904
definition was revised as of January 2015 to exclude fungemia and lower bacteriuria levels.15 Counts of new catheters, catheter days, and reinsertions were calculated with the module from phase 1. Catheters that were removed for more than 12 hours (ie, long enough to be captured by electronic documentation) and replaced in the same patient were defined as reinsertions. We report 4 main study outcomes. First, we examined CAUTI
rates per 1,000 device days and per 10,000 hospitalized patient days because the former has been shown to mask the effects of successful quality improvement initiatives targeting reduction in catheter utilization; the latter is influenced by the noncatheterized patient population.16 Second, we determined the number of initial catheter placements per 1,000 hospitalized patient days and total catheter days per 1,000 hospitalized patient days because phased interventions aimed to reduce both initial catheter placement and catheter duration. In addition to reporting mean and median catheter duration, we plotted the distribution of catheter duration by study period to better characterize changes. Mean catheter duration is commonly reported in the literature,6 even though the distribution of catheter duration is typically skewed toward shorter durations and does not follow a normal distribution. Most catheters remain for only 1 or 2 days; therefore, median values also do not adequately capture effects on longer-duration catheters.
Table 2. Outcomes by Phase of Intervention Variable
Patient days CAUTIs
CAUTIs per 10,000 patient days Relative risk (95% CI)b
CAUTIs per 1,000 catheter days Relative risk (95% CI)b
Urine cultures per 10,000 patient days Relative risk (95% CI)b
Catheter daysc
Catheter days per 1,000 patient days Relative risk (95% CI)b
New catheters
New catheters per 10,000 patient days Relative risk (95% CI)b Catheter reinsertions
Phase 1 1,118,362 1,013 9·06
4·66 2,153
217,478 194·46
59,679 533·6
2,186
Reinsertion rate per initial catheter, % 3·66 Relative risk (95% CI)b
Catheter durationd Mean days ± SD
Median days (IQR)
3·57 ± 5·26 2 (1,4)
Phase 2 1,397,023 809 5·79
0·639 (0·583–0·701) 3·25
0·698 (0·636–0·765) 2,065
0·988 (0·988–0·990) 248,978 178·22
0·916 (0·912–0·921) 64,432 461·2
0·864 (0·855–0.874) 2,032 3·15
0·861 (0·811–0·914)
3·80 ± 5·52 2 (2,4)
<·001 <·001
Brett E. Youngerman et al
Third, we calculated the rate of catheter reinsertion as a proportion of all catheters. Finally, we collected and analyzed descriptive data from the user logs of clinician interaction with the CDS tools.
Statistical analysis
Measures of CAUTI, catheter days, new catheters, and reinsertion were calculated as proportions of eligible patient days. Compar- isons between phases were made using the Pearson χ2 test for independence. Catheter duration was compared between phases using the nonparametric Kruskal-Wallis one-way analysis of variance. All analyses were conducted in R version 3·2·1 software (R Foundation for Statistical Computing, Vienna, Austria).17
Results
Between January 2011 and September 2015, the overall inpatient census was 3·85 million hospitalized patient days. We identified 179,070 unique catheters (or 46·4 catheters per 1,000 patient days) and 643,055 catheter days (or 166·7 catheter days per 1,000 hospitalized patient days). During this time, 2,121 CAUTIs occurred, for an overall rate of 3·30 per 1,000 catheter days or 5·50 per 10,000 hospitalized patient days. Also, 5,916
P Valuea <·001 <·001 <·001
Phase 3 312,409 107 3·42
0·378 (0·310–0·461) 2·20
0·472 (0·387–0·576) 1,977
<·001
0·978 (0·976–0·980) 48,632 155·67
<·001
0·801 (0·793–0·808) 13,787 441·3
<·001
0·827 (0·812–0·842) 368 2·67
0·729 (0·653–0·812)
3·62 ± 4·67 2 (2,4)
<·001 <·001
P Valuea <·001 <·001 <·001
Phase 4 909,223 150 1·65
0·182 (0·153–0·216) 1·17
0·252 (0·212–0·299) 1,970
<·001
0·977 (0·976–0·979) 127,967 140·74
<·001
0·723 (0·719–0·728) 35,897 394·8
<·001
0·740 (0·730–0·749) 1,167 3·25
0·894 (0·834–0·959)
3·48 ± 3·96 2 (2,4)
NOTE. CAUTIs, catheter-associated urinary tract infections; SD, standard deviation; IQR, interquartile range. aComparison to phase 1. Pearson’s χ2 test for proportions. The Student t test was used for the mean. Kruskal-Wallis one-way analysis of variance was used for median. bRelative risk by comparison to phase I. cCatheter days includes reinserted catheters. dCatheter duration was calculated for initial catheters only and excluded reinserted catheters.
<·001 <·001
P Valuea
<·001 <·001 <·001
<·001
<·001
·0017
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140
