A Paradox: Successful Urinary Catheter Reduction Initiative Leads to Increased CAUTI Rates

Background:

Catheter-associated urinary tract infections (CAUTIs) have become a target for systematic reduction efforts due to the fact (1) they are the most common hospital acquired infection; (2) they lead to excess cost, length of stay and patient morbidity; (3) evidence-based interventions exist to reduce these infections; and (4) CMS will no longer pay for the costs incurred by the rising case complexity due to hospital acquired CAUTIs.

Objective:

Despite broad-based education, hand-hygiene and environmental cleaning initiatives, CAUTI rates had not fallen over a 5 year period and, therefore, became an institutional target for rate reduction.  Our goal was to reduce both catheter associated urinary tract infections and urinary catheter use in all patient care units at Stamford Hospital.

Methods:

The CAUTI reduction initiative included the following key elements: (1) Nurse-driven catheter removal protocol; (2) CPOE  requirement for documentation of catheter insertion criteria; (3) Device specific charting module added to MD electronic progress notes; and (4) Biweekly unit-specific feedback on catheter use rates and infection rates.

Results:

Facility-wide indwelling urinary catheter use was successfully reduced by 32%, from 0.22 to 0.15 catheters/ patient-day over the 18 month implementation period.   This resulted in a 45% reduction in CAUTI from 4.78 to 2.64 infections/1000 catheter-days.  The ICU had assumed a leadership role in this effort since their data are reported to NHSN.  Catheter use reduction here was dramatic, falling 50% from 0.78 to 0.39 catheters/patient-day.  This reduction resulted in a decreased CAUTI rate when analyzed by patient-days (a 26% reduction to 2.91 infections/1000 patient-days), but a paradoxical 40% increase in CAUTI rate by NHSN definitions, from 5.35 to 7.48 infections/1000 catheter-days.

Conclusions:

We successfully reduced the facility-wide use of indwelling urinary catheters and their associated infections over an 18 month period.  The most successful component of this initiative was the nurse-driven catheter removal protocol.  Successful reduction in catheter use is most readily achieved by removing the low-risk catheter.  Many critical care patients legitimately require indwelling catheterization, leaving the high-risk catheter as the denominator.  We showed that although total numbers of CAUTI were reduced in the ICU, current NHSN standards requiring catheter-days to be the denominator resulted in an unfortunately misleading and paradoxical increase in CAUTI rates (40% in our case).  As clinical programs successfully reduce urinary catheter use, the appropriate denominator should become CAUTI per 1000 patient-days.  This would more accurately reflect the success of similarly aggressive patient safety programs.