David Ratz

A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care

BACKGROUND Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors--appropriate catheter use, aseptic insertion, and proper maintenance--and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI. METHODS The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates. RESULTS Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs. Tests for heterogeneity (ICU vs. non-ICU) were significant for catheter use (P=0.004) and catheter-associated UTI rates (P=0.001). CONCLUSIONS A national prevention program appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. (Funded by the Agency for Healthcare Research and Quality.).

PICC-associated bloodstream infections: prevalence, patterns, and predictors.

BACKGROUND Growing use of peripherally inserted central catheters (PICCs) has led to recognition of the risk of PICC-associated bloodstream infection. We sought to identify rates, patterns, and patient, provider, and device characteristics associated with this adverse outcome. METHODS A retrospective cohort of consecutive adults who underwent PICC placement from June 2009 to July 2012 was assembled. Using multivariable logistic and Cox-proportional hazards regression models, covariates specified a priori were analyzed for their association with PICC-associated bloodstream infection. Odds ratios (OR) and hazard ratios (HR) with corresponding 95% confidence intervals (CI) were used to express the association between each predictor and the outcome of interest. RESULTS During the study period, 966 PICCs were inserted in 747 unique patients for a total of 26,887 catheter days. Indications for PICC insertion included: long-term antibiotic administration (52%, n = 503), venous access (21%, n = 201), total parenteral nutrition (16%, n = 155), and chemotherapy (11%, n = 107). On bivariate analysis, intensive care unit (ICU) status (OR 3.23; 95% CI, 1.84-5.65), mechanical ventilation (OR 4.39; 95% CI, 2.46-7.82), length of stay (hospital, OR 1.04; 95% CI, 1.02-1.06 and ICU, OR 1.03; 95% CI, 1.02-1.04), PowerPICCs (C. R. Bard, Inc., Murray Hill, NJ; OR 2.58; 95% CI, 1.41-4.73), and devices placed by interventional radiology (OR 2.57; 95% CI, 1.41-4.68) were associated with PICC-bloodstream infection. Catheter lumens were strongly associated with this event (double lumen, OR 5.21; 95% CI, 2.46-11.04, and triple lumen, OR 10.84; 95% CI, 4.38-26.82). On multivariable analysis, only hospital length of stay, ICU status, and number of PICC lumens remained significantly associated with PICC bloodstream infection. Notably, the HR for PICC lumens increased substantially, suggesting earlier time to infection among patients with multi-lumen PICCs (HR 4.08; 95% CI, 1.51-11.02 and HR 8.52; 95% CI, 2.55-28.49 for double- and triple-lumen devices, respectively). CONCLUSIONS PICC-associated bloodstream infection is most associated with hospital length of stay, ICU status, and number of device lumens. Policy and procedural oversights targeting these factors may be necessary to reduce the risk of this adverse outcome.

Peripherally inserted central catheter‐related deep vein thrombosis: contemporary patterns and predictors

Despite growing use, peripherally inserted central catheters (PICCs) are associated with risk of deep vein thrombosis (DVT). We designed a study to determine patient, provider and device factors associated with this outcome.

Regional Variation in Urinary Catheter Use and Catheter-Associated Urinary Tract Infection: Results from a National Collaborative

OBJECTIVE To examine regional variation in the use and appropriateness of indwelling urinary catheters and catheter-associated urinary tract infection (CAUTI). DESIGN AND SETTING Cross-sectional study. PARTICIPANTS US acute care hospitals. METHODS Hospitals were divided into 4 regions according to the US Census Bureau. Baseline data on urinary catheter use, catheter appropriateness, and CAUTI were collected from participating units. The catheter utilization ratio was calculated by dividing the number of catheter-days by the number of patient-days. We used the National Healthcare Safety Network (NHSN) definition (number of CAUTIs per 1,000 catheter-days) and a population-based definition (number of CAUTIs per 10,000 patient-days) to calculate CAUTI rates. Logistic and Poisson regression models were used to assess regional differences. RESULTS Data on 434,207 catheter-days over 1,400,770 patient-days were collected from 1,101 units within 726 hospitals across 34 states. Overall catheter utilization was 31%. Catheter utilization was significantly higher in non-intensive care units (ICUs) in the West compared with non-ICUs in all other regions. Approximately 30%-40% of catheters in non-ICUs were placed without an appropriate indication. Catheter appropriateness was the lowest in the West. A total of 1,099 CAUTIs were observed (NHSN rate of 2.5 per 1,000 catheter-days and a population-based rate of 7.8 per 10,000 patient-days). The population-based CAUTI rate was highest in the West (8.9 CAUTIs per 10,000 patient-days) and was significantly higher compared with the Midwest, even after adjusting for hospital characteristics (P = .02). CONCLUSIONS Regional differences in catheter use, appropriateness, and CAUTI rates were detected across US hospitals.

Preventing device-associated infections in US hospitals: national surveys from 2005 to 2013

Background Numerous initiatives have focused on reducing device-associated infections, contributing to an overall decrease in infections nationwide. To better understand factors associated with this decline, we assessed the use of key practices to prevent device-associated infections by US acute care hospitals from 2005 to 2013. Methods We mailed surveys to infection preventionists at a national random sample of ∼600 US acute care hospitals in 2005, 2009 and 2013. Our survey asked about the use of practices to prevent the 3 most common device-associated infections: central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infection (CAUTI). Using sample weights, we estimated the per cent of hospitals reporting regular use (a score of 4 or 5 on a scale from 1 (never use) to 5 (always use)) of prevention practices from 2005 to 2013. Results The response rate was about 70% in all 3 periods. Use of most recommended prevention practices increased significantly over time. Among those showing the greatest increase were use of an antimicrobial dressing for preventing CLABSI (25–78%, p<0.001), use of an antimicrobial mouth rinse for preventing VAP (41–79%, p<0.001) and use of catheter removal prompts for preventing CAUTI (9–53%, p<0.001). Likewise, a significant increase in facility-wide surveillance was found for all three infections. Practices for which little change was observed included use of antimicrobial catheters to prevent either CLABSI or CAUTI. Conclusions US hospitals have responded to the call to reduce infection by increasing use of key recommended practices. Vigilance is needed to ensure sustained improvement and additional strategies may still be required, given an apparent continuing lag in CAUTI prevention efforts.

Do Clinicians Know Which of Their Patients Have Central Venous Catheters?: A Multicenter Observational Study

Context Central venous catheters (CVCs) are commonly used to care for hospitalized patients; however, their continued presence creates substantial risks, including infection and thrombosis. Although indwelling CVCs should be removed as soon as they are no longer needed, clinicians may not be aware of their presence. Contribution This study found that many interns, residents, and attending physicians were unaware that their patients had indwelling catheters, including triple-lumen and peripherally inserted central catheters. Implication Increased efforts are needed to ensure that clinicians are mindful of the presence of their patients CVCs. The Editors Central venous catheters (CVCs) are instrumental for the safe and comprehensive care of many hospitalized patients. Often inserted in intensive care unit (ICU) and non-ICU settings, CVCs provide reliable venous access for tasks ranging from hemodynamic monitoring to delivery of irritants, vesicants, and intravenous antibiotics. In adults, 2 devices are most used in this context: nontunneled triple-lumen catheters placed in the subclavian, jugular, or femoral veins and peripherally inserted central catheters (PICCs) inserted into upper-extremity veins (1, 2). Despite their many advantages, triple-lumen catheters and PICCs are associated with important risks, including central lineassociated bloodstream infections (CLABSIs) and venous thromboembolism (3, 4). In particular, PICC-related CLABSI and thromboembolism have recently garnered attention owing to their frequency, attributable cost, and potential for prevention (5, 6). Because the risk for these adverse outcomes increases with time, early removal of CVCs that are no longer clinically warranted is a key strategy for prevention (7, 8). However, accumulating evidence suggests that clinicians often do not remove unnecessary CVCs. For example, a study done at a large academic medical center found many patients with PICCs that were idle and not clinically justifiable (3). In another study, 6.6% of CVCs in non-ICU settings were found to be inappropriate and clinically unnecessary at the time of review (4). These findings are not unique to the United Statesconcerns about inappropriately prolonged use of vascular access devices are well-documented worldwide (912). In survey-based studies of inpatient providers, nearly half of all hospitalists stated that they had, at least once, forgotten that their patient had a PICC in situ (13, 14). These findings mirror trends noted with indwelling urinary catheters, in which 1 in 3 physicians was unaware that these devices were present (15). Given this background, we sought to determine how often interns, residents, general medicine attendings, hospitalists, and subspecialists know which of their hospitalized patients have a PICC or triple-lumen catheter. We hypothesized that clinicians who write orders for or those who are most proximal to patients (for example, interns and hospitalists) would be most likely to correctly identify which of their patients have CVCs. Further, we postulated that clinicians who insert CVCs (such as critical care specialists) or consciously deliberate on the choice of a vascular access device (such as hematologists or oncologists) would be more likely to be aware that a device was present. Methods Patients and Study Population Between April 2012 and September 2013, we conducted face-to-face interviews with hospitalized patients and their responsible clinicians at 3 academic medical centers in the United States. A responsible clinician was defined as an intern, resident, physician extender (for example, nurse practitioner or physician assistant), or attending physician who had provided care to a patient for at least 24 hours. Housestaff were defined as interns (year 1 of training), residents (beyond year 1 of training), or physician extenders who cared for patients under the supervision of an attending physician. At each site, patients and providers were randomly selected from general medicine teaching, hospitalist-only, and subspecialty services that often use CVCs (such as cardiology, gastroenterology and hepatology, hematology and oncology, and critical care) and were primarily responsible for patient care (for example, not consultants). Thus, any provider on duty or patient receiving care in a specialty or discipline of interest was eligible for study inclusion. Eligible patients were identified using electronic patient lists for provider teams at each site. At 2 sites, patients were approached for participation and interviewed for the presence of a CVC. At 1 site, CVCs were identified through use of a validated electronic tool (98% accuracy at correctly identifying CVC presence); these patients were included but not directly examined for device presence. After patients were interviewed or electronically identified, providers were approached to ascertain their awareness of device presence. Clinicians were blinded to which patients were participating in the study and were queried for all patients on their roster. Survey Methods Before morning team rounds, we approached patients to seek written informed consent for participation at 2 of our 3 sites. If patients could not provide consent and a family member was available, consent was obtained from next of kin. Requirement for informed consent was waived at our third site. After consent was obtained, patients were interviewed and a focused examination was done to determine the presence of a PICC or triple-lumen catheter in the jugular, subclavian, or femoral veins at 2 study sites. Central venous catheters were defined as PICCs inserted in any upper-extremity vein or triple-lumen catheters placed in the neck, chest, or groin. Patients with specialty catheters, including hemodialysis catheters, small-bore catheters (such as Pro-Line CTs [Medcomp]), tunneled lines, and midlines were excluded. We surveyed patients in ICU and non-ICU settings; those on surgical services were excluded. Patients were surveyed only once during hospitalization; surveys were done weekly at all sites. After team rounds, we interviewed medical providers for each patient and asked, As of this morning, does your patient have a PICC or a triple-lumen catheter in the neck, chest, or groin? All clinicians were interviewed after morning rounds to ensure that they had seen the patient the day that the survey was administered. Clinicians were interviewed separately and were not notified of our visit beforehand. We allowed clinicians to use such materials as written notes or sign-outs during the interview but they were not allowed access to electronic health records. Because teaching attendings were responsible for all patients on the team, they were queried about CVC presence for all patients on their list. Subspecialists were similarly queried for all patients on their inpatient specialty teams. Interns, residents, and physician extenders were questioned only about patients for whom they were primarily responsible, regardless of assignment to a general medicine or specialist team. All clinicians were surveyed the day that patients were examined. Statistical Analysis Descriptive statistics for patient, provider, device, and site characteristics were used to define the study samples. The primary outcome of interest was unawareness of PICC or triple-lumen catheter presence. Given the categorical nature of the data, differences among provider types and training levels were compared using chi-square tests, where appropriate. Stata MP, version 13.0 (StataCorp), was used for all statistical analyses, and Pvalues less than 0.050 were considered statistically significant. Institutional review boards at each site provided ethical and regulatory approval for the study. Role of the Funding Source The study was not funded by any agency. Results Of the 1082 patients approached, 990 (91.5%) consented to participate in the study. For these 990 patients, we did 1881 clinician assessments across the 3 study sites (Table 1). Clinician responses from interns (454), residents and physician extenders (513), general medicine teaching attendings (245), subspecialty attendings (176), intensivists (95), and hospitalists (398) were included. An average of 1.9 clinician assessments were associated with each patient. Table 1. Patient, Provider, and Site Characteristics The overall prevalence of CVCs (triple-lumen catheter or PICC) was 21.1% (209 of 990). More than one half of the 209 devices were PICCs (n= 126 [60.3%]); the remaining 83 devices were triple-lumen catheters inserted in the neck (n= 41 [19.6%]), chest (n= 24 [11.5%]), or groin (n= 18 [8.6%]). A total of 47.0% (39 of 83) of triple-lumen catheters were found in patients in ICU settings; conversely, 92.9% (117 of 126) of PICCs were found in non-ICU patients. For the 209 patients with CVCs, 21.2% (90 of 425) of responsible clinicians were unaware of the presence of a triple-lumen catheter or PICC (Table 2). Unawareness of PICCs was greatestmore than 1 in 4 responsible clinicians (25.1% [60 of 239]) were not aware of their presence. Lack of awareness of a triple-lumen catheter or PICC varied from 16.3% to 31.1% across sites (P= 0.038) and was most pronounced in non-ICU settings, where PICCs are most common (24.8% vs. 12.6% in non-ICU and ICU settings; P= 0.005). Of note, a small but substantial number of clinicians (5.6% [82 of 1456]) stated that their patients had a CVC when no device was found on examination. Table 2. Awareness of CVC Presence We tested whether proximity to patients was associated with awareness of device presence. Although interns were the clinicians most likely to write orders, almost 1 of every 5 surveyed was not aware that his or her patient had a triple-lumen catheter or PICC (19.1% [22 of 115]). Although medical residents were more frequently aware of device presence than interns, the difference did not reach statistical significance (13.8% vs. 19.1%; P= 0.27). However, teaching

A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents

Importance Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms. Objective To develop, implement, and evaluate an intervention to reduce catheter-associated UTI. Design, Setting, and Participants A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016. Interventions The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication. Main Outcomes and Measures Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist. Results In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001). Conclusions and Relevance In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

Health care–associated infection prevention in Japan: The role of safety culture

BACKGROUND Limited data exist on the use of infection prevention practices in Japan. We conducted a nationwide survey to examine the use of recommended infection prevention strategies and factors affecting their use in Japanese hospitals. METHODS Between April 1, 2012, and January 31, 2013, we surveyed 971 hospitals in Japan. The survey instrument assessed general hospital and infection prevention program characteristics and use of infection prevention practices, including practices specific to preventing catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Logistic regression models were used to examine multivariable associations between hospital characteristics and the use of the various prevention practices. RESULTS A total of 685 hospitals (71%) responded to the survey. Maintaining aseptic technique during catheter insertion and maintenance, avoiding routine central line changes, and using maximum sterile barrier precautions and semirecumbent positioning were the only practices regularly used by more than one-half of the hospitals to prevent CAUTI, CLABSI, and VAP, respectively. Higher safety-centeredness was associated with regular use of prevention practices across all infection types. CONCLUSIONS Although certain practices were used commonly, the rate of regular use of many evidence-based prevention practices was low in Japanese hospitals. Our findings highlight the importance of fostering an organization-wide atmosphere that prioritizes patient safety. Such a commitment to patient safety should in turn promote the use of effective measures to reduce health care-associated infections in Japan.

Vascular nursing experience, practice knowledge, and beliefs: Results from the Michigan PICC1 survey.

BACKGROUND Peripherally inserted central catheters (PICCs) are increasingly used in hospitalized patients. Yet, little is known about the vascular access nurses who often place them. METHODS We conducted a Web-based survey to assess vascular access nursing experience, practice, knowledge, and beliefs related to PICC insertion and care in 47 Michigan hospitals. RESULTS The response rate was 81% (172 received invitations, 140 completed the survey). More than half of all respondents (58%) reported placing PICCs for ≥5 years, and 23% had obtained dedicated vascular access certification. The most common reported indications for PICC insertion included intravenous antibiotics, difficult venous access, and chemotherapy. Many respondents (46%) reported placing a PICC in a patient receiving dialysis; however, 91% of these respondents reported receiving approval from nephrology prior to insertion. Almost all respondents (91%) used ultrasound to find a suitable vein for PICC insertion, and 76% used electrocardiography guidance to place PICCs. PICC occlusion was reported as the most frequently encountered complication, followed by device migration and deep vein thrombosis. Although 94% of respondents noted that their hospitals tracked the number of PICCs placed, only 40% reported tracking duration of PICC use. Relatedly, 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness. CONCLUSION This survey of vascular nursing experiences highlights opportunities to improve practices such as avoiding PICC use in dialysis, better tracking of PICC dwell times, and necessity. Hospitalists may use these data to inform clinical practice, appropriateness, and safety of PICCs in hospitalized patients.

Limiting the Number of Lumens in Peripherally Inserted Central Catheters to Improve Outcomes and Reduce Cost: A Simulation Study

BACKGROUND The number of peripherally inserted central catheter (PICC) lumens is associated with thrombotic and infectious complications. Because multilumen PICCs are not necessary in all patients, policies that limit their use may improve safety and cost. OBJECTIVE To design a simulation-based analysis to estimate outcomes and cost associated with a policy that encourages single-lumen PICC use. METHODS Model inputs, including risk of complications and costs associated with single- and multilumen PICCs, were obtained from available literature and a multihospital collaborative quality improvement project. Cost savings and reduction in central line-associated bloodstream infection and deep vein thrombosis events from institution of a single-lumen PICC default policy were reported. RESULTS According to our model, a hospital that places 1,000 PICCs per year (25% of which are single-lumen and 75% multilumen) experiences annual PICC-related maintenance and complication costs of