advanced Practice Practitioner) will document the necessity for the catheter by using the insertion criteria listed. 3. Clinicians inserting and maintaining a catheter should have knowledge of aseptic technique and procedures for catheter and drainage system maintenance. 4. Consideration should be given to alternatives to indwelling catheters, such as condom catheters or intermittent catheterization. 5. A daily assessment of catheter necessity should be performed and the catheter should be removed as soon as possible. 6. In the event of postoperative urinary retention (POUR), bladder scanning should be performed and the results reported to the physician/APP. Intermittent catheterization should be considered. 7. If physician/APP states the urinary catheter cannot be removed, the rationale or need for urinary catheter must be documented by the MD/APP. 8. A physician/APP order for indwelling catheter removal is not needed for removal of catheter on postoperative day 2 unless the patient still meets one of the insertion criteria. Insertion Criteria: 9. Patient requiring physiologic monitoring for shock, sepsis, or hypovolemia. 10. Patient with bladder outlet obstruction or known retention. 11. Patient requiring protection of low pelvic colon anastomosis. Removal Criteria: 12. Urinary catheters will be removed on POD 2 if none of the 3 insertion criteria are met.

In January 2009, the protocol was implemented to regulate urinary catheter use in surgical patients. Patients who had surgery prior to January 1, 2009 were assigned to the preintervention cohort, while those patients with procedures occurring on or after that date were assigned to the postintervention group. The primary outcome measure was postoperative CAUTI rate. Patients could meet one of two definitions for CAUTI. The first was a positive urine culture with > 100 000 colony-forming units (CFU), but with no more than two distinct organisms, and either a fever or at least one CAUTI symptom (Figure 3). Some patients did not meet the criteria but were documented with a diagnosis of CAUTI based upon the ACS NSQIP screening criteria, including a positive leukocyte esterase on urinalysis (demonstrating Figure 3. Criteria for Diagnosing Catheter-Associated Urinary Tract Infection

Urinary Tract Infection

• Positive urine culturea,b • With fever or • One UTI symptomc • Positive Leukocyte Esterase • Documentation of UTI in Chart • Two UTI symptomsc

a b

Urine culture is positive if it grows > 100 000 cfu. Urinary culture is considered positive if it grew no more than two bacterial species. c Frequency, urgency, and burning with urination were considered UTI symptoms.

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pyuria), documentation of CAUTI in their health record, and two of the listed symptoms. Urine cultures were ordered for indication of fever, urinary urgency, and frequency of urination or dysuria. Any catheterrelated urinary infection after protocol implementation was subjected to an internal audit to determine whether there were any lapses in compliance.

Statistical Analysis All analyses were conducted using SAS Software™ Version 9.4 (SAS Institute Inc., Cary, NC). Statistical significance was determined by a P value of < .05. Fisher’s exact test (two-tailed) with a 2 x 2 contingency was used for categorical data, including comparing CAUTI rates between our pre- and postintervention groups. Chi-squared two-tailed test was used to compare differences in patient characteristics.

Results We collected information on 3873 patients over the course of this study. There were no significant differences found with respect to patient characteristics between the pre- and postintervention groups (Table 1). Of the 1404 patients who were identified for analysis prior to January 2009, 36 patients (2.6%) met our definition of a CAUTI. After the protocol was established, 38 of the 2469 patients (1.5%) met our definition of a CAUTI (Table 2). This decrease was statistically significant with a P value of < .05. Postintervention ACS NSQIP data showing reduction in hospital rates is shown in Figure 4.

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Table 1. Comparison of Patient Characteristics in Pre- and Postintervention Groups

Average Age (years) Average BMI Male Race

Caucasian Black

a

Other

%

53.2 29.8

%

56.6

575

40.1

1079 94

231

Post-intervention N = 2469 29.5

P value .14 .37

986

39.9

76.9

1868

75.7

.61

6.7

193

7.8

.61

16.5

403

16.4

.40

.61

Inpatient

851

60.6

1501

60.8

.94

Smoker Within 1 Year

246

17.5

467

18.9

.53

Diabetes

212

Independent Functional Status

1297

ASA=2

ASA=1 ASA=3 ASA=4 ASA=5

Disseminated Cancer a

Pre-intervention N = 1404

Chronic Steroid Use

15.1

377

15.3

92.4

2266

698

49.7

1281

51.9

95

6.7

133

5.4

136 454 5

25 38

9.7

32.4 0.4 1.7 2.7

233 810 5

31 84

91.8

.72

9.5

.35

32.8

.35

0.2 1.3 3.4

.35 .35 .35 .88 .12

Other races include: Asian, Native American, American Indian, Native Alaskan, Native Hawaiian, Other Pacific Islander, and not identified. Table 2. Comparison of CAUTI Incidence in Pre- and Postintervention Groups

UTI

Pre-intervention N = 1404 36

%

2.6%

Post-intervention N = 2469 38

%

P value

1.5%

.028

Table 3. Comparison of Complications Between Patients in Pre- and Postintervention Groups

Urinary Tract Infection

Superficial Incisional SSI Deep Incisional SSI Organ/Space SSI

Wound Disruption

Pre-intervention N = 1404 36

2.6%

24

1.7%

31 15 8

Combined SSI/Wound Disruption

78

Acute Renal Failure

4

Pulmonary Embolism

2

Cardiac Arrest Requiring CPR

10

Bleeding Requiring Transfusion

84

Myocardial Infarction

DVT Requiring Therapy

%

2 7

2.2% 1.1% 0.6%

Post-intervention N = 2469

%

P value

38

1.5%

.028

16

0.6%

.002

67 24 14

5.6%

121

0.3%

14

0.1%

9

0.1% 0.7% 6.0% 0.5%

5 8

140 11

2.7% 1.0% 0.6% 4.9% 0.2% 0.6% 0.3% 0.4% 5.7% 0.4%

Sepsis 27 1.9% 44 1.8% Abbreviations: SSI, surgical site infection; DVT, deep vein thrombosis; CPR, cardiopulmonary resuscitation

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.251 .282 .858 .399 .387 .182 .280 .128 .05

.747 .364

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Discussion CAUTIs pose a significant burden to the health care system. They are associated with unnecessary postoperative morbidity, increased hospitalization, and an increase in 30-day mortality.15 In addition, they have a high cumulative financial impact, due to their high frequency of occurrence, despite being relatively inexpensive compared to other hospital acquired infections. Furthermore, treatment of CAUTI can complicate postoperative recovery as unnecessary antimicrobial therapy can result in antiobiotic-related adverse events, most notably, Clostridium difficile infections. Such complications can signifiThe rates of other complications, including surgi- cantly lengthen hospital stay and are associated with cal site infections, pulmonary embolism, acute renal real morbidity and mortality. In addition, multidrug failure, cardiac arrest, myocardial infarction, blood resistance (MDR) is a common problem among uritransfusion, deep vein thrombosis, and sepsis were nary pathogens, and can be a source of gram-negative similar between our pre- and postintervention groups bacteremia.16 (Table 3). Because early removal of IUC reduces infection The 1.1% reduction in CAUTI after protocol im- rates, CAUTI prevention strategies are most effective plementation resulted in an estimated $81,840 to when tailored towards avoiding prolonged catheter$320,540 annual savings based on the cost associated ization.15,17,18 Surgical intensive care units and patient with a hospital diagnosis of CAUTI. This estimate care areas (surgical wards, step-down units) have nowhen spread over 6200 surgical procedures per annum toriously high-catheter utilization.19 Our interventions in general, vascular, colorectal, and bariatric surgery, were aimed at both minimizing the duration of cathincreases the value by $13.20 – $51.70 per operation eterization and improving documentation of catheter (Table 4). usage. This was achieved initially through staff education and then through modification of the electronic Conclusion health record (EHR) to reflect best practices in cathOur intervention of adopting a guideline for peri- eter usage. The latter involved creating “hard stops” in operative catheter use addressing insertion, mainte- electronic order sets, mandatory selection from dropnance, and removal of IUC, in accordance with surgi- down menus for insertion indications and daily alerts cal care improvement project core measures, reduced for users reminding providers that a urinary catheter the risk of postoperative CAUTI from 2.6% to 1.5% as is in place. These alerts have been demonstrated to enanalyzed through the ACS NSQIP database. This risk courage and reinforce best practices.20 reduction saved our hospital an estimated $81,840 to The educational components were reviewed annu$320,540 annually ($87,714 – $343,546 when adjusted ally. Established benchmarks demonstrate that 89% for inflation for 2015). of nurses include routine hand hygiene before catheter insertion, 3% did not use Table 4. Value of Intervention sterile gloves and only 81% A. Absolute risk reduction for UTI 1.10% used a sterile barrier during placement, as recommendB. Vascular, colorectal, bariatric and general surgery cases/year 6200 ed by the manufacturer.21 C. Cost of postoperative UTI $1,200 – $4,700 Regular reinforcement of D. Annual value of intervention (E x B) $81,840 – $320,540 best practices can eliminate E. Value per case (A x C) $13.20-$51.70 these deficiencies. Equally Figure 4. Postintervention NSQIP Data Showing Reduction in our UTI Rates. The solid black line is the reference line. Each vertical line transecting it depicts a 95% confidence interval for CAUTI rates. The small dot on each vertical line depicts the odds ratio estimate for each institution.

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challenging is the reluctance of bedside staff to remove urinary catheters. The change at our hospital empowered staff, especially nurses, to routinely discuss management of IUCs and remove them at the appropriate postoperative day. Prevention strategies similar to ours have been employed by other institutions with variable success. Purvis et al 22 showed a reduction in their CAUTI rate from 4.7 per 1000 catheter days to 2.4 per 1000 catheter days after using a protocol to minimize catheter days. Chen and colleagues23 utilized a protocol for catheter management in an ICU setting, resulting in a 48% reduction in CAUTI rates as well as a 22% reduction in catheter utilization. Implementation of such protocols is relatively inexpensive and is often offset by the ultimate cost savings through prevention in hospital-acquired infections. They do however require significant cooperation from staff to ensure transparency, promote internal accountability and reiterate best practices periodically. Despite strict vigilance and adherence to preventive strategies, some patients with an indwelling urinary catheter will develop CAUTI. Multiple host risk factors can contribute to this, including age > 55, female gender, American Society of Anesthesiologists (ASA) classification > 1, patients with active sites of infection, and patients with a major preexisting condition such as diabetes, malnutrition, or renal insufficiency.1,18 Additional risk factors specific to postoperative patients include longer operative time, operative technique, (laparoscopic vs open), and whether surgery is elective or emergent.24 Laparoscopic and electively performed procedures have lower rates of CAUTI compared to their open and emergent counterparts.24 This is attributed to inherent advantages of the laparoscopic approach which leads to decreased pain, greater mobility, and consequently shorter catheterization time.25 Use of modified equipment (antibioticimpregnated catheters, silver-coated urinary catheters, etc.) and alternate methods of catheterization (external or suprapubic catheterization) can help mitigate risk and further reduce rates, but routine use is not yet recommended.26,27 Further, asymptomatic bacteriuria should not be treated with antibiotics, and resolves subsequently after catheter removal. Timely catheter removal is the core component of our intervention. Our study has a few limitations to consider. The study design did not include measuring total catheter days on surgical wards. This variable is usually reported as catheter days/1000 hospital days and consequently CAUTI are reported as CAUTI/1000 catheter days. Showing a decrease in both variables would have added further validity to our results. Secondly, our data 202

on financial savings is not generalizable to all US hospitals. The estimated hospital cost savings of $81,840 to $320,540 was extrapolated through hospital billing data for local treatment for a hospital-acquired UTI. Cost savings will vary among hospitals with different levels of acuity of care as well as different settings (ICU, step down) within the same institution. Organizational behaviors and institutional culture are a challenge to change. Patient safety-minded platforms such as the ACS NSQIP can be utilized to catalyze changes in these behaviors, but are not essential. We utilized the ACS NSQIP data to jumpstart a multifaceted approach for the adoption of bestpractices. Further research will hopefully bring forth newer methods and novel technologies to help reduce the burden of CAUTI on the health care system even further. REFERENCES 1. Chenoweth CE, Saint S. Urinary tract infections. Infect Dis Clin North Am. 2011;25(1):103–15. 2. Haley RW, Culver DH, White JW, et al. The nationwide nosocomial infection rate. A new need for vital statistics. Am J Epidemiol. 1985;121(2):159–67. 3. Wald HL, Ma A, Bratzler DW, et al. Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data. Arch Surg. 2008;143(6):551–7. 4. Yokoe DS, Mermel LA, Anderson DJ, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29 Suppl 1:S12–21. 5. Elpern EH, Killeen K, Ketchem A, et al. Reducing use of indwelling urinary catheters and associated urinary tract infections. Am J Crit Care. 2009;18(6):535–41. 6. Porter ME. A strategy for health care reform--toward a value-based system. N Engl J Med. 2009;361(2):109–12. 7. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477–81. 8. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. JAMA. 2007;298(23):2782–4. 9. Bologna RA, Tu LM, Polansky M, et al. Hydrogel/silver ion-coated urinary catheter reduces nosocomial urinary tract infection rates in intensive care unit patients: a multicenter study. Urology. 1999;54(6):982–7. 10. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28(1):68–75. 11. Tambyah PA, Knasinski V, Maki DG. The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care. Infect Control Hosp Epidemiol. 2002;23(1):27–31. 12. Umscheid CA, Mitchell MD, Doshi JA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32(2):101–14.

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