NARRATIVE REVIEW BMJ Qual Saf: first published as 10.1136/bmjqs-2012-001774 on 27 September 2013. Downloaded from Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review Jennifer Meddings,1 Mary A M Rogers,1 Sarah L Krein,1,2 Mohamad G Fakih,3 Russell N Olmsted,4 Sanjay Saint2,1 ▸ Additional material is ABSTRACT evidence regarding intervention bundles. published online only. To view Background Catheter-associated urinary tract Implementation strategies are important because please visit the journal online (http://dx.doi.org/10.1136/bmjqs- infections (CAUTI) are costly, common and often reducing UC use involves changing well- 2012-001774). preventable by reducing unnecessary urinary established habits. catheter (UC) use. 1Department of Internal Medicine, University of Michigan Methods To summarise interventions to reduce THE PROBLEM Medical School, Ann Arbor, UC use and CAUTIs, we updated a prior Urinary tract infection (UTI) has long been Michigan, USA systematic review (through October 2012), and a considered the most common 2VA Ann Arbor Healthcare meta-analysis regarding interventions prompting healthcare-associated infection (HAI), with System, Ann Arbor, Michigan, USA UC removal by reminders or stop orders. the vast majority of these infections occur- 3 Department of Internal A narrative review summarises other CAUTI ring after placement of the convenient, copyright. – Medicine, St. John Hospital and prevention strategies including aseptic insertion, uncomfortable,1 often unnecessary2 4 and Medical Center, Detroit, catheter maintenance, antimicrobial UCs, and easily forgotten urinary catheter.5 With an Michigan, USA 67 4St. Joseph Mercy Health bladder bundle implementation. estimated 449 334 healthcare-associated System, Ann Arbor, Michigan, Results 30 studies were identified and catheter-associated urinary tract infections USA summarised with interventions to prompt (CAUTIs) per year, associated with an add- – 7–9 Correspondence to removal of UCs, with potential for inclusion in itional cost (in 2007) of US$749 1007 Dr Jennifer Meddings, the meta-analyses. By meta-analysis (11 studies), per admission (or an estimated US$3744 http://qualitysafety.bmj.com/ Department of Internal the rate of CAUTI (episodes per 1000 catheter- when complicated by blood stream infec- Medicine, University of Michigan days) was reduced by 53% (rate ratio 0.47; 95% tions),10 it is not surprising that CAUTIs Medical School, 2800 Plymouth Road, Building 16, Room 427W, CI 0.30 to 0.64, p<0.001) using a reminder or were among the first hospital-acquired Ann Arbor, MI 48109, USA; stop order, with five studies also including conditions selected for non-payment by [email protected] interventions to decrease initial UC placement. Medicare as of October 2008,11 and have The pooled (nine studies) standardised mean Received 19 December 2012 been further targeted for complete elimin- 12 Revised 16 May 2013 difference (SMD) in catheterisation duration ation as a ‘never event,’ with a national Accepted 26 July 2013 (days) was −1.06 overall (p=0.065) including a goal to reduce CAUTI by 25% by 2014.13 Published Online First statistically significant decrease in stop-order These national initiatives renewed public on September 29, 2021 by guest. Protected 27 September 2013 studies (SMD −0.37; p<0.001) but not in and research interest in the prevention of reminder studies (SMD, −1.54; p=0.071). No CAUTI, prompting updates of several com- – significant harm from catheter removal strategies prehensive guidelines14 17 and reviews of is supported. Limited research is available strategies to prevent CAUTI released since regarding the impact of UC insertion and the 2001 Making Health Care Safer maintenance technique. A recent randomised report.18 controlled trial indicates antimicrobial catheters Open Access provide no significant benefit in preventing WHAT STRATEGIES MAY PREVENT Scan to access more free content symptomatic CAUTIs. CATHETER-ASSOCIATED URINARY Conclusions UC reminders and stop orders TRACT INFECTIONS? appear to reduce CAUTI rates and should be — To cite: Meddings J, Similar to other HAIs such as central Rogers MAM, Krein SL, et al. used to improve patient safety. Several evidence- line-associated blood stream infection — BMJ Qual Saf 2014;23: based guidelines have evaluated CAUTI many CAUTI prevention strategies have – 277 289. preventive strategies as well as emerging been ‘bundled’ into a composite of Meddings J, et al. BMJ Qual Saf 2014;23:277–289. doi:10.1136/bmjqs-2012-001774 277 Narrative review BMJ Qual Saf: first published as 10.1136/bmjqs-2012-001774 on 27 September 2013. Downloaded from ‘lifecycle’ of the catheter (1) begins with its initial placement, (2) continues when it remains in place, day after day, (3) ceases when it is removed and (4) may start over if another catheter is inserted after removal of the first one. Because avoiding unnecessary urinary catheter use is the most important strategy in prevention of CAUTI, we review the evidence on two types of interventions that target unnecessary urinary catheter use: (1) proto- cols and interventions to decrease unnecessary place- ment of urinary catheters (catheter lifecycle stage 1), and (2) interventions that prompt removal of unneces- 21 Figure 1 Lifecycle of the urinary catheter. This conceptual sary urinary catheters (catheter lifecycle stage 3). model illustrates four stages of the urinary catheter lifecycle as targets for interventions to decrease catheter use and catheter-associated urinary tract infection. REVIEW PROCESS The evidence summarised in this chapter was gener- ated using a literature search conducted for a prior multimodal sets of interventions known as ‘bladder systematic review and meta-analysis22 along with a bundles.’19 These bundles consist of educational inter- focused update of the published peer-reviewed litera- ventions to improve appropriate use and clinical skill ture (from August 2008 to October 2012) through a in catheter placement, behavioural interventions such MEDLINE search for intervention studies to reduce as catheter restriction and removal protocols, and use use of unnecessary urinary catheters in the acute care of specific technologies such as the bladder ultra- of adults. A CINAHL database search was also per- sound. Despite some early success in implementing a formed for interventions developed and implemented bladder bundle19 to reduce urinary catheterisation by nurses related to urinary catheter use. Studies were rates,20 CAUTI prevention has proven challenging for included if at least one outcome involving catheter use several important reasons. For example, monitoring or CAUTI events (table 1) was reported as a result of urinary catheter use and CAUTI rates to inform and the intervention, and with a comparison group (either copyright. sustain urinary catheter-related interventions is very preintervention vs postintervention, or a separate resource intensive. Perhaps more importantly, improv- control group). Details of the systematic literature ing practice regarding urinary catheter placement and searches and methods employed for selection and removal also requires interventions to change the reporting of the studies for this review are provided in expectations and habits of nurses, physicians and the online supplementary appendix. The online patients about the need for urinary catheters. supplementary appendix table summarises all the http://qualitysafety.bmj.com/ To help organise and prioritise the many potential intervention studies described in this review, including interventions to prevent CAUTI, we use the conceptual study designs, patient populations and the interven- model of the ‘lifecycle of the urinary catheter’21 to tions employed to avoid unnecessary catheter place- highlight that the highest yield interventions to prevent ment or to prompt catheter removal. This review was CAUTI will target at least one of the four ‘stages’ of supported by the Agency for Healthcare Research and the catheter’s ‘life.’ As illustrated in figure 1, the Quality (AHRQ), which had no role in the selection Table 1 Description of outcomes evaluated (adapted from the prior meta-analysis22) Measures of Catheter-associated Number of CAUTI episodes per 1000 catheter-days was recorded and a rate ratio was calculated on September 29, 2021 by guest. Protected Urinary Tract Infection (CAUTI) to compare preintervention vs postintervention. When rates of both asymptomatic and symptomatic development CAUTI were reported separately,57 the rates of symptomatic CAUTI were used for the meta-analysis.22 Cumulative risk of CAUTI during hospitalisation (ie, the percentage of patients who developed CAUTI) was also extracted for each study, and a risk ratio was calculated to compare risks before and after the intervention for the meta-analysis.22 Measures of urinary catheter use Mean number of days of urinary catheter use per patient was recorded before and after the intervention, and a standardised mean difference was calculated to compare the two groups for the meta-analysis.22 Percentage of patient days in which the catheter was in place (reported by the study directly, or calculated from ratio of catheter days/patient days if provided in the study), for the comparison group (before intervention or control group) and postintervention Percentage of patients studied who had a urinary catheter placed during the study period, for the comparison group (before intervention or control