Targeting the ED to reduce urinary catheter infections
In 2012, officials at Ascension Health noticed that catheter-associated urinary tract infection rates across the 101-hospital system were about even with national rates. They discovered the opportunity for improvement when they examined benchmarking data after St. Louis-based Ascension was named a hospital engagement network under the federal Partnership for Patients safety initiative.
“We were able to zero in on something that we really thought was preventable,” said Ann Hendrich, Ascension Health’s chief quality, safety and nursing officer.
Catheter-associated UTIs are the most common type of healthcare-associated infection in hospitals, accounting for more than 30% of infections reported to the Centers for Disease Control and Prevention’s online infection surveillance system. Such infections cost the U.S. healthcare system more than half a billion dollars and lead to more than 8,000 deaths annually, according to federal data.
Efforts to reduce these infections typically focus on removing catheters as soon as possible. But Dr. Mohamad Fakih, Ascension Health’s national infectious disease physician leader, said concentrating on appropriate catheter use in the emergency department helps avoid placing urinary catheters in the first place. “Others say, ‘Let’s get rid of it quickly.’ We say, ‘Let’s stop before we even put it in,’” he said.
The ED is a logical place to start because it’s the entry point to the hospital, often admitting more than half of patients, and it’s often the place where urinary catheters are placed, said Russ Olmsted, director of infection prevention and control services at St. Joseph Mercy Hospital, Ypsilanti, Mich., and past president of the Association for Professionals in Infection Control and Epidemiology.
Beginning in June 2012, Fakih led a six-month improvement project at 18 Ascension Health hospital EDs, including 673-bed St. John Hospital and Medical Center, Detroit, where he serves as medical director of infection prevention and control.
Fakih and his team drafted clear guidelines for urinary-catheter use, customized for ED patients. For instance, catheters were deemed appropriate for patients with urinary obstruction or hip fractures, and for patients who were scheduled for certain surgical procedures. But they were categorized as inappropriate for incontinent patients and patients with dementia. They also named a physician and nurse champion at each site and tasked them with promoting the project, explaining the clinical benefits and assisting with staff education.
The project was based on a successful pilot at St. John Hospital in 2007 and 2008, which showed a significant drop in ED urinary-catheter utilization after the introduction of well-defined guidelines and physician education.
“Before, it was just the norm to put a catheter in, and now it’s definitely not,” said Arlene Boestler, St. John Hospital’s clinical nurse manager and nurse champion for the project. She said the hospital embedded the criteria into the electronic health-record system so the indications automatically pop up when nurses chart a catheter.
“We’re now at a point where it’s just part of the culture,” said Dr. Margarita Pena, medical director for the hospital’s clinical decision unit and the physician champion for the program.
New urinary-catheter placements fell more than 30% across the 18 participating hospital EDs during the initiative, from 9.1% at the baseline to 6.1%, according to results published in June in the Annals of Emergency Medicine. The percentage of appropriate catheter placements—those that met the guidelines—jumped from 74% to 91%.
The project faced some challenges, including uneven progress among participating hospitals and some difficulty getting sites to submit data in a timely manner. For the most part, though, the process went smoothly, Fakih said. He stressed that catheters not only bring infection risk, but also limit patients’ mobility and are generally unpleasant. “Avoiding unnecessary ones addresses all of those issues,” Fakih said.
A national effort funded by the Agency for Healthcare Research and Quality to prevent catheter-associated UTIs, called “On the CUSP: STOP CAUTI,” has integrated Ascension Health’s approach into its program. It’s now in use in more than 200 EDs, Fakih said.
Olmsted said he has implemented the program at St. Joseph Mercy Hospital and seen good results. “My colleagues at Ascension have done a great job of identifying a key area of entry— the ED—and getting folks to ask, ‘Do we really need this catheter?’”