In 2011, U.S. hospitals reported nearly 250,000 healthcare-associated infections in just four categories, and more than 80,000 infections related to indwelling devices alone. More than 54,500 patients developed catheter-associated urinary tract infections (CAUTIs), while central line-associated bloodstream infections (CLABSIs) affected another 30,100.1
Long known as significant areas for infection prevention efforts, new reporting requirements have drawn more attention to these infection rates. As of January 2015, acute care hospitals participating in the Centers for Medicare and Medicaid Services’ (CMS) Quality Reporting Program must report all CAUTIs and CLABSIs occurring on adult and pediatric medical, surgical and medical/surgical wards in addition to the previously required reporting from intensive care units. In addition, changes in reimbursement policies mean that hospitals have up to 5% of their Medicare reimbursement tied to HAI and readmission rates (often related to HAIs) and 1% specifically linked to CAUTI and CLABSI rates.
How can your hospital stay ahead of the curve on preventing device-associated infections and protect both patients and revenues? This article looks at preventing CAUTIs.
CAUTIs by the numbers: The vast majority (70%-80%) of healthcare-associated urinary tract infections are related to indwelling urethral catheters, which 12% to 16% of adult patients have inserted during a hospital stay. Those catheters pose a 3% to 7% daily risk of developing bacteriuria.2 CAUTIs also increase the risk of bloodstream infections. For hospitals, CAUTIs cost between $896-$1,007 per instance, which Medicare and many private insurers will not reimburse. Putting all patients with catheters on antibiotics, as a prophylactic measure does not make sense since this would increase antimicrobial resistance and the risk of Clostridium difficile infection.
Risk factors: The longer a patient has a catheter in place, the greater his or her risk of infection, so the first line of defense against CAUTIs requires reducing unnecessary placement of catheters and removing them as soon as possible. The most recent guidelines from the Society for Healthcare Epidemiology of America/Infectious Disease Society of America (SHEA/IDSA) note that reminders to staff that a patient has a catheter in place with or without stop orders to promptly remove unneeded catheters reduced the CAUTI rate by 53% in one study and that restrictive urinary catheter policies combined with daily review of necessity decreased catheterization from 17.5% to 6.6% of patients in another.
Best practices: Practices recommended for all acute care hospitals include creating and educating staff and clinicians on catheter guidelines, such as acceptable indications for use, insertion by trained staff using aseptic technique and sterile equipment, use of the smallest possible catheter for proper drainage, and prompt removal. In addition, staff should secure the catheter following insertion, maintain a sterile, continuously closed drainage system, and replace the catheter and collection system following any break in aseptic technique, development of leakage or disconnection. The collection bag should remain below bladder level, but not on the floor, and be regularly emptied using a separate collecting container for each patient.
Special practices to consider: If the above techniques do not bring CAUTI rates to acceptable levels, hospitals may require daily review of catheter necessity and electronic reminders of the presence of a catheter and documentation of need for continued use.
Practices to avoid: SHEA/IDSA guidelines recommend that hospitals not use antimicrobial/antiseptic-impregnated catheters routinely. Most cases of bacteriuria in catheterized patients are asymptomatic and hospitals should not screen for infection or treat asymptomatic infections unless the patient is scheduled for an invasive urologic procedure. Unless needed to prevent obstruction, do not continuously irrigate the bladder with antimicrobials or use systemic antimicrobials prophylactically. Catheters should not be changed unless there is an indication of need, such as a break in aseptic technique or leakage.
Measuring success: Metrics that track the number of symptomatic CAUTIs based on days of insertion rather than patient days will understate the success of initiatives that encourage fewer insertions and quicker removal, so hospitals may want to calculate both, as well as the Standardized Infection Ratio (SIR) and the rate of bloodstream infections attributable to CAUTIs. Consider also using process measures that track compliance with documentation of insertion and removal dates and compliance with indication recommendations.
What other actions have you taken to reduce CAUTI rates at your hospital?
2012 CDC National and State HAI Progress Report. CDC.
Device-associated module: Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-Central Line-Associated Bloodstream Infection). CDC. January 2014, updated April 2015.
Lo E, Nicolle LE, Cofn SE, Gould C, Maragakis LL, Meddings J, et al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update. Infection Control, 35, pp 464-479.