Longstanding practice patterns are hard to change, but in a project led by Michigan hospital researchers, 71 organizations reduced their overall percentage of inappropriate urinary catheter use from 18.1% to 13.8% over two years.
The percentage of catheters meeting appropriateness criteria increased from 44.3% to 57.6%, measured in patient catheter days.
"Our results indicate that hospitals can improve appropriate urinary catheter use and that such efforts can be successfully implemented on a broad scale," wrote Sanjay Saint, MD, and co-authors in an article published Monday in the Archives of Internal Medicine.
In a set measurement period of 20-weeks, for example, the percentage of inappropriate catheter use was halved for patients whose only indication was non-obstructive renal insufficiency, and dropped by one-third for patients who were confused or incontinent, which are not justified reasons for a urinary catheter.
The project was sponsored by the Michigan Health and Hospital Association (MHA) Keystone Center, which had seen a 45% reduction at just one hospital after an aggressive nurse-led effort to remove unnecessary catheters in 2007.
An increase in the number of catheter days for each patient is associated with an increase in the number of CAUTIs, or catheter-associated urinary tract infections, as well as other complications. That has prompted hospital infection control teams to step up efforts to remove catheters no longer needed and not insert them unless they're absolutely necessary.
Additionally, the Centers for Medicare & Medicaid Services no longer reimburses hospitals the additional cost of caring for a patient with a urinary tract infection and has set a goal to reduce CAUTI by 25% by next year.
Urinary catheters were said to be appropriate for urinary tract obstruction, neurogenic bladder, urologic study or surgery on contiguous structures, sacral pressure ulcer (stage III or IV) with incontinence, and end of life care.
The interventions in the Michigan project included educating clinicians about the use of catheters, including distribution of "Bladder Bundle" manuals that included step-by-step description of the process, and of making sure to take daily assessments of catheter necessity during nursing rounds.
However, the Michigan researchers said that not all the hospitals improved their rates at the same pace or to the same extent.
"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."