Infection Control & Hospital Epidemiology
Table 1. Weekly audits on Urinary Catheter Indications and Compliance with Processes in 2015 at Both Facilities Variable
Urinary catheter present Appropriate catheter use
Accurate measurement of urinary output in critically ill Perioperative use
Acute urinary retention
Assist healing of perineal or sacral wounds Comfort for end-of-life care
Required immobilization for trauma or surgery Chronic indwelling catheter Inappropriate catheter use
713/934 (76.3) 546/713 (76.6) 383/713 (53.7) 112/713 (15.7) 29/713 (4.1) 1/713 (0.1) 9/713 (1.3) 4/713 (0.6) 8/713 (1.1)
167/713 (23.4)
Urinary output monitoring in critically ill patients (not requiring hourly monitoring) 152/713 (21.3) Morbid obesity, immobility, confusion or other conditions Incontinence without a sacral or perineal pressure sore Prolonged postoperative use Catheter with seal intact Catheter secured
3/713 (0.4) 1/713 (0.1) 11/713 (1.5)
Urinary bag below bladder
454/713 (63.7) 643/713 (90.2) 707/713 (99.2)
1495
Hospital A, No. (%) Hospital B, No. (%) P Value <.0001
862/1513 (57)
785/862 (91.1) <.0001 655/862 (76) 37/862 (4.3) 36/862 (4.2) 31/862 (3.6) 11/862 (1.3) 13/862 (1.5) 2/862 (0.2) 77/862 (8.9) 35/862 (4.1) 30/862 (3.5) 11/862 (1.3) 1/862 (0.1)
<.0001
661/861 (76.8) <.0001 755/861 (87.7) 858/862(99.5)
.118 .348
patients (9.5%), and acute urinary retention in 65 of 1,575 patients (4.1%). Catheter utilization was 76.3% in hospital A and 57% in hospital B (P < .0001). The appropriate reasons for use were 76.6% for hospital A compared to 91.1% for hospital B (P < .0001). Hospital B had a higher proportion of patients with urinary catheters used for fluid monitoring in critically ill patients (76% vs 53.7%; P < .0001). Compliance with proper maintenance: the catheters were
secured 88.8% of the time, and the urinary bag was below the bladder >99% of the time in both institutions combined; how- ever, the catheter seal was intact only in 63.7% of catheters for hospital A compared to 76.8% for hospital B (P < .0001). No significant changes in compliance were detected for the 3 catheter maintenance variables evaluated over the 6-month period. Comparing 2014 and 2015, urine culture rates in hospital A
were 30.9 and 13 per 1,000 patient days respectively (−57.9%; P < .0001), and in hospital B, the urine culture rates were 45.2 and 34.8 per 1,000 patient days, respectively (−23%; P < .0001) (Table 2). The decrease in the rate of urine cultures per 1,000 patient days at hospital A was accompanied by a reduction in positive urine culture rates per 1,000 patient days and a reduction in CAUTI event rates of >50% without reaching statistical sig- nificance. On the other hand, although the positive urine culture rate per 1,000 patient days did not increase for hospital B, the CAUTI event rates increased without reaching statistical sig- nificance (Table 2). There were no significant differences in the percentage of positive urine cultures at both facilities based on the number of urine cultures done over the 2014 and 2015 periods; however, positive urine culture rates per 1,000 patient days for hospital B in 2015 were >3 times higher than hospital A.
The CAUTI rates in 2015 were 0.8 (hospital A) and 2.2 (hospital B) per 1,000 catheter days (P = .06).
Discussion
We evaluated urinary catheter use, appropriateness, maintenance, and culturing practices at 2 large tertiary-care centers. We observed minimal to no improvement in the use of urinary catheters with our intervention, consistent with the results of recent national efforts.5 Most catheter indications were labeled for accurate measurement of urinary output and for perioperative indications. The differences in urinary catheter utilization between the 2 institutions may be related to different practice patterns at each facility and the interpretation of the need for fluid monitoring. Both facilities had high compliance with the main- tenance elements, with hospital A having a higher proportion of patients with broken catheter seal. Securement devices were used in ~90% of the patients. We found significant differences in culturing practices
between the 2 institutions for baseline and intervention periods. The reduction in obtaining urine cultures in hospital A was not associated with an increase in the proportion of positive urine cultures. Hospital B had an increase in CAUTI rates with a stable and lower catheter utilization ratio, but hospital B requested almost 3 times more urine cultures per 1,000 patient days com- pared to hospital A. This striking variation between the 2 hos- pitals has a powerful effect on the identification of surveillance- based NHSN CAUTI events. Culturing practices greatly affect the number of NHSN-defined CAUTI events, regardless of whether these labeled events are clinically present.6
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