Catheter-associated urinary tract infections are the Rodney Dangerfield of nosocomial infections. Too many nurses and doctors are inserting Foley catheters without sufficient regard for what is a potentially dangerous invasive device.
CAUTIs, or catheter-associated urinary tract infections, just aren't taken very seriously by many hospital providers. And that means doctors and nurses are missing opportunities to help their patients immensely, not just during their hospital stays but for months after they've been discharged.
In fact, "CAUTIs are the Rodney Dangerfield of nosocomial infections. They just can't get any respect," says Sanjay Saint, MD, a liaison to the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee and an infection expert at the University of Michigan Medical School.
OK, I laughed when he said that during a phone interview this week, even though my own painful encounters with such infections decades ago were hardly funny.
But Saint, an author of two influential papers published this week in JAMA Internal Medicine that examined efforts to reduce CAUTIs in Michigan and in the rest of the country, wasn't throwing a punch line. He was quite serious.
The problem is that in many hospital settings too many nurses and doctors are inserting "the Foley" for their own convenience, without regard for whether the patient really needs what should be regarded as a potentially dangerous invasive device, he says. And too many nurses and doctors fail to assess on a daily basis whether it's time for the catheter to come out, a proven strategy that reduces CAUTI rates.
In part, Saint blames the fact that what we measure in terms of outcomes in catheter use is all wrong. We only measure when their use results in an infection. What we also should measure, he says, are events like falls that occur when patients try to get up to use the toilet and trip on the catheter tubing.
See Also: 3 Reasons Urinary Catheters are Overused in Hospitals
There are also a lot of other uncounted adverse events linked to catheters, such as "trauma at the time of Foley insertion, or inadvertent removal with the balloon fully inflated that can lead to urethral trauma and blood in the urine," he says.
The people who measure outcomes from catheter use should also consider the pain and discomfort the catheters cause patients who have to live with them. Worse, perhaps, is that the immobility they encourage can lead to pressure ulcers and blood clots. "There are all these non-infectious complications associated with the Foley," he says.
Do most providers appreciate that? No, he says. Part of the issue is that unlike its more serious kin, the central line-associated bloodstream infection or CLABSI, whose infection rates have been dramatically reduced, CAUTI rates have stayed relatively static.
"The single most important way to prevent CLABSI is to put chlorhexidine gluconate rather than povidone-iodine in the central venous catheter tray," Saint says. "Once you do that, by default, people who insert the catheter will use chlorhexidine, and this single intervention will reduce infections 50%.
But with CAUTI, there is no such simple technical solution. The main interventions require more challenging behavior changes, "and that's the reason CAUTIs will not likely be decreasing at the same rate as CLABSIs," Saint says.
Sarah Krein, a co-author on the two papers with Saint, pointed out during an interview this week that many nursing staff don't fear the CAUTI as much as they do other infections because, "it's just one of those events that people think is very treatable. A lot of nurses have experienced UTIs themselves, and they haven't died."
Additionally, mortality from CAUTI is relatively rare, occurring usually when the infection gets into the bloodstream, which Saint says happens in only 1% to 3% of patients, and usually just to those who are already very sick with serious illnesses or compromised immune systems.
She and Saint say that providers also believe— lthough there is little evidence this is so and in fact the opposite may be true—that if they remove the catheter, the patient will be more likely to get out of bed and fall perhaps trying to find the bathroom. In fact, since having a catheter prompts the urge to urinate, patients may try to get out of bed more often, forgetting the catheter is attached.
In any case, failure to understand the seriousness of the Foley keeps providers from considering the negative impact on sedentary patients' muscles and strength when their ability to move is constrained.
"I think we need to reframe the discussion," Saint says. "Rather, we should think about catheter use in terms of enhancing patient mobility."
Maybe, in addition to having penalties for 30-day mortality or 30-day readmissions, there should be a 30-day fall rate or 30-day pressure ulcer rate for patients who had or have catheters, I suggested.
"From a patient's perspective, that's exactly what they would want," Saint replies. "A lot of hospitals are concerned about falls that occur during hospitalization because that's a medical-legal risk they incur.
"We worry about falls that occur during hospitalization, but from the patient's perspective, it doesn't matter if they fall during hospitalization, or during their nursing home stay, or at home. A fall… is a fall… is a fall, with potential consequences including grave ones like hip fracture. Or even death," he says.
And then, there are the federal financial incentives, which have all but ignored the hospital-acquired CAUTI.
It didn't start out that way. CAUTIs were among the original eight hospital-acquired conditions, for which Medicare would not reimburse hospitals under authority of a 2005 law as of Oct. 1, 2008. But in fact, very few hospitals have failed to recapture reimbursement for extra CAUTI-necessitated care.
That's because patients who develop urinary tract infections are usually so sick, they have many serious diagnoses that merit payment under different diagnostic related group codes. "The hospitals get reimbursed anyway," Saint says
It was anticipated that like CLABSI, CAUTI would be folded into the value-based purchasing algorithm Oct. 1, 2014. But inconsistency in the way various hospitals measure CAUTIs—for example, how many colony forming units a urine sample must have before it's classified as infected, has prompted the CDC to return to the measurement board for a standard definition.
For Saint and Krein, there are positive signs. Hospitals across the country are getting better. "We're increasingly seeing hospitals ask if a patient still needs that Foley." A new survey being sent out to hospitals across the country this year will update progress.
At the University of Michigan and the Ann Arbor VA Medical Center, Saint and Krein and their colleagues have been working on catheter use "since before it was sexy to study CAUTI," he says. They've even developed a CAUTI cost calculator, that should get hospital finance chiefs interested in understanding the impact CAUTI has on hospital bottom lines.
At long last, he hopes, CAUTIs may get the respect they deserve. Eventually.