Hospital-acquired infections are a persistent problem that has become even more worrisome as as antimicrobial resistance has increased. Researchers have been exporing the best ways to reduce hospital-acquired infections, and HHS’s Agency for Healthcare Research and Quality (AHRQ) has provided tools and resources for hospitals. Under the Affordable Care Act, hospitals with the worst scores for hospital-acquired conditions can face a reduction in Medicare payments (this provision took effect in fiscal year 2015). In late 2015, AHRQ announced that hosptial-acquired conditions dropped 17% between 2010 and 2014, although the majority of the decline was due to drops in adverse drug events and pressure uclers rather than infections.
As I’ve written before, researchers have identified effective ways to reduce hospital-acquired infections from central lines and catheteters. Catheters are important because urinary tract infections are the most common healthcare-associated infections. Reducing UTIs in hospital patients isn’t rocket science. CDC recommends strategies like inserting catheters only for appropriate indications, leaving them in only as long as needed, and using aseptic techniques and sterile equipment to insert them. Programs to ensure consistent use of these strategies can include system of reminders to remove unnecessary catheters and/or protocols to allow nurses to direct their removal.
While the changes necessary to reduce catheter-associated urinary tract infections (CAUTIs) may be relatively simple and inexpensive, they still require sustained time and attention from hospital staff who already face extensive demands. Individual hospitals or regions have successfully reduced CAUTIs, but can their succssful practices be scaled up and implemented nationwide?
To answer that question, AHRQ funded a nationwide collaborative effort based on the successful Michigan Health and Hospital Association (MHA) Keystone Center’s approach to CAUTI reduction. The national program launched in 2011, and a study just published in the New England Journal of Medicine reports results from the first four cohorts, which included 926 units (some of which are intensive care units) in 603 hospitals located in 32 states, the District of Columbia, and Puerto Rico. These hospitals represent more than 10% of US acute-care hospitals.
Hospital teams received trainings through in-person meetings, coaching calls, and webinars. The program involved both technical and “socioadaptive” aspects — in other words, participants didn’t just learn about the necessary steps for CAUTI prevention, they also received training on barriers that are common within organizations and tools to overcome them. As Mohamed G. Fakih and colleagues explained in a 2013 Infection Control & Hospital Epidemiology article on the program, this included resources such as scripts nurses can use when a patient or family member requests a catheter. In recognition of differences that can exist between units, participants were allowed to tailor interventions to their particular structures and cultures.
After analyzing 18 months worth of data from the 926 hospital units, Sanjay Saint and colleagues report in NEJM:
In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs.
The authors suggest a few reasons why CAUTIs decreased in non-ICU units but not in the ICUs, including that ICU patients are more likely to have serious conditions that require monitoring of urine output or that involve fevers coupled with routine culturing of bodily fluids to investigate infection sources.
While researchers will need to keep exploring ways to reduce CAUTIs in ICUs, this study suggests that the ongoing national initiative is successfully reducing these infections in non-ICU hospital units. This is great news not only for hospital patients, but for those of us concerned about antibiotic resistance (which should be everyone). Fewer infections means fewer antibiotic prescriptions, and that translates to fewer chances for bacteria to develop resistance to the drugs that are so important to public health.