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Preventing Catheter-Associated Urinary Tract Infection in U.S. Hospitals: From Ideas to Action

Urinary catheters are frequently used in hospitalized patients and result in substantial morbidity and costs due to catheter-associated urinary tract infection (CAUTI). Urinary catheters may also cause non-infectious complications resulting from reduced mobility or urethral trauma from improper placement or removal. Despite the clinical and economic consequences of CAUTI, a 2005 national survey of both VHA and non-VHA hospitals revealed that preventing CAUTI was a low priority for most U.S. hospitals, with little attention given to either CAUTI or urinary catheters as a patient safety problem.1

Several recent initiatives may lead to increased attention on preventing CAUTI, including:

  1. changes in the Centers for Medicare and Medicaid Services (CMS) reimbursement policy to not pay hospitals for the costs incurred for hospital-acquired CAUTI;
  2. publication of CAUTI prevention recommendations by the Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC) and others (www.cdc.gov/hicpac/cauti/001_cauti.html); and
  3. a statewide collaborative in Michigan that focuses specifically on the prevention of CAUTI,2 using an approach that successfully reduced rates of central line-associated bloodstream infection (CLABSI).3

Have these initiatives been effective? While complete results are not yet available, preliminary data collected in 2009 through another national survey suggest there is still much to be done to prevent CAUTI in U.S. hospitals. For example, the CMS payment change does not affect VHA hospitals and so has not increased CAUTI as a hospital priority within VHA. However, even for non-VHA hospitals, of which the majority report that payment changes have led to a moderate to large increase in the prevention of CAUTI as a hospital priority, the reported use of most prevention practices remains low. Specifically both timely removal of urinary catheters and using them only when indicated are perhaps the most effective methods for preventing CAUTI or other catheter-associated complications. Yet, many hospitals—both VHA and non-VHA—do not have a routine system for monitoring catheter placement or discontinuation, and the implementation of effective strategies to promote appropriate use remains elusive. Even in Michigan, where most hospitals have been involved in a program that focuses on the timely removal of urinary catheters, efforts to reduce inappropriate catheter use have been variable.

What can be done? Besides identifying potential gaps in the prevention of health care-associated infection, and specifically CAUTI, the focus of our research is to develop, test, and evaluate strategies to address these gaps. Currently we are working with the Michigan Hospital Association Keystone Center for Patient Safety and Quality and hospitals in Michigan to assess and, building on current efforts, to develop effective CAUTI prevention strategies across hospitals.2 In addition, we look forward to collaborating with the VA's Inpatient Evaluation Center (IPEC) and others as part of a VHA focused CAUTI prevention initiative. While our approach to CAUTI prevention will likely include many of the same general strategies used in prior infection prevention efforts (e.g., the model used by Pronovost and colleagues to reduce CLABSI),3 preventing CAUTI presents several unique challenges: (1) the lack of highly effective products or approaches for preventing CAUTI; (2) the ubiquity of urinary catheter use throughout the hospital and not primarily in a specialized setting like the intensive care unit; and, (3) the limited importance placed on CAUTI prevention by hospital personnel. Challenges notwithstanding, some of the fundamental components for preventing CAUTI include:

  1. A simple summary of key recommendations for preventing CAUTI such as through the mnemonic "ABCDE"(see box).
  2. Engaging nurses as key champions for CAUTI prevention and appropriate urinary catheter use.
  3. Education about catheter risks with particular
  4. emphasis on non-infectious as well as infectious complications.
  5. Use of stop-orders or nurse-based removal protocols, either computerized or paper-based.
  6. Establishing consistent, rigorously derived (yet practical and user-friendly) indications for catheter placement and discontinuation.

Improving patient safety and quality of care requires moving beyond simply disseminating scientific evidence. Nevertheless, identifying and implementing effective strategies to ensure the use of proven practices in real-world clinical settings remains challenging. Our in-depth study of hospital-based infection prevention—with a focus on CAUTI—is an example of research underway throughout VA to address this challenge. While we hope to reduce CAUTI and improve urinary catheter use in hospitals across the United States, our broader goal is to use infection prevention as a model for developing methods for uncovering and then addressing the many complexities that affect the safety of hospitalized patients.

  1. Saint S, et al. A Multicenter Qualitative Study on Preventing Hospital Acquired Urinary Tract Infection in U.S. Hospitals. Infection Control and Hospital Epidemiology 2008; 29:333-41.
  2. Saint S, et al. Translating Hospital-Associated Urinary Tract Infection
  3. Prevention Research into Practice via the Bladder Bundle. Joint Commission Journal on Quality and Patient Safety 2009; 25:449-55.
  4. Pronovost PJ, et al. Improving Patient Safety in Intensive Care Units in Michigan. Journal of Critical Care 2008; 23:207-21.

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