Visiting Scholar Takes on CAUTIs
When catheter-associated urinary tract infections (CAUTIs) were not reduced at The Ohio State University Wexner Medical Center after clinical decision support (CDS) interventions were implemented, ABMS Visiting Scholar Zachary N. Gordon, MD, was asked to figure out why.
“CAUTIs are one of the most common healthcare-associated infections,” said Dr. Gordon, who finished his residency last month, serving as Chief Resident in the Department of Urology at Wexner Medical Center. He also served as Chair of the Resident Quality and Patient Safety Forum, the CAUTI Reduction Task Force, and a Sentinel Event Alert Workgroup evaluating the safe use of health information technology. “It’s important for urologists to be leaders in hospital-wide efforts to reduce CAUTIs. As the experts in catheter use, we work with our colleagues in infectious disease and epidemiology who are experts in infection prevention and control,” he added.
The “why” turned into Dr. Gordon’s research project for the Visiting Scholars Program, now in its second year. The one-year, part-time program facilitates research projects designed to improve patient care. The program also exposes the scholars to the fields of professional assessment and education, health policy, and quality improvement (QI).
The evidence-based CDS interventions that were implemented included restricting catheter use to six specific indications. Providers were required to specify the indication for catheter placement at order entry. A nurse-driven catheter removal protocol, which was embedded in the order for placement, empowered nurses to discontinue catheters when patients no longer met the criteria for use without having to obtain an additional physician order. Computer alerts reminded physicians and/or nurses to assess catheter necessity daily, and either document the indication for ongoing catheter use or remove the catheter per the protocol. But 18 months after implementing the CDS interventions, catheter utilization had not declined.
In order to determine compliance with the indications for catheter use, Dr. Gordon conducted an audit of 100 consecutive inpatients in non-intensive care unit (ICU) locations with indwelling urinary catheters across Wexner’s three hospitals. He performed a retrospective chart review to determine if the indication selected was valid and appropriate for each patient. Dr. Gordon found that the indication of “accurate measurement of urinary output in the critically ill” was so vaguely worded that it likely resultedin its inappropriate selection and unnecessary urinary catheter use. The indication was intended to mean hourly monitoring in ICU patients, he explained. And it wasn’t the only indication that was unclear.
Dr. Gordon and his team also started revising the hospital guidelines on CAUTI reduction and prevention to clarify the appropriate indications. Before being implemented, however, the revised guidelines must be approved through the Evidence-Based Medicine Review Committee. Once approved, the team will roll out educational efforts explaining the newly worded indications, said Dr. Gordon, who in addition to being an ABMS Visiting Scholar was named the inaugural Science and Quality Scholar for 2016-2017 by the American Urological Association.
Next, the team turned its attention to urine cultures because the cultures are obtained for the evaluation of fever and largely used to identify CAUTIs. Team members reviewed all CAUTIs at Wexner for a five-month period using the National Healthcare Safety Network’s surveillance definition. The team found that most patients with CAUTI had alternative explanations, such as pneumonia or bacteremia, for their fevers. Obtaining unnecessary urine cultures when patients have a fever unrelated to the catheter could falsely increase CAUTI rates and result in inappropriate use of antibiotics, he said. “These findings told us that we really need to do a better job of antibiotic stewardship and making decisions about when to order a urine culture,” added Dr. Gordon, who began a two-year Clinical Informatics Fellowship at the Regenstrief Institute on the Indiana University - Purdue University Indianapolis campus this month. The Regenstrief Institute is an internationally respected informatics and health care research organization, recognized for its role in improving quality of care, increasing efficiency of health care delivery, preventing medical errors, and enhancing patient safety.
The majority of evidence-based CAUTI prevention strategies published in the past decade have primarily focused on reducing catheter use and appropriate indications for catheter use. “Although the guidelines state you need to evaluate a patient and look for other sources of fever before attributing it to CAUTI, little attention has been given to the appropriate evaluation of fever and ordering of urine cultures,” Dr. Gordon explained. To address this gap, revising the hospital guidelines also will serve to reinforce the appropriate indications for obtaining a urinalysis and/or urine culture, as well as discourage the practice of obtaining “pan cultures” in response to fever.
Another QI process will begin as the team rolls out the newly worded guidelines. Implementing any type of QI intervention requires significant education, noted Dr. Gordon, who won best poster presentation for this QI project at ABMS’ QI Forum held in May 2016. Consequently, the team is in the process of determining how best to educate the physicians and nurses about further optimizing urinary catheter utilization. Measuring compliance and conducting ongoing audits are useful in assessing compliance with the CDS interventions. Although the nurses were more than 90 percent compliant with physically documenting the interventions, Dr. Gordon said, the substance of their documentation was often incorrect. The audit was instrumental in providing such insights, he said, adding, “What we’ve learned from this process could apply to other healthcare-associated infections such as central line-associated bloodstream infections and C. difficile infections.”
Did you know?
Urinary tract infections (UTIs) are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network, according to the Centers for Disease Control and Prevention. Among UTIs acquired in the hospital, approximately 75 percent are associated with a urinary catheter. Between 15 percent and 25 percent of hospitalized patients receive urinary catheters during their hospital stay.