Published in the October 2005 issue of Today’s Hospitalist
A relatively simple intervention that hospitalists can initiate using a chart-based reminder system can help ensure that urinary catheters don’t remain in place longer than necessary, reducing urinary tract infection (UTI) rates and possibly reducing length of stay and total hospital costs.
A new study led by Sanjay Saint, MD, MPH, a research investigator at the Ann Arbor VA Medical Center and an associate professor of medicine at the University of Michigan Health System in Ann Arbor, found that even when relatively small numbers of physicians participated, the reminder system reduced morbidity and improved the economic results.
The reminders reduced the average proportion of time that patients were catheterized by 7.6 percent when compared to the baseline. On the wards that did not use the reminder system, by comparison, the average proportion of time that patients were catheterized actually rose 15.1 percent above baseline.
When looking at the two-thirds of doctors who actually used the reminder system, their patients’ proportion of days with a catheter went down 25.7 percent.
That’s an important gain, according to Dr. Saint, because UTIs account for an estimated 40 percent of hospital-acquired infections. In addition, most of those UTIs, 3 percent of which lead to bacteremia, are catheter-related.
The results are also important because of the sheer scope of the problem. About one-quarter of inpatients have urinary catheters in place for some period during their hospital stay. In the United States alone, recent data show that approximately 25 million catheters are inserted annually.
Dr. Saint says that the study results shine a light on one way that hospitalists can improve patient safety at their hospitals.
“Hospitalists, because they’re so attuned to some of the common, even mundane issues that occur in hospitalized patients, can be part of the solution,” he explains. “I see hospitalists as champions for some of these simple interventions.”
In the reminder system that Dr. Saint and his colleagues developed, a nurse placed a reminder “flag” on the charts of all patients in whom a catheter was in place for longer than 48 hours. Physicians were then asked to sign a page on the chart to indicate that they had reviewed the patient’s catheter status. Physicians who did not respond were paged by nurses and asked to complete the form.
Dr. Saint likens the system to the antibiotic “stop orders” used by residents to make sure they continue patient antibiotics every 48 hours.
The 16-month trial included 5,678 inpatients, approximately half of whom received the intervention at the University of Michigan Medical Center in Ann Arbor, where Dr. Saint directs the patient safety enhancement program. Results were published in the August 2005 issue of the Joint Commission Journal on Quality and Patient Safety.
The intervention produced a net total savings of $249 annually when UTI reduction and costs (primarily nursing time) were analyzed. While Dr. Saint acknowledges the savings are modest, he predicts they would likely be far more significant if a system had higher rates of physician adherence and was used in concert with a computerized physician order entry (CPOE) system.
Dr. Saint says that the reminder system could be automated as a “forcing function,” eliminating the need for nurses to place stickers on patient charts. He estimates that that the per-protocol effectiveness rate of the system would save more than $50,000 annually in large facilities with a patient census comparable to the University of Michigan.
Even with poor adherence, he adds, “My best guess is that it would be cost-neutral.”
The catheter reminder system might seem unnecessary given the daily “or even more frequent “patient assessment that occurs in hospitals. But Dr. Saint notes that a previous study pointed out that approximately one-third of physicians are unaware that their patients have urinary catheters in place, leading to over-utilization of the devices.
“About half of the days a patient has a catheter,” he explains, “it’s medically unnecessary. And often, physicians don’t know it’s still in place until it’s time for discharge and the nurse calls and asks whether it should be removed. The response is often, ‘What catheter?’ ”
Related research has also found that about 30 percent of patient charts don’t indicate that the catheter is in place, despite the fact that a physician order is required for its placement. “It’s a phenomenon I call the ‘immaculate catheterization,’ ” Dr. Saint quips.
Unnecessary catheterization is no laughing matter, and the University of Michigan study is one of several in recent years that have highlighted the issue and its associated morbidity. Because catheters cause discomfort and reduce mobility for patients, removing them significantly decreases the risk of infection and, potentially at least, length of stay.
And as every hospitalist knows, because recently catheterized patients being discharged to their homes must demonstrate their ability to urinate, finding out that a catheter is still in place on the day of discharge can extend hospitalization. “That can add several hours, or even up to a full day, to the admission,” Dr. Saint explains.
He acknowledges that catheter reminder systems could, in theory, produce unintended consequences, including the inappropriate early removal of the devices. But he thinks that’s unlikely, at least based on his study’s results.
For one, the intervention was studied in the medicine and pulmonary wards, not in the ICU, where the measurement of “intake and output” that a catheter provides can be critically important.
More important, while the University of Michigan study found a reduction of more than 25 percent in catheterization days in patients whose physicians responded to the protocol, re-insertion rates were not affected by the intervention.
“We didn’t find any evidence of the latter,” he says, “so that’s good news.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.