UTI prevention fails to keep pace with other anti-infection efforts

A study says many physicians and hospitals haven't thought about the risks associated with urinary catheters.

By — Posted Jan. 3, 2012

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Most hospitals say the Centers for Medicare & Medicaid Services' no-pay policy for hospital-acquired conditions has pushed them to make greater efforts to prevent health care-associated infections. But a study says preventing one item on the no-pay policy has gotten less of a push: catheter-associated urinary tract infections.

Nearly all hospitals have implemented practices aimed at reducing the incidence of central-line associated bloodstream infections and ventilator-associated pneumonia, says a study published online Dec. 6, 2011, in the Journal of General Internal Medicine (link). But less than half of hospitals are taking similar action against the nosocomial infection patients are likeliest to contract -- a urinary tract infection associated with the use of indwelling urinary catheters.

"Urinary tract infection is the Rodney Dangerfield of health care-associated infections because it gets no respect, even though it's the most common," said Sanjay Saint, MD, MPH, professor of internal medicine at the University of Michigan Medical School and senior author of the study.

About a quarter of patients have a urinary catheter in place at some point during their hospital stay. Catheter-associated UTIs account for more than 30% of all hospital-acquired infections and occur more than 500,000 times annually, according to the Centers for Disease Control and Prevention. The infections usually add two to four days to a patient's hospital stay and increase health spending by about $500 million a year. Though central-line infections are far more dangerous and costly, UTIs sometimes spread to the bloodstream and are deadly, killing about 13,000 Americans a year, the CDC says.

"For many clinicians and doctors, they haven't really thought critically about a device as ubiquitous as the urinary catheter," said Dr. Saint, associate chief of medicine at the Veterans Affairs Ann Arbor Healthcare System. "It just seems like a part of regular medical care in the same way that the patient gets their blood pressure checked every four hours and, yeah, they get a urinary catheter. There is not as much of an appreciation of the potential harms associated with urinary catheters."

Minimizing catheter use

That lack of recognition of the potential dangers posed by indwelling urinary catheters is reflected in the study's results. For example, more than 90% of the 500 hospitals surveyed for the study have implemented the CDC-recommended practice of using chlorhexidine site antisepsis to prevent central-line infections.

But less than half of hospitals said they use a portable bladder ultrasound scanner to measure urinary output as an alternative to catheterization, a practice that can help prevent UTIs. A minority of hospitals have implemented other UTI prevention practices such as condom catheters for male patients, antimicrobial urinary catheters and automated reminders to remove catheters as soon as possible, the study found.

A key to preventing UTIs is to minimize catheter use. Physicians should avoid using urinary catheters in patients whose only indication is incontinence, said Dr. Saint, who has studied UTIs for more than a decade.

"There is no excuse not to act, and we do have more evidence of what practices we should be doing to prevent this common patient safety problem," he said.

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Lack of action on UTIs

Catheter-associated urinary tract infection is the most common nosocomial infection in the country, and in October 2008 the Centers for Medicare & Medicaid Services stopped paying hospitals extra to treat patients who acquire UTIs during their stay. Yet most non-Veterans Health Administration hospitals have failed to implement preventive practices shown to slash UTIs.

Preventive practice 2005 use rate 2009 use rate
Bladder ultrasound 29% 39%
Reminder/stop order 9% 20%
Antimicrobial urinary catheter 30% 45%
Condom catheter 12% 10%

Source: "Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009," Journal of General Internal Medicine, Dec. 6, 2011 (link)

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