Daily Reminders and Earlier Removal of Central Venous and Urinary Catheters
Abstract & Commentary
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: In this before-after study in a surgical ICU, addition to the daily physician worksheet of a red box requiring the checking of "yes" or "no" to continued need for central venous and urinary catheters was associated with a significant reduction in the duration of catheterization.
Source: Seguin P, et al. Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization. Intensive Care Med 2010 18 Mar 2010; Epub ahead of print; doi: 10.1007/s00134-010-1829-1.
This study from a surgical ICU in a french university hospital sought to determine the effect on catheterization duration of a daily reminder notifying physicians that the patient had a central venous catheter (CVC) or urinary tract catheter (UTC) and asking whether there was continued need for that catheter. The authors used a before-and-after study design. In the "before" period, the number and duration of CVCs and UTCs in the unit were tracked for a 10-month period, along with the incidence of catheter-associated infections and clinical patient data. For 10 months, starting 2 months after the "before" phase ended, a red box questioning the continued utility of the catheter was added to every daily physician worksheet for all patients with CVCs or UTCs. As part of the routine charting and ordering for each patient every day, the physician was required to check "yes" or "no" to the continued utility of the catheter. If "no" was checked, the nurses in the unit removed the catheter that day.
There were 676 patients in the "before" period and 595 in the "after" period. Duration of catheterization (median [interquartile range]) was significantly less in the "after" period: for CVC, from 5 (3-9) to 4 (3-7) days (P < 0.001), and for UTC, from 5 (3-11) to 4 (3-8) days (P = 0.010). For CVCs, the incidence of catheter-related infections fell from 1.8% to 0.3% (P = 0.029 unadjusted, and 0.010 when adjusted for age, diagnosis, and SAPS II score) in the second study period, although the difference in incidence per 1000 device-days (2.8 vs 0.7) was not different after adjustment as mentioned (P = 0.051). For UTCs, the incidence of catheter-related infections was not different (4.3% vs 3.0%; P = 0.23 after adjustment), and the same was true for the rate per 1000 device-days (5.0 vs 4.9; P = 0.938). The authors conclude that, "This study showed that a simple reminder on the patient's daily care sheet significantly decreased the duration of central venous and urinary tract catheterization."
This study has a number of potentially important design problems, the paper omits aspects of the methods and potential discussion points that could have bearing on its validity, and the causality imputed in the authors' concluding statement is assumed rather than demonstrated by the results. In the methods section, the historical baseline durations of CVCs and UTCs in the authors' unit are given as 8 ± 6 and 9 ± 7 days, respectively, yet the observed median "before" rates preceding the intervention described were 5 days in each case. This substantial discrepancy and its relationship to the 1-day average reduction in duration for both catheters following the intervention are not discussed. A concern is that the daily reminder may not have been the only thing different with respect to physicians' tendency to remove catheters sooner than in the past. It is not possible from the information in the paper to assess this or several other questions about the methods, or about other aspects of care in this particular ICU that might have affected the study's findings.
These design and interpretation difficulties notwithstanding, though, the association between the physician reminder and a shorter duration of catheterization supports the notion that changing clinician behavior is an important step in improving outcomes in the ICU. For catheters in ICU patients, time is money. That is, the longer patients have them, the more it costs in terms of the devices and their care, and also in terms of complications. When patients no longer need CVCs and/or UTCs, getting them out as quickly as possible is not only cost-effective but more importantly is also better for the patients in several ways.