Sunday, July 05, 2015

Urine trouble

"Put in a Foley," is a common order for a patient undergoing surgery.  This form of urinary catheter, also called an indwelling catheter, is very useful in that you can obtain an ongoing measurement of urine output, an important indicator of the patient's status.  The downside of a Foley is the potential for a urinary tract infection (bacteriuria). As noted here: Catheter-related urinary tract infection (UTI) occurs because urethral catheters inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesion and causing mucosal irritation.

Some surgeons recognize this potential and so have standing orders to remove the Foley a day after surgery. If the patient needs help in voiding, a "straight catheter" is used as needed to empty the bladder.  Although this approach involves an insertion into the urethra, with some modest risk, the risk of a UTI is dramatically reduced.

In other hospitals, the Foley is the default for the duration of the patient's need for assistance. It is simply easier to leave it in, rather than to be concerned with timing the use of the straight catheter and the need for numerous insertions.

Why it matters.

Does this all matter? After all, what's the harm in a UTI? Just add some antibiotic to the patient's regime and kill those bugs. Were it so easy. It turns out than a UTI can have an impact on the patient's overall prognosis.

An old study from from 1954 to 1964 presented data data in England on paraplegics. They said, "The results where no catheterisation or only intermittent catheterisation had been used by the referring hospital are superior to those where a Gibbon catheter was used and infinitely superior to those where a Foley catheter was used."

An MD friend of mine noted:

They did not use p-values (maybe that was not the standard in those days?), but if you run the math based on the data in the article, you find that the rate of bacteriuria is 0% in the no catheter group, 7.5% in the intermittent catheter group, and 60.9% in the Foley catheter group!  

In a more recent study, a group at Brown University (Rhode Island Hospital) did a review of the trauma registry at their Level 1 trauma center from 2003 to 2008, which included over 5,700 patients. They found that after controlling for other factors like injury severity, diabetes, age, etc, patients with a UTI (who comprised 11.9% of the patients) had an in-hospital mortality of 9.6%, significantly higher than those patients without a UTI (3.5%, p < 0.001).

The first step: Guidelines

Based mainly on the risk of getting a UTI--and not necessarily considering all the additional downstream impacts on patients--clinical guidelines were issued by the Infectious Diseases Society of America in 2009.  Likewise, the CDC's most recent guidelines on the subject, also from 2009, said the following:

- Insert catheters only for appropriate indications, and leave in place only as long as needed.

- Avoid use of urinary catheters in patients and nursing home residents for management of incontinence.

- For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use.

So, how are we doing?  If you asked the question in 2008, you wouldn't be able to tell. This article summarized the results from a survey of over 700 hospitals:

Overall, 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. 

Four years later, another article reported severe underreporting problems in 2009:

According to epidemiologic studies, the majority of hospital-acquired UTIs are catheter-associated, with rates ranging from 59 percent to 86 percent. In this study, only 2.6 percent of all hospital-acquired UTIs were coded in claims as being catheter-associated in 2009.  

"You can't solve a problem you don't admit you have," is one of my favorite expressions.

Is it any better now?

So time has passed, and we should be doing much better, right?

AHRQ published some survey results in 2013.  This was not a full-scale data collection. Rather it covered about 800 hospitals who chose to participate.  Among this self-selected group:

There has been a decrease in CAUTI rates from baseline ranging from 6.3 percent relative reduction during post-baseline period two (months post-baseline) to 16.1 percent relative reduction during post-baseline period six (14 months post-baseline).

I'm not sure what this signified, so for fun, I went to CMS' Hospital Compare website to see how the hospitals who helped write the AHRQ report were doing on avoiding catheter associated UTIs.

St. John Hospital and Medical Center: "Worse than the U.S. National Benchmark."
University of Michigan Health System: "Worse than the U.S. National Benchmark."
Johns Hopkins Hospital: "No Different than U.S. National Benchmark."

Another expression I like is, "There is no virtue in benchmarking yourself to a substandard norm."

Even more so on Hospital Compare, where the benchmark is simply an indication of whether you are doing better or worse than the current national average.

Healthcare-associated infections are reported using a standardized infection ratio (SIR). This calculation compares the number of infections in a hospital to a national benchmark based on data reported to National Healthcare Safety Network (NHSN). Each hospital's SIR is shown in the graph view. Lower numbers are better. A score of zero (0) - meaning no infections - is best.
  • If the confidence interval for the score falls below 1, then the hospital had fewer infections than similar hospitals.
  • If the confidence interval for the score includes 1, then the hospital had a comparable number of infections as similar hospitals.
  • If the confidence interval for the score falls above 1, then the hospital had more infections than similar hospitals.
And how much less value is the SIR when you learn that the CDC found a 3% increase in the SIR rate for this disease.

You'd think that with such a loosey-goosey benchmark, the institutional authors of the AHRQ report--presumably the most committed hospitals in the country--would show up as better than average.  But they don't.

Where would you go?

On the search for success stories, I went to UHC, where:

Fifteen participating member organizations significantly reduced the incidence of hospital-acquired infections (HAIs) during the UHC Imperatives for Quality (IQ) Program’s Infections Due to Devices Improvement Collaborative


Twelve teams achieved a 12% reduction in their CAUTI rates.

Let's say your local hospital tells you that its CAUTI rate is 1.4 infections/1000 days--a 12% reduction from previously.  This sounds great until you learn that some of the best performers are at 0.7 infections/1000 days.  Are you comfortable going to a place that has twice the infection rate of some other place in your community?

I know which I'd prefer. And I'd prefer even more a hospital that is totally transparent with regard to its compliance with the main protocol for avoiding UTIs in the first place--removing the Foley quickly after surgery.  Transparency suggests that such a hospital is willing to hold itself accountable to a high standard of care.  There aren't many who will do that, but here's an example--what you see when you go to the MedStar Health website:


Tom, MD said...

Have long been a proponent of get it out. Also promotes patient getting out of bed to decrease blood clots. We put in the EMR as part of the post op order set.

MPI2015 said...

This issue continues to plague many hospitals - as you pointed out, some of these are extremely notable hospitals. As I've worked with many who have focused on this issue as I tackled other issues for our IQ program, I'm always surprised by the extent of the variation in the root causes. Many do not use their own data to help guide their assessments. Many do not want to invest in the resources necessary. Implementation of culture change towards safety takes a backseat, at times, due to the immediate concerns that the hospitals are dealing with on a daily basis. I sometimes wonder how we can move the needle, despite these circumstances. So, with each project, I hope that the evidence based information, data and resources will reach the right audience to tackle these issues- inch by inch, hospital by hospital, system by system.