Quantitative Results of a National Intervention to Prevent Hospital-Acquired Catheter-Associated Urinary Tract Infection: A Pre-Post Observational Study

Decreasing Urinary Catheterization in Kidney Injury (DUCKI): an effectiveness and deimplementation study in the Intensive Care Unit

Funding

EAA is funded by the Washington University Department of Anesthesiology's Division of Clinical and Translational Research (DoCTR). Research reported in this publication was supported by the Washington University Institute of Clinical and Translational Sciences grant UL1TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (1). The content is solely the responsibility of the authors and does not necessarily represent the official view of the NIH.

KEY POINTS

This hybrid 1 implementation science study investigated the effectiveness of a program to reduce IUC utilization in ICU patients with AKI and ESRD. The DUCKI protocol successfully decreased IUC rates by 67% in the study's targeted group of AKI and ESRD patients within an academic surgical ICU and was maintained over 2 years of follow up. Using implementation science to introduce evidence-based strategies like DUCKI is effective at increasing adoption and sustaining the practice.Oliguric patients offer a path of less resistance in changing catheterization practices.DUCKI can safely minimize IUC use in specific ICU populations.The protocol offers the potential for broader interventions to reduce catheter-associated risks in all ICU patients.

BACKGROUND

Indwelling urinary catheter use remains high in the surgical intensive care unit despite targeted, national efforts. When hospital-based initiatives occur, it is unclear if decreases in utilization are sustained.

OBJECTIVES

In 2021, we used implementation science to develop the Decreasing Urinary Catheters in Kidney Injury (DUCKI) program, targeting decreased indwelling catheterization in patients with acute kidney injury (AKI) with oliguria or end stage renal disease (ESRD). Three years later, we evaluated the effectiveness of DUCKI.

METHODS

This was a hybrid 1 implementation study. Outcomes of DUCKI eligible patients were evaluated through chart review with comparisons made between the 2021 and 2023 cohorts. Physicians and nurses were surveyed on the implementation effort.

RESULTS

∼12.5% of patients were eligible for DUCKI. 70 patients in 6 months in 2021 and 19 patients in month in 2023 met DUCKI criteria. The average indwelling catheterization rate in DUCKI patients dropped to 10% from 80% in 2021. In 2023, the catheterization rate in DUCKI patients remains low (9%). Overall rates in the unit declined from 74% pre-implementation to 70% in 2021 and 66% in 2023. There were no serious adverse events associated with the protocol. The acceptability survey was completed by ICU stakeholders pre (n=88) and post (n=77) intervention. Respondents generally rated DUCKI positively, although a minority (26%) reported increased burden to workflow.

CONCLUSIONS

Low indwelling catheterization rates in patients with oliguric AKI or ESRD were sustained in the ICU's DUCKI implementation program. This program has contributed to sustained decrease in overall unit catheterization.

Spectroscopic and Thermal Characterisation of Interpenetrating Hydrogel Networks (IHNs) Based on Polymethacrylates and Pluronics, and Their Physicochemical Stability under Aqueous Conditions

This study describes the physicochemical characterisation of interpenetrating hydrogel networks (IHNs) composed of either poly(hydroxyethylmethacrylate, p(HEMA)) or poly(methacrylic acid, p(MAA)), and Pluronic block copolymers (grades F127, P123 and L121). IHNs were prepared by mixing the acrylate monomer with Pluronic block copolymers followed by free radical polymerisation. p(HEMA)-Pluronic blends were immiscible, evident from a lack of interaction between the two components (Raman spectroscopy) and the presence of the glass transitions (differential scanning calorimetry, DSC) of the two components. Conversely, IHNs of p(MAA) and each Pluronic were miscible, displaying a single glass transition and secondary bonding between the carbonyl group of p(MAA) and the ether groups in the Pluronic block copolymers (Raman and ATR-FTIR spectroscopy). The effect of storage of the IHNs in Tris buffer on the physical state of each Pluronic and on the loss of Pluronic from the IHNs were studied using DSC and gravimetric analysis, respectively. Pluronic loss from the IHNs was dependent on the grade of Pluronic, time of immersion in Tris buffer, and the nature of the IHN (p(HEMA) or p(MAA)). At equilibrium, the loss was greater from p(HEMA) than from p(MAA) IHNs, whereas increasing ratio of poly(propylene oxide) to poly(ethylene oxide) decreased Pluronic loss. The retention of each Pluronic grade was shown to be primarily due to its micellization; however, hydrogen bonding between Pluronic and p(MAA) (but not p(HEMA)) IHNs contributed to their retention.

Systematic review of contemporary interventions for improving discharge support and transitions of care from the patient experience perspective

AIM

To synthesize the impact of improvement interventions related to care coordination, discharge support and care transitions on patient experience measures.

METHOD

Systematic review. Searches were completed in six scientific databases, five specialty journals, and through snowballing. Eligibility included studies published in English (2015-2023) focused on improving care coordination, discharge support, or transitional care assessed by standardized patient experience measures as a primary outcome. Two independent reviewers made eligibility decisions and performed quality appraisals.

RESULTS

Of 1240 papers initially screened, 16 were included. Seven studies focused on care coordination activities, including three randomized controlled trials [RCTs]. These studies used enhanced supports such as improvement coaching or tailoring for vulnerable populations within Patient-Centered Medical Homes or other primary care sites. Intervention effectiveness was mixed or neutral relative to standard or models of care or simpler supports (e.g., improvement tool). Eight studies, including three RCTs, focused on enhanced discharge support, including patient education (e.g., teach back) and telephone follow-up; mixed or neutral results on the patient experience were also found and with more substantive risks of bias. One pragmatic trial on a transitional care intervention, using a navigator support, found significant changes only for the subset of uninsured patients and in one patient experience outcome, and had challenges with implementation fidelity.

CONCLUSION

Enhanced supports for improving care coordination, discharge education, and post-discharge follow-up had mixed or neutral effectiveness for improving the patient experience with care, compared to standard care or simpler improvement approaches. There is a need to advance the body of evidence on how to improve the patient experience with discharge support and transitional approaches.

Leaving no culture undrawn: Time to revisit the CLABSI and CAUTI metrics

Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are quality metrics for many ICUs, and financial ramifications can be applied to hospitals and providers who perform poorly on these measures. Despite some perceived benefits to tracking these metrics, there are a range of issues associated with this practice: lack of a solid evidence base that documenting them has led to decreased infection rates, moral distress associated with identifying these infections, problems with their definitions, and others. We discuss each of these concerns while also including international perspectives then recommend practical steps to attempt to remediate use of the CLABSI and CAUTI metrics. Specifically, we suggest forming a task force consisting of key stakeholders (e.g., providers, Centers for Medicare & Medicaid Services (CMS), patients/families) to review CLABSI and CAUTI-related issues and then to create a summary statement containing recommendations to improve the use of these metrics.

Behavioral Strategies in Diagnostic Stewardship

Diagnostic stewardship refers to the responsible and judicious use of diagnostic tests to reduce low value care and improve patient outcomes. This article provides an overview of behavioral strategies, their relevance to diagnostic stewardship and highlights behavioral determinants that drive diagnostic testing behavior, drawing on theoretic frameworks. Additionally, we provide concrete examples of evidence-based behavioral strategies for promoting appropriate diagnostic testing while acknowledging associated challenges. Finally, we highlight the significance of evaluating these strategies and provide an overview of evaluation frameworks and methods.

Effectiveness of national and subnational interventions for prevention and control of health-care-associated infections in acute hospitals in high-income and upper-middle-income counties: a systematic review update

This systematic review, commissioned and funded by WHO, aimed to update a review of infection prevention and control (IPC) interventions at a national level to inform a review of their IPC Core Components guidelines (PROSPERO CRD42021297376). CENTRAL, CINAHL, Embase, MEDLINE, and WHO IRIS were searched for studies meeting Cochrane's Effective Practice and Organisation of Care (EPOC) design criteria, published from April 19, 2017, to Oct 14, 2021. Primary research studies examining national IPC interventions in acute hospitals in any country with outcomes related to rates of health-care-associated infections were included. Two independent reviewers extracted data and assessed quality using the EPOC risk of bias criteria. 36 studies were categorised per intervention type and synthesised narratively: care bundles (n=2), care bundles with implementation strategies (n=9), IPC programmes (n=16), and regulations (n=9). Designs included 21 interrupted time-series, nine controlled before-and-after studies, four cluster-randomised trials, and two non-randomised trials. Evidence supports the effectiveness of care bundles with implementation strategies. However, evidence for IPC programmes and regulations was inconclusive as studies were heterogeneous regarding populations, interventions, and outcomes. The overall risk of bias was high. Recommendations include the involvement of implementation strategies in care bundles and for further research on national IPC interventions with robust study designs and in low-income and middle-income settings.

Implementing strategies to prevent infections in acute-care settings

This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.

Effect of Time of Daily Data Collection on the Calculation of Catheter-associated Urinary Tract Infection Rates

Introduction

According to the National Healthcare Safety Network (NHSN) definitions for Catheter-associated urinary tract infections (CAUTI) rates, determination of the number of urinary catheter days must occur by calculating the number of catheters in place "for each day of the month, at the same time of day" but does not define at what time of day this occurs. The purpose of this review was to determine if a data collection time of 11 am would yield a greater collection of urinary catheter days than that done at midnight.

Methods

During a 20-month period, the number of urinary catheter days was calculated using once-a-day electronic measurements to identify a urinary catheter presence. We used data collected at 11 am and collected at midnight (our historic default) in comparing the calculated urinary catheter days and resultant CAUTI rates.

Results

There were 7,548 patients who had a urinary tract catheter. The number of urinary catheter days captured using the 11 am collection time was 15,425, and using the midnight collection time was 10,234, resulting in a 50.7% increase. The CAUTI rate per 1,000 urinary catheter days calculated using the 11 am collection method was 0.58, and using the midnight collection method was 0.88, a reduced CAUTI rate of 33.6%.

Conclusion

The data collection time can significantly impact the calculation of urinary catheter days and on calculated CAUTI rates. Variations in how healthcare systems define their denominator per current National Healthcare Safety Network policy may result in significant differences in reported rates.

Trends in central-line-associated bloodstream infections and catheter-associated urinary tract infections in a large acute-care hospital system in New York City, 2016-2019

BACKGROUND

Central-line bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) negatively impact clinical outcomes and hospital reimbursement. In this report, 4 year trends involving 11 hospitals in New York City were examined.

METHODS

Data from the National Healthcare Safety Network (NHSN) were extracted for 11 acute-care hospitals belonging to the NYC Health + Hospital system from 2016 through 2019. Trends in device infections per 1,000 patient days, device utilization ratios, and standardized infection ratios (SIRs) were examined for the 11 hospitals and for the entire system.

RESULTS

Over the 4-year period, there were progressive declines in central-line days, infections per 1,000 central-line days, and device utilization ratios for the system. The average annual SIRs for the system also declined: 1.40 in 2016, 1.09 in 2017, 1.04 in 2018, and 0.82 in 2019. Case-mix indices correlated with SIRs for CLABSIs. Level 1 trauma centers had higher SIRs and a disproportionately greater number of CLABSIs in patients located in NHSN-defined surgical intensive care units. Similar trends with CAUTIs were noted, with progressive declines in catheter days, infections per 1,000 patient days, device utilization ratios, and SIRs (1.42 in 2016, 0.93 in 2017, 1.18 in 2018, and 0.78 in 2019) over the 4-year period.

CONCLUSIONS

Across an 11-hospital system, continuing efforts to reduce device utilization and infection rates resulted in declining SIRs for CLABSIs and CAUTIs. Hospitals with higher case-mix indices, and particularly level 1 trauma centers, had significantly higher central-line infection rates and SIRs.

Protocolized Urine Sampling is Associated with Reduced Catheter-associated Urinary Tract Infections: A Pre- and Postintervention Study

Background

Standard urine sampling and testing techniques do not mitigate against detection of colonization, resulting in false positive catheter-associated urinary tract infections (CAUTI). We aimed to evaluate whether a novel protocol for urine sampling and testing reduces rates of CAUTI.

Methods

A preintervention and postintervention study with a contemporaneous control group was conducted at 2 campuses (test and control) of the same academic medical center. The test campus implemented a protocol requiring urinary catheter removal prior to urine sampling from a new catheter or sterile straight catheterization, along with urine bacteria and pyuria screening prior to culture. Primary outcomes were test campus CAUTI rates, compared between each 9-month pre- and postintervention epoch. Secondary outcomes included the percent reductions in CAUTI rates, compared between the test campus and a propensity score–matched cohort at the control campus.

Results

A total of 7991 patients from the test campus were included in the primary analysis, and 4264 were included in the propensity score–matched secondary analysis. In the primary analysis, the number of CAUTI cases per 1000 patients was reduced by 77% (6.6 to 1.5), the number of CAUTI cases per 1000 catheter days was reduced by 63% (5.9 to 2.2), and the number of urinary catheter days per patient was reduced by 37% (1.1 to 0.69; all P values ≤ .001). In the propensity score–matched analysis, the number of CAUTI cases per 1000 patients was reduced by 82% at the test campus, versus 57% at the control campus; the number of CAUTI cases per 1000 catheter days declined by 68% versus 57%, respectively; and the number of urinary catheter days per patient decreased by 44% versus 1%, respectively (all P values < .001).

Conclusions

Protocolized urine sampling and testing aimed at minimizing contamination by colonization was associated with significantly reduced CAUTI infection rates and urinary catheter days.

Qualitative Assessment of a State Partner-Facilitated Health Care-Associated Infection Prevention National Collaborative

BACKGROUND

The Centers for Disease Control and Prevention (CDC) funded a 3-year national collaborative focused on facilitating relationships between health care-associated infection (HAI) prevention stakeholders within states and improving HAI prevention activities within hospitals. This program-STRIVE (States Targeting Reduction in Infections via Engagement)-targeted hospitals with elevated rates of common HAIs.

OBJECTIVE

To use qualitative methods to better understand STRIVE's effect on state partner relationships and HAI prevention efforts by hospitals.

DESIGN

Qualitative case study, by U.S. state.

SETTING

7 of 22 eligible STRIVE state partnerships.

PARTICIPANTS

Representatives from state hospital associations, state health departments, and other participating organizations (for example, Quality Innovation Networks-Quality Improvement Organizations), referred to as "state partners."

MEASUREMENTS

Phone interviews (n = 17) with each organization were conducted, recorded, and transcribed.

RESULTS

State partners reported that relationships with each other and with participating hospitals improved through STRIVE participation. The partners saw improvements in hospital-level HAI prevention activities, such as improved auditing and feedback practices and inclusion of environmental services in prevention efforts; however, some noted those improvements may not be reflected in HAI rates. Many partners outlined plans to sustain their partner relationships by working on future state-level initiatives, such as opioid abuse prevention and antimicrobial stewardship.

LIMITATION

Only 7 participating states were included; direct feedback from participating hospitals was not available.

CONCLUSION

Although there were no substantial changes in aggregate HAI rates, STRIVE achieved its goal of improving state partner relationships and coordination. This improved collaboration may lead to a more streamlined response to future HAI outbreaks and public health emergencies.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.