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Mrziglod L, Saydan S, Schwab F, Zohlnhöfer-Momm D, Gastmeier P, Hansen S. Reducing urinary catheter use in geriatric patients - results of a single-center champion-led intervention. BMC Infect Dis 2023; 23:94. [PMID: 36788487 PMCID: PMC9930210 DOI: 10.1186/s12879-023-08064-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 02/08/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Indwelling urinary tract catheters (UTC) are a well-known risk factor for urinary tract infections (UTI). Because geriatric patients are at high risk of infection, an intervention with a focus on appropriate and minimal UTC use was introduced in 4 acute care geriatric wards. METHODS Between 11/2018 and 1/2020, unit-based data on UTC use and nosocomial UTI was collected in accordance with the methods of the German national surveillance system KISS. From 6/2019 to 1/2020, a champion-led intervention was implemented which focused on: (i) feedback of surveillance data, (ii) education and training in aseptic UTC insertion and maintenance, (iii) HCW's daily assessment of UTC necessity based on a checklist and (iv) timely removal of unnecessary UTCs. UTC use, incidence, and incidence densities for catheter-associated UTI (CAUTI) were calculated before and during the intervention. In addition, we analyzed adherence to a scheduled daily assessment of UTC necessity. Rate ratios (RR) with 95% confidence intervals (95%CI) were calculated. Differences based on the quality of checklist completion were evaluated using the Kruskal Wallis test. RESULTS We analyzed the data of 3,564 patients with a total 53,954 patient days, 9,208 UTC days, and 61 CAUTI. Surveillance data showed a significant decrease in the pooled UTC utilization rate from 19.1/100 patient days to 15.2/100 patient days (RR = 0.80, 95%CI 0.77-0.83, p < 0.001). CAUTI per 100 patients dropped from 2.07 to 1.40 (RR = 0.68, 95%CI 0.41-1.12, p = 0.1279). Overall, 373 patients received a UTC during the intervention. Of those patients 351 patients had an UTC ≥ 2 days. The analysis of these patients showed that 186 patients (53%) received a checklist as part of their chart for daily evaluation of UTC necessity. 43 (23.1%) of the completed checklists were of good quality; 143 (76.9%) were of poor quality. Patients in the group whose checklists were of good quality had fewer UTC days (median 7 UTC days IQR (3-11)) than patients whose checklists were of poor quality (11 UTC days IQR (6-16), p = 0.001). CONCLUSION We conclude that a champion-led, surveillance-based intervention reduces the use of UTC among geriatric patients. Further research is needed to determine to what extent the use of checklists in daily medical UTC assessment affects the prevention of CAUTI. The fact that patients whose checklists were completed well had fewer UTC days should encourage a conscientious and thorough daily review of the need for UTC.
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Affiliation(s)
- L Mrziglod
- grid.6363.00000 0001 2218 4662Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany ,Department of Internal Medicine - Geriatrics, Vivantes Wenckebach Klinikum, Berlin, Germany
| | - S Saydan
- grid.6363.00000 0001 2218 4662Institute of Hygiene and Environmental Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany ,German National Reference Center for Surveillance of Nosocomial Infections, Berlin, Germany
| | - F Schwab
- grid.6363.00000 0001 2218 4662Institute of Hygiene and Environmental Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany ,German National Reference Center for Surveillance of Nosocomial Infections, Berlin, Germany
| | - D Zohlnhöfer-Momm
- Department of Internal Medicine - Geriatrics, Vivantes Wenckebach Klinikum, Berlin, Germany
| | - P Gastmeier
- grid.6363.00000 0001 2218 4662Institute of Hygiene and Environmental Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany ,German National Reference Center for Surveillance of Nosocomial Infections, Berlin, Germany
| | - S Hansen
- Institute of Hygiene and Environmental Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany. .,German National Reference Center for Surveillance of Nosocomial Infections, Berlin, Germany.
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Keneally RJ, Chow JH, Pla RA, Heinz ER, Mazzeffi MA. Racial disparities in catheter related urinary tract infections among elderly trauma patients in the US. Am J Infect Control 2022; 50:77-80. [PMID: 34955191 DOI: 10.1016/j.ajic.2021.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Catheter associated urinary tract infections (CAUTIs) have become a focus for reducing healthcare costs. Reimbursement may be reduced to hospitals with higher rates. The implementation of bundles or other efforts to reduce infection numbers may not be as robust at hospitals caring for more diverse patient populations. This may lead to a disparity in hospital-associated infections rates that may lead to lower reimbursement and a downward spiral of quality of care and racial disparities. METHODS We analyzed patients in the National Trauma Data Bank from 2016 to 2017. The final analysis included patients 65 years or older with one or more day of mechanical ventilation. This was the population had the highest rate of CAUTI. We compared white patients to non-whites using students t test, Mann Whitney U test, or chi-square as appropriate. Logistic regression with odds ratios (ORs) and 95% confidence intervals (CI) was computed to identify risk factors for of CAUTI. RESULTS Risk factors for developing a CAUTI were race (OR 1.44, 95% confidence interval (95%CI) 1.23-1.71), injury severity score (OR 1.10 per increase of one, 95% CI 1.01-1.02), care at a teaching hospital (OR 1.17, 95%CI 1.02-1.35), private insurance (OR 1.28, 95%CI 1.09-1.51), hypertension (OR 1.18, 95%CI 1.02-1.37), female gender (OR 1.54, 95%CI 1.33-1.77). Non-white patients received care at teaching hospitals more often and had a higher rate of government insurance or no insurance. DISCUSSION The Center for Medicare and Medicaid Services (CMS) has put in place a reimbursement modification 87 plan based on the rates of hospital-associated infections including CAUTIs. We have demonstrated non-white 88 patients have higher odds for developing a CAUTI. CONCLUSION CMS may potentially worsen the racial disparity by further cutting reimbursement to hospitals who care for higher proportions of non-whites.
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Reducing Catheter-Associated Urinary Tract Infection: The Impact of Routine Screening in the Geriatric Hip Fracture Population. J Trauma Nurs 2021; 28:290-297. [PMID: 34491944 DOI: 10.1097/jtn.0000000000000603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI. OBJECTIVE The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI. METHODS A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis. RESULTS Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without. CONCLUSIONS Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI.
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Maurer LR, Sakran JV, Kaafarani HM. Predicting and Communicating Geriatric Trauma Outcomes. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-020-00209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Tan D, Wiseman T, Betihavas V, Rolls K. Patient, provider, and system factors that contribute to health care-associated infection and sepsis development in patients after a traumatic injury: An integrative review. Aust Crit Care 2020; 34:269-277. [PMID: 33127233 DOI: 10.1016/j.aucc.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 07/24/2020] [Accepted: 08/02/2020] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Patients after traumatic injury continue to develop health care-associated infections. The aim of this review was to identify risk factors for developing hospital-acquired infection and sepsis in patients experiencing a traumatic injury. DESIGN This is an integrative review following the framework of Whittemore and Knafl. DATA SOURCES An electronic database search was undertaken using Scopus and Medline databases in early October 2019. Hand searching of key references was also conducted. The existing literature published between January 2007 and September 2019 was searched to identify clinically relevant studies that reflected current healthcare practices and systems. REVIEW METHODS Four reviewers independently assessed articles for inclusion eligibility. Full-text versions of the articles were systematically appraised using the Critical Appraisal Skills Programme. The Preferred Reporting Items for Systematic reviews and Meta-Analyses format was used. RESULTS A total of 15 studies from the United Kingdom, the United States of America, China, and South Korea were included. Twelve of the 15 studies were focused exclusively on patient-based risk factors including gender and comorbidities. Provider-based factors were identified as nurse staffing levels between different categories of nurses with various levels of proficiency. System-level risk factors included interhospital admissions, surgical interventions, and length of stay. CONCLUSIONS Hospital-acquired infections are preventable, and it is imperative that provider and system risk factors that contribute to patients with traumatic injuries from developing a hospital-acquired infection be identified. Patients with traumatic injuries are unable to amend any patient-related risk factors such as comorbidities or gender. However, the identification of provider and system risk factors that contribute to patients with traumatic injuries from developing a hospital-acquired infection would provide clinically relevant and applicable strategies at the macro and meso level being implemented.
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Affiliation(s)
- Debbie Tan
- Susan Wakil School of Nursing & Midwifery, University of Sydney, Australia
| | - Taneal Wiseman
- Susan Wakil School of Nursing & Midwifery, University of Sydney, Australia
| | | | - Kaye Rolls
- School of Nursing, Health Impacts Research Cluster, Faculty of Science Medicine and Health, University of Wollongong, Illawarra Health and Medical Research Institute Limited, Australia
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Ladhani HA, Tseng ES, Claridge JA, Towe CW, Ho VP. Catheter-Associated Urinary Tract Infections among Trauma Patients: Poor Quality of Care or Marker of Effective Rescue? Surg Infect (Larchmt) 2020; 21:752-759. [PMID: 32212990 DOI: 10.1089/sur.2019.211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Catheter-associated urinary tract infection (CAUTI) is associated generally with worse outcomes among hospitalized patients, but the impact of CAUTI on clinical outcomes is poorly described in trauma patients. We hypothesized that trauma patients with CAUTI would have worse outcomes such as longer length of stay (LOS), fewer discharges to home, and higher outcome of death. Methods: Patients with LOS >2 d in the 2016 Trauma Quality Improvement Program (TQIP) database were included. Patients with and without CAUTI were matched 1:1 via a propensity score using patient, injury, and hospital factors as covariates. Matched pair analysis was performed to compare difference in clinical outcomes between patients with and without CAUTI. Results: There were 238,274 patients identified, of whom 0.7% had a diagnosis of CAUTI. Prior to matching, CAUTI patients had a higher mortality rate (6.6% vs. 3.4%, p < 0.01), but groups differed significantly. There were 1,492 matched pairs created, with effective reduction in bias; post-match propensity score covariates all had absolute standardized differences <0.1. In matched pair analysis, CAUTI patients had lower outcome of death compared with patients without CAUTI (6.7% vs. 10.1%, p < 0.01). The CAUTI was associated with longer length of stay, more intensive care unit and ventilator days, more unplanned events, and fewer discharges to home (all p < 0.01). Conclusions: Trauma patients with CAUTI had lower outcome of death compared with patients without CAUTI, despite worse clinical outcomes in all other aspects. This difference may be associated with "rescue" care in the form of unplanned events, and CAUTI may be an unintended consequence of this "rescue" care, rather than a marker of poor quality of care.
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Affiliation(s)
- Husayn A Ladhani
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Esther S Tseng
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Christopher W Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Division of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Tyson AF, Campbell EF, Spangler LR, Ross SW, Reinke CE, Passaretti CL, Sing RF. Implementation of a Nurse-Driven Protocol for Catheter Removal to Decrease Catheter-Associated Urinary Tract Infection Rate in a Surgical Trauma ICU. J Intensive Care Med 2018; 35:738-744. [PMID: 29886788 DOI: 10.1177/0885066618781304] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Early removal of urinary catheters is an effective strategy for catheter-associated urinary tract infection (CAUTI) prevention. We hypothesized that a nurse-directed catheter removal protocol would result in decreased catheter utilization and CAUTI rates in a surgical trauma intensive care unit (STICU). METHODS We performed a retrospective, cohort study following implementation of a multimodal CAUTI prevention bundle in the STICU of a large tertiary care center. Data from a 19-month historical control were compared to data from a 15-month intervention period. Pre- and postintervention indwelling catheter utilization and CAUTI rates were compared. RESULTS Catheter utilization decreased significantly with implementation of the nurse-driven protocol from 0.78 in the preintervention period to 0.70 in the postintervention period (P < .05). As a result of the bundle, the CAUTI rate declined significantly, from 5.1 to 2.0 infections per 1000 catheter-days in the pre- vs postimplementation period (Incident Rate Ratio [IRR]: 0.38, 95% confidence interval: 0.21-0.65). CONCLUSIONS Implementation of a nurse-driven protocol for early urinary catheter removal as part of a multimodal CAUTI intervention strategy can result in measurable decreases in both catheter utilization and CAUTI rates.
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Affiliation(s)
- Anna F Tyson
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Eileen F Campbell
- Department of Infection Prevention, Carolinas Medical Center, Charlotte, NC, USA
| | - Lacey R Spangler
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Samuel W Ross
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Caroline E Reinke
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | - Ronald F Sing
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Gotlib Conn L, Nathens AB, Perrier L, Haas B, Watamaniuk A, Daniel Pereira D, Zwaiman A, da Luz LT. What is the quality of reporting on guideline, protocol or algorithm implementation in adult trauma centres? Protocol for a systematic review. BMJ Open 2018; 8:e021750. [PMID: 29743331 PMCID: PMC5942428 DOI: 10.1136/bmjopen-2018-021750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/05/2018] [Accepted: 04/05/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Quality improvement (QI) is mandatory in trauma centres but there is no prescription for doing successful QI. Considerable variation in implementation strategies and inconsistent use of evidence-based protocols therefore exist across centres. The quality of reporting on these strategies may limit the transferability of successful initiatives across centres. This systematic review will assess the quality of reporting on guideline, protocol or algorithm implementation within a trauma centre in terms of the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). METHODS AND ANALYSIS We will search for English language articles published after 2010 in EMBASE, MEDLINE, CINAHL electronic databases and the Cochrane Central Register of Controlled Trials. The database search will be supplemented by searching trial registries and grey literature online. Included studies will evaluate the effectiveness of guideline implementation in terms of change in clinical practice or improvement in patient outcomes. The primary outcome will be a global score reporting the proportion of studies respecting at least 80% of the SQUIRE 2.0 criteria and will be obtained based on the 18-items identified in the SQUIRE 2.0 guidelines. Secondary outcome will be the risk of bias assessed with the Risk Of Bias In Non-randomised Studies- of Interventions tool for observational cohort studies and with the Cochrane Collaboration tool for randomised controlled trials. Meta-analyses will be conducted in randomised controlled trials to estimate the effectiveness of guideline implementation if studies are not heterogeneous. If meta-analyses are conducted, we will combine studies according to the risk of bias (low, moderate or high/unclear) in subgroup analyses. All study titles, abstracts and full-text screening will be completed independently and in duplicate by the review team members. Data extraction and risk of bias assessment will also be done independently and in duplicate. ETHICS AND DISSEMINATION Results will be disseminated through scientific publication and conferences. PROSPERO REGISTRATION NUMBER CRD42018084273.
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Affiliation(s)
- Lesley Gotlib Conn
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Avery B Nathens
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laure Perrier
- University of Toronto Libraries, Toronto, Ontario, Canada
| | - Barbara Haas
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Aaron Watamaniuk
- Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Diego Daniel Pereira
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ashley Zwaiman
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Luis Teodoro da Luz
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Bliemel C, Buecking B, Hack J, Aigner R, Eschbach DA, Ruchholtz S, Oberkircher L. Urinary tract infection in patients with hip fracture: An underestimated event? Geriatr Gerontol Int 2017. [PMID: 28621029 DOI: 10.1111/ggi.13077] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Urinary tract infections (UTI) represent a common perioperative complication among elderly patients with hip fracture. To determine the impact of UTI on the perioperative course of elderly patients with hip fractures, a prospective study was carried out. METHODS A total of 402 surgically-treated geriatric hip fracture patients were consecutively enrolled at a level 1 trauma center. On admission, all patients received an indwelling urinary catheter. Clinically symptomatic patients were screened more closely for UTI. Patients diagnosed with UTI were compared with asymptomatic patients. Outcomes in both patient groups were measured using in-hospital mortality, overall length of hospital stay, wound infection, functional results and mobility at discharge. Multivariate regression analysis was carried out to control for influencing factors. RESULTS A total of 97 patients (24%) sustained a UTI during in-hospital treatment. UTI were independently associated with inferior functional outcomes as assessed by the Barthel Index (β = -0.091; P = 0.031), Timed Up and Go test (β = 0.364; P = 0.001) and Tinetti test (β = -0.169; P = 0.001) at discharge. Additionally, length of hospital stay was significantly longer for patients with a UTI diagnosis (β = 0.123; P = 0.029) after controlling for all other variables. No differences were observed in the rate of wound infection (odds ratio 1.185; P = 0.898) or in-hospital mortality (P < 0.997). CONCLUSIONS Patients with UTI seem to be at risk of inferior functional outcomes. In addition to an early detection of symptomatic UTI and a targeted antibiotic therapy, perioperative care should focus on preserving functional ability to protect these patients from further loss of independence and prolonged clinical courses. Geriatr Gerontol Int 2017; 17: 2369-2376.
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Affiliation(s)
- Christopher Bliemel
- Center for Orthopedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
| | - Benjamin Buecking
- Center for Orthopedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
| | - Juliana Hack
- Center for Orthopedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
| | - Rene Aigner
- Center for Orthopedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
| | | | - Steffen Ruchholtz
- Center for Orthopedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
| | - Ludwig Oberkircher
- Center for Orthopedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
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Zielinski MD, Kuntz MM, Polites SF, Boggust A, Nelson H, Khasawneh MA, Jenkins DH, Harmsen S, Ballman KV, Pieper R. A prospective analysis of urinary tract infections among elderly trauma patients. J Trauma Acute Care Surg 2015; 79:638-42. [PMID: 26402539 PMCID: PMC4582427 DOI: 10.1097/ta.0000000000000796] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Catheter-associated urinary tract infections (CAUTIs) have been deemed "reasonably preventable" by the Centers for Medicare and Medicaid, thereby eliminating reimbursement. Elderly trauma patients, however, are at high risk for developing urinary tract infections (UTIs) given their extensive comorbidities, immobilization, and environmental changes in the urine, which provide the ideal environment for bacterial overgrowth. Whether these patients develop CAUTI as a complication of their hospitalization or have asymptomatic bacteriuria (ASB) or UTI at admission must be determined to justify the "reasonably preventable" classification. We hypothesize that a significant proportion of elderly patients will present with ASB or UTI at admission. METHODS Institutional review board permission was obtained to perform a prospective, observational clinical trial of all elderly (≥65 years) patients admitted to our Level I trauma center as a result of injury. Urinalysis (UA) and culture (UCx) were obtained at admission, 72 hours, and, if diagnosed with UTI, at 2 weeks after injury. Mean cost of UTI was calculated based on Centers for Disease Control and Prevention estimates of $862 to $1,007 per UTI. RESULTS Of 201 eligible patients, 129 agreed to participate (64%). Mean (SD) age was 81 (8.6) years. All patients had a blunt mechanism of injury (76% falls), with a mean Injury Severity Score (ISS) of 13.8 (7.6). Of the 18 patients (14%) diagnosed with CAUTI, 14 (78%) were present at admission. In addition, there were 18 patients (14%) with ASB at admission. The most common bacterial species present at admission urine culture were Escherichia coli (24%) and Enterococcus (16%). Clinical features associated with bacteriuria at admission included a history of UTI, positive Gram stain result, abnormal microscopy, and pyuria. The estimated loss of reimbursement for 18 UTIs at admission was $15,516 to $18,126; however, given an estimated cost of $1,981 to screen all patients with UA and UCx at admission, up to $16,144 savings was realized. CONCLUSION Many elderly trauma patients present with UTI. Screening UA and UCx at admission for elderly trauma patients identifies these UTIs and is cost-effective. LEVEL OF EVIDENCE Epidemiologic study, level II.
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Affiliation(s)
- Martin D Zielinski
- From the Mayo Clinic (M.D.Z., M.M.K., S.F.P., A.B., H.N., M.A.K., D.H.J., S.H., K.V.B.), Rochester, Minnesota; and J. Craig Venter Institute (R.P.), Baltimore, Maryland
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