Three cultural habits within hospitals, including "general disinterest" among staff, can hinder catheter-associated urinary tract infections prevention efforts, researchers find.
It's not surprising that Michigan's hospital caregivers adopted proven strategies to prevent catheter-associated urinary tract infections (CAUTIs) faster than hospitals in other states, and had lower infections overall. It was Michigan, after all, that launched the 2007 Keystone Project, which has become a model for reducing infections nationwide.
But even in the Wolverine state, three troublesome obstacles continue to block the use of best practices in most settings.
That's according to a pair of studies published Monday in JAMA Internal Medicine by Michigan researchers who used survey responses and in-person interviews in hospitals.
The survey was conducted two years after implementation of the Keystone Bladder Bundle Initiative that dramatically reduced CAUTIs in that state and which has since been the topic of numerous other infection control projects around the country, such On the CUSP (Comprehensive Unit-based Safety Program to Eliminate Healthcare-associated Infections.)
Though the findings generally noted improvement across the nation, "we found there's a lot more room for improvement" in non-Michigan hospitals as well as those in Michigan, says Sanjay Saint, MD, a principal author in both studies who directs the Veterans Administration and University of Michigan Patient Safety Enhancement Program. He adds that success in preventing CAUTI is low-tech, requiring cultural changes rather than structural innovations or the purchase of expensive equipment.
While CAUTIs relatively rarely result in bloodstream infections and aren't usually associated with extremely expensive care or mortality, "how a hospital uses evidence based prevention techniques gives insight into how that hospital deals with similar types of hospital-acquired conditions, such as falls, pressure ulcers and clostridium difficile infections," he says.
The first of the two reports found that even in Michigan hospitals, three cultural habits block better CAUTI prevention efforts, explains Sarah Krein, PhD, RN, another principal investigator who is a general medicine research associate professor at the University of Michigan.
One habit that infection preventionists, clinical personnel, and senior executives have complained about is that they have had trouble getting physicians and nurses to understand the importance of removing catheters as soon as possible to prevent infections.
"CAUTI prevention just isn't always that high on their radar screens," Krein explains. "In some hospitals, physicians really don't pay that much attention to it because they have other things on their minds, and at some hospitals, there were physicians who thought there was no reason to pay attention to this. There was general disinterest."
Part of the problem is the concern, somewhat unfounded, that if urinary catheters are removed, patients will be more likely to try to go to the bathroom on their own and will fall, she says. However, the opposite could occur. People with catheters may not realize they have them, try to make their way to the bathroom on their own, and then trip.
For some nurses, removing a catheter may mean they have to spend more time helping patients go to the bathroom, "and that means they don't have as much time for other patients," Krein says.
A second habit identified by survey responders is that catheters are initially placed, or not removed as soon as they could be, because patients or their family members request them, which surprised Krein and Saint. Patients and families request them perhaps because the patient is incontinent, or feels humiliated, she says.
"When family members requested it, it was usually a loved one who thought it might be painful for the patient to get out of bed."
The third "key culprit" is placing catheters that don't really need to be inserted. Krein says, it is emergency department staff who place them out of habit and convenience, and because they are busy, regardless of whether the patient really needs an indwelling catheter.
Survey responders complained that they were frustrated because so many patients were being admitted with them. "They'd say to the ED, 'Hey guys, we have these criteria to get rid of these devices, but you keep sending them to us, sometimes without orders.' "
"In most EDs, there aren't a lot of restrooms, and it takes time to go get a bedside commode. Or if staff need to get a urine specimen, they would insert an indwelling catheter so they wouldn't have to deal with it."
Krein emphasized that these were some of the issues that Michigan researchers heard from the providers they interviewed.
In the second JAMA report, the researchers surveyed 78 hospitals in Michigan and 392 in other states. They found that Michigan hospitals were more likely to have reminders or stop orders to prompt nursing staff to check daily for catheter necessity and to use bladder ultrasound testing for monitoring bladder health after catheter removal.
Likewise, comparing data collected by the Centers for Disease Control and Prevention, Michigan hospitals reduced rates of CAUTI by 25% between 2009 and 2010, while hospitals in other states reduced infections by only 6%.
Saint says that providers throughout the nation need to understand that the placement of an unnecessary urinary catheter may have other long-standing repercussions that not only can lead to poorer patient outcomes, but cost the hospital money in longer lengths of stay and lower reimbursement when CAUTI joins central line associated bloodstream infections in Medicare pay for performance initiatives.
Those repercussions can take the form of pressure ulcers, lack of muscle strength, balance problems and falls not just within the hospital, but after the patient is discharged to home simply because the patient was catheterized in bed for long periods of time. "There are a lot of non-infectious harms related to the Foley catheter," he says.
A survey to update those findings is underway this year, and both Saint and Krein say they hope to see much better adoption of infection prevention strategies, not just in poorer performing states, but in Michigan as well.
In an invited commentary, Paul Pottinger of the University of Washington, Seattle, Division of Allergy and Infectious Diseases, writes that "fewer than half of American hospitals are thought to deploy CAUTI prevention techniques in an organized fashion," even though there is a lot of documentation that the CAUTI prevention bundle can reduce infection rates.
The three obstacles Saint and Krein identified in their report are surmountable, Pottinger writes: "Education, empowerment, and engagement… nothing high-tech, nothing particularly expensive or glamorous. But these steps should yield real results."