Infection Control & Hospital Epidemiology


effect.22 The increase in mean catheter duration of 0·23 days in the same period was due to a disproportionate decrease in the place- ment of short-duration catheters (those remaining <1full day) (Fig. 3B). An absolute reduction in catheters of all durations occurred with each phase of intervention (Fig. 3A). Only the new order in phase 4 specifically targeted new


catheter placement. Catheters are often placed without appro- priate indication23,24 and numerous guidelines and education initiatives have aimed to minimize initial use.7,25–30 Our approach directed clinicians through guidelines at the point of decision making in the EHR order, which has mostly been reported in small pilot studies27–29 with few hospital-wide implementations.7 The order set rarely (<1% of instances) led clinicians to select alternatives; however, given their low baseline utilization, we detected a dramatic increase in the overall use of these alternatives (Table S3). The impact of this intervention on new catheter placement was difficult to isolate because it followed prior, unexpected reductions; however, we detected a further decline in new catheter placement in phase 4 after relative stabilization between phases 2 and 3.


Promoting catheter removal


Reminders of catheter duration are a popular approach to pro- moting catheter removal, but empiric results are mixed. Several studies have shown that IUCs remain in use when they are no longer needed31,32 and that physicians are often unaware of their presence.33 In one meta-analysis,6 some reminders were associated with large effects, but the weighted mean did not meet statistical significance (standardized mean difference [SMD], −1·54; 95% confidence interval [CI], −3·20 to 0·13). Our triggered-reminder system in phase 3 was associated with a measurable reduction in mean catheter duration of 0.19 days from phase 2, a measure that underestimates the true effect size given the concurrent dis- proportionate decreased use of short-duration catheters. Total catheter days also declined by a greater percentage than new catheters between phase 2 and 3. Electronic reminder systems effectively reach a wide clinical


907


catheter removal.30,38–40 In the aforementioned meta-analysis,6 standing stop orders yielded consistent reductions in catheter duration (SMD, −0·37 days; 95% CI, −0·56 to −0·18). In phase 4 of this study, we detected a further 0·23-day decrease in mean catheter duration and a further decline in total catheter days in addition to the prior reductions. The limitation of automated removal protocols is that they


require a change in the expectations and responsibilities of nurses and clinicians. Clinicians, fearing premature removal of catheters and increased need for reinsertion, may be reluctant to accept protocols that they perceive to supersede clinical judgment. Nurses may be uncomfortable assuming responsibility for deci- sions previously left to clinicians.41 As a result, automated pro- tocols often require significant training and auditing; thus, they have largely been implemented in individual units.6,28,42 In addition, adherence is often poor.43 Our intervention built on the existing electronic tracking


platform and improved interdisciplinary communication to pro- mote the rapid adoption of automatic removal orders across multiple campuses. Clinicians received an electronic warning about autoexpiration upon initial IUC order entry and each day of catheter use in the existing pop-up reminder. All orders expired at noon on day 2 after placement, giving clinicians many opportunities to assess catheter appropriateness before removal and monitor voiding trials afterward. Notably, we did observe a small increase in the reinsertion rate from 2·67% before auto- mated removal to 3·25% afterward. This rate remained lower than the 3·66% rate at the start of the study period and was at the low end of rates reported in the literature,6 but this finding does support the hypothesized tradeoff between early removal and reinsertion.


Limitations


audience, but variable results6 suggest that design and imple- mentation drive success. Alert fatigue can lead users to ignore or override even well-designed reminders.34,35 In CDS design, it is a common adage that successful tools provide the right informa- tion, to the right people, through the right channels, in the right format, and at the right points in the workflow.10 Our alert synthesized and presented relevant nurse documenta-


tion to decisionmakers at atimewhentheywereformulating adaily plan, thus streamlining interdisciplinary communication that might otherwise not occur.36 The alert also stopped triggering until the following day once an assessment was made, avoiding repeated reminders. The triggered alert led to a nearly 40-fold increase in views of the tracking tool compared to the optional tab. Our opt-out rate (ie, users selecting “not primary clinician”)of37·2% was lower than that reported in many prior studies,34,35 but it still suggests that the reminder reached many clinicians for whomit was not intended. Additionally, only a relatively small portion of assessments (9·2%) led to a decision to “remove today.” Clinicians selected “maintain” in most cases (67·5%) and noted that the catheter had been “already removed” in 22.9% of cases, likely due to the lag time in our elec- tronic tracking system (Table S1). Automatic IUC order expiration, or standing stop orders,


change the default option, a powerful technique in behavior modification,37,38 and one that is highly effective in promoting


This study has 2 principal limitations. First, a before-and-after study design by nature does not account for confounding factors that could affect CAUTI rates and catheter use. While individual units may have had independent CAUTI initiatives, there were no other hospital-wide interventions targeting CAUTI during the study period. Second, our sequential approach (ie, 2 simultaneous interventions in phase 4, and the change in CAUTI definition in phase 4) makes it challenging to compare the effects of each strategy, though this was not our primary objective.


Conclusions and relevance


In conclusion, the phased introduction of CDS 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 catheter use with potential application to other indwelling lines and devices.


Supplementary material. To view supplementary material for this article, please visit https://doi.10.1017/ice.2018.114


Acknowledgments. The authors wish to thank Rohit Chaudhry, Frank F. Hong, andOliver (Jun) Yang (New York-PresbyterianHospital) for assistance with data collection.


Financial support. The Value Institute and EpiPortal are supported by New York-Presbyterian Hospital. No external funding was used in support of this study.


Conflicts of interest. All authors report no conflicts of interest relevant to this article.


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