cauti prevention in a vha nursing home cohort 823


figure 2. Catheter utilization among reporting facilities during the 12-month collaborative. Legend: Number of catheters used per 100 resident days.


Unlike the reductions in CAUTI rates observed among community-based nursing homes while participating in the AHRQ Safety Program for Long-Term Care,10 there was no change in CAUTI rates (or other measured outcomes) among participating VHA nursing homes. Several potential factors might help to explain the differing results between the VHA and community-based nursing homes: efforts to reduce infections, including CAUTI, initiated by the VHA several years prior to the AHRQ program; the more readily available infection prevention resources and infrastructure among VHA nursing homes, as part of a large integrated healthcare system; and differences in resident populations. First, VHA nursing homes began the program with mark-


edly lower baseline CAUTI rates than the non-VHA commu- nity-based nursing homes (2.26 VHA vs 6.78 non-VHA CAUTIs per 1,000 catheter days).10 Indeed, VHA nursing homes demonstrated a significant reduction in CAUTI rates, beginning in 2011, following nationwide implementation of the previously described program (41% annual reduction from 2011 through 2014 [P=.0001]).15 Thus, at the end of the 12-month AHRQ program, the average rate for participating community-based nursing homes (2.63 per 1,000 catheter days)10 was similar to the observed rate for the VHA cohort throughout the program period. This relatively low rate among VHA nursing homes does not mean that opportunities for additional improvement do not exist but rather suggests that more specific targeting of other prevalent safety concerns may be needed. For example, reducing catheter utilization rates in VHA nursing homes, which are currently ~11%, might provide a specific opportunity for further improvement by preventing noninfectious harms and potentially further reducing infectious complications as well.18,19 Second, a fundamental aspect of a quality improvement


collaborative involves providing expertise, resources, and support to participating facilities. Non-VHA nursing homes


are required, by law, to have an infection prevention and control program in order to be reimbursed for resident care through the Centers for Medicare and Medicaid Services.20,21 Nonetheless, nursing homes vary with respect to the resources allotted for infection prevention activities.14,22 For example, among participating community-based nursing homes, an average of 12 hours per week was allocated for infection prevention activities. While 79% indicated they had a committee that reviewed infection rates, including CAUTI, only 66% performed CAUTI surveillance.14 In contrast, par- ticipating VHAnursing homes reported an average of 33 hours per week devoted to overall infection prevention activities, and nearly all had a committee that reviews infection rates and conducted CAUTI surveillance. This more robust infection prevention infrastructure is likely related to being part of a large integrated healthcare system and the fact that many VHA nursing homes are collocated or closely aligned with a VHA medical center.14 Although difficult to measure directly, resources to support infection prevention activities in VHA nursing homes appear to be more readily available, and as a consequence, the expertise, education, and tools provided by the collaborative may have had less impact on these VHA facilities compared with their community-based counterparts. Third, certain notable differences exist between resident populations in community-based versus VHA nursing homes.14 Although no resident-specific data were collected as part of the collaborative, residents in VHA nursing homes are predominantly older men, whereas in community-based facilities, approximately two-thirds of residents are female.23 While research suggests that females are at higher risk for developing urinary tract infections,24 use of indwelling devices (eg, urinary catheters, gastrostomy tubes, peripheral and central intravenous catheters) may be more prevalent among residents in VHA nursing homes.3 This reflects, in part, the types of residents who receive care in these facilities, which includes residents with spinal cord injury as well as those with complex or special care requirements (eg, ventilator care and hospice or end-of-life care). Indeed, among nursing homes participating in the AHRQ collaborative, urinary catheter utilization among VHA nursing homes (11%) was sub- stantially higher than in the non-VHA community-based nursing homes (4.5%).10 The lack of change in catheter utilization among community-based nursing homes suggests that a decrease in catheter use was likely not a primary reason for the reduction in CAUTI found among community-based nursing homes. This does not mean, however, that efforts to reduce catheter use, especially in VHA nursing homes, are not warranted. This study has several limitations. First, participation in the collaborative was voluntary. Although nearly half of VA nursing homes (63 of 133) were initially enrolled, only 55 provided sufficient data for assessing outcomes, and this number dropped to just 23 during the final program month. As such, these findings may not be generalizable to all VHA nursing homes and may have been influenced by facility


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