Ahead of the Curve in CAUTI Reduction
Catheter-associated urinary tract infections (CAUTI) account for more than 30 percent of all hospital-acquired infections nationwide and are associated with increased morbidity and mortality rates. Approximately 13,000 deaths per year in the U.S. are attributed to CAUTI.
In 2009, leadership and care providers at BWH took a closer look at CAUTI and created a multidisciplinary taskforce charged with defining best practices for catheter maintenance and care of patients with catheters in order to reduce the rate of infection. Pilot data gathered from several units indicated a reduction of greater than 6 percent in CAUTI rates at BWH.
From a regulation standpoint, the work couldn't have been more timely. The Joint Commission created a National Patient Safety Goal on reducing CAUTI for hospitals in 2012, and CMS has begun requiring hospitals to report rates of CAUTI in their intensive care units publicly.
"We formed the taskforce because it was the right thing to do for our patients to ensure they are receiving the highest quality care," said Jen Beloff, MSN, RN, APN-C, director of Quality Programs in the Center for Clinical Excellence, who serves as one of the taskforce's leaders. "Because urinary catheters permeate all areas of the hospital, we wanted to make sure that we had a representative on the taskforce from any patient care area that would insert, maintain or discontinue a patient's catheter."
The taskforce included physicians and nursing representatives from the Emergency Department, Operating Room and inpatient areas, as well as quality improvement specialists.
After a comprehensive review of literature, several key themes emerged as crucial ways to reduce CAUTI rates:
1. Avoidance of unnecessary catheters
2. Insertion using aseptic technique and maintenance based on best practice guidelines
3. Daily review of patient plan of care and prompt removal of catheters when indicated
"We reviewed the practice at BWH to see how we measured up compared to the guideline recommendations and best practices," said Beloff.
They found that nursing orientation did not require a formal review of CAUTI. In addition, there wasn't a daily review of a patient's plan of care related to the ongoing need for an indwelling catheter, or communication about it during hand-offs. Removal of the catheter was based solely on the physician's order.
The taskforce developed several recommendations that were implemented throughout the hospital:
- Build decision support to prompt inpatient clinicians regarding urinary catheter removal
- Roll out CAUTI education to ED staff (11 percent of patients admitted to the ED have a catheter placed)
- Implement decision support in ED order entry system
- Develop CAUTI guidelines for the hospital and updating of nursing policies
- Educate staff regarding CAUTI risk and urinary catheter care
- Develop metrics for measurement of CAUTI and urinary catheter utilization
Decision support developed in BICS now prompts physicians to discontinue the patient's catheter or indicate that it is still necessary, in which case the clinician will be prompted again 24 hours later. In the ED, decision support was created to capture the indication for urinary catheter insertion.
Nursing, under the leadership of Jeanne Praetsch, MS, RN, CCRN, revised its policies on catheter maintenance and removal and developed education for nurses on the evident risks associated with prolonged catheter use.
"Since this education, we've seen more discussion and collaboration among care teams about when it's time to remove a catheter," said Praetsch, the unit educator for Tower 12A/16CD. "Nurses play an important role in developing the plan of care and determining whether a catheter is still necessary."
Posters reflecting the best practices for catheter maintenance, such as ensuring that the catheter is always above the bladder, were hung on clinical units. Staff also received education and reminders through presentations in clinical areas, and the revision of the policy and guidelines on BWHPikeNotes.org
The taskforce met with Central Transport staff to go over some of the guidelines, such as not hanging a catheter over the top of a patient's wheelchair; rather, to keep it below the bladder.
Catheter utilization rates for all units are now placed in the Balanced Scorecard; adding CAUTI rates for the intensive care units is also in the works.
The Cost of Hospital-Acquired Infections
Reducing hospital-acquired infections is the right thing to do for patient care. In addition, it also reduces costs to the hospital. Patients with a catheter-associated urinary tract infection generally:
- have an increased length of stay by 0.5 to 1 day;
- cost between $500 and $3,000 to treat, depending on the severity of the infection;
- Cost the U.S. health care system more than $4 million annually for treatment
CAUTI performance will be one of the hospital-acquired infection measures in future value-based purchasing agreements.