"Possible differences between high and low performing hospitals might include varying levels of commitment from each institution to make this effort a high priority, or differential involvement of champions to support the effort," they wrote. "External forces influencing the decision to fully adopt safe processes may also play an important role, whether related to public reporting or financial incentives."
The authors acknowledged that their study had some design elements that may have biased the results. First, there was no control group and it may have been that more appropriate catheter use would have happened anyway, perhaps in response to the 2008 CMS policy to deny reimbursement for additional care required by hospital acquired infections.
Also, the authors wrote, the hospitals participating may have been more willing to initiate change in their urinary catheter practices than hospitals that chose not to participate.
Lastly, they cautioned they did not measure changes in rates of catheter-associated infections at these hospitals, only the process measures that logically would have led to a reduction.
In an invited commentary accompanying the article, Michelle Mourad, MD and Andrew Auerbach, MD, of the University of California San Francisco said many hospitals have found it difficult to overcome barriers. Those include lack of knowledge of appropriate urinary catheter use criteria, failure to notice that a catheter is in place especially when it was inserted elsewhere and failure to remove it when appropriate.
Despite the success of bedside placards, computer reminders and stop orders, "clinical implementation of these practices remains low," they wrote, adding that such incentives are used "in fewer than 1 in 10 U.S. hospitals."
They called for a greater emphasis on infection control interventions and better incentives for compliance, and especially in the appointment of a "champion" who is "focused on overcoming barriers to implementation."