Which is the most important factor in reducing hospital acquired urinary tract infections?

The Purpose of This Guide

This guide and the appended tools are designed to support implementation of evidence-based practices and elimination of catheter-associated urinary tract infections (CAUTI) in your hospital unit. When used with the Comprehensive Unit-based Safety Program (CUSP) Toolkit, the practices outlined in this guide reduced CAUTI in more than 950 hospitals across the country in On the CUSP: Stop CAUTI, an initiative funded by the Agency for Healthcare Research and Quality (AHRQ).

The Problem

Health care-associated infections are one of the most common complications of hospital care. In 2011 there were an estimated 722,000 hospital-acquired infections, approximately 75,000 of which were fatal.1 Health care-associated infections cost U.S. hospitals an estimated $40 billion each year.2 Catheter-associated urinary tract infections are among the most common types of health care-associated infections.3

Research suggests CAUTIs are highly preventable and that perhaps as many as 50 to 70 percent of these episodes can be prevented.4, 5 As many as one-fourth of all hospital inpatients may have a short-term, indwelling urinary catheter placed during their hospital stay, and a significant portion of these catheters are placed without appropriate indications.6, 7

Complications associated with CAUTI result in increased length of stay of 2-4 days, patient discomfort, and excess health care costs, and contribute to increased mortality. The estimated total U.S. cost per year for CAUTI is $340–450 million.8 However, most cases of CAUTI are preventable, and since October 2008, the Centers for Medicare & Medicaid Services will no longer reimburse costs associated with hospital-acquired CAUTI. In a 2007 study, cases with CAUTI resulted in $1,300 to $1,600 in additional cost per patient.9 

The Solution

To achieve CAUTI reduction and sustain these improvements, a strategy to address both unit culture and clinical practice is necessary. Culture consists of the unit team’s values, attitudes, and beliefs, which will all have an impact on the unit’s ability to improve clinical practice. The CUSP Toolkit, which is described on the following pages and is available on the AHRQ Web site, can be used to improve unit culture and create a working environment favorable to improving clinical practice.

The clinical components of reducing CAUTI consist of three parts:

• Appropriate catheter use.
• Proper catheter insertion and maintenance.
• Prompt catheter removal.

This guide presents strategies for eliminating the primary risk factor for CAUTI: unnecessary use of indwelling urinary catheters. Many of these catheters are placed without indications. The guide’s section on appropriate catheter use lists the appropriate indications for catheter placement as well as inappropriate indications and potential alternatives to indwelling urinary catheters. The guide then presents strategies for fostering appropriate insertion and maintenance of catheters and for encouraging prompt removal of catheters.

Appropriate use of urine cultures and nontreatment of asymptomatic bacteriuria are also critical factors in improving patient safety and are addressed in this guide to the extent that they directly relate to CAUTI prevention and surveillance efforts. This guide also presents steps a hospital unit can take to measure the effectiveness of a CAUTI reduction strategy, and finally, strategies for sustaining and spreading your improvements.