Reducing Healthcare-associated UTIs Requires Both Technical and Behavioral Interventions

Both inappropriate catheter use and rates of catheter-associated urinary tract infections (UTIs) can be reduced in the non-intensive care unit (ICU) setting, but not necessarily in the ICU, through a national prevention program, according to the interim results of a study published recently in the New England Journal of Medicine.

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Although catheter-associated UTIs are among the most common health care—associated infections worldwide,

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they are largely avoidable when recommended infection-prevention practices are followed.

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Both technical and behavioral/culture (socioadaptive) aspects contribute to inappropriate catheter use and high rates of catheter-associated UTIs. This prompted the development of the Department of Health and Human Service's “National Action Plan to Prevent Health Care—Associated Infections: Road Map to Elimination,”

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to reduce catheter-associated UTIs, which not only proved to be unsuccessful, but was actually associated with increased rates.

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Despite this setback, the Agency for Healthcare Research and Quality partnered with the research and education affiliate of the American Hospital Association (Health Research and Educational Trust) and other sponsor organizations in another attempt to reduce catheter-associated UTIs. To achieve this goal, a new nationwide approach intended to ensure US hospital implementation of the Comprehensive Unit-based Safety Program (CUSP)/On the CUSP: Stop CAUTI was initiated. CUSP/On the CUSP: Stop CAUTI is particularly focused on technical and socioadaptive aspects of catheter-associated UTI prevention in non-ICUs and ICUs.

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"About one in five hospital patients has a catheter collecting their urine. Many of them may not actually need a catheter," first author and professor of internal medicine Sanjay Saint, MD, MPH, from the Hospital Outcomes Program of Excellence, Veterans Affairs (VA) Ann Arbor Healthcare System, the Department of Internal Medicine, University of Michigan (UM) Medical School, and the VA/UM Patient Safety Enhancement Program, told Contagion. In order to better this clinical situation, Dr. Saint and his colleagues used a program modeled after one that had been used successfully to reduce bloodstream infections associated with the use of central venous catheters. A total of nine cohorts of hospital units joined this catheter-associated UTI rate reduction program, which was conducted over the course of one year. The baseline period lasted for the first three months of the program.

The interim study results from four of the nine cohorts were more encouraging for non-ICU settings as opposed to ICUs, which represented 59.7% and 40.3% of the 926 assessed hospital units, respectively. Prior to any adjustments in the statistical analyses, the 2.82 catheter-associated UTIs per 1000 catheter-days at three months decreased to 2.19 per 1000 catheter-days at 12 months. This represented a 22.3% decreased for all 926 participating units. In an analysis adjusted for hospital characteristics including size (number of beds), rural or urban location, teaching or nonteaching hospital, and critical-access (Medicare reimbursement) status, rates were significantly decreased from 2.40 infections per 1000 catheter-days at three months to 2.05 per 1000 catheter-days at 12 months. When non-ICU and ICU settings were compared, the observed reductions were found to occur primarily in non-ICUs. More specifically, the non-ICU catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days between 3 and 12 months (P < 0.001), while the ICU rates did not change significantly from the 2.48 infections per 1000 catheter-days at three months to the 2.50 infections per 1000 catheter-days at 12 months (P = 0.90).

As for catheter use in general in the two settings, the unadjusted analysis showed a reduction in use from 19.8% to 18.2% in non-ICUs and from 61.1% to 57.6% in ICUs. Similar to the finding for catheter-associated UTI rates, significant changes were noted for non-ICUs, but not for ICUs. In non-ICUs, use decreased from 20.1% at three months to 18.8% at 12 months (P <0.001) while use in ICUs changed little, from 62.8% to 61.9% between three and 12 months (P = 0.15). Study findings also revealed significant associations between hospital characteristics and catheter use in ICUs, where use was found to be significantly lower in rural, as opposed to non-rural, areas (P < 0.001) and in ICUs in critical-access hospitals, as opposed to those in non-critical-access hospitals (P = 0.03).

Regarding the broader implications of his team's study results, Dr. Saint told Contagion that, "Our program shows we can make a difference in catheter-associated UTI rates and the use of indwelling catheters in the non-ICU setting. Both technical and behavioral interventions are needed to decrease hospital infection. Factors important to the success of our catheter-associated UTI prevention program included a focus on appropriate catheter use and alternatives to the use of an indwelling catheter, emphasis on aseptic insertion when the indwelling catheter is needed, and proper maintenance and removal of the urinary catheter. General infection prevention principles such as proper hand hygiene is also crucial."

William Perlman, PhD, CMPP is a former research scientist currently working as a medical/scientific content development specialist. He earned his BA in Psychology from Johns Hopkins University, his PhD in Neuroscience at UCLA, and completed three years of postdoctoral fellowship in the Neuropathology Section of the Clinical Brain Disorders Branch of the National Institute of Mental Health.

References

1. Saint S, Greene MT, Krein SL, et al. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. N Engl J Med 2016;374:2111—2119.
2. Report on the burden of endemic health care-associated infection worldwide: a systematic review of the literature. Geneva: World Health Organization, 2011. Available at: http://apps.who.int/iris/bitstream/10665/80135/1/9789241501507_eng.pdf. Accessed June 13, 2016.
3. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32: 101—14.
4. National action plan to prevent health care-associated infections: road map to elimination. Washington, DC: Department of Health and Human Services, 2009. Available at: http://www.health.gov/hai/prevent_hai.asp. Accessed June 13, 2016.
5. National and state healthcare-associated infections progress report. Atlanta: Centers for Disease Control and Prevention, 2015 Available at: http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report-2015.pdf. Accessed June 13, 2016.
6. Fakih MG, George C, Edson BS, Goeschel CA, Saint S. Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies. Infect Control Hosp Epidemiol 2013;34:1048—1054.