Infection Control & Hospital Epidemiology (2018), 39, 902–908 doi:10.1017/ice.2018.114
Original Article
Reducing indwelling urinary catheter use through staged introduction of electronic clinical decision support in a multicenter hospital system
Brett E. Youngerman MD1, Hojjat Salmasian MD, MPH, PhD2, Eileen J. Carter PhD, RN3,4, Michael L. Loftus MD, MBA5, Rimma Perotte PhD6,7, Barbara G. Ross MS, RN8, E. Yoko Furuya MD, MS8, Robert A. Green MD, MPH9,10
and David K. Vawdrey PhD6,7 1Department of Neurological Surgery, New York-Presbyterian Hospital Columbia University Medical Center, New York, New York, 2Data Science and Evaluation, Brigham and Women’s Hospital, Boston, Massachusetts, 3School of Nursing, Columbia University, New York, New York, 4Department of Nursing, New York- Presbyterian Hospital, New York, New York, 5Department of Radiology, Weill Cornell Medical College, New York, New York, 6The Value Institute, New York- Presbyterian Hospital, New York, New York, 7Department of Biomedical Informatics, Columbia University, New York, New York, 8Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York, 9Division of Emergency Medicine, Columbia University Medical Center, New York, New York and 10Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York
Abstract
Objective: To integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs). Design, Setting, and Participants: This 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015. Interventions: Phase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication. Results: Overall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3.85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9.06 in phase 1 to 1.65 in phase 4 (relative risk [RR], 0.182; 95% confidence interval [CI], 0.153–0.216; P<.001). New catheters per 1,000 patient days declined from 53.4 in phase 1 to 39.5 in phase 4 (RR, 0.740; 95% CI, 0.730; P<.001), and catheter days per 1,000 patient days decreased from 194.5 in phase 1 to 140.7 in phase 4 (RR, 0.723; 95% CI, 0.719–0.728; P<.001). The reinsertion rate declined from 3.66% in phase 1 to 3.25% in phase 4 (RR, 0.894; 95% CI, 0.834–0.959; P=.0017). Conclusions: The phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.
(Received 28 February 2018; accepted 25 April 2018; electronically published June 13, 2018)
Healthcare-associated infections (HAIs) are a leading cause of pre- ventable morbidity, mortality, and healthcare expenditure, and catheter-associated urinary tract infection (CAUTI) is the most common type of HAI.1 Successful efforts to reduce CAUTI have generally focused on 1 ormore of the 4 stages of the urinary catheter life cycle: (1) catheter placement, (2) catheter care, (3) catheter removal, and sometimes (4) catheter reinsertion.2 The greatest risk factor for CAUTI is prolonged indwelling urinary catheter (IUC)
Author for correspondence: Brett E. Youngerman, Department of Neurological Surgery,
Columbia University Medical Center, 710 West 168 Street, New York, NY, 10032. E-mail:
bey2103@cumc.columbia.edu Cite this article: Youngerman BE, et al. (2018). Reducing indwelling urinary catheter
use through staged introduction of electronic clinical decision support in a multicenter hospital system. IInfection Control& Hospital EpidemiologyI 2018, 39, 902–908. doi: 10.1017/ ice.2018.114
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
use.3–5 Reducing catheter use, whether by avoiding initial placement or by removing catheters promptly, is key to preventing CAUTI. Initiatives aimed at reducing IUC use include criteria for
placement and checklists, reminders, and protocols encouraging timely removal.6 Most of these efforts are time and labor intensive and thus are limited in scalability. The largest interventions use electronic clinical decision support (CDS) tools,7–9 which promise reliability, automation, scalability, and targeted incorporation into the workflow of the appropriate decision maker. However, the optimal design and implementation of CDS tools targeting catheter use remain unknown. The effectiveness of CDS tools varies with their ability to
provide useful information to the appropriate practitioners at the right point in their workflow.10 Electronically generated remin- ders present potential hazards in the form of alert fatigue, and automated processes threaten to supersede clinical judgment and
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