Study Suggests National Program to Prevent Catheter-Associated Urinary Tract Infection is Successful in Non-ICU Settings
Catheter-associated urinary tract infection (CAUTI) is a common device-associated infection in the U.S., and one of the most common healthcare-associated infections world-wide. However, up to 69% of CAUTIs are considered avoidable provided that recommended infection prevention practices are implemented. CAUTI prevention guidelines recommend appropriate use, aseptic insertion, proper maintenance, and timely removal of urinary catheters, as well as hand hygiene. In addition to these "technical aspects" of implementation, there has been a recent focus on the role of behavior and culture change – the socio-adaptive component of implementation – in quality improvement. Funded by the Agency for Healthcare Research and Quality, the National Implementation of Comprehensive Unit-based Program (CUSP) to reduce CAUTI focused on both the technical and socio-adaptive aspects of implementation. Main features of the program include: dissemination of educational materials and toolkits to sponsor organizations and hospitals; data collection; guidance on technical practices to prevent CAUTI; and an emphasis on addressing socio-adaptive aspects. This study examined CAUTI and catheter utilization outcomes in 926 units within 603 hospitals in 30 states. Of the participating units, 60% were non-ICUs and 40% were ICUs. Catheter utilization and CAUTI rate data were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months).
- Participation in the program led to reduced CAUTI rates. Across all participating units, unadjusted CAUTI rates decreased by 22% – from 2.82 at the end of baseline to 2.19 per 1,000 urinary catheter-days at the end of sustainability. In adjusted analysis, CAUTI rates decreased from 2.40 to 2.05.
- Reductions occurred mainly in non-ICU settings, where CAUTI rates decreased from 2.28 to 1.54 (32% reduction). Rates did not significantly change in ICU settings (2.48 to 2.50).
- Catheter utilization also decreased significantly in adjusted analysis in non-ICUs (20% to 19%), but did not significantly change in ICUs (63% to 62%).
- The reason ICUs have had less success in CAUTI prevention is unclear. Authors suggest that it could be related to the belief that if a patient is ill enough to require ICU admission, they are unstable enough to need a urinary catheter for close urine output monitoring. The frequent occurrence of fever in critically ill patients, coupled with routine urine culturing to determine possible infectious sources could also lead to higher CAUTI rates in ICUs compared to non-ICUs.
- This was not a randomized trial, thus confounding variables may have played a role in the findings.
- Participation was voluntary, so findings may not be generalizable to all U.S. hospitals.
- Hospitals were expected to tailor how they implemented the intervention given their particular environment, which may or may not have been done.
Drs. Saint, Greene, and Krein are part of HSR&D's Center for Clinical Management Research, Ann Arbor, MI.
Saint S, Greene M, Krein S, et al. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. The New England Journal of Medicine. June 2, 2016;374(22):2111-119.