A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents

Abstract

IMPORTANCE Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms. OBJECTIVE To develop, implement, and evaluate an intervention to reduce catheter-associated UTI. DESIGN, SETTING, AND PARTICIPANTS A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington, DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016. INTERVENTIONS The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication. MAIN OUTCOMES AND MEASURES Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist. RESULTS In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001). CONCLUSIONS AND RELEVANCE In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults

“…More recently CAUTI prevention efforts have also included a socioadaptive component, specifically encouraging improvements in attitudes and behavior concerning patient safety. Two large-scale studies of CAUTI prevention in acute care and long-term care suggest that interventions that combine both cultural change and technical training can be successful at decreasing CAUTI [83–84]. …”

Beyond barriers and facilitators: the central role of practical knowledge and informal networks in implementing infection prevention interventions

“…This is particularly true in the field of healthcare-associated infection (HAI) prevention. Some of the brightest success stories in QI have emerged from large-scale efforts to reduce HAIs such as central venous catheter-related bloodstream infections (CRBSIs)2 or catheter-associated urinary tract infections 3. The light dims, however, when efforts to export these interventions to other settings fail to meaningfully improve outcomes 4 5…”

A national collaborative approach to reduce catheter-associated urinary tract infections in nursing homes: A qualitative assessment

“…14 Both organizational and facility leads identified critical benefits, such as improvements in IPC knowledge, that empowered staff and contributed to changes in practice. This study highlights the value of using a collaborative approach for providing external support as well as several potentially important strategies for strengthening and more effectively promoting IPC activities in nursing homes.…”

“…Similarly, this national collaborative, although significantly larger in scale than these other initiatives, resulted in a substantial reduction in CAUTI rates among participating community-based nursing homes. 14 Among the positive benefits identified by both organizational and facility leads were specific changes in catheter care practices and staff empowerment. Indeed, improved knowledge, resulting from access to evidenced-based practices and practical tools, was considered a critical element in encouraging staff to discuss with physicians about when catheters and urine cultures may or may not be warranted.…”

“…13 This multimodal program, which focused on implementing CAUTI prevention practices and improving safety culture, teamwork, and communication, as well as general IPC practices and antibiotic stewardship, resulted in a substantial reduction in CAUTI among a cohort of more than 400 community-based nursing homes. 14 We conducted a qualitative assessment to understand implementation successes and challenges and experiences of participants involved in the program. In this paper, we describe the key findings to inform nursing home and IPC leaders as well as those engaged in quality improvement as we work together to enhance IPC in nursing homes.…”