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Putting catheters on a clock

Why stop orders are a key to preventing catheter-associated UTIs

October 2010

Published in the October 2010 issue of Today’s Hospitalist

BECAUSE CATHETER-ASSOCIATED urinary tract infections (UTIs) are the most common inpatient infection, it stands to reason that hospitals are using a full court press to ramp up prevention efforts. But two recent studies give mixed news on how well hospitals are poised to prevent UTIs.

The good news is that a systematic study published last month by Clinical Infectious Diseases quantified just how successful prevention efforts can be. That study found that targeting timely catheter removal with reminders or stop orders prevents more than half “52% ” of catheter-associated UTIs.

But another study found less reason for optimism. That research, published in the June issue of Infection Control & Hospital Epidemiology, suggests that Medicare’s no-pay rule, which analysts predicted would give hospitals a powerful financial incentive to reduce UTIs, might fall victim to poor UTI documentation.

In that study, a review of claims filed before Medicare’s no-pay rule took effect found that none of 80 discharges, which listed UTI as a secondary diagnosis, was coded as either catheter-associated or hospital-acquired. A chart review of those claims, by comparison, found that 35% of those UTIs were both indeed hospital-acquired and catheter-associated.

While the study didn’t look at UTI coding since the no-pay rule took effect, it does point to issues with UTI documentation. If physicians don’t clearly identify UTIs as catheter-associated and hospital-acquired, coders can’t describe those conditions in hospital claims. That in turn could render the no-pay rule less effective as an incentive for preventing infections.

Jennifer Meddings, MD, a general internist with the University of Michigan Health System in Ann Arbor and health policy researcher, is the lead author of both studies. She spoke with Today’s Hospitalist about what interventions work to reduce catheter-associated UTIs.

Hospitals have made a lot of headway with reminder and stop-order systems for antibiotics. Why do so few do the same for catheters?

Antibiotic ordering restrictions can be implemented rigorously because drug distribution is well-controlled. But urinary catheters are a generic hospital supply that aren’t assigned or dispensed, and they’re often placed without a physician order. The first intervention we suggest is to make it a policy in your hospital or ED that a patient can get a catheter only when a physician orders one.

What can be done via CPOE to make catheter use more appropriate?

One thing is to use “smart” orders, so that physicians ” instead of just ordering a catheter “must first choose a type of catheter based on indications. Lesson No. 1 is to make it as easy to order a lower risk type of catheter, like a condom or intermittent straight catheter, as an indwelling one.

Smart orders should be tied to nursing instructions for daily maintenance, but they should also put the catheter on a clock. As soon as you place an order, it should generate a stop order for when the catheter should be removed, which is what we do with certain antibiotics.

You always hear that people have alert fatigue with CPOE. How do you make sure that removal reminders aren’t ignored?

First, make sure that reminders go only to a primary team member who can do something about it. We had to change that here: Catheter-removal reminders used to pop up once someone accessed the chart, so physical therapists were seeing them at times instead of the primary team of residents or the attending.

Second, use stop orders instead of reminders; stop orders require action, so they’re harder to ignore. Doctors have to either re-order the catheter after 24 or 48 hours. The default is removing it.

Unfortunately, in most hospitals, you need to take four steps to remove an unnecessary catheter: Physicians have to become aware there is a catheter; they have to recognize that the catheter is no longer needed; they have to write an order to remove it; and the nurse has to remove it. We’re now piloting a “nurse empowered” stop order that allows nurses to bypass those steps and remove a catheter without a physician order.

It was thought that Medicare’s no-pay rule would goad hospitals into better prevention. But your June study found that none of the UTIs was coded in a way that payment would be withheld, if the rules had been in effect. Why is that?

I talked to our coders, and according to federal policy, coders can use only providers’ notes “physicians, physician assistants or nurse practitioners “to code diagnoses.

It turns out that nurses’ notes “which are separate documentation, such as bedside flow sheets “are often the only place you can find out if a patient had a catheter placed during a hospitalization. Coders don’t review nursing notes, and if they did, they’d have to have a provider addend his or her previous notes to reflect that additional catheter-associated diagnosis.

You did note that many of the patients with UTIs were complex patients, so not paying to treat their UTI wouldn’t have saved Medicare much money.

That’s true, but even if facilities aren’t feeling a financial impact related to catheter-associated UTIs, they may still be inspired to tackle this complication and get their rates down. I think that’s a potentially good consequence of the no-pay rule for catheter-associated UTIs.

But any policy “like value-based purchasing or pay for performance “designed to change the behavior of hospitals and doctors will also change outcomes for patients. Part of my interest as a researcher is to study if negative consequences occur as a result of financial incentives.

What are some potentially negative consequences of the no-pay rule for catheter-associated UTIs?

The pressure is on to document a UTI as “present-on-admission” because that comorbidity can bump an admission, and what it pays, up from an uncomplicated to a complicated admission.

That’s fine if patients have a symptomatic UTI, but many patients, particularly older individuals, have asymptomatic bacteriuria. Some hospital surveys suggest that some hospitals are responding to the no-pay policy by screening everyone with urinalysis and potentially treating many, if not all, positive cultures with antibiotics.

That’s a big problem in terms of drug resistance. We specifically advise against screening for asymptomatic UTIs because that has not been shown to improve care. And infection control experts recommend against treating those infections.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.