Jennifer Meddings

Systematic Review and Meta-Analysis: Reminder Systems to Reduce Catheter-Associated Urinary Tract Infections and Urinary Catheter Use in Hospitalized Patients

BACKGROUND Prolonged catheterization is the primary risk factor for catheter-associated urinary tract infection (CAUTI). Reminder systems are interventions used to prompt the removal of unnecessary urinary catheters. To summarize the effect of urinary catheter reminder systems on the rate of CAUTI, urinary catheter use, and the need for recatheterization, we performed a systematic review and meta-analysis. METHODS Studies were identified in MEDLINE, the Cochrane Library, Biosis, the Web of Science, EMBASE, and CINAHL through August 2008. Only interventional studies that used reminders to physicians or nurses that a urinary catheter was in use or stop orders to prompt catheter removal in hospitalized adults were included. A total of 6679 citations were identified; 118 articles were reviewed, and 14 articles met the selection criteria. RESULTS The rate of CAUTI (episodes per 1000 catheter-days) was reduced by 52% (P < .001) with use of a reminder or stop order. The mean duration of catheterization decreased by 37%, resulting in 2.61 fewer days of catheterization per patient in the intervention versus control groups; the pooled standardized mean difference (SMD) in the duration of catheterization was -1.11 overall (P = 070), including a statistically significant decrease in studies that used a stop order (SMD, -0.30; P = .001) but not in those that used a reminder (SMD, -1.54; P = .071). Recatheterization rates were similar in control and intervention groups. CONCLUSION Urinary catheter reminders and stop orders appear to reduce the rate of CAUTI and should be strongly considered to enhance the safety of hospitalized patients.

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

Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review

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

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update

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

Effect of Nonpayment for Hospital-Acquired, Catheter-Associated Urinary Tract Infection: A Statewide Analysis

Background Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use. Methods To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interventions prompting UC removal by reminders or stop orders. A narrative review summarises other CAUTI prevention strategies including aseptic insertion, catheter maintenance, antimicrobial UCs, and bladder bundle implementation. Results 30 studies were identified and summarised with interventions to prompt removal of UCs, with potential for inclusion in the meta-analyses. By meta-analysis (11 studies), the rate of CAUTI (episodes per 1000 catheter-days) was reduced by 53% (rate ratio 0.47; 95% CI 0.30 to 0.64, p<0.001) using a reminder or stop order, with five studies also including interventions to decrease initial UC placement. The pooled (nine studies) standardised mean difference (SMD) in catheterisation duration (days) was −1.06 overall (p=0.065) including a statistically significant decrease in stop-order studies (SMD −0.37; p<0.001) but not in reminder studies (SMD, −1.54; p=0.071). No significant harm from catheter removal strategies is supported. Limited research is available regarding the impact of UC insertion and maintenance technique. A recent randomised controlled trial indicates antimicrobial catheters provide no significant benefit in preventing symptomatic CAUTIs. Conclusions UC reminders and stop orders appear to reduce CAUTI rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing UC use involves changing well-established habits.

Accuracy of Hospital Administrative Data in Reporting Central Line–Associated Bloodstream Infections in Newborns

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method

BACKGROUND Most (59% to 86%) hospital-acquired urinary tract infections (UTIs) are catheter-associated urinary tract infections (CAUTIs). As of 2008, claims data are used to deny payment for certain hospital-acquired conditions, including CAUTIs, and publicly report hospital performance. OBJECTIVE To examine rates of UTIs in adults that are coded in claims data as hospital-acquired and catheter-associated events and evaluate how often nonpayment for CAUTI lowers hospital payment. DESIGN Before-and-after study of all-payer cross-sectional claims data. SETTING 96 nonfederal acute care Michigan hospitals. PATIENTS Nonobstetric adults discharged in 2007 (n = 767 531) and 2009 (n = 781 343). MEASUREMENTS Hospital rates of UTIs (categorized as catheter-associated or hospital-acquired) and frequency of reduced payment for hospital-acquired CAUTIs. RESULTS Hospitals frequently requested payment for non-CAUTIs as secondary diagnoses: 10.0% (95% CI, 9.5% to 10.5%) of discharges in 2007 and 10.3% (CI, 9.8% to 10.9%) in 2009. Hospital rates of CAUTI were very low: 0.09% (CI, 0.06% to 0.12%) in 2007 and 0.14% (CI, 0.11% to 0.17%) in 2009. In 2009, 2.6% (CI, 1.6% to 3.6%) of hospital-acquired UTIs were described as CAUTIs. Nonpayment for hospital-acquired CAUTIs reduced payment for 25 of 781 343 (0.003%) hospitalizations in 2009. LIMITATIONS Data are from only 1 state and involved only 1 year before and after nonpayment for complications. Hospital prevention practices were not examined. CONCLUSION Catheter-associated UTI rates determined by claims data seem to be inaccurate and are much lower than expected from epidemiologic surveillance data. The financial impact of current nonpayment policy for hospital-acquired CAUTI is low. Claims data are currently not valid data sets for comparing hospital-acquired CAUTI rates for the purpose of public reporting or imposing financial incentives or penalties. PRIMARY FUNDING SOURCE Blue Cross Blue Shield of Michigan Foundation.

Inappropriate Testing for Urinary Tract Infection in Hospitalized Patients: An Opportunity for Improvement

OBJECTIVES: Central line-associated bloodstream infections (CLABSIs) are a significant source of morbidity and mortality in the NICU. In 2010, Medicaid was mandated not to pay hospitals for treatment of CLABSI; however, the source of CLABSI data for this policy was not specified. Our objective was to evaluate the accuracy of hospital administrative data compared with CLABSI confirmed by an infection control service. METHODS: We evaluated hospital administrative and infection control data for newborns admitted consecutively from January 1, 2008, to December 31, 2010. Clinical and demographic data were collected through chart review. We compared cases of CLABSI identified by administrative data (International Classification of Diseases, Ninth Revision, Clinical Modification 999.31) with infection control data that use national criteria from the Centers for Disease Control and Prevention as the gold standard. To ascertain the nature possible deficiencies in the administrative data, each patients medical record was searched to determine if clinical phrases that commonly refer to CLABSI appeared. RESULTS: Of 2920 infants admitted to the NICU during our study period, 52 were identified as having a CLABSI: 42 by infection control data only, 7 through hospital administrative data only, and 3 appearing in both. Against the gold standard, hospital administrative data were 6.7% sensitive and 99.7% specific, with a positive predictive value of 30.0% and a negative predictive value of 98.6%. Only 48% of medical records indicated a CLABSI. CONCLUSIONS: Our findings from a major children’s hospital NICU indicate that International Classification of Diseases, Ninth Revision, Clinical Modification code 993.31 is presently not accurate and cannot be used reliably to compare CLABSI rates in NICUs.

Disrupting the Life Cycle of the Urinary Catheter

Catheter-associated urinary tract infection (CAUTI) and unnecessary urinary catheter use remain important patient safety problems in 2015, despite nonpayment for hospital-acquired CAUTI since 2008, nationwide public reporting of CAUTIs since 2011, and increasing adoption of interventions to reduce catheter use (14). National reports of urinary catheter use have remained relatively unchanged since 2009, with catheter utilization ratios (catheter-days/patient-days) in 2013 reported as 0.60 for intensive care units (ICUs) and 0.17 for non-ICU wards (5). Even within the large On the CUSP: Stop CAUTI collaborative funded by the Agency for Healthcare Research and Quality (AHRQ), which uses many interventions to remove unnecessary urinary catheters, the catheter use ratios from June 2014 were 0.56 for ICUs and 0.18 for non-ICUs (6, 7). Key tools for reducing urinary catheter use are lists of appropriate and inappropriate catheter indications, which restrict use to appropriate indications and prompt catheter removal when catheters are no longer appropriate. In the United States, hospitals implementing interventions to prevent CAUTI and reduce catheter use, including hospitals in the On the CUSP project, generally rely on the 2009 Guideline for Prevention of Catheter-Associated Urinary Tract Infections from the Healthcare Infection Control Practices Advisory Committee (HICPAC) for guidance regarding appropriate and inappropriate catheter indications (8). In our experience as team members of the On the CUSP project and bedside clinicians caring for medical patients in university and Department of Veterans Affairs (VA) hospitals, urinary catheter use varies widely, even among clinicians and hospitals trying to implement similar appropriateness criteria (9). Specifically, in the On the CUSP project, urinary catheter use appears highest among hospitals in the Western United States (10). Hospitals in this region used accurate measurement of urinary output in critically ill patients outside of the ICU setting and urinary incontinence without a sacral or perineal pressure ulcer as indications for urinary catheter use more than did hospitals in other regions (10). Hospitals in the Midwestern United States had the highest rates for using other conditions, such as morbid obesity, transfer from the ICU, immobility, dementia, and patient request, as indications for use (10). A recent national survey of catheter placement practices in acute care hospitals demonstrated that many hospitals reported placing catheters for reasons beyond the HICPAC list of appropriate indications, including for patient request and urinary incontinence without obstruction (9). In summary, although the 2009 HICPAC CAUTI guideline about appropriate catheter indications was instrumental for informing many interventions to reduce catheter use, implementation of appropriate and inappropriate indication lists has been challenging for 3 reasons: 1) broad interpretation of such indications as critical illness; 2) bedside clinician concerns that pragmatic patient-specific issues, such as incontinent patients who are very difficult to turn for skin care, are not addressed; and 3) the need for more specific guidance on use of alternatives to indwelling catheters, such as external condom catheters and intermittent straight catheters (ISCs). To address these concerns, we applied a well-established method for evaluating appropriateness of medical technologythe RAND/UCLA Appropriateness Methodto more rigorously define the appropriateness of 3 types of urinary catheters (indwelling Foley catheter, ISC, and external condom catheter). Our objective was to develop a list of catheter indications assessed as appropriate, inappropriate, or of uncertain appropriateness for these urinary catheter types that can guide nurses and physicians considering catheters in hospitalized medical patients. We focused on indications for urinary catheters most commonly considered on medicine services and excluded perioperative care because we expected the literature review and clinical expertise required for perioperative indications to be different. Methods Overview of the RAND/UCLA Appropriateness Method The RAND/UCLA Appropriateness Method was developed to enable measuring the overuse of medical and surgical procedures in the RAND Corporation/University of California, Los Angeles, Health Services Utilization Study (11). For procedures that may be overused, this method assesses the procedure as appropriate when the expected health benefit (e.g., increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g., mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin that the procedure is worth doing, exclusive of cost (12, 13). The goal of the method is to combine the best available scientific literature with the collective judgment of experts to yield a statement on the appropriateness of a procedure with regard to specific patient characteristics, such as symptoms, medical history, or test results. This list of indications may be used retrospectively to assess the appropriateness of procedures received or prospectively as a clinical decision aid for improving the use of the procedure. As illustrated in Figure 1, the first step of the RAND/UCLA Appropriateness Method is a literature review to synthesize the latest available scientific evidence on the procedure to be rated. From the literature search, a list of specific clinical scenarios or indications is produced, from which a rating document for assessing appropriateness is generated. A panel of experts is identified, often on the basis of participation in or recommendation by various relevant medical societies. In a modified Delphi process, the panelists assess the benefit-to-harm ratio of the procedure for each indication in the rating document on a 1 to 9 scale; 1 means the expected harm greatly exceeds the expected benefit, and 9 means the expected benefit greatly outweighs the expected harms. Panelists perform the first round of ratings independently without interaction with other panelists. Figure 1. Overview of the RAND/UCLA Appropriateness Method. For the next round or rounds of rating, panelists meet at a conference led by a moderator experienced in the method. During the conference the panelists discuss the ratings, focusing on areas of disagreement or uncertainty, and have the opportunity to modify the indication list as needed. No attempt is made to force consensus. Following the discussion at the conference, the panelists individually re-rate the appropriateness of the indications by using the same 1 to 9 scale. Each indications final assessment is classified by the RAND/UCLA Appropriateness Method according to the panels median score and level of disagreement among panelists. Disagreement represents a wide difference of opinion by the panelists. For our panel of 15 members, disagreement existed if at least 5 panelists rated the appropriateness of an indication from 1 to 3 and at least 5 panelists rated the appropriateness from 7 to 9. If disagreement is found, those indications are considered to be of uncertain appropriateness. For indications without disagreement, median panel score ranges are used to classify indications as follows: 1 to 3, inappropriate; 4 to 6, uncertain appropriateness; and 7 to 9, appropriate. RAND/UCLA Appropriateness Method Versus the Method Used for the 2009 HICPAC CAUTI Guideline Literature Search Similar to the method used to generate the 2009 HICPAC guideline, the RAND/UCLA Appropriateness Method began with a literature search for guidance regarding urinary catheter use. The literature search was used to generate a list of potentially appropriate indications for indwelling urinary catheters for consideration by experts with diverse clinical and research expertise. However, both the HICPAC team and our team found very little in the literature with which to estimate risks and benefits of urinary bladder drainage strategies by clinical indication in order to guide development of an appropriate indications list. As a consequence, both the HICPAC team and our team reviewed the literature for other types of guidance on appropriate and inappropriate uses of catheters. The HICPAC CAUTI working group started with the indications discussed in the original 1981 Centers for Disease Control and Prevention CAUTI prevention guideline (14) and consulted other major CAUTI guidelines being developed around the same time (15, 16) to develop a draft list of indications (Gould C. Personal communication. 12 September 2014). Similarly, because our teams initial systematic search of the literature (Figure 2, Strategy 1) did not yield articles quantifying risks and benefits of urinary catheters by clinical indication (although it did yield 9 articles discussing indications), we also reviewed CAUTI guidelines (Figure 2, Strategy 2), including the HICPAC guideline and guidelines focused on clinical conditions for which urinary catheters are commonly considered, such as pressure ulcers, paralysis or neurologic bladder issues, and urologic diagnoses (including incontinence) (8, 1429). In addition, because we had recently performed 2 systematic reviews of controlled intervention studies to reduce CAUTI or urinary catheter use (30, 31), we reviewed the 30 studies and the references (Figure 2, Strategy 3) yielded by these systematic reviews. We sought guidance from these studies because implementation of many interventions required a list of appropriate and inappropriate urinary catheter indications. Figure 2. Summary of evidence search and selection. APIC = Association for Professionals in Infection Control and Epidemiology; CAUTI = catheter-associated urinary tract infection; CDC = Centers for Disease Control and Prevention; HICPAC = Healthcare Infection Control Practices Advisory Committee; IDSA = Infectious Dis

Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss

Urine cultures are frequently obtained for hospitalized patients. We reviewed documented indications for culture and compared these with professional society guidelines. Lack of documentation and important clinical scenarios (before orthopedic procedures and when the patient has altered mental status without a urinary catheter) are highlighted as areas of use outside of current guidelines.