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A systematic program for analyzing processes associated with catheter placement and removal for surgical patients decreased urinary tract infections (UTI) for all hospitalized patients. These results are believed to be the first report of a quality improvement effort in surgery to benefit an entire institutional patient population. The program may serve as a model for hospitals to generate their own institution-specific best practice catheter management guidelines. It was described today by physicians from the University of Texas MD Anderson Cancer Center, Houston, at the 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Conference.
UTI is the fourth most common type of health care-associated infection in U.S. hospitals. More than 93,000 UTIs occurred in acute care hospitals in 2011, and they accounted for 12 percent of all hospital-reported infections. Complications from UTI cause patient discomfort, prolong the hospital stay, raise health care costs, and increase mortality. Approximately 13,000 deaths are attributable to UTI each year.1
UTI is commonly associated with the placement of urinary catheters. The Centers for Disease Control and Prevention (CDC) established guidelines for preventing catheter-associated UTI (CAUTI) in 2010.2 ACS NSQIP published best practice guidelines for preventing CAUTI in 2009.3
Based on assessment of their initial outcomes data, a postoperative UTI reduction program was the first surgical quality improvement initiative undertaken by MD Anderson Cancer Center after joining ACS NSQIP in 2011. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals. ACS NSQIP was created by surgeons to help hospitals gauge the quality of their surgical programs and improve surgical outcomes by collecting robust, accurate, and precise clinical patient information and by benchmarking performance of similar hospitals with similar patients.
From a sample of 1,000 surgical cases at MD Anderson Cancer Center in the NSQIP data base, the researchers identified UTIs in 3 of every 100 patients, which was a higher overall rate than expected.
“The NSQIP data were highly detailed, categorized by type of surgery, and tracked the number of postoperative occurrences for 30 days after an operation. Our data analysis determined that urinary tract infections were occurring across all surgical specialties at some level, suggesting that hospital-wide processes rather than surgical subspecialty processes might be involved,” according to lead author Thomas A. Aloia, MD, FACS, an associate professor of surgical oncology at the University of Texas and NSQIP Surgeon Champion at the cancer center.
A surgical quality improvement team headed by Aloia first developed a system to evaluate factors that could be contributing to the UTI rate and bundled them together in an analytical framework that would single out weak points in catheter management. “The quality assessment to quality improvement (QA to QI) program was a way to galvanize clinical providers to assess all the processes around urinary tract catheter placement and management and find the solutions that made the most sense,” he explained.
Their S.T.O.P. UTI program evaluated four categories of catheter management processes and screening for infection: Sterile placement, Timing of removal, Optimal positioning, and Proper sampling. UTI cases were reviewed to determine whether providers were maintaining sterile conditions during placement of urinary catheters, removing catheters according to recognized time frames, positioning catheters so they would not create potential reflux back into the bladder, and obtaining clean, uncontaminated urine samples to validate the diagnosis of UTI.
The surgical quality improvement team partnered with nursing staff and pharmacy as well as frontline personnel, such as advance practice providers and trainees, along with infection control physicians to collect, evaluate, and regularly report data to the surgical faculty.
The S.T.O.P. UTI quality assessment tool identified a specific subset of processes that could be contributing to UTIs. The subsequent targeted quality improvement program reduced the infection rate by 66 percent within 18 months. In total, since program initiation the rate has fallen six-fold, from 2.9 percent down to 0.46 percent. These reductions were estimated to result in 450 fewer UTIs per year and save more than $1 million annually for surgery cases alone.
Interestingly, the best practices put in place in the surgical environment appear to have crossed over to impact the CAUTI rate across the entire hospital, as nonsurgical CAUTI rates have now dropped by half.
As Aloia explained, “There is no single fix for UTIs. Every hospital has a unique culture and historical differences in the ways they manage urinary catheters. So the solutions we make in our institution may be totally different from the solutions in another hospital. S.T.O.P. UTI is a method any hospital can use to assess process in their own setting and find areas where they can improve.”
For example, clinical practice guidelines in the last few years have tended to focus on timely removal of catheters. “However,” Dr. Aloia said, “there are very appropriate reasons to keep catheters in some patients longer than two days. Reducing UTI rates involves more than just removing a catheter in a certain time frame. Every aspect of catheter management should be evaluated before targeting one process for improvement.”
Other study authors are Charles Levenback, MD, and Weiming Shi, MD.
1 CDC. Urinary Tract Infection (catheter-associated and non-catheter-associated UTI) and other urinary system infection events. Accessed July 12, 2016. Available at: http://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf.
2 Gould CV, Umscheid, CA, Agarwal, RK, et al. Guidelines for prevention of catheter-associated urinary tract infection 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-26.
3 ACS NSQIP. ACS NSQIP Prevention of Catheter-Associated Urinary Tract Infection Best Practice Guidelines. Accessed July 12, 2016. Available at http://www.uphs.upenn.edu/surgery/Education/medical_students/BP_Guidelines_UTI.pdf.
Source: American College of Surgeons