​A combination of technical and cultural interventions can reduce catheter-associated urinary tract infections (CAUTIs) in inpatient units other than intensive care units (ICUs), a nationwide study of 603 hospitals found. The study, published June 2, 2016 in the New England Journal of Medicine, was based on a program developed by the Michigan Health and Hospital Association Keystone Center. The findings have important implications for hospitals because Medicare has identified CAUTIs as a preventable hospital-acquired condition and will not pay for care to treat the condition. The interventions, also called care "bundles," included appropriate catheter use, aseptic insertion, proper maintenance, and timely removal, as well as cultural and behavioral changes, such as providing feedback to units regarding catheter use and infection rates and emphasizing teamwork. The researchers found that CAUTI rates decreased by 32% in non-ICUs from 2.28 to 1.54 infections per 1,000 days of catheter use before and after the intervention, respectively. The units also decreased the overall use of catheters from 20.1% to 18.8% by avoiding unnecessary or unnecessarily prolonged catheterizations and using alternative urine collection methods. Catheter use and CAUTI rates in ICUs were unchanged. The researchers suggest possible reasons, including differences in routine care processes between ICUs and non-ICUs and the fact that the ICU has sicker patients. An editorial accompanying the study notes that the technical protocols have been continually taught as best practices; the behavioral aspects, focusing on camaraderie and communication, for example, "may be requisites for success." However, another study published on May 25, 2016 in BMJ Quality and Safety found that hospital units with improvements in safety culture may not be any more successful than others at preventing catheter-associated infections. The authors said they expected to find a correlation between results on the Hospital Survey on Patient and Safety Culture (HSOPS) and catheter-associated infection rates. But when they analyzed data from HSOPS with data from two prospective cohort studies from acute-care ICUs and non-ICUs for central-line bloodstream infection (CLABSI) and CAUTI they were surprised to discover that was not the case. Infection rates declined over the study period by 47% for CLABSI and 23% for CAUTI. HSOPS response rates were "low overall," the authors said, at 24% for the CLABSI group and 43% for the CAUTI group. These results suggested no significant association between safety culture as assessed by HSOPS and CLABSI or CAUTI outcomes. An important finding of the study, according to the authors, is that reducing CLABSI and CAUTI rates may be possible without improving safety culture. However, the authors said, another possible interpretation is that safety culture did improve at these units, but the HSOPS tool did not accurately measure it. In either case, the authors said, given the amount of time, training, and financial resources allotted to programs focusing on safety culture, there may be a need to reassess and reprioritize their components.

HRC Recommends: Urinary tract infections are the most common type of healthcare-associated infection, and 80% of such infections are caused by the use of an indwelling urethral catheter. Unfortunately, catheters are often used or continued without a valid indication. Strategies to reduce such use include daily review of catheter necessity, physician reminders, automatic stop orders, protocols that let nurses discontinue catheters, and use of bladder scanners to measure urinary retention. Tools to reduce CAUTI are available from AHRQ and one of the partner organizations participating in the study.