Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients

Abstract

U p to 25% of hospitalized patients will have an indwelling urinary catheter inserted (1). While most of these catheters are required for optimal patient care, about one in five is unnecessary (2). Catheter-related urinary tract infections are the leading cause of nosocomial infection. They account for up to 40% of hospital-acquired infections, with an incidence of 3% to 10% per day of indwelling catheterization (1,(3)(4)(5). Bacteremia occurs in 1% to 4% of those who develop nosocomial bacteriuria (6). Most patients also find an indwelling urinary catheter to be uncomfortable and activity restricting (7). Given these potential morbidities, it is remarkable how infrequently the use of a urinary catheter is documented by a physician's order in the medical record (8).The strongest predictor for catheter-associated bacteriuria is the duration of catheterization (3,4). Thus, methods to shorten this period should reduce the risk of nosocomial urinary tract infection, yet physicians are often unaware that their own hospitalized patients have a urinary catheter in place (9). Furthermore, these "forgotten" catheters were about twice as likely to be unnecessary as those remembered by the physician (9). Thus, a system that would remind physicians which of their patients had urinary catheters might shorten the duration of catheterization.One such approach involves using automatic reminders to physicians through computerized medical record systems (10 -15). At our Veterans Affairs (VA) medical center, nearly all patient records and orders are entered into a computer. We hypothesized that a computer-based order for inserting an indwelling urinary catheter, combined with computer-generated reminders to remove the catheter, would improve documentation of urinary catheters, alert physicians that the catheter was in place, and encourage discontinuing catheterization that was no longer required. METHODSAll inpatients at the VA Puget Sound Health Care System are cared for by teams of resident physicians supervised by University of Washington faculty. Patients on the medicine and cardiology services are predominantly housed on two hospital wards (second and fourth floor), with most of each team's patients on a single ward. During the first 8 weeks of the study, the fourth floor served as the study ward and the second floor served as the control ward; during the second 8 weeks, the second floor became the study ward and the fourth floor became the control.At the beginning of each month, a training session is held to teach incoming residents about the computer system. During this session, one of the investigators (PBC) explained the purpose of the study, including the direct association between duration of catheterization and catheter-associated urinary tract infection, and instructed residents on use of the computerized urinary catheter study order. We also explained the purpose of the study to the ward nurses and encouraged them to remind physicians to place a computerized order for each indwelling urinary catheter. Physicians whos...

Using A Criteria-Based Reminder To Reduce Use Of Indwelling Urinary Catheters And Decrease Urinary Tract Infections

“…1,5,6,8,15 Strategies to decrease the duration of catheterization have been recommended, such as reminding physicians to review whether a catheter is still appropriate and using automatic stop orders to facilitate the removal of catheters when the devices are no longer needed. 8,22 However, in 2 studies, 20,23 use of these approaches had no significant effect on the rate of UTIs. Using a before-and-after crossover design, Cornia et al 23 found that use of "computerbased order entry" did not significantly decrease the UTI rate.…”

“…8,22 However, in 2 studies, 20,23 use of these approaches had no significant effect on the rate of UTIs. Using a before-and-after crossover design, Cornia et al 23 found that use of "computerbased order entry" did not significantly decrease the UTI rate. In another study, using a randomized design, Loeb et al 20 found that use of automatic stop orders was not associated with a decrease in the incidence of UTIs.…”

Role of biofilm in catheter-associated urinary tract infection☆

“…62 Studies of the appropriateness of use of urinary catheters indicate that 21% to 38% of initial urinary catheterizations are unjustified, and one-third to one-half of days of continued catheterization are unjustified. [63][64][65] When inpatient physicians and students at 4 academic medical centers were asked whether or not each of their patients had a urinary catheter, they incorrectly reported that their patient did not have a catheter 28% of the time.…”

“…64 In a recent controlled study, instituting a computerized urinary catheter order and a computer-generated stop order 72 hours after insertion reduced the duration of catheterization by about one-third (3 days). 62 Thus, a computerized reminder system might reduce CAUTI by prompting removal of "forgotten" catheters. 32 If the urinary catheter cannot be removed, a possible solution is to move it from the urethra to another location.…”

Improving patient safety: moving beyond the "hype" of medical errors

“…In a systematic review of 80 patient-safety interventions, 16 those with reasonable supporting evidence consisted largely of clinical therapies such as prophylaxis of venous thromboembolism. Frequently espoused "systembased" interventions, such as improving facility design and work flow with technology and robotics, adding forcing functions to procedures (e.g., automatic stop orders for Foley catheters 17 or precautions against the storage of concentrated potassium solutions with ward stock) 18 and improving product labels have only modest supporting evidence. For example, computerized practitioner order entry has decreased medication errors in several studies but has not significantly reduced actual adverse drug events.…”