Where: 16 hospitals, all participants in the Michigan Health & Hospital Association (MHA) Keystone: Hospital-Associated Infection project.
The issue: Reducing unnecessary use of catheters, and thereby, catheter-associated urinary tract infections (CA-UTIs).
Four years ago, Mohamad Fakih, FACP, and colleagues at St. John Hospital and Medical Center in Detroit decided to do something about CA-UTIs in their hospital. The most obvious method for reducing the rate of infection was to reduce the use of catheters, they concluded. “If you don't have a catheter, you don't have an infection related to the catheter,” said Dr. Fakih, who is medical director of infection control services at St. John.
Prior research had shown that CA-UTIs are the most prevalent hospital-acquired infection. “It's not necessarily related with high levels of mortality, but it certainly extends length of stay and we know it is preventable,” said Sam Watson, executive director of the MHA Keystone Center for Patient Safety & Quality. Mr. Watson became involved in the project after a nurse-led intervention developed by Dr. Fakih showed success at reducing catheter use at St. John.
Based on that success, the MHA Keystone Center, which leads projects on a number of quality issues, adopted the intervention and implemented it in 16 other hospitals in early 2008.
How it works
Participating hospitals began by organizing a “bladder bundle” team, which typically included nurses, hospitalists and other hospital staff, to compare their hospital's use of catheters to the CDC guidelines. Then, hospital staff, especially nurses, were shown the statistics for their units and trained about the appropriate uses for catheters.
“A nurse educator went and advised other nurses about indications for urinary catheter implantation,” said Dr. Fakih. In addition to lectures, posters and cards were used to remind clinicians to think twice before using a catheter.
Then, for the next few weeks, a nurse educator participated in multidisciplinary daily rounds. If a patient had a catheter, the patient's nurse was asked if it was needed. If the use of the catheter didn't meet CDC guidelines, the patient's nurse was asked to contact the attending physician to obtain an order for catheter removal.
The hardest part of the project was changing hospital culture so that catheters are no longer seen as a harmless convenience, according to the project leaders. “More often than not, the urinary catheters are placed for convenience—convenience for the patient, convenience for the staff,” said Mr. Watson.
One solution was to make the new protocols equally convenient. “You have to link it to a process that is easy and simple for the nurse,” said Dr. Fakih. “The reason why she has the catheter in is she doesn't want to clean a patient who is incontinent every two hours.” However, that same patient probably needs to be turned to reduce the risk of pressure sores, so if cleaning and turning can be bundled together as one task, the absence of a catheter can be a little bit less of a burden.
When the project was first implemented at St. John, Dr. Fakih measured catheter use before, immediately following, and four weeks after the intervention to see if the changes were sustained. “We were able to decrease utilization by about 45% of those catheters that were not needed by CDC criteria,” he said.
In the Keystone program, where 20 hospital units have been implementing the project for at least a year, improvements have also been recorded. “What we have seen so far is about a 25% decrease in catheter use,” said Mr. Watson.
Most participating hospitals are tracking catheter use, because it is much easier to measure than CA-UTI rates.
Although nurses are most often the ones dealing with catheters, such a change in hospital culture and protocol requires the involvement of physicians, the Michigan leaders said. “I'm an infectious disease specialist, but I think hospitalists should be the main physician champions in the hospital, because they are the ones who are seeing most of these patients,” said Dr. Fakih.
To help the project succeed, hospitalists may need to look a little harder while seeing patients. “Many times the physician doesn't realize the catheter is still in,” said Mr. Watson. “It has to be agreed upon by the medical staff—’Yes, here are our criteria.’ You need the physicians to support the rationale for why the catheter should or shouldn't be in place.”
After the project's success in 16 pilot hospitals in 2008, the Keystone Center expanded it to more facilities across the state. Now, in 2010, the Agency for Healthcare Research and Quality is funding implementation in hospitals in 10 other states.