UTIs create a danger field, but they get no respect
Catheters go unchecked, infections not reported
Though they are the most common infectious complication in hospitals, urinary tract infections (UTIs) get no respect.
"UTIs are the Rodney Dangerfield of nosocomial infections," says Sanjay Saint, MD, MPH, Professor of Medicine at the University of Michigan Health Systems in Ann Arbor.
Before we explore the reasons for this historical apathy, it should be noted that it is all about to change. The Centers for Medicare & Medicaid Services' (CMS) recent decision to halt payment on additional costs generated by UTIs and two other infections (mediastinitis, catheter-related vascular infections) is getting the respectful attention of many a hospital administrator. Arguments against the CMS changes note that not all infections are preventable and cite the possibility of unintended consequences such as increased testing and possible inappropriate treatment for hospital patients on admission.
However, Saint is the lead author of a recent study that could scarcely be more damning to hospitals with regard to UTI prevention.1 In findings that bolster the CMS contention that many UTIs are preventable, Saint and colleagues found that urinary catheters — a well-established risk of infection if not removed as soon as possible — are not even monitored at a large number of hospitals. In a particularly striking finding, one-third of hospitals surveyed did not conduct any type of UTI surveillance. "If you don't track the infection, how will you know that you are reducing it or preventing it?" he tells Hospital Infection Control. "It does indirectly bolster [the CMS] argument that hospitals need to do more to prevent nosocomial UTIs. I think it will further incentivize hospitals to focus on prevention of catheter-related [CR-]UTIs."
No standardized prevention method
The researchers surveyed infection control professionals in 719 U.S. hospitals asking about their current practices to prevent UTIs. The overall survey response rate was 72%. Overall, 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Despite the strong link between urinary catheters and subsequent UTI, the authors found no strategy that appeared to be widely used to prevent hospital-acquired UTIs. The most commonly used practices — bladder ultrasound and antimicrobial catheters — were each used in fewer than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in less than 10% of U.S. hospitals, they concluded. "It points out that hospitals don't have a standardized approach to preventing the most common nosocomial infection," Saint says.
UTIs can be deadly
The conventional wisdom is that UTIs rarely lead to serious or fatal infections, but the Michigan Health & Hospital Association's Keystone Center for Patient Safety & Quality estimates that 5% of all deaths caused by health care-associated (HAI) infections are from CR-UTIs. That's 5,000 fatal infections if one uses the typical ballpark figure of 100,000 HAI deaths annually. In addition, the sheer number of UTIs is overwhelming with indwelling urinary catheters ("Foleys") being placed into 15%-25% of patients admitted to acute care hospitals. On an annual basis in U.S. hospitals there are some 5 to 9 million indwelling urinary catheters placed into patients during their admission, the Keystone Center estimates.
Essentially, bacteria use the catheter as a gateway to the bladder, meaning the longer it is left in place the greater the risk of infection. (See Figure 1.) About 900,000 patients develop a UTI annually. Even though the infection may be asymptomatic, almost 80% of patients with an indwelling urinary catheter will receive an antibiotic, the center reminds. In many instances, this selects for a multidrug-resistant organism that may be more difficult to treat and also creates a reservoir of resistant bugs that can be transmitted to other patients. UTIs result in a burden of morbidity and expense, even considering the relatively low treatment cost of $500 to $1,000 per infection. If a secondary bacteremia develops the cost per episode increases to $2,800, the Keystone Center reports. The Keystone project has developed a "bladder bundle" of preventive strategies to help ICPs reduce these infections.
"The bladder bundle [recommends] several things, including appropriate indications for urinary catheter use and proper aseptic techniques during insertion to prevent any infection from occurring," Saint says. "Once the patient has a urinary catheter, [it recommends] some type of a reminder system to remove it. [Clinicians] should also consider alternatives to indwelling catheterization. One alternative would be the use of portable bladder ultrasound scanning to avoid indwelling catheterization in the first place."
Reminders make it a systems problem
Saint is a strong advocate of using catheter reminder systems that prompt clinicians to remove the devices in a timely fashion. "One of the simplest and most cost-effective approaches — that has high validity in some studies — would be the use of a urinary catheter reminder, whether it is computerized, nursing-based, or a written reminder,"3-5 he says.
Such a reminder system should be aimed at both physicians and nurses, who must work in collaboration to prevent UTIs. "I think physicians just take for granted that this has more to do with nursing care than something they should be invested in," he says. "This isn't just a nursing issue or doctors' issue. This is more of a systems issue. That's why I have been very supportive of some type of a urinary catheter reminder system, rather than just relying on overworked clinicians to remember that the patient has a urinary catheter. The system can help us do the right thing."
Why hasn't the right thing already been done — why do UTIs get no respect?
"I think the perception is that that they are relatively easy and straightforward to treat and the morbidity is less [compared to infections such as] ventilator-associated pneumonia (VAP) and catheter-related bloodstream infections (CR-BSIs)," Saint says. "Based on the data that I've seen, UTIs do seem easier to treat and do not have as much morbidity as VIPs and CR-BSIs, but it is still substantial given the high number of patients who have urinary catheters. The fact is that a third to one-half of the days that a patient has a urinary catheter, it meets no medically justified indication. A third of doctors are unaware that their own patients have a urinary catheter in place."
While no infection may result from this neglect, there are noninfectious factors that make the patient's stay all the more miserable — and the healing more difficult.
"It is just as important to emphasize the non-infectious complications of urinary catheter use," Saint says. "Patients find urinary catheters uncomfortable, painful, and restrictive of their activities of daily living. If you couple both the infectious and noninfectious consequences of urinary catheters — when they may not even be serving a medical purpose — it heightens the importance of preventing urinary catheter-related problems."
An accompanying editorial underscoring Saint's findings emphasized that "to optimize patient safety, documentation of the use and duration of any invasive device that carries a risk to the patient is necessary. There seems no reasonable argument against expecting facilities to collect, distribute, and act on this information for indwelling urethral catheters."5 The editorial's author — Lindsay E. Nicolle, MD, a professor in the department of internal medicine and medical microbiology at University of Manitoba Health Sciences Centre in Winnipeg, Canada — elaborated on her position in an interview with HIC.
"We are still in a transition phase from when people didn't pay a lot of attention to invasive procedures in terms of monitoring them and moving to a period of time when probably all this will be monitored," she says. "Perhaps because they are not causing as much death or prolongation of stay as the other common nosocomial infections, people tend to ignore them."
In that regard, Saint's paper and the coming CMS changes should send an unmistakable message that the days of benign neglect toward UTIs are coming to an end.
"Here we have a risk procedure — putting in a urinary catheter — and we aren't monitoring it," she says. "We aren't measuring how many people we are doing this to or for how long. [Electronic monitoring] should make it easy to do this, but in fact we don't do that and most places can't do that. I am hoping this is going to be a stepping stone toward institutions acknowledging that they need to start doing this and moving in that direction."
- Saint S, Kowalski CP, Kaufman SR. Preventing hospital-acquired urinary tract infection in the United States: A national study. Clin Infect Dis 2008; 46:243-250.
- Saint S, et al. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf 2005; 31(8):455-462.
- Reilly L, et al. Reducing Foley catheter device days in an intensive care unit: Using the evidence to change practice. AACN Adv Crit Care 2006; 17(3):272-283.
- Huang WC, et al. Catheter-associated UTIs in intensive care units can be reduced by prompting physicians to remove unnecessary catheters. Infect Control Hosp Epidemiol 2004; 25: 974-978.
- Nicolle LE. Editorial commentary: The prevention of hospital-acquired urinary tract infection. Clin Infect Dis 2008; 46:251-253.