Ten pillars for the expansion of health system infection prevention capacity

The COVID-19 pandemic has accelerated changes in health care across the nation. Particularly, infection prevention programs have been subjected to pressures and increased responsibilities with no expansion in support. In addition, there is a rapid trend for health systems to merge to ensure long term sustainability. Based on our experience leading infection prevention at one of the largest health systems in the United States, we outline how systems can provide and increase capacity to optimize and enhance the hospital level infection prevention programs and outcomes. In this commentary, "Ten Pillars for the Expansion of Health System Infection Prevention Capacity" we offer 10 categories of what we have found to establish a successful and functioning infection prevention program. The pillars to support the infection prevention programs focus on structure, processes, empowerment, and partnerships, and the elements and strategies that comprise them.

Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic Bacteriuria

Importance

Guidelines recommend withholding antibiotics in asymptomatic bacteriuria (ASB), including among patients with altered mental status (AMS) and no systemic signs of infection. However, ASB treatment remains common.

Objectives

To determine prevalence and factors associated with bacteremia from a presumed urinary source in inpatients with ASB with or without AMS and estimate antibiotics avoided if a 2% risk of bacteremia were used as a threshold to prompt empiric antibiotic treatment of ASB.

Design, Setting, and Participants

This cohort study assessed patients hospitalized to nonintensive care with ASB (no immune compromise or concomitant infections) in 68 Michigan hospitals from July 1, 2017, to June 30, 2022. Data were analyzed from August 2022 to January 2023.

Main Outcomes and Measures

The primary outcome was prevalence of bacteremia from a presumed urinary source (ie, positive blood culture with matching organisms within 3 days of urine culture). To determine factors associated with bacteremia, we used multivariable logistic regression models. We estimated each patient's risk of bacteremia and determined what percentage of patients empirically treated with antibiotics had less than 2% estimated risk of bacteremia.

Results

Of 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years; 8595 female patients [74.2%]; 2235 African American or Black patients [19.3%], 184 Hispanic patients [1.6%], and 8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI, and 161 (1.4%) had bacteremia from a presumed urinary source. Only 17 of 2126 patients with AMS but no systemic signs of infection (0.7%) developed bacteremia. On multivariable analysis, male sex (adjusted odds ratio [aOR], 1.45; 95% CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21-2.46), urinary retention (aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log of serum leukocytosis (aOR, 3.38; 95% CI, 2.48-4.61), and pyuria (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia. No single factor was associated with more than 2% risk of bacteremia. If 2% or higher risk of bacteremia were used as a cutoff for empiric antibiotics, antibiotic exposure would have been avoided in 78.4% (6323 of 8064) of empirically treated patients with low risk of bacteremia.

Conclusions and Relevance

In patients with ASB, bacteremia from a presumed urinary source was rare, occurring in less than 1% of patients with AMS. A personalized, risk-based approach to empiric therapy could decrease unnecessary ASB treatment.

Diagnostic stewardship and the coronavirus disease 2019 (COVID-19) pandemic: Lessons learned for prevention of emerging infectious diseases in acute-care settings

The coronavirus disease 2019 (COVID-19) pandemic has demonstrated the importance of stewardship of viral diagnostic tests to aid infection prevention efforts in healthcare facilities. We highlight diagnostic stewardship lessons learned during the COVID-19 pandemic and discuss how diagnostic stewardship principles can inform management and mitigation of future emerging pathogens in acute-care settings. Diagnostic stewardship during the COVID-19 pandemic evolved as information regarding transmission (eg, routes, timing, and efficiency of transmission) became available. Diagnostic testing approaches varied depending on the availability of tests and when supplies and resources became available. Diagnostic stewardship lessons learned from the COVID-19 pandemic include the importance of prioritizing robust infection prevention mitigation controls above universal admission testing and considering preprocedure testing, contact tracing, and surveillance in the healthcare facility in certain scenarios. In the future, optimal diagnostic stewardship approaches should be tailored to specific pathogen virulence, transmissibility, and transmission routes, as well as disease severity, availability of effective treatments and vaccines, and timing of infectiousness relative to symptoms. This document is part of a series of papers developed by the Society of Healthcare Epidemiology of America on diagnostic stewardship in infection prevention and antibiotic stewardship.1.

Recommendations for change in infection prevention programs and practice

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.

Comparison of Severe Maternal Morbidities Associated With Delivery During Periods of Circulation of Specific SARS-CoV-2 Variants

IMPORTANCE

Infection with SARS-CoV-2, which causes COVID-19, is associated with adverse maternal outcomes. While it is known that severity of COVID-19 varies by viral strain, the extent to which this variation is reflected in adverse maternal outcomes, including nonpulmonary maternal outcomes, is not well characterized.

OBJECTIVE

To evaluate the associations of SARS-CoV-2 infection with severe maternal morbidities (SMM) in pregnant patients delivering during 4 pandemic periods characterized by predominant viral strains.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients delivering in a multicenter, geographically diverse US health system between March 2020 and January 2022. Individuals with SARS-CoV-2 infection were propensity-matched with as many as 4 individuals without evidence of infection based on demographic and clinical variables during 4 time periods based on the dominant strain of SARS-CoV-2: March to December 2020 (wild type); January to June 2021 (Alpha [B.1.1.7]); July to November 2021 (Delta [B.1.617.2]); and December 2021 to January 2022 (Omicron [B.1.1.529]). Data were analyzed from October 2021 to June 2022.

EXPOSURES

Positive SARS-CoV-2 nucleic acid amplification test result during the delivery encounter.

MAIN OUTCOMES AND MEASURES

The primary outcome was any SMM event, as defined by the US Centers for Disease Control and Prevention, during hospitalization for delivery. Secondary outcomes were number of SMM, respiratory SMM, nonrespiratory SMM, and nontransfusion SMM events.

RESULTS

Over all time periods, there were 3129 patients with SARS-CoV-2, with a median (IQR) age of 29.1 (24.6-33.2) years. They were propensity matched with a total of 12 504 patients without SARS-CoV-2, with a median (IQR) age of 29.2 (24.7-33.2) years. Patients with SARS-CoV-2 infection had significantly higher rates of SMM events than those without in all time periods, except during Omicron. While the risk of any SMM associated with SARS-CoV-2 infection was increased for the wild-type strain (odds ratio [OR], 2.74 [95% CI, 1.85-4.03]) and Alpha variant (OR, 2.57 [95% CI, 1.69-4.01]), the risk during the Delta period was higher (OR, 7.69 [95% CI, 5.19-11.54]; P for trend < .001). The findings were similar for respiratory complications, nonrespiratory complications, and nontransfusion outcomes. For example, the risk of nonrespiratory SMM events for patients with vs without SARS-CoV-2 infection were similar for the wild-type strain (OR, 2.16 [95% CI, 1.40-3.27]) and Alpha variant (OR, 1.96 [95% CI, 1.20-3.12]), highest for the Delta variant (OR, 4.65 [95% CI, 2.97-7.29]), and not significantly higher in the Omicron period (OR, 1.21 [95% CI, 0.67-2.08]; P for trend < .001).

CONCLUSIONS AND RELEVANCE

This cohort study found that the SARS-CoV-2 Delta variant was associated with higher rates of SMM events compared with other strains. Given the potential of new strains, these findings underscore the importance of preventive measures.

Impact of COVID-19 pandemic on hospital onset bloodstream infections (HOBSI) at a large health system

Background

The COVID-19 pandemic has had a considerable impact leading to increases in health care-associated infections, particularly bloodstream infections (BSI).

Methods

We evaluated the impact of COVID-19 in 69 US hospitals on BSIs before and during the pandemic. Events associated with 5 pathogens (Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Candida sp.) were stratified by community onset (CO) if ≤ 3 days from admission or hospital onset (HO) if > 3 days after admission. We compared pre-pandemic CO and HO rates with pandemic periods and the rates of BSI for those with and without COVID-19.

Results

COVID-19 patients were less likely to be admitted with COBSI compared to others (10.85 vs 22.35 per 10,000 patient days; P < .0001). There was a significant increase between pre-pandemic and pandemic HOBSI rates (2.78 vs 3.56 per 10,000 patient days; P < .0001). Also, COVID-19 infected patients were 3.5 times more likely to develop HOBSI compared to those without COVID-19 infection (9.64 vs 2.74 per 10,000 patient-days; P < .0001).

Conclusions

The COVID-19 pandemic period was associated with substantial increases in HOBSI and largely attributed to COVID-19 infected patients. Future research should evaluate whether such measures would be beneficial to incorporate in evaluating infection prevention trends.

Optimal Urine Culture Diagnostic Stewardship Practice- Results from an Expert Modified-Delphi Procedure

BACKGROUND

Urine cultures are nonspecific for infection and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. This study aimed to develop expert guidance on best practices for urine culture diagnostic stewardship.

METHODS

A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped in three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed in a virtual meeting, and a then second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed.

RESULTS

165 questions were reviewed with the panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional reflex urine cultures and urine white blood cell as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions.

CONCLUSIONS

These 18 guidance statements can optimize use of the imperfect urine culture for better patient outcomes.

171. Rising Rates of Gram-Negative Bacilli Blood Stream (GNB-BSI) Infection in Adults

Background

Monitoring bloodstream infections provides updates of the microbiology and antibiotic susceptibility trends. We elected to examine GNB-BSI.

Methods

We retrospectively studied adults (≥18 years old) inpatients with gram-negative bacilli (GNB) bloodstream infection (BSI; January 1, 2010–December 31, 2017), determined the demographics, onset place, microbiology and source. The results were stratified to study year and evaluated by the extended Mantel–Haenszel chi square for linear trends.

Results

GNB were encountered in 4520/14314 (31.6%) positive blood culture (BC) accounting for 2811 BSI episodes (2291 patients) with a steadily increasing rate (table). The 3 most common organisms were Escherichia coli (EC; 44.4%), Klebsiella pneumoniae (KP; 19.2%) and Pseudomonas aeruginosa (PA; 9.6%). GNB-BSI rate increase was mainly in EC-BSI (P = 0.01). The rate of other GNB-BSI did not change. Source distribution of EC-BSI did not change and antibiotic resistance did not change.

Conclusion

GNB-BSI is rising, primarily due to EC, without changes in source distribution or antibiotic susceptibility. Prospective studies to look at EC lineage and virulence factors are needed to determine the reason for EC-BSI rise.

Disclosures

All authors: No reported disclosures.

157. Hospital-Onset Staphylococcus aureus Bacteremia Is Associated with More Than Twice the Mortality Compared with Community-Onset: Evaluation of 58 Hospitals

Background

Staphylococcus aureus is a common pathogen that is implicated with both community and healthcare-associated infections. S. aureus infections lead to sepsis and bacteremia, and are associated with considerable morbidity and mortality despite available antimicrobial therapy.

Methods

Utilizing a clinical decision support system, patients with the presence of at least 1 positive blood culture for S. aureus were identified from April 2018 to March 2019, in 58 hospitals from a single health system. Patients were then matched in the outcomes measures database to obtain the following outcome measures: mortality, complications rate, length-of-stay (LOS), and cost. The S. aureus bacteremia (SAB) outcome measures were compared between community-onset (CO), and hospital-onset (HO).

Results

There were 2,700 SAB cases within the system identified during that time period. Baseline characteristics were similar between patients with CO-SAB and HO-SAB. CO-SAB accounted for 89.4% (2,413/2,700) of the overall cases, while 10.6% (287/2,700) of the cases were HO-SAB. For overall SAB, the observed mortality rate was 11.9% (321/2,700), complications rate was 35%, observed LOS was 11.97 days, and mean observed cost per admission was $29,114. There is a statistically significant higher observed absolute mortality rate (14.8%, 95% CI 9.61, 19.93), complications rate (53.3%), LOS (11.06 days), and cost per admission ($33,285) for HO-SAB, compared with CO-SAB.

Conclusion

HO-SAB is associated with more than twice the mortality, complication rate, LOS, and cost compared with CO-SAB. Structured efforts to reduce the risk for HO SAB and optimizing management of SAB are essential to improve patient outcomes.

Disclosures

All authors: No reported disclosures.

2096. System-Wide Multi-Pronged Approach Leads to Successful Reduction of Fluoroquinolone Use Across a Large Health System

Background

Overuse of fluoroquinolones has been associated with increased rates of Clostridioides difficile infections, MRSA, and resistant Gram-negative infections due to selective pressure on normal flora. In addition, the FDA has issued several safety alerts regarding systemic use of fluoroquinolone antibiotics due to concerns for serious adverse events and antimicrobial resistance. Considerable variability in the utilization of this antibiotic class across the system resulted in a system-wide initiative to reduce inappropriate prescribing.

Methods

A national initiative included the integration of system-wide approved adult criteria for use into electronic health record order sets and pharmacy clinical decision support systems. System-wide education on the initiative involved learning modules, education toolkits and webinars. Fluoroquinolone utilization rates were reported monthly to help facilities determine the success of initiatives to improve performance.

Results

The fluoroquinolone criteria for use were integrated into several disease-specific order sets system-wide to include: pneumonia, acute exacerbation of COPD, chronic bronchitis, sepsis, acute pyelonephritis, and skin and soft-tissue infection. The learning modules were assigned to all acute care pharmacists resulting in 1,783 completions. Education toolkits were utilized by antimicrobial stewardship teams for provider education. A significant reduction in fluoroquinolone utilization rates, defined by days of therapy (DOT) per 1000 patient-days, was seen across 94 facilities (Figure 1). This resulted in a 45.84% reduction in fluoroquinolone rates from 2017 (56.96, 95% CI 56.72, 57.21) to 2018 (30.85, 95% CI 30.66, 31.04).

Conclusion

Developing and implementing a multi-pronged approach to maximize the effective use of fluoroquinolones can result in significant reductions in utilization across a diverse health system.

Disclosures

All authors: No reported disclosures.

2099. Use of Infectious Diseases Source-Specific Electronic Sepsis Order Sets is associated with Improved Survival in Sepsis: An Evaluation of 46 Hospitals in a Large Health Care System

Background

Compliance with evidence-based treatment bundles in patients with sepsis can lead to improved survival in persons with sepsis or septic shock. A way to ensure the adoption of best practices is the early use standardized order sets based on suspected source of infection.

Methods

The patient population was built by connecting electronic health record (EHR) to administrative data. In the EHR, we identified patients who had a sepsis discharge diagnosis code based on the International Statistical Classification of Disease and Related Health Problems (ICD−10), from August 1, 2018 to February 28, 2019. We evaluated the empiric use of sepsis order sets and patient outcomes. We adjusted for age, gender, Elixhauser Comorbidity Score (ECS), intensive care unit (ICU) status, and admission type. For the analysis, we included patients age 18 and older from facilities where we were able to match greater than 70 percent of patients. Matching was done by facility on medical record number and discharge date.

Results

There were 26,604 patients included in the analysis. The overall mortality rate was 10.67% (n = 2,839). Mortality associated with sepsis in patients that had a sepsis order set used was 8.92% (791/8,872), while for those whom a sepsis order set was not used was 11.55% (2,048/17,732). When mortality data were adjusted for age, gender, ECS, ICU status, admission type and hospital size, the use of sepsis order sets was associated with an adjusted odds ratio of 0.793 (95% CI 0.722, 0.868). In addition, in all sepsis patients who had an ICU admission, the use of the sepsis order sets was associated with an adjusted odds ratio of 0.804 (95% CI 0.725, 0.890). Similarly, in all sepsis patients who did not have an ICU admission, the use of the sepsis order sets was associated with an adjusted odds ratio of 0.688 (95% CI 0.556, 0.847).

Conclusion

The use of the standardized sepsis order sets in patients with sepsis was associated with a 20.7% relative risk reduction in mortality. In conjunction with rapid recognition of sepsis, early initiation of the sepsis order sets may lead to improved mortality in patients with sepsis.

Disclosures

All authors: No reported disclosures.

1161. Frequency of Urine Cultures, their Positivity, and CAUTI: Analysis of a Large Health System

Background

Hospitalized patients with bacteriuria are often identified based on positive urine cultures during the workup of urinary tract infection (UTI). However, the frequency of obtaining urine cultures varies between hospitals and may affect the detection of asymptomatic bacteriuria and symptomatic UTI.

Methods

We evaluated the frequency of urine cultures, their positivity and any association to CAUTI in the inpatient setting (excluding emergency department) of 53 hospitals during 2017 and 2018. Total inpatient urine cultures, positive urine cultures and positive urine cultures identified >2 days post-admission were normalized to patient-days. In addition, the rates of positive urine cultures >2 days post-admission were compared per institution to the corresponding CAUTI SIR. We compared small (75,000 patient-days per year).

Results

A total of 238,451 urine cultures were obtained in 53 hospitals over a period of 2 years with bacteriuria detected in 97,138 (40.74%). Hospitals varied in how often urine cultures were obtained, the % of positive urine cultures, and positive urine cultures per 10,000 patient-days (table). Medium size hospitals had significantly higher number of cultures per 10,000 compared with large hospitals (mean difference= 191; P = 0.006), while % positives were significantly lower (mean difference= -8.4; P = 0.02). There was no significant association between the rate of positive urine cultures >2 days after admission and CAUTI SIR (figure).

Conclusion

Our findings underscore the importance of addressing appropriate urine culturing as part of the infection workup in the hospital setting. A lower detection of bacteriuria after 2 days of admission did not necessarily result in a reduction of CAUTI, reflecting the importance of working on a better identification of patients likely to have a urinary tract infection.

Disclosures

All authors: No reported disclosures.

1016. Standardized Antimicrobial Administration Ratio (SAAR) and Clostridioides difficile Infection Standardized Infection Ratio (SIR): Are they connected? An Evaluation of 28 Hospitals

Background

Clostridioides difficile infections (CDIs) are the most prevalent healthcare-associated infection in the U.S. Of all CDIs, most are related to healthcare exposures and are potentially preventable by reducing unnecessary antibiotic use and interrupting patient-to-patient transmission of CDI.

Methods

The adult SAARs for 4 antimicrobial agent categories were compared with the CDI SIR at 28 facilities with greater than 100 beds across the health system for the calendar year of 2018. The 4 adult antimicrobial agent categories chosen for comparison were: antibacterial agents posing the highest risk for CDI, broad-spectrum antibacterial agents predominantly used for hospital-onset infections (BSHO), broad-spectrum antibacterial agents predominantly used for community-acquired infections (BSCA) and all antibacterial agents.

Results

The 2018 aggregate CDI SIR for the 28 facilities was 0.609. The aggregate SAAR for the adult antimicrobial agent categories were 1.05 for the antibacterial agents posing the highest risk for CDI, 1.05 for BSHO, 0.88 for BSCA, and 1.03 for all antibacterial agents. No correlation was seen between any of the 4 adult SAAR antimicrobial agent categories and the facility CDI SIR (Figure 1–4).

Conclusion

While reducing unnecessary antibiotics is an important strategy in preventing CDIs, having a higher observed vs. predicted administration ratio in the four antimicrobial agent categories studied was not correlated with a higher CDI SIR, including the CDI SAAR category. Reduction of CDI is challenging requiring a multipronged approach to include infection control strategies, appropriate testing, and antimicrobial stewardship.

Disclosures

All authors: No reported disclosures.

998. Missclassification of Community and Hospital Onset Bloodstream Infections Using Laboratory-Identified Events

Background

Laboratory-identified bloodstream infections (LAB-ID-BSI) are classified as community onset (CO) if blood culture (BC) is collected within 3 days after facility admission and hospital onset if ≥4 days. This classification is often based on a computer-generated subtraction of the day of admission from day of onset. This method may miss recent prior hospitalizations at the same or different facilities.

Methods

We reviewed BC results (January 1, 2010–December 31, 2016), selected patients with BSI and defined the place of onset as CO (day 0–3) and HO (≥4 days) of admission based on LABID-BSI. All patients with CO were further evaluated to determine whether they were recently hospitalized. The source and microbiology of patients with hospitalization within 14 days of the onset of BSI was compared with HO and CO without prior admission within 6 months.

Results

We encountered 5,179 BSI episodes, 3866 (74.6%) were CO. Prior hospitalization in any hospital within 1–14 and 15–180 days of onset was documented in 659 (17.0%) and 1,465 (37.9%), respectively. Source of bacteremia and type of organisms in patients with prior hospitalization within 1–14 days were closer to HO than patients without prior hospitalization with higher frequency of Intravenous catheters (IVC), polymicrobial bacteremia, and candidemia (table).

Conclusion

Using Lab-ID events to classify BSI, one in six patients may risk being misclassified as CO. This underestimates BSI related to hospital setting. Onset classification should be based on thorough historical information and not a computer-generated subtraction of admission and Lab event dates.

Infective endocarditis; soft tissue/bone; pneumonia; abdomen; unknown/miscellaneous; polymicrobial. Gram-positive; Gram-negative; anaerobes; Candida spp. a: P < 0.01; chi square test.

Disclosures

All authors: No reported disclosures.

"I Never Would Have Caught That Before": Pharmacist Perceptions of Using Clinical Decision Support for Antimicrobial Stewardship in the United States

To systematically improve the appropriateness of antibiotic prescribing, antimicrobial stewardship programs have been developed. There is a paucity of literature examining how pharmacists perform antimicrobial stewardship using a clinical decision support system in a hospital setting. The purpose of this qualitative study was to develop a model exploring how pharmacists perform antimicrobial stewardship to identify areas for programmatic improvement. Semistructured interviews were conducted across a health care system until saturation of themes was reached. Pharmacists identified that self-efficacy and time were vital for antimicrobial stewardship to be performed, while culture of the hospital and attitude facilitated the process of stewardship. Antimicrobial stewardship programs using clinical decision support tools should ensure pharmacists have adequate time to address rules, provide easy-to-use resources and training to support self-efficacy, and engage influential physicians to support a culture of collaboration.

Taking advantage of public reporting: An infection composite score to assist evaluating hospital performance for infection prevention efforts

BACKGROUND

The standardized infection ratio (SIR) evaluates individual publicly reported health care-associated infections, but it may not assess overall performance.

METHODS

We piloted an infection composite score (ICS) in 82 hospitals of a single health system. The ICS is a combined score for central line-associated bloodstream infections, catheter-associated urinary tract infections, colon and abdominal hysterectomy surgical site infections, and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia and Clostridium difficile infections. Individual facility ICSs were calculated by normalizing each of the 6 SIR events to the system SIR for baseline and performance periods (ICS_ib and ICS_ip, respectively). A hospital ICS_ib reflected its baseline performance compared with system baseline, whereas a ICS_ip provided information of its outcome changes compared with system baseline.

RESULTS

Both the ICS_ib (baseline 2013) and ICS_ip (performance 2014) were calculated for 63 hospitals (reporting at least 4 of the 6 event types). The ICS_ip improved in 36 of 63 (57.1%) hospitals in 2014 when compared with the ICS_ib in 2013. The ICS_ib 2013 median was 0.96 (range, 0.13-2.94) versus the 2014 ICS_ip median of 0.92 (range, 0-6.55). Variation was more evident in hospitals with ≤100 beds. The system performance score (ICS_sp) in 2014 was 0.95, a 5% improvement compared with 2013.

CONCLUSIONS

The proposed ICS may help large health systems and state hospital associations better evaluate key infectious outcomes, comparing them with historic and concurrent performance of peers.

Current trends in candidemia and species distribution among adults: Candida glabrata surpasses C. albicans in diabetic patients and abdominal sources

Candidemia rate and species distribution vary according to the type of patients, country of origin and antifungal prophylaxis use. To present current candidemia epidemiological trends. A retrospective examination of candidemia in adults (≥18 years-old) hospitalised from 2007 to 2015. Cases were identified through the microbiology laboratory. Candida species were distinguished based on colony morphology and VITEK-2 YBC cards, (bioMerieux, Durham, NC, USA). Patient characteristics, species distribution, source and outcome were assessed. We encountered 275 patients (294 episodes) with candidemia. The rate of candidemia dropped in 2010 (P = 0.003) without further decline. Nearly all cases (97.5%) were healthcare-associated. C. albicans (n = 118) and C. glabrata (n = 77) proportions varied without a discernable trend. C. glabrata was more common in diabetics [52.9% vs. 32.0% (non-diabetics); P = 0.004] and abdominal sources [53.3% vs. 35.5% (other sources); P = 0.03], especially gastric/duodenal foci [88.9% vs. 44.1% (other abdominal foci); P = 0.02]. All-cause 30-day mortality rate was 43.3% without changes over time or differences between C. albicans and C. glabrata. In conclusion, the candidemia rate remains stable after a decline in 2010. C. albicans remains the most common species but C. glabrata predominates in diabetics and abdominal sources. These findings suggest possible species-related differences in colonisation dynamics or pathogenicity.

A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care

BACKGROUND

Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors--appropriate catheter use, aseptic insertion, and proper maintenance--and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI.

METHODS

The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates.

RESULTS

Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs. Tests for heterogeneity (ICU vs. non-ICU) were significant for catheter use (P=0.004) and catheter-associated UTI rates (P=0.001).

CONCLUSIONS

A national prevention program appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. (Funded by the Agency for Healthcare Research and Quality.).

Regional variation in urinary catheter use and catheter-associated urinary tract infection: results from a national collaborative

OBJECTIVE

To examine regional variation in the use and appropriateness of indwelling urinary catheters and catheter-associated urinary tract infection (CAUTI).

DESIGN AND SETTING

Cross-sectional study.

PARTICIPANTS

US acute care hospitals.

METHODS

Hospitals were divided into 4 regions according to the US Census Bureau. Baseline data on urinary catheter use, catheter appropriateness, and CAUTI were collected from participating units. The catheter utilization ratio was calculated by dividing the number of catheter-days by the number of patient-days. We used the National Healthcare Safety Network (NHSN) definition (number of CAUTIs per 1,000 catheter-days) and a population-based definition (number of CAUTIs per 10,000 patient-days) to calculate CAUTI rates. Logistic and Poisson regression models were used to assess regional differences.

RESULTS

Data on 434,207 catheter-days over 1,400,770 patient-days were collected from 1,101 units within 726 hospitals across 34 states. Overall catheter utilization was 31%. Catheter utilization was significantly higher in non-intensive care units (ICUs) in the West compared with non-ICUs in all other regions. Approximately 30%-40% of catheters in non-ICUs were placed without an appropriate indication. Catheter appropriateness was the lowest in the West. A total of 1,099 CAUTIs were observed (NHSN rate of 2.5 per 1,000 catheter-days and a population-based rate of 7.8 per 10,000 patient-days). The population-based CAUTI rate was highest in the West (8.9 CAUTIs per 10,000 patient-days) and was significantly higher compared with the Midwest, even after adjusting for hospital characteristics (P = .02).

CONCLUSIONS

Regional differences in catheter use, appropriateness, and CAUTI rates were detected across US hospitals.

How and when nurses collect urine cultures on catheterized patients: A survey of 5 hospitals

BACKGROUND

Obtaining a specimen for urine culture is a key element in evaluating for catheter-associated urinary tract infections (CAUTIs). Evaluating nurses' knowledge regarding appropriate reasons and methods to obtain urine culture specimens are the first steps to improving practice.

METHODS

Nurses at 5 hospitals completed a 40-question survey regarding their knowledge, training, and practices of appropriate reasons for obtaining urine cultures. The survey included different scenarios of patients with urinary catheters and when they would expect to obtain urine cultures. A 12-point scoring system calculated responses regarding urine collection appropriateness.

RESULTS

There were 394 nurses who responded to the survey. Of them, 76.1% reported receiving education on CAUTI risk reduction within the last 12 months. Although 327 (83%) of all nurses surveyed reported that they never collect urine samples by draining directly from the drainage bag, only 58.4% viewed others to be fully compliant with that standard (P < .001). Nurses who considered their knowledge to be above average to excellent had similar knowledge assessment scores (out of 12 points) for triggers to obtain urine cultures (mean score, 4.9 ± 1.72) compared with those that reported average to poor knowledge (mean score, 4.64 ± 1.78; P = .15).

CONCLUSIONS

Important opportunities exist for nurses to optimize the decisions to obtain urine cultures and the process for obtaining them. Addressing nurses' knowledge and practice may lead to more appropriate use of urine cultures.

Implementing a National Program to Reduce Catheter-Associated Urinary Tract Infection: A Quality Improvement Collaboration of State Hospital Associations, Academic Medical Centers, Professional Societies, and Governmental Agencies

Catheter-associated urinary tract infection (CAUTI) represents a significant proportion of healthcare-associated infections (HAIs). The US Department of Health and Human Services issued a plan to reduce HAIs with a target 25% reduction of CAUTI by 2013. Michigan's successful collaborative to reduce unnecessary use of urinary catheters and CAUTI was based on a partnership between diverse hospitals, the state hospital association (SHA), and academic medical centers. Taking the lessons learned from Michigan, we are now spreading this work throughout the 50 states. This national spread leverages the expertise of different groups and organizations for the unified goal of reducing catheter-related harm. The key components of the project are (1) centralized coordination of the effort and dissemination of information to SHAs and hospitals, (2) data collection based on established definitions and approaches, (3) focused guidance on the technical practices that will prevent CAUTI, (4) emphasis on understanding the socioadaptive aspects (both the general, unit-wide issues and CAUTI-specific challenges), and (5) partnering with specialty organizations and governmental agencies who have expertise in the relevant subject area. The work may serve in the future as a model for other large improvement efforts to address other hospital-acquired conditions, such as venous thromboembolism and falls.

Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm

Preventing catheter-associated urinary tract infection (CAUTI) remains a significant challenge for US hospitals. The "On the CUSP: Stop CAUTI" initiative represents the single largest national effort (involving >950 hospitals) to mitigate urinary catheter risk. The program brings together key organizations to assist state hospital associations and hospitals by providing education and coaching support, addressing both the technical aspects of preventing CAUTI and CAUTI-specific socio-adaptive challenges. At the local level, engaging health care workers, from physicians and nurses to other ancillary services, is critical. This includes (1) making the importance of addressing CAUTI stakeholder specific, (2) ensuring support from leaders of essential disciplines, (3) underscoring the importance of the collaborative nature of CAUTI prevention, and (4) identifying champions within the organization to lead and be accountable for the work. Sustainability is ensured by integrating the process into the health care worker's daily routine activities.

Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review

BACKGROUND

Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use.

METHODS

To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interventions prompting UC removal by reminders or stop orders. A narrative review summarises other CAUTI prevention strategies including aseptic insertion, catheter maintenance, antimicrobial UCs, and bladder bundle implementation.

RESULTS

30 studies were identified and summarised with interventions to prompt removal of UCs, with potential for inclusion in the meta-analyses. By meta-analysis (11 studies), the rate of CAUTI (episodes per 1000 catheter-days) was reduced by 53% (rate ratio 0.47; 95% CI 0.30 to 0.64, p<0.001) using a reminder or stop order, with five studies also including interventions to decrease initial UC placement. The pooled (nine studies) standardised mean difference (SMD) in catheterisation duration (days) was -1.06 overall (p=0.065) including a statistically significant decrease in stop-order studies (SMD -0.37; p<0.001) but not in reminder studies (SMD, -1.54; p=0.071). No significant harm from catheter removal strategies is supported. Limited research is available regarding the impact of UC insertion and maintenance technique. A recent randomised controlled trial indicates antimicrobial catheters provide no significant benefit in preventing symptomatic CAUTIs.

CONCLUSIONS

UC reminders and stop orders appear to reduce CAUTI rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing UC use involves changing well-established habits.

First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals

BACKGROUND

Hospitals can better focus their efforts to prevent health care-associated infections (HAIs) if they identify specific areas for improvement.

METHODS

We administered a 96-question survey to infection preventionists at 71 Ascension Health hospitals to evaluate opportunities for the prevention of catheter-associated urinary tract infection, central line-associated bloodstream infection, ventilator-associated pneumonia, and surgical site infection.

RESULTS

Seventy-one (100%) infection preventionists completed the survey. The majority of hospitals had established policies for urinary catheter placement and maintenance (55/70, 78.6%), central venous catheter maintenance (68/71, 95.8%), and care for the mechanically ventilated patient (62/66, 93.9%). However, there was variation in health care worker practice and evaluation of competencies and outcomes. When addressing device need, 55 of 71 (77.5%) hospitals used a nurse-driven evaluation of urinary catheter need, 26 of 71 (36.6%) had a team evaluation for central venous catheters on transfer out of intensive care, and 53 of 57 (93%) assessed daily ventilator support for continued need. Only 19 of 71 (26.8%) hospitals had annual nursing competencies for urinary catheter placement and maintenance, 29 of 71 (40.8%) for nursing venous catheter maintenance, and 38 of 66 (57.6%) for appropriate health care worker surgical scrubbing.

CONCLUSION

We suggest evaluating infection prevention policies and practices as a first step to improvement efforts. The next steps include implementing spread of evidence-based practices, with focus on competencies and feedback on performance.

Compounding pharmacy conundrum: "we cannot live without them but we cannot live with them" according to the present paradigm

Compounding pharmacies serve a critical role in modern health care to meet special patient care needs. Although the US Food and Drug Administration (FDA) has clearly delineated jurisdiction over drug companies and products manufactured under Good Manufacturing Practice (GMP) regulations to ensure quality, potency, and purity, compounding pharmacies are regulated by the State Boards and are not registered by the FDA. In recent years, some compounding pharmacies acted like a manufacturer, preparing large amounts of injectable drugs with interstate activities. Multiple outbreaks have been linked to compounding pharmacies, including a recent outbreak of fungal meningitis related to contaminated methylprednisolone, exposing &gt; 14,000 patients in multiple states. This tragedy underscores the urgency of addressing safety related to compounding pharmacies. There is a call for action at the federal and state levels to set minimum production standards, impose new labeling conditions on compounded drugs, and require large-scale compounders be regulated by the FDA. "Industrial" compounding must come under FDA oversight, require those pharmacies to meet GMP standards, and ensure quality and safe products for patient use. Moreover, compliance with the Institute for Safe Medication Practices 2011 recommendations that any type of sterile compounding must be in compliance with the United States Pharmacopoeia chapter 797 guidelines will reduce the risk of patient harm from microbial contamination. Finally, other critical factors that require close attention include addressing injectable products compounded in hospitals and other outpatient health-care centers. The FDA and State Boards of Pharmacy must be adequately funded to exercise the oversight effectively.

Peripheral venous catheter care in the emergency department: education and feedback lead to marked improvements

BACKGROUND

Peripheral venous catheters (PVCs) can be associated with serious complications. We evaluated the effect of education and feedback on processes related to PVC placement.

METHODS

We implemented an educational intervention in a 72-bed Emergency Department (ED) over 12 months (4 periods, each a quarter). During preimplementation period, we evaluated PVC placement, condition, accurate documentation, and demonstration of aseptic steps for medication infusion. With implementation, ED nurses had formal education, with direct observations and feedback. For postimplementation periods 1 and 2, we continued direct observations and feedback, reducing the number of audits per week.

RESULTS

Of 2,568 PVCs evaluated in the ED, accurate documentation on dressing improved from 83 of 803 (10.3%) preimplementation to 300 of 476 (63%) at the end of the study (P < .0001). Correct documentation in ED records improved from 498 of 803 (62%) preimplementation to 409 of 476 (85.9%) at the end of study (P < .0001). We observed 273 attempts to place PVC; of them, 220 (80.6%) were completed. The overall compliance with the procedure steps was very poor preimplementation (n = 3/63, 4.8%) and improved in implementation (n = 17/55, 30.9%) and postimplementation periods 1 (n = 19/60, 31.7%) and 2 (n = 14/42, 33.3%, P < .0001). ED health care workers showed significant improvement in knowledge with education.

CONCLUSION

Education and real-time feedback to ED health care workers are associated with an increased and sustained compliance with processes to reduce the risk of infection from PVCs.

Sustained reductions in urinary catheter use over 5 years: bedside nurses view themselves responsible for evaluation of catheter necessity

BACKGROUND

Multiple approaches are needed to improve urinary catheter use and sustain compliance with the appropriate indications for catheter use.

METHODS

We evaluated the effect of 3 interventions over 5 years: a nurse-driven multidisciplinary effort for early urinary catheter removal, an intervention in an emergency department to promote appropriate placement, and twice-weekly assessment of urinary catheter prevalence with periodic feedback on performance for nonintensive care units. We also assessed the views of bedside nurses, case managers, and nurse managers with respect to appropriate catheter use, how often need is assessed, and who they consider responsible for the evaluation of urinary catheter need.

RESULTS

There was a significant reduction in urinary catheter use from 17.3%-12.7% during the 5-year period (linear regression with time as independent variable, R(2), 0.61; P < .0001). Of bedside nurses responding to the questionnaire, 222 of 227 (97.8%) identified themselves as responsible or as sharing the responsibility for catheter necessity evaluation, 223 of 229 (97.4%) were confident in their knowledge, and 166 of 222 (74.8%) viewed physicians as receptive to their requests for catheter removal >70% of the time.

CONCLUSIONS

A multifaceted approach to promote appropriate urinary catheter use is associated with sustained reductions in catheter use. Bedside nurses view themselves responsible for the evaluation of catheter presence and need.

In vitro activities of LTX-109, a synthetic antimicrobial peptide, against methicillin-resistant, vancomycin-intermediate, vancomycin-resistant, daptomycin-nonsusceptible, and linezolid-nonsusceptible Staphylococcus aureus

LTX-109 and eight other antimicrobial agents were evaluated against 155 methicillin-resistant Staphylococcus aureus (MRSA) isolates, including strains resistant to vancomycin and strains with decreased susceptibility to daptomycin and linezolid, by microdilution tests to determine MICs. Time-kill assays were performed against representative MRSA, vancomycin-intermediate S. aureus (VISA), and vancomycin-resistant S. aureus (VRSA) isolates. LTX-109 demonstrated a MIC range of 2 to 4 μg/ml and dose-dependent rapid bactericidal activity against S. aureus. This activity was not influenced by resistance to other antistaphylococcal agents.

Introducing a population-based outcome measure to evaluate the effect of interventions to reduce catheter-associated urinary tract infection

BACKGROUND

The catheter-associated urinary tract infection (CAUTI) measure recommended by the National Healthcare Safety Network (NHSN) accounts for the risk of infection in patients with an indwelling urinary catheter, but might not adequately reflect all efforts aimed to enhance patient safety by reducing urinary catheter use.

METHODS

We used computer-based Monte Carlo simulation to compare the NHSN-recommended CAUTI rate (CAUTIs per 1,000 catheter-days) with the proposed "population CAUTI rate" (CAUTIs per 10,000 patient-days). We simulated 100 interventions with a wide range of effects on catheter utilization and CAUTI risk in patients with catheters, and then compared the 2 measures before and after intervention across the simulated interventions.

RESULTS

Out of our 100 simulated interventions, 93 yielded reductions in CAUTI; however, in 25 (27%) of these 93 simulations, the NHSN CAUTI rate increased after the intervention. In addition, among the 68 simulations in which both the NHSN and the population CAUTI rates decreased, the percent decreases in the population CAUTI rate were consistently greater than those in the NHSN rate.

CONCLUSION

The population CAUTI rate-CAUTIs per 10,000 patient-days-should be calculated along with the NHSN rate, particularly in settings where interventions lead to substantial reductions in catheter placement. We suspect that this population CAUTI rate may eventually emerge as a primary outcome for hospital-based quality improvement interventions for reducing urinary catheter utilization, especially those focusing on avoiding urinary catheter placement.

Delayed peripheral venous catheter-related Staphylococcus aureus bacteremia: onset ≥ 24 hours after catheter removal

Peripheral venous catheter (PVC)-associated bacteremia usually develops during the indwelling period. We present a review of 14 patients who developed delayed onset Staphylococcus aureus bacteremia (D-SAB), 1-6 days after PVC removal, and compare them to 29 patients with early onset PVC-related S. aureus bacteremia (E-SAB). At the time of removal, the catheter site exhibited inflammation in 8 (57.1%) cases. At SAB onset, PVC site inflammation developed in all patients. Compared to E-SAB, patients with D-SAB were more often aged ≥ 65 y (71.4% vs. 34.5%; p = 0.03) and on corticosteroids (35.7% vs. 6.9%; p = 0.02). D-SAB was more complicated with persistent (> 3 days) bacteremia (42.9% vs. 13.8%; p = 0.04), metastatic infections (35.7% vs. 6.9%; p = 0.02), and slightly higher mortality (21.4% vs. 10.3%; p = 0.3). Logistic regression revealed that the predictors of D-SAB were corticosteroids (odds ratio (OR) 2.10, 95% confidence intervals (CI) 1.16-58.61) and age ≥ 65 y (OR 1.63, 95% CI 1.12-23.30). These patients may have impaired local/systemic defenses that lead to D-SAB, or a blunted host response with delayed recognition.

A prospective clinical trial of cholecalciferol 2000 IU/day in colorectal cancer patients: evidence of a chemotherapy-response interaction

BACKGROUND

We have previously reported a negative correlation between the effect of chemotherapy and 25-hydroxy vitamin D(3) (25-D(3)) levels in patients with colorectal cancer. Based on this finding, we hypothesized that the response to vitamin D(3) supplementation may be attenuated in patients with colorectal cancer.

AIM

To determine 25-D(3) response to 2000 IU/day vitamin D(3) supplementation in patients with colorectal cancer.

MATERIALS AND METHODS

Fifty evaluable colorectal cancer patients were treated with vitamin D(3) at 2000 IU/day for 6 months. Serum 25-D(3) levels were measured at baseline, 3, and 6 months of supplementation.

RESULTS

The mean 25-D(3) level was 17.5 ng/ml at baseline, 31.6 ng/ml at 3 months, and 33.8 ng/ml at 6 months. The most important factor in determining 25-D(3) response was chemotherapy status. A rise in 25-D(3) of ≥10 ng/ml at the 3-month interval was observed in 92% of chemotherapy-free patients vs. 39% of chemotherapy patients. Similar differences in response were noted at the 6-month interval.

CONCLUSION

Depressed 25-D(3) levels are common in patients with colorectal cancer. Active chemotherapy is associated with an attenuated response to 2000 IU of D(3) supplementation in this patient population. Alternative vitamin D(3) dosing schedules need further investigation in colorectal cancer patients undergoing chemotherapy.

Sustained improvements in peripheral venous catheter care in non-intensive care units: a quasi-experimental controlled study of education and feedback

BACKGROUND AND OBJECTIVES

Peripheral venous catheters (PVCs) can be associated with serious infectious complications. We evaluated the effect of education and feedback on process measures to improve PVC care and infectious complications.

DESIGN

Quasi-experimental controlled crossover study with sampling before and after education.

SETTING

An 804-bed tertiary care teaching hospital.

PARTICIPANTS

Nurses and patients in 10 non-intensive care units.

METHODS

We implemented a process to improve PVC care in 10 non-intensive care units. The 4 periods (each 3 months in duration) included a preintervention period and a staggered educational intervention among nurses. During intervention period 1, 5 units participated in the intervention (group A), and 5 units served as a control group (group B). Group B underwent the intervention during intervention period 2, and both groups A and B received feedback on performance during intervention period 3. Process measures were evaluated twice monthly, and feedback was given to nurses directly and to the unit manager on a monthly basis.

RESULTS

During the preintervention period, there were no significant differences between groups A and B. Of 4,904 intravascular catheters evaluated, 4,434 (90.4%) were peripheral. By the end of the study, there were significant improvements in processes, compared with the preintervention period, including accurate documentation of dressing (from 442 cases [38%] to 718 cases [59%]; P < .0001), catheter dressing being intact (from 968 cases [88.5%] to 1,024 cases [95.2%]; P < .0001), and correct demonstration of scrubbing the hub before infusion (from 161 demonstrations [54%] to 316 demonstrations [95%]; P < .0001). There was a significant reduction in PVC-associated bloodstream infection, from 2.2 cases per 10,000 patient-days during the preintervention period (5 cases) to 0.44 cases per 10,000 patient days during the 3 intervention periods (3 cases; P = .016).

CONCLUSIONS

Education and real-time feedback to nurses increases and sustains compliance with processes to reduce the risk of infection from PVCs.

Reducing inappropriate urinary catheter use: a statewide effort

BACKGROUND

Indwelling urinary catheters may lead to both infectious and noninfectious complications and are often used in the hospital setting without an appropriate indication. The objective of this study was to evaluate the results of a statewide quality improvement effort to reduce inappropriate urinary catheter use.

METHODS

Retrospective analysis of data collected between 2007 and 2010 as part of a statewide collaborative initiative before, during, and after an educational intervention promoting adherence to appropriate urinary catheter indications. The data were collected from 163 inpatient units in 71 participating Michigan hospitals. The intervention consisted of educating clinicians about the appropriate indications for urinary catheter use and promoting the daily assessment of urinary catheter necessity during daily nursing rounds. The main outcome measures were change in prevalence of urinary catheter use and adherence to appropriate indications. We used flexible generalized estimating equation (GEE) and multilevel methods to estimate rates over time while accounting for the clustering of patients within hospital units.

RESULTS

The urinary catheter use rate decreased from 18.1% (95% CI, 16.8%-19.6%) at baseline to 13.8% (95% CI, 12.9%-14.8%) at end of year 2 (P < .001). The proportion of catheterized patients with appropriate indications increased from 44.3% (95% CI, 40.3%-48.4%) to 57.6% (95% CI, 51.7%-63.4%) by the end of year 2 (P = .005).

CONCLUSIONS

A statewide effort to reduce inappropriate urinary catheter use was associated with a significant reduction in catheter use and improved compliance with appropriate use. The effect of the intervention was sustained for at least 2 years.