Comprehensive Unit-based Safety Program May Reduce Catheter-Associated Urinary Tract Infection

EBM Focus - Volume 11, Issue 26

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Reference - N Engl J Med 2016 Jun 2;374(22):2111 (level 2 [mid-level] evidence)

  • Catheter-associated urinary tract infection (CAUTI) is a common and often preventable healthcare-associated infection, but efforts to reduce CAUTI rates have been largely unsuccessful.
  • An 18-month national program in the United States aimed at improving technical skill as well as cultural and behavioral issues surrounding CAUTI prevention significantly reduced CAUTI rates and catheter use in non-intensive care units.
  • Overall, these results suggest that programs aimed at cultural and behavioral changes in units as well as improvements in technical skills can reduce CAUTI rates, although improvements in intensive care units (ICUs) may be especially challenging.

CAUTI is the most common healthcare-associated infection worldwide (Curr Opin Infect Dis 2012 Aug;25(4):365). An estimated 65-70% of CAUTIs in the United States are preventable by following guideline recommendations for appropriate catheter use, removing catheters as soon as possible, using closed drainage systems, and following proper aseptic technique (including hand hygiene measures) during insertion and maintenance (Infect Control Hosp Epidemiol 2011 Feb;32(2):101, Clin Infect Dis 2010 Mar 1;50(5):625). However, a recent national initiative in the United States to prevent healthcare-associated infections with a goal of reducing CAUTI by 25% found a 6% increase in CAUTI from 2009 to 2013 (HAI 2015 progress report PDF), suggesting reducing CAUTI may be more difficult than initially thought. Another nationwide effort, the Comprehensive Unit-based Safety Program (CUSP), began in 2011 as an attempt to improve CAUTI rates using both technical skills and socioadaptive techniques aimed at addressing cultural and behavioral issues that may impact CAUTI prevention efforts. The results of the first CUSP cohorts have been recently published.

Overall, 926 inpatient units (40% ICUs) in 603 hospitals completed the 18-month CUSP program between March 2011 and November 2013. The primary recommendations of the program included daily assessments of the presence of and need for an indwelling catheter, avoidance of indwelling catheters when possible by using alternative urine-collecting methods, and emphasis on use of aseptic technique during catheterization and maintenance. Additional recommendations focused on addressing any knowledge gaps in urinary management processes through training and providing feedback to unit nurses and physicians regarding catheter use and CAUTI rates. The rates of CAUTI during the baseline period and at the end of the 18-month intervention can be found in the table below. Additionally, the rates of catheter use significantly decreased from 20.1% to 18.8% in non-ICUs (incidence rate ratio 0.93, 95% CI 0.9-0.96), but not in ICUs (62.8% vs. 61.9%).

Although the techniques for preventing CAUTI have been well established, national level programs have found it difficult to reduce CAUTI rates. The results of this study suggest that programs focusing on socioadaptive techniques as well as technical skills can improve CAUTI rates and reduce catheter use in non-ICU settings. The reasons behind the lack of improvement in ICUs are unknown, but this result is consistent with other surveillance data (HAI 2014 progress report PDF). Of note, this study did not report their parameters for CAUTI diagnoses, but changes in the National Healthcare Safety Network definition of CAUTI in March 2012 have influenced reported CAUTI rates and are likely to be a confounding factor in this study. Overall, the results of CUSP suggest that reducing the incidence of CAUTI is a practical goal that can be achieved, if incrementally, through programs aimed at improving unit culture and behaviors as well as knowledge and skills.

For more information, see the Catheter-associated urinary tract infection (CAUTI) topic in DynaMed.