Christine P. Kowalski

Catheter-Associated Urinary Tract Infection and the Medicare Rule Changes

By failing to prepare, you are preparing to fail. Benjamin Franklin, inventor of the flexible urinary catheter Catheter-associated urinary tract infection is the most frequent health careassociated infection in the United States (1, 2). Urinary catheter use is common, with approximately 1 in 5 patients admitted to an acute care hospital receiving an indwelling catheter (1, 3), and the rate of catheter use is even higher among Medicare patients (4). Infection frequently occurs after placement of urinary catheters; each day of catheter use is associated with an approximately 5% increase in bacteriuria (5), which is asymptomatic most of the time (3, 6) and usually requires no treatment. Because clinicians must distinguish asymptomatic bacteriuria from symptomatic urinary tract infection to avoid unnecessary administration of antimicrobial therapy, we provide a clinical definition of asymptomatic bacteriuria in Table 1 (7). Each episode of catheter-associated urinary tract infection costs at least

Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study

600 (3, 8, 9), and each episode of urinary tractrelated bacteremia costs at least

Maternal cigarette smoking during pregnancy and the risk of having a child with cleft lip/palate.

2800 (3, 10). Because catheter-associated urinary tract infection is common, costly, and believed to be reasonably preventable, the Centers for Medicare & Medicaid Services (CMS) chose it as 1 of the complications for which hospitals no longer receive additional payment to compensate for the extra cost of treatment (as of 1 October 2008). Thus, from a hospitals perspective, catheter-associated urinary tract infection may become an even more costly complication (1113). Table 1. Clinical Definition of Asymptomatic Bacteriuria Because of the possible far-reaching consequences of the CMS rule changes and the high frequency of catheter-associated infection, our aim in this Perspective is to provide practical and timely information and guidance for hospital-based administrators, policymakers, epidemiologists, and clinicians. We first address the preventability of catheter-associated urinary tract infection, then discuss the CMS rule changes about payment for treatment of catheter-associated urinary tract infection. Finally, we offer our assessment of the possible consequences of the rule changes as well as our guidance for hospital administrators and clinicians. How Preventable Is Catheter-Associated Urinary Tract Infection? The Centers for Medicare & Medicaid Services were asked to select hospital-acquired complications that could reasonably be prevented through the application of evidence-based guidelines. Does catheter-associated urinary tract infection fit this criterion? Perhaps. More than 2 decades ago, the Centers for Disease Control and Prevention proposed some recommended practices for preventing catheter-associated urinary tract infection that appropriately emphasize the benefits of hand hygiene, aseptic catheter insertion, and proper maintenance by using a closed urinary drainage system (14). More recently, the Healthcare-Associated Infections Allied Task Force from the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America provided an evidence-based compendium of the various practices available (15, 16). With regard to catheter-associated urinary tract infection, the compendium focused on the importance of maintaining an appropriate infrastructure for infection surveillance and prevention, education, and training of health care personnel about catheter-associated urinary tract infection, appropriate insertion and maintenance of the indwelling catheter, consideration of alternatives to indwelling catheter use (for example, condom and intermittent catheterization), and early removal of the indwelling catheter by using reminders or stop orders (15, 16). Of note, practices also can be bundled together, as demonstrated by the approach used in Michigan intensive care units to reduce the incidence of vascular catheterrelated infection (17). Studies of multimodal interventions include such interventions as educational programs directed at nurses, physicians, or both (included nearly universally in the studies we reviewed for this article); restricting the initial placement of indwelling urinary catheters in various settings (for example, emergency department, intensive care unit or inpatient floor, preoperative area or operative room); systems to remind physicians or nurses of urinary catheter presence, with recommendation for removal; methods to facilitate prompt urinary catheter removal when it is no longer necessary, such as nurse-initiated catheter removal protocols that do not require a physician order; and surveillance and feedback about catheter-associated urinary tract infection rates. Implementing multimodal interventions to prevent hospital-acquired catheter-associated urinary tract infection is not a new idea (18, 19). For example, more than 10 years ago, Dumigan and colleagues (19) used a multidisciplinary team approach to produce guidelines for appropriate catheter placement in addition to a protocol enabling nurses to remove unnecessary catheters without a physician order. When these interventions were implemented in 3 intensive care units, catheter-associated urinary tract infection rates decreased by 17% to 45%, with postintervention catheter-associated urinary tract infection rates of 8.3 to 11.2 per 1000 catheter-days. Several types of reminders to remove urinary catheters have been studied as interventions. Daily reminders from nurses to physicians after a catheter has been in place for a specified interval (such as 3 to 5 days) are part of several multimodal interventions (2022). These before-and-after studies without a concurrent control group demonstrate significantly reduced incidence of catheter-associated urinary tract infection. Other forms of catheter removal reminders include electronic reminders to physicians that a urinary catheter was placed in the emergency department (23) and expiring urinary catheter orders (for example, stop orders) that remind clinicians to remove catheters after prespecified periods. The orders can target physicians (24) or can authorize nurses to remove unnecessary catheters (on the basis of specific criteria) without requiring an additional order from the physician (23, 25, 26). Multimodal studies including stop orders have had mixed results, ranging from no significant changein the only randomized, controlled trial performed to evaluate this intervention (26)to reduced catheter-associated urinary tract infection rates in before-and-after studies, including 2 studies that demonstrated more than a 50% reduction in rates of catheter-associated urinary tract infection (23, 25). Other interventions that decrease inappropriate urinary catheter use include restricting use to acceptable indications for placement, usually by prompting physicians to designate an appropriate indication as part of the catheter placement order (24, 25, 27). The most impressive reductions come from interventions that use a reminder system to aid early removal of unnecessary catheters, often in combination with urinary catheter placement restrictions. Most of these studies, however, excluded patients who needed long-term catheterization, and the reminders did not completely eliminate risk for catheter-associated urinary tract infection. The bulk of the evidence is consistent with the view that multimodal strategies could prevent between 25% and 75% of catheter-associated urinary tract infections. On the basis of these findings, we conclude that reduction (not elimination) of catheter-associated urinary tract infection is possible. Inaction, however, is common. In a national study conducted in 2005 of approximately 600 U.S. hospitals (28), 56% reported having no system for monitoring which patients had urinary catheters placed and 74% reported not monitoring how long a catheter had been in place. Only 9% used some type of catheter removal reminder or stop order (28). Overview of the CMS Rule Changes Value-based purchasing is a quality improvement strategy explicitly linking payment with health care outcomes by paying more for better health care and less for inferior care. Value-based purchasing could improve the quality of hospital care while also lowering health care costs. The current hospital payment system is the antithesis of value-based purchasing, because hospitals can receive additional payments when patients develop complications during their stay, including hospital-acquired infection. One approach is to hold hospitals financially accountable for failing to prevent complications. This strategy underlies the hospital payment rule change, implemented by CMS as the Hospital-Acquired Conditions Initiative, in which CMS will no longer pay hospitals extra when patients develop specified complications after admission (Table 2) (4, 2931). Table 2. Hospital-Acquired Conditions Not Eligible for Additional Payment The Deficit Reduction Act of 2005 (Section 5001c) mandated the Secretary of Health and Human Services to choose at least 2 hospital-acquired complications that meet 3 criteria: complications with high cost, high volume, or both; complications that result in the assignment of the case to a diagnosis-related group that has a higher payment when present as a secondary diagnosis; and complications that could reasonably have been prevented through the application of evidence-based guidelines. For discharges occurring on or after 1 October 2008, hospitals paid by the Inpatient Prospective Payment System will not receive additional payment for the following conditions when acquired during hospitalization: catheter-associated urinary tract infection, decubitus ulcer, vascular catheterassociated infection, serious preventable events (such as blood incompatibility), injury due to fall or trauma, serious glycemic control states, and specific postoperative infections and venous thromboembolic conditions (Table 2). This initiative has 2 main components: mandated use of a code call

Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle.

BACKGROUND Although urinary tract infection (UTI) is the most common hospital-acquired infection in the United States, to our knowledge, no national data exist describing what hospitals in the United States are doing to prevent this patient safety problem. We conducted a national study to examine the current practices used by hospitals to prevent hospital-acquired UTI. METHODS We mailed written surveys to infection control coordinators at a national random sample of nonfederal US hospitals with an intensive care unit and >or=50 hospital beds (n=600) and to all Veterans Affairs (VA) hospitals (n=119). The survey asked about practices to prevent hospital-acquired UTI and other device-associated infections. RESULTS The response rate was 72%. Overall, 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and 9% used catheter reminders. VA hospitals were more likely than non-VA hospitals to use portable bladder scanners (49% vs. 29%; P=.001), condom catheters (46% vs. 12%; P=.001), and suprapubic catheters (22% vs. 9%; P=.001); non-VA hospitals were more likely to use antimicrobial urinary catheters (30% vs. 14%; P=.001). CONCLUSIONS Despite the strong link between urinary catheters and subsequent UTI, we found no strategy that appeared to be widely used to prevent hospital-acquired UTI. The most commonly used practices--bladder ultrasound and antimicrobial catheters--were each used in fewer than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in <10% of US hospitals.

Use of Central Venous Catheter-Related Bloodstream Infection Prevention Practices by US Hospitals

Maternal cigarette smoking during pregnancy as a risk factor for having a child with cleft lip/palate has been suggested by several epidemiologic studies. However, most of these studies contained small sample sizes, and a clear association between these two factors could not be established. The U.S. Natality database from 1996 and a case-control study design were used to investigate the association between maternal smoking during pregnancy and having a child with cleft lip/palate. The records of 3,891,494 live births from the 1996 U.S. Natality database were extracted to obtain cleft lip/palate cases and random controls. The National Center for Health Statistics collects maternal and newborn demographic and medical data from the birth certificates of all 50 states. New York (excluding New York City), California, Indiana, and South Dakota did not collect smoking data, and the data from these states were excluded from the analysis. A total of 2207 live births with cleft lip/palate cases were identified, and 4414 controls (1:2 ratio) were randomly selected (using the SAS program) from live births with no congenital defects. Odds ratios and 95 percent confidence intervals were determined from logistic regression models, adjusting for confounding variables, including maternal demographic and medical risk factors. A significant association was found between any amount of maternal cigarette use during pregnancy and having a child with cleft lip/palate [unadjusted odds ratio 1.55 (1.36, 1.76), p < 0.001]. Univariate analysis showed that maternal education level, age, race, and maternal medical conditions (diabetes and pregnancy-associated hypertension) were potential confounders. After adjusting for these confounders, the odds ratio remained significant [Mantel-Haenszel odds ratio 1.34 (1.16, 1.54), p < 0.001]. To determine the dose response of cigarette smoking during pregnancy, the cigarette consumption per day was divided into four groups: none, 1 to 10, 11 to 20, and 21 or more. A dose-response relationship was found when comparing each smoking category with the no smoking reference group: 1.50 (1.28, 1.76), 1.55 (1.23, 1.95), and 1.78 (1.22, 2.59), respectively. This means that increased cigarette smoking during pregnancy resulted in increased odds of having a child with cleft lip/palate. This is the largest study to date to test the association between maternal cigarette smoking during pregnancy and having a newborn with cleft lip/palate. The significant trend in the dose-response relationship strongly suggests the association of smoking tobacco and this common congenital deformity. These results emphasize the public health risks associated with smoking during pregnancy. To prevent this devastating craniofacial anomaly, educational initiatives should be considered that will alert expectant mothers to the association between smoking during pregnancy and the occurrence of cleft lip/palate.

Qualitative research methods: Key features and insights gained from use in infection prevention research

BACKGROUND Catheter-associated urinary tract infection (CAUTI), a frequent health care-associated infection (HAI), is a costly and common condition resulting in patient discomfort, activity restriction, and hospital discharge delays. The Centers for Medicare & Medicaid Services (CMS) no longer reimburses hospitals for the extra cost of caring for patients who develop CAUTI. The Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety & Quality has initiated a statewide initiative, MHA Keystone HAI, to help ameliorate the burden of disease associated with indwelling catheterization. In addition, a long-term research project is being conducted to evaluate the current initiative and to identify practical strategies to ensure the effective use of proven infection prevention and patient safety practices. OVERVIEW OF THE BLADDER BUNDLE INITIATIVE IN MICHIGAN The bladder bundle as conceived by MHA Keystone HAI focuses on preventing CAUTI by optimizing the use of urinary catheters with a specific emphasis on continual assessment and catheter removal as soon as possible, especially for patients without a clear indication. COLLABORATION BETWEEN RESEARChERS AND STATE WIDE PATIENT SAFETY ORGANIZATIONS: A synergistic collaboration between patient safety researchers and a statewide patient safety organization is aimed at identifying effective strategies to move evidence from peer-reviewed literature to the bedside. Practical strategies that facilitate implementation of the bundle will be developed and tested using mixed quantitative and qualitative methods. DISCUSSION Simply disseminating scientific evidence is often ineffective in changing clinical practice. Therefore, learning how to implement these findings is critically important to promoting high-quality care and a safe health care environment.

The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study.

OBJECTIVE To examine the extent to which US acute care hospitals have adopted recommended practices to prevent central venous catheter-related bloodstream infections (CR-BSIs). PARTICIPANTS AND METHODS Between March 16, 2005, and August 1, 2005, a survey of infection control coordinators was conducted at a national random sample of nonfederal hospitals with an intensive care unit and more than 50 hospital beds (n=600) and at all Department of Veterans Affairs (VA) medical centers (n=119). Primary outcomes were regular use of 5 specific practices and a composite approach for preventing CR-BSIs. RESULTS The overall survey response rate was 72% (n=516). A higher percentage of VA compared to non-VA hospitals reported using maximal sterile barrier precautions (84% vs 71%; P=.01); chlorhexidine gluconate for insertion site antisepsis (91% vs 69%; P<.001); and a composite approach (62% vs 44%; P=.003) combining concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Those hospitals having a higher safety culture score, having a certified infection control professional, and participating in an infection prevention collaborative were more likely to use CR-BSI prevention practices. CONCLUSION Most US hospitals are using maximal sterile barrier precautions and chlorhexidine gluconate, 2 of the most strongly recommended practices to prevent CR-BSIs. However, fewer than half of non-VA US hospitals reported concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Wider use of CR-BSI prevention practices by hospitals could be encouraged by fostering a culture of safety, participating in infection prevention collaboratives, and promoting infection control professional certification.

Barriers to Reducing Urinary Catheter Use: A Qualitative Assessment of a Statewide Initiative

Infection control professionals and hospital epidemiologists are accustomed to using quantitative research. Although quantitative studies are extremely important in the field of infection control and prevention, often they cannot help us explain why certain factors affect the use of infection control practices and identify the underlying mechanisms through which they do so. Qualitative research methods, which use open-ended techniques, such as interviews, to collect data and nonstatistical techniques to analyze it, provide detailed, diverse insights of individuals, useful quotes that bring a realism to applied research, and information about how different health care settings operate. Qualitative research can illuminate the processes underlying statistical correlations, inform the development of interventions, and show how interventions work to produce observed outcomes. This article describes the key features of qualitative research and the advantages that such features add to existing quantitative research approaches in the study of infection control. We address the goal of qualitative research, the nature of the research process, sampling, data collection and analysis, validity, generalizability of findings, and presentation of findings. Health services researchers are increasingly using qualitative methods to address practical problems by uncovering interacting influences in complex health care environments. Qualitative research methods, applied with expertise and rigor, can contribute important insights to infection prevention efforts.

Preventing Ventilator-Associated Pneumonia in the United States: A Multicenter Mixed-Methods Study

OBJECTIVE Healthcare-associated infection (HAI) is costly and causes substantial morbidity. We sought to understand why some hospitals were engaged in HAI prevention activities while others were not. Because preliminary data indicated that hospital leadership played an important role, we sought better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in US hospitals. METHODS We report phases 2 and 3 of a 3-phase study. In phase 2, 14 purposefully sampled US hospitals were selected from among the 72% of 700 invited hospitals whose lead infection preventionist had completed a quantitative survey on HAI prevention during phase 1. Qualitative data were collected during 38 semistructured phone interviews with key personnel at the 14 hospitals. During phase 3, we conducted 48 interviews during 6 in-person site visits to identify recurrent and unifying themes that characterize behaviors of successful leaders. RESULTS We found that successful leaders (1) cultivated a culture of clinical excellence and effectively communicated it to staff; (2) focused on overcoming barriers and dealt directly with resistant staff or process issues that impeded prevention of HAI; (3) inspired their employees; and (4) thought strategically while acting locally, which involved politicking before crucial committee votes, leveraging personal prestige to move initiatives forward, and forming partnerships across disciplines. Hospital epidemiologists and infection preventionists often played more important leadership roles in their hospitals patient safety activities than did senior executives. CONCLUSIONS Leadership plays an important role in infection prevention activities. The behaviors of successful leaders could be adopted by others who seek to prevent HAI.

How Active Resisters and Organizational Constipators Affect Health Care–Acquired Infection Prevention Efforts

IMPORTANCE Preventing catheter-associated urinary tract infection (CAUTI), a common health care-associated infection, is important for improving the care of hospitalized patients and in meeting the goals for reduction of health care-associated infections set by the US Department of Health and Human Services. OBJECTIVE To identify ways to enhance CAUTI prevention efforts based on the experiences of hospitals participating in the Michigan Health and Hospital Association Keystone Center for Patient Safety statewide program to reduce unnecessary use of urinary catheters (the Bladder Bundle). DESIGN Qualitative assessment of data collected through semistructured telephone interviews with key informants at 12 hospitals and in-person interviews and site visits at 3 of the 12 hospitals. The analysis focused on perceptions and key issues identified by hospitals as influencing implementation of CAUTI prevention practices as recommended by the Bladder Bundle initiative. SETTING Twelve purposefully sampled hospitals in Michigan. PARTICIPANTS Key informants including infection preventionists, clinical personnel, and senior executives. RESULTS Common barriers to Bladder Bundle implementation and appropriate urinary catheter use included (1) difficulty with nurse and physician engagement, (2) patient and family request for indwelling catheters, and (3) catheter insertion practices and customs in the emergency department. Strategies to address these barriers were also identified by several of the participating hospitals, including (1) incorporating urinary management (eg, planned toileting) as part of other patient safety programs, such as a fall reduction program, (2) explicitly discussing the risks of indwelling urinary catheters with patients and families, and (3) engaging with emergency department nurses and physicians to implement a process that ensures that appropriate indications for catheter use are followed. CONCLUSIONS AND RELEVANCE The Bladder Bundle program provides a model for implementing strategies to reduce CAUTI. These findings provide actionable information to inform CAUTI prevention-related activities in hospitals throughout the country.