Background The most effective way to reduce catheter-associated urinary tract infections (CA-UTIs) is to avoid unnecessary urinary catheterisation and to minimise the duration of catheterisation.
Aim To implement and assess the effect of an intervention to reduce the duration of urinary tract catheterisation.
Methods This quality improvement project was set up as a before–after comparison consisting of a 2-month pre-intervention period, a period in which the intervention was implemented and a 2-month post-intervention period. The intervention included educational sessions to increase physicians' awareness and the daily reassessment of catheter use. The primary endpoint was the duration of catheterisation. Secondary endpoints were the catheter utilisation ratio, the length of hospital stay, the number of hospital-acquired symptomatic CA-UTIs and the number of appropriate indications for catheterisation.
Results During the total study period, 149 patients (18.3%) were catheterised at some time during their hospital stay. There was a statistically significant decrease in the duration of catheterisation (median 7 vs 5 days; p<0.01), length of hospital stay (median 13 vs 9 days; p<0.01), and number of hospital-acquired CA-UTIs (4 vs 0, p=0.04) in the pre-intervention versus post-intervention period.
Conclusions An intervention to raise more awareness of the risks of inappropriate catheterisation can reduce the duration of catheterisation along with the length of hospital stay and the number of hospital-acquired symptomatic CA- UTIs, even in a short period of time.
- Healthcare quality improvement
- Nosocomial infections
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Indwelling urinary catheters are widely used in hospitalised patients. Between 15% and 25% of hospitalised patients have a urinary catheter placed some time during their hospital stay.1 ,2 Common indications are urinary retention or monitoring of urine output in critically ill patients. Unfortunately, the use of indwelling catheters has associated risks, such as the development of urinary tract infections (UTIs) which account for nearly 40% of all hospital-acquired infections. Approximately 80% of these UTIs are associated with the use of urinary catheters and the duration of catheterisation is the most important risk factor.1–3 Catheter-associated (CA) UTIs can lead to increases in length of hospital stay and healthcare costs.4 ,5
Although catheterisation can be an essential intervention in patient care, indwelling urinary catheters are often used unnecessarily. In 21–54% of catheterised patients the urinary catheter is inserted without appropriate indications.2 ,6–8 Even when catheterisation was initially properly indicated, catheters often remain in situ longer than clinically necessary. This is partly due to the fact that physicians are often unaware that their patient has a urinary catheter.9 The most effective way to reduce CA-UTIs is to avoid urinary catheterisation and to minimise the duration of catheterisation. Several interventions have proven to be successful in reducing inappropriate urinary catheter use and CA-UTI rates. These interventions include catheter placement restrictions such as the requirement of a physician's order, nurse-led or computerised daily reminders to review the need for catheterisation, and prewritten stop orders to remove catheters when criteria for catheterisation were not met.10–16 The aim of this quality improvement project was to reduce the duration of urinary catheterisation and the number of hospital-acquired CA-UTIs on an internal medicine department in a university hospital in The Netherlands.
Setting, patients and data collection
This study was conducted on three wards of the internal medicine department (total number of 50 beds) of the Academic Medical Centre (AMC) in Amsterdam, The Netherlands. It was set up as a before–after comparison consisting of a pre-intervention period (April and May 2012), a period in which the intervention was implemented (June 2012) and a post-intervention period (July and August 2012). All consecutive patients who had an indwelling urinary catheter inserted some time during their hospitalisation were included in the study. Patients who were chronically catheterised before admission, who had a condom catheter, suprapubic catheter or who were practicing intermittent catheterisation were excluded.
During both periods a trained research nurse (JJ) visited the wards daily to identify all catheterised patients. Data were collected through medical record review or provided by nursing staff. Patients' age, sex, admission diagnosis, duration of catheterisation and hospital stay (in days), and the initial indication for insertion of the urinary catheter were determined. Furthermore, the patients' comorbidity status was assessed using the Charlson Comorbidity Index,17 a weighted cumulative score based on 17 disease groups. Data concerning the length of hospital stay of all patients admitted to the internal medicine department were retrieved from a database of the hospital production registration system.
The purpose of the pre-intervention period was to collect baseline data to develop the best suitable interventions for our hospital. These findings were presented to a multidisciplinary team consisting of two internal medicine specialists, a resident, three senior staff nurses, a research nurse, a clinical microbiologist and an infection prevention practitioner. The pre-intervention period revealed that, at our department, most initial indications for urinary catheter use were appropriate (89.2%, see results). Therefore, the intervention mainly focused on reducing the duration of catheterisation.
Next, we wanted to increase the awareness of physicians about the significance of prompt removal of urinary catheters when no longer necessary. Therefore, an educational session was held. The nursing staff were informed during separate educational sessions on each participating ward. Physicians and nurses were required to discuss the necessity of each patient's urinary catheter during the routine bedside discussions, which are held daily for each individual patient at our department. The nursing staff were encouraged to remind physicians to remove unnecessary urinary catheters. Furthermore, posters were displayed at doctors' offices and coffee rooms to serve as a continuous reminder.
Endpoints and definitions
The primary endpoint was the duration of catheterisation. Secondary endpoints were the catheter utilisation ratio (defined as the total number of catheter-days divided by the total number of patient-days), the duration of hospital stay, the number of hospital-acquired symptomatic CA-UTIs and the number of appropriate indications for catheterisation. A hospital-acquired symptomatic CA-UTI was defined as significant bacteriuria that occurred after admission to the hospital, accompanied by symptoms or signs attributable to the urinary tract with no other identified source of infection in patients with a urinary catheter in place within the previous 48 h prior to infection onset.1 Appropriateness of indications for catheterisation was based on previously published guidelines (see also table 3).1 ,3 ,6 ,18
Statistical analyses were carried out using SPSS V.19 (IBM, Armonk, New York, USA). Categorical variables are presented as frequencies and continuous variables as median with range. The differences between the study periods were assessed by χ2 tests (for categorical variables) and Mann–Whitney U tests (for continuous variables). Differences were considered to be statistically significant at p<0.05.
A total number of 816 patients were admitted to the internal medicine department during the total study (pre-intervention and post-intervention) period and 149 patients (18.3%) were catheterised at some time during their hospital stay. These 149 patients (74 in the pre-intervention period and 75 in the post-intervention period) were included in our study. The median patient age was 66 years (range 20–95), and 74 (49.7%) of the patients were men. All other demographic and clinical characteristics of the study population are listed in table 1. No statistically significant differences in demographic data were found between the pre-intervention and post-intervention period in terms of age, sex, principle diagnosis, Charlson comorbidity index score or in-hospital mortality.
The length of hospitalisation significantly decreased among catheterised patients in the post-intervention period (median 9 days) compared with the pre-intervention period (median 13 days) (p=0.01). However, the median duration of hospitalisation of all patients (catheterised and non-catheterised) at the internal medicine department did not differ between the two study periods (4 days in the pre-intervention vs 4 days in the post-intervention period; p=0.31).
Urinary catheter use and CA-UTIs
During the pre-intervention period, 74 patients (18.6%) had a urinary catheter inserted and 75 patients (17.9%) during the post-intervention period. Regarding the primary endpoint, the median duration of catheterisation significantly decreased after the intervention (7 days in the pre-intervention vs 5 days in the post-intervention period; p<0.01; table 2). The catheter utilisation ratio (total catheter-days divided by total patient-days) decreased non-significantly from 0.63 to 0.60. Four patients (5.4%) developed a CA-UTI during the pre-intervention period and no patients developed a CA-UTI during the post-intervention period (p=0.04). This corresponds to a reduction in CA-UTI rates (4.0 vs 0 infections per 1000 catheter-days).
Indications for urinary catheter insertion are listed in table 3. In this study, most initial indications were appropriate (89.2% in the pre-intervention vs 94.7% in the post-intervention period (p=0.22)), with the majority of appropriate catheterisations being for ‘monitoring of urine output’. Only a few urinary catheters were inserted with an initially inappropriate indication (10.8% in the pre-intervention vs 5.3% in the post-intervention period (p=0.22)).
The aim of this quality improvement project was to reduce duration of catheterisation for patients admitted to the department of internal medicine. Our study revealed that an intervention to raise more awareness of the risks of inappropriate catheterisation reduced the mean duration of catheterisation, length of hospital stay and number of hospital-acquired CA- UTIs. However, the catheter utilisation ratio remained nearly the same (δ −0.03), which is a result of the decreased duration of hospital stay during the post-intervention period in this patient group. Nevertheless, this shorter hospital stay cannot be explained by a difference in severity of illness, as the Charlson comorbidity index remained the same during both study periods. Moreover, the duration of hospitalisation of all patients admitted to the internal medicine department did not differ between the two study periods. We speculate that the observed decrease in length of hospital stay of the catheterised patients is also a result of our intervention. This is supported by the findings of others, who found a decrease in the duration of catheterisation and in length of hospital stay after an intervention to remind physicians to remove unnecessary catheters.12 ,19 ,20
The strength of this quality improvement project is that we demonstrated that it is possible to improve patient care by reducing the duration of catheterisation, as recommended by several guidelines,1 ,3 ,18 with simple and cheap interventions in a short time period. Furthermore, we found a reduction in the incidence of symptomatic CA-UTIs that might be due to the decreased duration of catheterisation.
Our study has several limitations. It was conducted in one department (internal medicine) at a single university institution, which limits the generalisation of our results. However, the demographic characteristics showed that our patient population was representative of general medical patients. Furthermore, the appropriateness of urinary catheter use was only examined at the time of insertion based on the indication for catheter insertion and was not prospectively evaluated on a daily basis. A recent study, prospectively evaluating the appropriateness of catheter use, found that 31% of the catheter days were deemed to be inappropriate.21 Therefore, we think that we might have underestimated the number of inappropriate indications. Finally, the data collection during the post-intervention period was rather short. However, even within this short period, we were able to reduce the duration of catheterisation and hospitalisation, and number of symptomatic CA-UTIs. Furthermore, we did not evaluate the influence of each individual intervention, which may decrease the generalisability. However, we have integrated the catheter item on the checklist of the daily rounds, because we believe that this may have been the key ingredient of this intervention, which could be implemented in other institutions where rounds are conducted in multidisciplinary teams.
Recently, the awareness of the problem of CA-UTIs and interest in their prevention has increased tremendously. Several intervention studies have focused on strategies to limit the use and duration of urinary catheters and to decrease CA-UTI rates. Most effective strategies described are reminder systems to reassess the need for a urinary catheter.10 Nurse-generated daily reminders can significantly reduce the duration of catheterisation, inappropriate catheter use, CA-UTI rate,12–14 ,22 length of hospital stay, and hospital and antibiotic costs.12 Reminder stickers or prewritten stop orders, but also a computerised order entry system, linked with an automatically generated computer reminder to the ordering physician 3 days after placement have been shown to be successful as well.15 ,16 ,23
Commitment to the intervention and constant awareness, even after the intervention, is crucial to induce a sustained reduction in catheter use. Several studies observed an increase in catheter use when the intervention had ended.14 ,24 ,25 When the intervention was resumed, the catheter use decreased again.24 ,25 This indicates that long-term commitment and repeated efforts are necessary to sustain the obtained results. Therefore, we structured the daily reminder into the checklist of the routine ward rounds. Furthermore, we implemented a sheet in our set of quality improvement checklists that are carried by every physician and resident in our hospital.
To summarise, we showed that raising more awareness among physicians and nurses by daily reassessment of catheter use can reduce the duration of catheterisation. Furthermore, we showed a reduction in the length of hospital stay and the number of symptomatic CA-UTIs. We can only hypothesise that this shorter hospital stay was also a result of our intervention. Although not directly measured, we expect substantial cost savings by the reduction of length of hospital stay and CA-UTI incidence.
The authors would like to thank all other members of the project group, Carla van Elzelingen (infection prevention expert), Joppe Hovius (resident internal medicine), Peter Sluijter (senior staff nurse), Fatiha Stitou Laaroussi (senior staff nurse), Marc van der Valk (internal medicine specialist), and Gwenda Veenboer (senior staff nurse) for their participation and support.
Contributors JJ designed the study, wrote the protocol, collected the data, did the analysis, and wrote the manuscript and answered the reviewer comments. BMB analysed the data. SEG was the supervisor, received the grant, designed the study, wrote the protocol and manuscript and answered the reviewer comments. All authors discussed the design and contributed to writing the manuscript.
Funding This work was supported by the Institutional Board of the AMC to improve the quality of patient care.
Competing interests SEG has received compensation from Astratech Sweden for an International Advisory Board about catheter-associated urinary tract infections.
Ethics approval Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.
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