OUTCOMES RESEARCH IN REVIEW
Successful Reduction of Catheter-Associated Urinary Tract Infection Rates in Nursing Homes Through a Multicomponent Prevention Intervention
Mody L, Greene MT, Meddings J, et al. A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents. JAMA Intern Med 2017;177:1154–62.
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Objective. To determine the effect of implementing an intervention to reduce catheter-associated urinary tract infections (CAUTIs) in nursing homes.
Design. Prospective implementation project.
Setting and participants. The study was conducted between March 2014 and August 2016 in 12-month cohorts of community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. A total of 568 nursing homes located across 48 states, Washington DC, and Puerto Rico were recruited to participate.
Intervention. The intervention was developed with the goal of modifying the elements of the Comprehensive Unit-Based Safety Program utilized in hospitals for adoption in nursing homes. The intervention included a technical bundle, that is, catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning , as well as socioadaptive interventions focused on empowering teams, addressing implementation challenges, offering solutions, promoting resident safety culture, team building, leadership, and resident and family engagement. The interventions were implemented over a 12-month period. To be included in the data analysis, nursing homes need to remain active through the end of the 12-month period and report 2 months or more of outcome data and device-days. Nursing homes that reported large fluctuations in reported data were excluded from the analysis. A total of 433 nursing homes remained active throughout the intervention period.
Main outcome measures. The main study outcome measure was the CAUTI incidence rate, defined as the number of CAUTIs divided by the number of catheter-days and multiplied by 1000. National Healthcare Safety Network definitions were used. The criteria for UTI
included objective systemic and localizing clinical findings along with laboratory-based criteria. A secondary outcome was the urinary catheter utilization ratio, defined as the number of catheter-days divided by the number of resident-days multiplied by 100 and reported as a percentage. Participating nursing homes collected data on the daily number of CAUTIs, catheter days, resident days, and urine cultures for each month of the project period and these metrics were reported using the Health Research and Educational Trust, a research affiliate of the American Hospital Association, Comprehensive Data System.
Main outcome measures. The main study outcome measure was the CAUTI incidence rate, defined as the number of CAUTIs divided by the number of catheter-days and multiplied by 1000. National Healthcare Safety Network definitions were used. The criteria for UTI included objective systemic and localizing clinical findings along with laboratory-based criteria. A secondary outcome was the urinary catheter utilization ratio, defined as the number of catheter-days divided by the number of resident-days multiplied by 100 and reported as a percentage. Participating nursing homes collected data on the daily number of CAUTIs, catheter days, resident days, and urine cultures for each month of the project period and these metrics were reported using the Health Research and Educational Trust, a research affiliate of the American Hospital Association, Comprehensive Data System.
Conclusion. A multicomponent intervention implemented in community-based nursing homes across the country was associated with a reduction in CAUTI rates. The study shows that the intervention to reduce CAUTI can be implemented on a large scale and can be associated with improvement in patient safety.
Catheter-associated urinary tract infection is a common condition that affects nursing home residents, as nursing home residents often have an indwelling urinary catheter on admission to the nursing home. These infections can be costly, lead to hospital admissions, and can contribute to the development of multidrug-resistant organisms, which pose a significant public health threat . CAUTIs, however, are potentially preventable through the use of practices that promote judicious use of urinary catheters and attention to aseptic insertion and catheter care [3,4]. Although prior randomized controlled trials demonstrated the potential impact of interventions that reduce incidence of urinary tract infections , the interventions have not been adopted widely.
Recognizing the importance of improving safety through reducing CAUTIs, the Agency for Healthcare Research and Quality has established toolkits and implementation guides for health care facilities to adopt better practices for reducing catheter-associated infections. This study adds to the current literature by demonstrating the feasibility and beneficial impact of widespread implementation of AHRQ tools.
The study evaluated the impact of the intervention in a large cohort of nursing homes, comparing outcome measures pre and post intervention. One limitation of the study is that other factors that were present concurrently may have contributed to the observed changes in CAUTI outcomes. The study also did not have a control group, and the changes in outcome rates were not compared with rates in homes that did not participate in the project. Also, it is not possible to examine the effect of the individual components of the intervention as this intervention had multiple components delivered simultaneously. Despite these drawbacks, the study makes a strong case that project implementation is associated with a reduction in CAUTI rates of more than 50%.
A next step to better understand how best to disseminate the intervention is to identify factors associated with greater improvements in outcomes among the cohort of nursing homes and also to understand the variations in how nursing homes are implementing the intervention and what impact these differences might have. This in turn may guide further efforts to broaden the impact through more nuanced application of the intervention.
Applications for Clinical Practice
This study demonstrates that CAUTI can be prevented through a multicomponent intervention that focuses on appropriate use and discontinuation of urinary catheters and proper catheter care. Given that these tools and guides are available for use through AHRQ, nursing homes should examine the potential for adoption in their facilities. This can enhance the safety for their residents by reducing the risk of a potentially preventable complication.
—William W. Hung, MD, MPH
1. Agency for Healthcare Research and Quality. Prevent catheter-associated urinary tract infection. CAUTI implementation guide. Accessed 11 Aug 2017 at www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-k.pdf.
2. Chitnis AS, Edwards JR, Ricks PM, et al. Device-associated infection rates, device utilization, and antimicrobial resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010. Infect Control Hosp Epidemiol 2012;33:993–1000.
3. Meddings J, Rogers MA, Krein SL, et al. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 2014;23:277–89.
4. Willson M, Wilde M, Webb ML, et al. Nursing interventions to reduce the risk of catheter-associated urinary tract infection: part 2: staff education, monitoring, and care techniques. J Wound Ostomy Continence Nurs 2009;36:137–54.
5. Meddings J, Saint S, Krein SL, et al. Systematic Review of interventions to reduce urinary tract infection in nursing home residents. J Hosp Med 2017;12:356–68.
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