M. Todd Greene

Reducing inappropriate urinary catheter use: a statewide effort.

BACKGROUND Indwelling urinary catheters may lead to both infectious and noninfectious complications and are often used in the hospital setting without an appropriate indication. The objective of this study was to evaluate the results of a statewide quality improvement effort to reduce inappropriate urinary catheter use. METHODS Retrospective analysis of data collected between 2007 and 2010 as part of a statewide collaborative initiative before, during, and after an educational intervention promoting adherence to appropriate urinary catheter indications. The data were collected from 163 inpatient units in 71 participating Michigan hospitals. The intervention consisted of educating clinicians about the appropriate indications for urinary catheter use and promoting the daily assessment of urinary catheter necessity during daily nursing rounds. The main outcome measures were change in prevalence of urinary catheter use and adherence to appropriate indications. We used flexible generalized estimating equation (GEE) and multilevel methods to estimate rates over time while accounting for the clustering of patients within hospital units. RESULTS The urinary catheter use rate decreased from 18.1% (95% CI, 16.8%-19.6%) at baseline to 13.8% (95% CI, 12.9%-14.8%) at end of year 2 (P < .001). The proportion of catheterized patients with appropriate indications increased from 44.3% (95% CI, 40.3%-48.4%) to 57.6% (95% CI, 51.7%-63.4%) by the end of year 2 (P = .005). CONCLUSIONS A statewide effort to reduce inappropriate urinary catheter use was associated with a significant reduction in catheter use and improved compliance with appropriate use. The effect of the intervention was sustained for at least 2 years.

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.).

Hospital Performance for Pharmacologic Venous Thromboembolism Prophylaxis and Rate of Venous Thromboembolism : A Cohort Study

IMPORTANCE Hospitalization for acute medical illness is associated with increased risk of venous thromboembolism (VTE). Although efforts designed to increase use of pharmacologic VTE prophylaxis are intended to reduce hospital-associated VTE, whether higher rates of prophylaxis reduce VTE in medical patients is unknown. OBJECTIVE To examine the association between pharmacologic VTE prophylaxis rates and hospital-associated VTE. DESIGN, SETTING, AND PARTICIPANTS Retrospective, multicenter cohort study conducted at 35 Michigan hospitals participating in a statewide quality collaborative from January 1, 2011, through September 13, 2012. Trained medical record abstractors at each hospital collected data from 31 260 general medical patients. Use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission were recorded using a combination of medical record review and telephone follow-up. Hospitals were grouped into tertiles of performance based on rate of pharmacologic prophylaxis use on admission for at-risk patients. MAIN OUTCOMES AND MEASURES Association between hospital performance and time to development of VTE within 90 days of hospital admission. RESULTS A total of 14 563 of 20 794 patients (70.0%) eligible for pharmacologic prophylaxis received prophylaxis on admission. The rates of pharmacologic prophylaxis use at hospitals in the high-, moderate-, and low-performance tertiles were 85.8%, 72.6%, and 55.5%, respectively. A total of 226 VTE events occurred during 1 765 449 days of patient follow-up. Compared with patients at hospitals in the highest-performance tertile, the hazard of VTE in patients at hospitals in moderate-performance (hazard ratio, 1.10; 95% CI, 0.74-1.62) and low-performance (hazard ratio, 0.96, 95% CI, 0.63-1.45) tertiles did not differ after adjusting for potential confounders. Results remained robust when examining mechanical prophylaxis, prophylaxis use throughout the hospitalization, and subsequent inpatient stays after discharge from the index hospitalization. CONCLUSIONS AND RELEVANCE The occurrence of 90-day VTE in medical patients after hospitalization is low. Patients who receive care at hospitals that have lower rates of pharmacologic prophylaxis do not have higher adjusted hazards of VTE, even after accounting for individual receipt of pharmacologic prophylaxis. Efforts to increase rates of pharmacologic VTE prophylaxis in hospitalized medical patients may not substantively reduce this adverse outcome.

Depression, antidepressant medications, and risk of Clostridium difficile infection

BackgroundAn ancillary finding in previous research has suggested that the use of antidepressant medications increases the risk of developing Clostridium difficile infection (CDI). Our objective was to evaluate whether depression or the use of anti-depressants altered the risk of developing CDI, using two distinct datasets and study designs.MethodsIn Study 1, we conducted a longitudinal investigation of a nationally representative sample of older Americans (n = 16,781), linking data from biennial interviews to physician and emergency department visits, stays in hospital and skilled nursing facilities, home health visits, and other outpatient visits. In Study 2, we completed a clinical investigation of hospitalized adults who were tested for C. difficile (n = 4047), with cases testing positive and controls testing negative. Antidepressant medication use prior to testing was ascertained.ResultsThe population-based rate of CDI in older Americans was 282.9/100,000 person-years (95% confidence interval (CI)) 226.3 to 339.5) for individuals with depression and 197.1/100,000 person-years for those without depression (95% CI 168.0 to 226.1). The odds of CDI were 36% greater in persons with major depression (95% CI 1.06 to 1.74), 35% greater in individuals with depressive disorders (95% CI 1.05 to 1.73), 54% greater in those who were widowed (95% CI 1.21 to 1.95), and 25% lower in adults who did not live alone (95% CI 0.62 to 0.92). Self-reports of feeling sad or having emotional, nervous or psychiatric problems at baseline were also associated with the later development of CDI. Use of certain antidepressant medications during hospitalization was associated with altered risk of CDI.ConclusionsAdults with depression and who take specific anti-depressants seem to be more likely to develop CDI. Older adults who are widowed or who live alone are also at greater risk of CDI.

The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities

BACKGROUND Peripherally inserted central catheters are associated with upper-extremity deep vein thrombosis. Whether they also are associated with lower-extremity deep vein thrombosis or pulmonary embolism is unknown. We examined the risk of venous thromboembolism in deep veins of the arm, leg, and chest after peripherally inserted central catheter placement. METHODS We conducted a multicenter, retrospective cohort study of 76,242 hospitalized medical patients from 48 Michigan hospitals. Peripherally inserted central catheter presence, comorbidities, venous thrombosis risk factors, and thrombotic events within 90 days from hospital admission were ascertained by phone and record review. Cox proportional hazards models were fit to examine the association between peripherally inserted central catheter placement and 90-day hazard of upper- and lower-extremity deep vein thrombosis or pulmonary embolism, adjusting for patient-level characteristics and natural clustering within hospitals. RESULTS A total of 3790 patients received a peripherally inserted central catheter during hospitalization. From hospital admission to 90 days, 876 thromboembolic events (208 upper-extremity deep vein thromboses, 372 lower-extremity deep vein thromboses, and 296 pulmonary emboli) were identified. After risk adjustment, peripherally inserted central catheter use was independently associated with all-cause venous thromboembolism (hazard ratio [HR], 3.16; 95% confidence interval [CI], 2.59-3.85), upper-extremity deep vein thrombosis (HR, 10.49; 95% CI, 7.79-14.11), and lower-extremity deep vein thrombosis (HR, 1.48; 95% CI, 1.02-2.15). Peripherally inserted central catheter use was not associated with pulmonary embolism (HR, 1.34; 95% CI, 0.86-2.06). Results were robust to sensitivity analyses incorporating receipt of pharmacologic prophylaxis during hospitalization. CONCLUSIONS Peripherally inserted central catheter use is associated with upper- and lower-extremity deep vein thrombosis. Weighing the thrombotic risks conferred by peripherally inserted central catheters against clinical benefits seems necessary.

Epidemiology of Hospital-Acquired Urinary Tract-Related Bloodstream Infection at a University Hospital

Little is known about the epidemiology of nosocomial urinary tract-related bloodstream infection. In a case series from an academic medical center, Enterococcus (28.7%) and Candida (19.6%) species were the predominant microorganisms, which suggests a potential shift from gram-negative microorganisms. A case-fatality rate of 32.8% highlights the severity of this condition.

Predictors of hospital-acquired urinary tract-related bloodstream infection.

OBJECTIVE Bloodstream infection (BSI) secondary to nosocomial urinary tract infection is associated with substantial morbidity, mortality, and additional financial costs. Our objective was to identify predictors of nosocomial urinary tract-related BSI. DESIGN Matched case-control study. SETTING Midwestern tertiary care hospital. PATIENTS Cases (n=298) were patients with a positive urine culture obtained more than 48 hours after admission and a blood culture obtained within 14 days of the urine culture that grew the same organism. Controls (n=667), selected by incidence density sampling, included patients with a positive urine culture who were at risk for BSI but did not develop one. Methods. Conditional logistic regression and classification and regression tree analyses. RESULTS The most frequently isolated microorganisms that spread from the urinary tract to the bloodstream were Enterococcus species. Independent risk factors included neutropenia (odds ratio [OR], 10.99; 95% confidence interval [CI], 5.78-20.88), renal disease (OR, 2.96; 95% CI, 1.98-4.41), and male sex (OR, 2.18; 95% CI, 1.52-3.12). The probability of developing a urinary tract-related BSI among neutropenic patients was 70%. Receipt of immunosuppressants (OR, 1.53; 95% CI, 1.04-2.25), insulin (OR, 4.82; 95% CI, 2.52-9.21), and antibacterials (OR, 0.66; 95% CI, 0.44-0.97) also significantly altered risk. CONCLUSIONS The heightened risk of urinary tract-related BSI associated with several comorbid conditions suggests that the management of nosocomial bacteriuria may benefit from tailoring to certain patient subgroups. Consideration of time-dependent risk factors, such as medications, may also help guide clinical decisions in reducing BSI.

Estimating hospital costs of catheter‐associated urinary tract infection

Healthcare-associated infections are common, costly, and potentially deadly. However, effective prevention strategies are underutilized, particularly for catheter-associated urinary tract infection (CAUTI), one of the most common healthcare-associated infections. Further, since 2008, the Centers for Medicare and Medicaid Services no longer reimburses hospitals for the additional costs of caring for patients who develop CAUTI during hospitalization. Given the resulting payment pressures on hospitals stemming from this decision, it is important to factor in cost implications when attempting to encourage decision makers to support infection prevention measures. To this end, we present a simple tool (with easy-to-use online implementation) that hospitals can use to estimate hospital costs due to CAUTI, both before and after an intervention, to reduce inappropriate urinary catheterization. Using previously published cost and risk estimates, we show that an intervention yielding clinically feasible reductions in catheter use can lead to an estimated 50% reduction in CAUTI-related costs. Our tool is meant to complement the Society of Hospital Medicines Choosing Wisely campaign, which highlights avoiding placement or continued use of nonindicated urinary catheters as a key area for improving decision making and quality of care while decreasing costs. Journal of Hospital Medicine 2013;8:519–522.

National Survey of Practices to Prevent Healthcare-Associated Infections in Thailand: The Role of Safety Culture and Collaboratives

OBJECTIVE To evaluate hospital characteristics and practices used by Thai hospitals to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP), the 3 most common types of healthcare-associated infection (HAI) in Thailand. DESIGN Survey. SETTING Thai hospitals with an intensive care unit and 250 or more hospital beds. METHODS Between January 1, 2010, and October 31, 2010, research nurses collected data from all eligible hospitals. The survey assessed hospital characteristics and practices to prevent CAUTI, CLABSI, and VAP. Ordinal logistic regression was used to assess relationships between hospital characteristics and use of prevention practices. RESULTS A total of 204 (80%) of 256 hospitals responded. Most hospitals (93%) reported regularly using alcohol-based hand rub. The most frequently reported prevention practice by infection was as follows: for CAUTI, condom catheters in men (47%); for CLABSI, avoiding routine central venous catheter changes (85%); and for VAP, semirecumbent positioning (84%). Hospitals with peripherally inserted central catheter insertion teams were more likely to regularly use elements of the CLABSI prevention bundle. Greater safety scores were associated with regular use of several VAP prevention practices. The only hospital characteristic associated with increased use of at least 1 prevention practice for each infection was membership in an HAI collaborative. CONCLUSIONS While reported adherence to hand hygiene was high, many of the prevention practices for CAUTI, CLABSI, and VAP were used infrequently in Thailand. Policies and interventions emphasizing specific infection prevention practices, establishing a strong institutional safety culture, and participating in collaboratives to prevent HAI may be beneficial.

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.