Reduction of unnecessary use of indwelling urinary catheters

Patient engagement to counter catheter-associated urinary tract infections with an app (PECCA): a multicentre, prospective, interrupted time-series and before-and-after study

BACKGROUND

The risk of urinary tract infections (UTIs) is increased by unnecessary placement and prolonged use of urinary catheters.

AIM

To assess whether inappropriate use of catheters and catheter-associated UTI were reduced through patient participation.

METHODS

In this multicentre, interrupted time-series and before-and-after study, we implemented a patient-centred app which provides catheter advice for patients, together with clinical lessons, feedback via e-mails and support rounds for staff members. Data on catheter use and infections were collected during a six-month baseline and a six-month intervention period on 13 wards in four hospitals in the Netherlands. Dutch Trial Register: NL7178.

FINDINGS

Between June 25th, 2018 and August 1st, 2019, 6556 patients were included in 24 point-prevalence surveys, 3285 (50%) at baseline and 3271 (50%) during the intervention. During the intervention 249 app users and a median of seven new app users per week were registered (interquartile range: 5.5-13.0). At baseline, inappropriate catheter use was registered for 175 (21.9%) out of 798 catheters, compared to 55 (7.0%) out of 786 during the intervention. Time-series analysis showed a non-significant decrease of inappropriate use of 5.8% (95% confidence interval: -3.76 to 15.45; P = 0.219), with an odds ratio of 0.27 (0.19-0.37; P < 0.001). Catheter-associated UTI decreased by 3.0% (1.3-4.6; P = 0.001), with odds ratio 0.541 (0.408-0.716; P < 0.001).

CONCLUSION

Although UTI significantly decreased after the implementation, patient participation did not significantly reduce the prevalence of inappropriate urinary catheter use. However, the inappropriate catheter reduction of 5.8% and an odds ratio of 0.27 suggest a positive trend. Patient participation appears to reduce CAUTI and could reduce other healthcare-associated infections.

Pragmatic review of interventions to prevent catheter-associated urinary tract infections (CAUTIs) in adult inpatients

BACKGROUND

Urinary tract infections (UTIs) are one of the most common hospital-acquired complications. Insertion of a urinary catheter and the duration of catheterization are the main risk factors, with catheter-associated UTIs (CAUTIs) accounting for 70-80% of hospital-acquired UTIs. Guidance is available regarding the prevention of hospital-acquired CAUTIs; however, how best to operationalize this guidance remains a challenge.

AIM

To map and summarize the peer-reviewed literature on model-of-care interventions for the prevention of CAUTIs in adult inpatients.

METHODS

PubMed, CINAHL and SCOPUS were searched for articles that reported UTI, CAUTI or urinary catheter outcomes. Articles were screened systematically, data were extracted systematically, and interventions were classified by intervention type.

FINDINGS

This review included 70 articles. Interventions were classified as single component (N=19) or multi-component (N=51). Single component interventions included: daily rounds or activities (N=4), protocols and procedure changes (N=6), reminders and order sets (N=5), audit and feedback interventions (N=3), and education with simulation (N=1). Overall, daily catheter reviews and protocol and procedure changes demonstrated the most consistent effects on catheter and CAUTI outcomes. The components of multi-component interventions were categorized to map common elements and identify novel ideas.

CONCLUSION

A range of potential intervention options with evidence of a positive effect on catheter and CAUTI outcomes was identified. This is intended to provide a 'menu' of intervention options for local decision makers, enabling them to identify interventions that are relevant and feasible in their local setting.

Inappropriate urinary catheterisation: a review of the prevalence, risk factors and measures to reduce incidence

Urinary tract infections (UTIs) comprise the second most common type of healthcare-associated infections, with up to 80% of UTIs caused by indwelling urinary catheters. Current research suggests that the best way to prevent catheter-associated UTIs (CAUTIs) is to reduce unnecessary catheterisation. Few reviews have focused on the prevalence, risk factors and preventive measures for inappropriate catheterisation. This article, consequently, sought to evaluate the current evidence on the prevalence, risk factors and measures that can be taken to prevent inappropriate urinary catheterisation.

Prevalence and appropriateness of indwelling urinary catheters in Japanese hospital wards: a multicenter point prevalence study

BACKGROUND

Indwelling urinary catheters are commonly used in hospitalized patients, which can lead to the development of urinary catheter complications, including catheter-associated urinary tract infection (CAUTI). Limited reports on the appropriateness of urinary catheter use exist in Japan. This study investigated the prevalence and appropriateness of indwelling urinary catheters, and the incidence of CAUTI in non-intensive care unit (non-ICU) wards in Japanese hospitals.

METHODS

This prospective observational study was conducted in 7 non-ICU wards from 6 hospitals in Japan from October 2017 to June 2018. At each hospital the study teams evaluated urinary catheter prevalence through in-person bedside evaluation for at least 5 days of each week for 3 months. Catheter associated urinary tract infection (CAUTI) incidence and appropriateness of catheter use was collected via chart review.

RESULTS

We assessed 710 catheter-days over 5528 patient-days. The mean prevalence of indwelling urinary catheter use in participating wards was 13% (range: 5% to 19%), while the mean incidence of CAUTI was 9.86 per 1000 catheter-days (range: 0 to 33.90). Approximately 66% of the urinary catheter days assessed had an appropriate indication for use (range: 17% to 81%). A physician's order for catheter placement was present in only 10% of catheterized patients.

CONCLUSION

This multicenter study provides epidemiological information about the appropriate use of urinary catheters in Japanese non-ICU wards. A multimodal intervention may help improve the appropriate use of urinary catheters.

Intensive care unit rounding checklists to reduce catheter-associated urinary tract infections

OBJECTIVE

To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs).

DESIGN

Retrospective before-and-after study that took place between March 2013 and February 2017.

SETTING

An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU.

PATIENTS

Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI.

INTERVENTION

Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods.

RESULTS

There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532).

CONCLUSIONS

Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.

The recent advances in surface antibacterial strategies for biomedical catheters

As one of the most common hospital-acquired infections, catheter-related infections (CRIs) which are caused by microbial colonization lead to increasing morbidity and mortality of patients and life threat for medical staffs. In this case, a variety of efforts have been made to design functional materials to limit bacterial colonization and biofilm formation. In this review, we focus on the recent advances in surface modification strategies of biomedical catheters used to prevent CRIs. The tests for the evaluation of the performances of modified catheters are listed. Future prospects of surface antibacterial strategies for biomedical catheters are also outlined.

A Smartphone App for Engaging Patients With Catheter-Associated Urinary Tract Infections: Protocol for an Interrupted Time-Series Analysis

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are the main cause of health care-associated infections, and they increase the disease burden, antibiotic usage, and hospital stay. Inappropriate placement and unnecessarily prolonged usage of a catheter lead to an elevated and preventable risk of infection. The smartphone app Participatient has been developed to involve hospitalized patients in communication and decision-making related to catheter use and to control unnecessary (long-term) catheter use to prevent CAUTIs. Sustained behavioral changes for infection prevention can be promoted by empowering patients through Participatient.

OBJECTIVE

The primary aim of our multicenter prospective interrupted time-series analysis is to reduce inappropriate catheter usage by 15%. We will evaluate the efficacy of Participatient in this quality improvement study in clinical wards. Our secondary endpoints are to reduce CAUTIs and to increase patient satisfaction, involvement, and trust with health care services.

METHODS

We will conduct a multicenter interrupted time-series analysis-a strong study design when randomization is not feasible-consisting of a pre- and postintervention point-prevalence survey distributed among participating wards to investigate the efficacy of Participatient in reducing the inappropriate usage of catheters. After customizing Participatient to the wards' requirements, it will be implemented with a catheter indication checklist among clinical wards in 4 large hospitals in the Netherlands. We will collect clinical data every 2 weeks for 6 months in the pre- and postintervention periods. Simultaneously, we will assess the impact of Participatient on patient satisfaction with health care services and providers and the patients' perceived involvement in health care through questionnaires, and the barriers and facilitators of eHealth implementation through interviews with health care workers.

RESULTS

To reduce the inappropriate use of approximately 40% of catheters (currently in use) by 15%, we aim to collect 9-12 data points from 70-100 patients per survey date per hospital. Thereafter, we will conduct an interrupted time-series analysis and present the difference between the unadjusted and adjusted rate ratios with a corresponding 95% CI. Differences will be considered significant when P<.05.

CONCLUSIONS

Our protocol may help reduce the inappropriate use of catheters and subsequent CAUTIs. By sharing reliable information and daily checklists with hospitalized patients via an app, we aim to provide them a tool to be involved in health care-related decision-making and to increase the quality of care.

TRIAL REGISTRATION

Netherlands Trial Register NL7178; https://www.trialregister.nl/trial/7178.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/28314.

Urinary System Iatrogenic Injuries: Problem Review

INTRODUCTION

From May to December 2019, a literature review of the urinary system iatrogenic injury problem was performed. The most cited, representative articles in PubMed, Scopus, and WoS databases dedicated to this problem were selected. Urinary system iatrogenic injuries include ureter, bladder, urethra, and kidney traumas. It is widely thought that the main causes of such injuries are urological, obstetric, gynecological, and surgical operations on the retroperitoneal space, pelvis, or perineum.

METHODS

The purpose of the study is to describe all aspects of the iatrogenic injure problem, under the established scheme and for each of the most damaged organs: the urethra, bladder, kidney, and ureter. The treatment of confirmed iatrogenic injuries largely depends on the period of its detection. Modern medical procedures provide conservative or minimally invasive treatment. An untimely diagnosis worsens the treatment prognosis. "Overlooked" urinary system trauma is a serious threat to society and a particular patient. Thus, incorrect or traumatic catheterization can lead to infection (RR 95%) and urethral stricture (RR ≥11-36%), and percutaneous puncture nephrostomy can cause the risk of functional renal parenchyma loss (median 5%), urinary congestion (7%), or sepsis (0.6-1.5%).

RESULTS

Lost gain, profits, long-term and expensive, possibly multistage treatment, stress and depression, and the risks of suicide put a heavy financial, moral, and ethical burden on a person and society. Also, iatrogenic injury might have legal consequences.

DISCUSSION/CONCLUSION

Thus, the significant problem of urinary tract iatrogenic injuries is still difficult to solve. There is a need to implement mandatory examining algorithms for patients at risk, as well as the multidisciplinary principle for all pelvic surgery.

Change in staff perspectives on indwelling urinary catheter use after implementation of an intervention bundle in seven Swiss acute care hospitals: results of a before/after survey study

OBJECTIVE

To evaluate changes in staff perspectives towards indwelling urinary catheter (IUC) use after implementation of a 1-year quality improvement project.

DESIGN

Repeated cross-sectional survey at baseline (October 2016) and 12-month follow-up (October 2017).

SETTING

Seven acute care hospitals in Switzerland.

PARTICIPANTS

The survey was targeted at all nursing and medical staff members working at the participating hospitals at the time of survey distribution. A total of 1579 staff members participated in the baseline survey (T₀) (49% response rate) and 1527 participated in the follow-up survey (T₁) (47% response rate).

INTERVENTION

A multimodal intervention bundle, consisting of an evidence-based indication list, daily re-evaluation of ongoing catheter need and staff training, was implemented over the course of 9 months.

MAIN OUTCOME MEASURES

Staff knowledge (15 items), perception of current practices and culture (scale 1-7), self-reported responsibilities (multiple-response question) and determinants of behaviour (scale 1-7) before and after implementation of the intervention bundle.

RESULTS

The mean number of correctly answered knowledge questions increased significantly between the two survey periods (T₀: 10.4, T₁: 11.0; p<0.001). Self-reported responsibilities with regard to IUC management by nurses and physicians changed only slightly over time. Perception of current practices and culture in regard to safe urinary catheter use increased significantly (T₀: 5.3, T₁: 5.5; p<0.001). Significant changes were also observed for determinants of behaviour (T₀: 5.3, T₁: 5.6; p<0.001).

CONCLUSION

We found small but significant changes in staff perceptions after implementation of an evidence-based intervention bundle. Efforts now need to be targeted at sustaining and reinforcing these changes, so that restrictive use of IUCs becomes an integral part of the hospital culture.

Trends in prevalence of healthcare-associated infections and antimicrobial use in hospitals in the Netherlands: 10 years of national point-prevalence surveys

BACKGROUND

Prevalence of healthcare-associated infections (HCAIs) and antimicrobial use in hospitals in the Netherlands has been measured using voluntary biannual national point-prevalence surveys (PPSs).

AIM

To describe trends in the prevalence of patients with HCAI, risk factors, and antimicrobial use in 2007-2016.

METHODS

In the PPS, patient characteristics, use of medical devices and antimicrobials, and presence of HCAI on the survey day are reported for all hospitalized patients, excluding patients in the day-care unit and psychiatric wards. Analyses were performed using linear and (multivariate) logistic regression, accounting for clustering of patients within hospitals.

FINDINGS

PPS data were reported for 171,116 patients. Annual prevalence of patients with HCAI with onset during hospitalization decreased from 6.1% in 2007 to 3.6% in 2016. The adjusted odds ratio (OR) for trend was 0.97 (95% confidence interval: 0.96-0.98). Most prominent trends were seen for surgical site infections (1.6%-0.8%; OR: 0.91 (0.90-0.93)) and urinary tract infections (2.1%-0.6%; OR: 0.85 (0.83-0.87)). From 2014 on, HCAIs at admission were also registered with a stable prevalence of approximately 1.5%. The mean length of stay decreased from 10 to 7 days. The percentage of patients treated with antibiotics increased from 31% to 36% (OR: 1.03 (1.02-1.03)).

CONCLUSION

Repeated PPS data from 2007 to 2016 show a decrease in the prevalence of patients with HCAI with onset during hospitalization, and a stable prevalence of patients with HCAI at admission. The adjusted OR of 0.97 for HCAI during hospitalization indicates a true reduction in prevalence of approximately 3% per year.

Long-term prevention of catheter-associated urinary tract infections among critically ill patients through the implementation of an educational program and a daily checklist for maintenance of indwelling urinary catheters: A quasi-experimental study

BACKGROUND

Removing an indwelling urinary catheter as soon as possible is the cornerstone of catheter-associated urinary tract infections (CAUTI) prevention. However, implementing this measure may be challenging in clinical settings. To evaluate the impact of implementing a healthcare workers (HCWs) educational program and a daily checklist for indwelling urinary catheter indications among critical patients on the incidence of CAUTI.

METHODS

This was a quasi-experimental study performed in a general intensive care unit of a tertiary-care hospital over a 12 years period, from January 1, 2005 to December 31, 2016. Rates of urinary catheter use and incidence density of CAUTI were monthly evaluated following the Centers for Disease Control and Prevention (CDC) criteria throughout the study period. Phase I (2005-2006) was the pre-intervention period. In phase II (2007-2010), HCWs routine training on CAUTI prevention was performed twice-a-year. In phase III (2011-2014), we implemented a daily checklist for indwelling urinary catheter indications, in addition to the biannual training. In phase IV, (2015-2016) the biannual training was replaced by training only newly hired HCWs and the daily checklist was maintained.

RESULTS

The mean rate of urinary catheter utilization decreased from phase I to phase IV (73.1%, 74.1%, 54.9%, and 45.6%, respectively). Similarly, the incidence density of CAUTI decreased from phase I to phase IV (14.9, 7.3, 3.8, and 1.1 per 1000 catheter-days, respectively).

CONCLUSIONS

HCWs education and daily evaluation of indwelling urinary catheter indications were highly effective in reducing the rates of catheter utilization as well as the incidence density of CAUTI.

Current status of indwelling urinary catheter utilization and catheter-associated urinary tract infection throughout hospital wards in Korea: A multicenter prospective observational study

To evaluate the frequency and appropriateness of indwelling urinary catheters (IUC) use and the incidence of catheter-associated urinary tract infections (CA-UTI), and explore the risk factors for CA-UTI in hospitals as a whole, we conducted a study. This study was divided into two parts; a point-prevalence study on Dec 12^th 2012 and a prospective cohort study from Dec 13^th 2012 to Jan 9^th 2013 were performed in six hospitals in Korea. All hospitalized patients with newly-placed IUCs were enrolled and monitored weekly for 28 days after IUC placement. In the point-prevalence study, the IUCs were present in median 14.9/100 hospitalized patients (1Q 14, 3Q 16) across the six hospitals. In the prospective cohort study, the median IUC-days per patient was 5 (1Q 3, 3Q 10) and the median CA-UTI prevalence per 1,000 catheter days was 1.9 (1Q 0.7, 3Q 3.8) with significant inter-hospital variation. The proportion of patients with inappropriate IUC maintenance increased with number of IUC-days (8.5% on day 7, 9.4% on day 14, 16.3% on day 21, and 23.1% on day 28). Urinary output monitoring (23/36, 63.9%) was the most common indication for inappropriate use after 1 week of ICU placement. In multivariate analysis, IUC-days was significantly associated with the development of CA-UTI (odds ratio 1.122, 95% confidence interval 1.074–1.173, P< 0.001). IUC-days and CA-UTI rates vary between hospitals. IUC-days is a risk factor for CA-UTI, and is correlated with inappropriate use.

Avoidance of urinary catheterization to minimize in-hospital complications after transcatheter aortic valve implantation: An observational study

Background:

Contemporary transcatheter aortic valve implantation (TAVI) devices and approach present opportunities to review historical practices initially informed by early treatment development and cardiac surgery. The avoidance of urinary catheterization in the older TAVI population is a strategy to minimize in-hospital complications. The purpose of the study was to explore elimination-related complications following the phased implementation of a default strategy of avoiding urinary catheterization in patients undergoing transfemoral (TF) TAVI.

Methods:

We conducted an observational study using a retrospective chart review of patients treated between 2011 and 2013 to identify patient characteristics, peri-procedure details, in-hospital outcomes and elimination-related complications in patients who did or did not receive a peri-procedure indwelling catheter. Descriptive analyses were used to report differences between the groups; we conducted a regression analysis to explore the relationship between the practice of urinary catheterization and total procedure time.

Results:

Of the 408 patients who underwent TF TAVR, 188 (46.1%) received a peri-procedure indwelling urinary catheter and 220 (53.9%) did not. There was no difference in in-hospital mortality (2.2%), disabling stroke (0.5%), or other major cardiac adverse events. The avoidance of a urinary catheter resulted in significantly lower rates of urinary tract infection requiring a new antibiotic regimen (1.4% versus 6.1%, p = 0.014), haematuria documented by medicine or nursing (3.7% versus 17.6%, p = 0.001), and the need for continuous bladder irrigation (2.7% versus 0%, p = 0.027).

Conclusion:

The avoidance of a urinary catheter may contribute to improved outcomes in patients undergoing TAVI. The intervention should be further evaluated within the broader study of minimalist TAVI.

De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study

BACKGROUND

Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25-50%, and to evaluate the affecting factors of our de-implementation strategy.

METHODS

In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated.

DISCUSSION

This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications.

TRIAL REGISTRATION

Dutch trial registry: NTR6015 . Registered 9 August 2016.

Surface modification strategies for combating catheter-related complications: recent advances and challenges

This review summarizes the progress made in addressing bacterial colonization and other surface-related complications arising from catheter use.

Role of duration of catheterization and length of hospital stay on the rate of catheter-related hospital-acquired urinary tract infections

Objective

Our aim is to prove that duration of catheterization and length of hospital stay (LOS) are associated with the rate of hospital-acquired urinary tract infections (UTI), while taking into account type of urinary catheter used, the most common organisms found, patient diagnosis on admission, associated comorbidities, age, sex, precautions that should be taken to avoid UTI, and comparison with other studies.

Methods

The study was done in a university teaching hospital with a 920-bed capacity; this hospital is a tertiary care center in Riyadh, Saudi Arabia. The study was done on 250 selected patients during the year 2010 as a retrospective descriptive study. Patients were selected as purposive sample, all of them having been exposed to urinary catheterization; hospital-acquired UTI were found in 100 patients. Data were abstracted from the archived patients’ files in the medical record department using the annual infection control logbook prepared by the infection control department. The data collected were demographic information about the patients, clinical condition (diagnosis and the LOS), and possible risk factors for infection such as duration of catheterization, exposure to invasive devices or surgical procedures, and medical condition.

Results

There was a statistically significant association between the rate of UTI and duration of catheterization: seven patients had UTI out of 46 catheterized patients (15%) at 3 days of catheterization, while 30 patients had UTI out of 44 catheterized patients (68%) at 8 days of catheterization (median 8 days in infected patients versus 3 days in noninfected patients; P-value <0.05), which means that the longer the duration of catheterization, the higher the UTI rate. There was a statistically significant association between the rate of UTI and LOS: three patients had UTI out of 37 catheterized patients (8%) at 10 days LOS, while 42 patients had UTI out of 49 catheterized patients (85.7%) at 18 days LOS. The longer the LOS, the higher the UTI rate: LOS for each patient (median 18 days for infected patients versus 10 days for noninfected patients; P-value <0.05), and number of hospital-acquired catheter-related UTI (100 patients had UTI out of 250 catheterized patients, P=0.04).

Conclusion

Reduction of the duration of catheterization and LOS of the patient have a positive impact in reduction of catheter-related UTI.

A Tool to Assess the Signs and Symptoms of Catheter-Associated Urinary Tract Infection: Development and Reliability

The purpose of this pilot study was to determine the inter-rater reliability of four clinical manifestations of catheter-associated urinary tract infections (CAUTI) among hospitalized adults with short-term indwelling urinary catheters using a tool developed for this purpose: the CAUTI Assessment Profile (CAP). Study participants included 30 non-pregnant English-speaking adults, recruited from two community hospitals. Three nurses assessed each participant for fever, suprapubic tenderness, flank tenderness, and delirium using standardized techniques. Based on the generalized Kappa statistic and 95% confidence intervals, there was evidence of strong inter-rater reliability for fever (K = 1.00, 0.793-1.207), suprapubic tenderness (K = 0.39, 0.185-0.598), and delirium (K = 0.58, 0.379-0.792), but not for flank tenderness (K = 0.29, -0.036 to 0.617). This study provides preliminary evidence that the CAP can be used to consistently identify these clinical signs and symptoms of CAUTI in hospitalized adults.