From the 2018 HVPAA National Conference
Jennifer Frontera (NYU Langone Hospital – Brooklyn), Stephanie Sterling (NYU Langone Health), Karen Delorenzo (NYU Langone Hospital – Brooklyn), Archana Saxena (NYU Langone Hospital – Brooklyn), Erwin Wang (NYU Langone Hospital – Brooklyn), Jonathan Austrian (NYU Langone Health), Frank Volpicelli (NYU Langone Health), Joseph Weisstuch (NYU Langone Hospital – Brooklyn), Bret Rudy (NYU Langone Hospital – Brooklyn)
Catheter-associated urinary tract infections are preventable, reportable hospital acquired events associated with increased morbidity and mortality. Excess urinary catheter use leads to increased exposure to infection. Sampling urine from an indwelling catheter for >24 hours may lead to false positive results from colonization and can lead to inappropriate antibiotic administration.
To determine if a protocol of limited urinary catheter placement, early removal, clean urine sampling, and urine screening with reflex culture would reduce the risk of CAUTI and false positive urine cultures due to colonization in a population of critically ill patients.
A multi-disciplinary protocol was developed that established strict criteria for urinary catheter utilization and[Office1] placement and instituted daily assessment for catheter removal. A two-provider assist model for urinary catheter placement was instituted to ensure sterility and appropriate technique. Urine sampling was carefully proscribed to limit false positives due to colonization. For urinary catheters in place for longer than 24 hours, urine samples could only be sent after catheter removal and then via sterile straight catheterization or new catheter placement. To assess for infection, urine culture screening was performed using flow cytometry to determine bacterial load, and a routine urine culture was performed on positive urine culture screens. Education on the new protocol was iteratively rolled out to nurses, residents, and advance practice providers. We compared a pre-protocol three-month epoch from December 2016-February 2017 to a three-month epoch from December 2017-February 2018, allowing for a six-month protocol training period between comparator time frames.
From multidisciplinary education and reeducation initiatives alone, a multi-pronged approach resulted in a decrease in both the incidence of CAUTIs and the use of urinary catheters. In comparing the months prior to and the months following from the launch of educational initiatives, there was a 70% reduction in CAUTI rate. There was an 80% reduction in the number of CAUTIs and a 33% reduction in the number of catheter-days. Best practice alerts are currently live and their effect is currently being assessed.
Multidisciplinary educational initiatives around CAUTI reduction including strict criteria around indications, insertion techniques, and testing for infection have already been successful in reducing both the rate and number of CAUTIs as well as the overall use of urinary catheters. The compounded effect of best practice alerts is being evaluated.
Implications for the Patient
Educational initiatives with structure practices can reduce the rate and number of CAUTIs and decrease the use of urinary catheters.