Even Surgeons Can Use Quality Improvement Science To Eliminate CAUTIs From ICUs

Author(s):
Laura Kreiner; Jeffrey Claridge; Joseph Golob Jr M.D.

Background:

As stewards for change, surgeons must embrace nontraditional investigative methodologies such as quality improvement science to improve patient care and eliminate preventable harms. Yearly, 1.7 million patients are affected by such harms, of which catheter associated urinary tract infections (CAUTIs) comprise 450,000 nosocomial infections.

Hypothesis:

Utilizing quality improvement science, we hypothesized that creation of a CAUTI stewardship program would decrease urine catheter-days, urine cultures obtained, and CAUTI rates.

Methods:

January 1, 2017 to February 28, 2018 urine catheter utilization, number of urine cultures obtained, and CAUTI rate per 1000 catheter-days were collected in an academic surgical and trauma intensive care unit. A CAUTI stewardship program was established on August 1, 2017.  The program standardized urine catheter utilization and urine culture practices. CAUTIs were defined using Centers for Disease Control definitions. Statistical process control was used to compare urine catheter use, urine culture practice, and CAUTI rates before and after program initiation. To monitor for urosepsis as a balancing measure, blood cultures sent after program initiation were screened for Gram-negative bacteremia (E. coli, Proteus, Pseudomonas, and Enterobacter).

Results:

A total of 8,454 patient-days were evaluated including 6,315 urine catheter-days (74.7%).  263 urine cultures were obtained.  13 CAUTIs were identified.  Process control charts demonstrated special cause variation, signifying a statistically significant decrease in urine catheter-days, urine cultures obtained and CAUTI rates after program implementation.  CAUTIs were eliminated during the 7-month post intervention period.  During the study period, 474 blood cultures were obtained of which 70 (14.8%) were positive including 6 patients with Gram negative bacteremias of interest. These bacteremias were identical pathogens concurrently associated with bacterial infections in other locations (intra-abdominal and pulmonary sources).

Conclusions:

This study demonstrates the importance of utilizing quality improvement science to eliminate preventable harms. A CAUTI stewardship program concentrating on urine catheter insertion, maintenance, and removal, in conjunction with culture stewardship, safely eliminated CAUTIs.  Statistically significant process improvements were demonstrated in decreased urinary catheter use, number of urine cultures collected, and overall decrease in CAUTI rate.