Urine Trouble

"Put inward a Foley," is a mutual monastic tell for a patient undergoing surgery.  This shape of urinary catheter, too called an indwelling catheter, is real useful inward that y'all tin obtain an ongoing measure of urine output, an of import indicator of the patient's status.  The downside of a Foley is the potential for a urinary tract infection (bacteriuria). As noted here: Catheter-related urinary tract infection (UTI) occurs because urethral catheters inoculate organisms into the bladder too promote colonization past times providing a surface for bacterial adhesion too causing mucosal irritation.

Some surgeons recognize this potential too thence bring standing orders to take away the Foley a twenty-four hr menstruum afterwards surgery. If the patient needs assist inward voiding, a "straight catheter" is used equally needed to empty the bladder.  Although this approach involves an insertion into the urethra, alongside some pocket-size risk, the direct chances of a UTI is dramatically reduced.

In other hospitals, the Foley is the default for the duration of the patient's demand for assistance. It is only easier to acquire out it in, rather than to live on concerned alongside timing the operate of the at nowadays catheter too the demand for numerous insertions.

Why it matters.

Does this all matter? After all, what's the price inward a UTI? Just add together some antibiotic to the patient's government too kill those bugs. Were it thence easy. It turns out than a UTI tin bring an touching on on the patient's overall prognosis.

An old study from from 1954 to 1964 presented information data inward England on paraplegics. They said, "The results where no catheterisation or solely intermittent catheterisation had been used past times the referring infirmary are superior to those where a Gibbon catheter was used too infinitely superior to those where a Foley catheter was used."

An physician friend of mine noted:

They did non operate p-values (maybe that was non the criterion inward those days?), but if y'all run the math based on the information inward the article, y'all uncovering that the charge per unit of measurement of bacteriuria is 0% inward the no catheter group, 7.5% inward the intermittent catheter group, too 60.9% inward the Foley catheter group!  

In a to a greater extent than recent study, a grouping at Brown University (Rhode Island Hospital) did a review of the trauma registry at their Level 1 trauma pump from 2003 to 2008, which included over 5,700 patients. They institute that afterwards controlling for other factors similar injury severity, diabetes, age, etc, patients alongside a UTI (who comprised 11.9% of the patients) had an in-hospital mortality of 9.6%, significantly higher than those patients without a UTI (3.5%, p < 0.001).

The offset step: Guidelines

Based mainly on the direct chances of getting a UTI--and non necessarily considering all the additional downstream impacts on patients--clinical guidelines were issued past times the Infectious Diseases Society of America in 2009.  Likewise, the CDC's most recent guidelines on the subject, too from 2009, said the following:

- Insert catheters solely for appropriate indications, too acquire out inward house solely equally long equally needed.

- Avoid operate of urinary catheters inward patients too nursing family residents for management of incontinence.

- For operative patients who bring an indication for an indwelling catheter, take away the catheter equally presently equally possible postoperatively, preferably inside 24 hours, unless in that location are appropriate indications for continued use.

So, how are nosotros doing?  If y'all asked the interrogation inward 2008, y'all wouldn't live on able to tell. another article reported severe underreporting problems inward 2009:

According to epidemiologic studies, the bulk of hospital-acquired UTIs are catheter-associated, alongside rates ranging from 59 pct to 86 percent. In this study, solely 2.6 pct of all hospital-acquired UTIs were coded inward claims equally beingness catheter-associated inward 2009.  

"You can't solve a occupation y'all don't acknowledge y'all have," is 1 of my favorite expressions.

Is it whatsoever improve now?

So fourth dimension has passed, too nosotros should live on doing much better, right?

AHRQ published some survey results inward 2013.  This was non a full-scale information collection. Rather it covered virtually 800 hospitals who chose to participate.  Among this self-selected group:

There has been a decrease inward CAUTI rates from baseline ranging from 6.3 pct relative reduction during post-baseline menstruum 2 (months post-baseline) to 16.1 pct relative reduction during post-baseline menstruum half dozen (14 months post-baseline).

I'm non certain what this signified, thence for fun, I went to CMS' Hospital Compare website to run into how the hospitals who helped write the AHRQ study were doing on avoiding catheter associated UTIs.

St. John Hospital too Medical Center: "Worse than the U.S. National Benchmark."
University of Michigan Health System: "Worse than the U.S. National Benchmark."
Johns Hopkins Hospital: "No Different than U.S. National Benchmark."

Another aspect I similar is, "There is no virtue inward benchmarking yourself to a substandard norm."

Even to a greater extent than thence on Hospital Compare, where the benchmark is only an indication of whether y'all are doing improve or worse than the electrical current national average.

Healthcare-associated infections are reported using a standardized infection ratio (SIR). This calculation compares the number of infections inward a infirmary to a national benchmark based on information reported to National Healthcare Safety Network (NHSN). Each hospital's SIR is shown inward the graph view. Lower numbers are better. A score of nada (0) - pregnant no infections - is best.

• If the confidence interval for the score falls below 1, too thence the infirmary had fewer infections than similar hospitals.
• If the confidence interval for the score includes 1, too thence the infirmary had a comparable number of infections equally similar hospitals.
• If the confidence interval for the score falls to a higher house 1, too thence the infirmary had to a greater extent than infections than similar hospitals.

And how much less value is the SIR when y'all larn that the CDC found a 3% increase inward the SIR charge per unit of measurement for this disease.

You'd recall that alongside such a loosey-goosey benchmark, the institutional authors of the AHRQ report--presumably the most committed hospitals inward the country--would present upwards equally improve than average.  But they don't.

Where would y'all go?

On the search for success stories, I went to UHC, where:

Fifteen participating fellow member organizations significantly reduced the incidence of hospital-acquired infections (HAIs) during the UHC Imperatives for Quality (IQ) Program’s Infections Due to Devices Improvement Collaborative. 

Significantly?

Twelve teams achieved a 12% reduction inward their CAUTI rates.

Let's say your local infirmary tells y'all that its CAUTI charge per unit of measurement is 1.4 infections/1000 days--a 12% reduction from previously.  This sounds neat until y'all larn that some of the best performers are at 0.7 infections/1000 days.  Are y'all comfortable going to a house that has twice the infection charge per unit of measurement of some other house inward your community?

I know which I'd prefer. And I'd prefer fifty-fifty to a greater extent than a infirmary that is totally transparent alongside regard to its compliance alongside the primary protocol for avoiding UTIs inward the offset place--removing the Foley apace afterwards surgery.  Transparency suggests that such a infirmary is willing to concur itself accountable to a high criterion of care.  There aren't many who volition produce that, but here's an example--what y'all run into when y'all become to the MedStar Health website:

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