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Catheters: A Connection to Infection

Nurses are taught to prioritize and catheter care can sometimes be put on the back burner, resulting in healthcare-associated infections.

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On Oct. 8, 2008 the new Centers for Medicare and Medicaid Services (CMS) nonpayment policy for hospital associated conditions (HAC) went into effect.

This policy refuses payment for a diagnosis which could have been prevented using evidence-based practice, resulting in increased payment for a secondary diagnosis not present on admission, and is associated with an elevated cost of treatment and greater occurrence.

Eight conditions were selected from the 2002 National Quality Forum "never events." Never events are identified as conditions that should have been prevented and should never have occurred.1

Healthcare associated infections (HAI) are one of the most common complications of hospital care. An estimated two million patients develop a HAI each year in the U.S. and approximately 99,000 of them die as a result of this infection.2

Catheter-associated urinary tract infections (CAUTI) are the single largest source of bacteremia in hospitalized patients. Urinary tract infections (UTI) currently account for approximately 40% of all HAI's in the U.S., with greater than 80% being attributed to indwelling catheters.3

Incidence of Infection

A urinary tract infection is the body's inflammatory response to colonization of the urinary tract. An UTI is considered a CAUTI when a patient has an indwelling urinary catheter at the time of infection or within seven days of the onset of two or more signs or symptoms of a UTI.3

More than 500,000 CAUTI's occur annually in the U.S.4 Currently, the cost of treating a single urinary tract infection ranges from $980 - $2,900 depending on the presence of associated bacteremia.3

In addition to increased hospital costs, CAUTI's are also associated with increased length of stays (LOS) and increased mortality rates. CAUTI's add an estimated additional 90,000 hospital days per year in the United States, adding an additional annual cost of $424 million - $451 million.3

The incidence of acquiring a CAUTI in a hospital significantly increases with prolonged use of an indwelling urinary catheter. When a catheter remains in place for 30 days or longer, the incidence approaches 100% chance of colonization of bacteria in the bladder.3 Approximately 30 million indwelling urinary catheters are used each year in the United States and the majority of these catheter days occur in hospital intensive care units (ICU).

Many patients in ICU's require mechanical ventilation and sedation, therefore significantly decreasing the ability to urinate on one's own. Additionally, ICU patients may have prolonged use of indwelling catheters due to understaffing and the lack of support staff for the nurses in the unit (Is this true? I would think this happening more on a med-surg floor than the ICU). Prolonged use of indwelling catheters has been shown to be the number one risk factor of a patient developing a CAUTI.

Reducing CAUTI

Nurses are taught to prioritize, and unfortunately, catheter care is often put on the back burner to deal with the larger picture of life and death illnesses. Furthermore, when there is a high nurse to patient ratio and the nurses feel unsupported by other staff members, this can quickly lead to nurse burnout. Nurse burnout has been associated with a decreased quality of nursing care, leading to an increased rate of urinary tract infections, along with other hospital-acquired infections.2

Efforts to reduce CAUTI's in hospitals must focus on evidence-based practice on indwelling urinary catheters during insertion, maintenance, and removal as early as possible. To quote Ben Franklin, the inventor of the flexible urinary catheter, "By failing to prepare, you are preparing to fail."5

To help in the reduction of CAUTI rates, it has been recommended to use an anti-infected impregnated urinary catheter..6

Many facilities have adapted an assessment tool to monitor the need for the indwelling catheter and have implemented a nurse driven urinary catheter removal protocol. This protocol allows the nurse to use his or her assessment skills to independently determine if the patient continues to meet the criteria for an indwelling urinary catheter on a daily basis. If the criterion is not met according to the nurse, the protocol allows them to remove the catheter at that time without having to receive an additional physician order.

Another recommendation to assist in reducing CAUTI rates is to implement a unit-based quality nurse. This nurse would assume the responsibility of rounding daily on each patient with a urinary catheter in the unit. They would provide education to the other nurses regarding proper catheter care and assess the readiness for removal.7

As urinary catheters would be the quality nurses' sole responsibility, this would alleviate some of the burden felt by the staff nurses in the inability to perform proper catheter care due to understaffing or burnout.

CAUTI's are viewed to be reasonably preventable, occur frequently, and are costly. These factors led CMS to put hospital acquired CAUTI's on their list for non-payment of additional costs associated with CAUTI's.

Efforts have to be continuously made to help in reducing these rates for the sake of the safety and health of our patients. Education, nurse driven monitoring, and additional nursing staff on the units help to provide the care necessary to assist in reducing these preventable infections.

Over two decades ago, the CDC gave guidelines including proper hand hygiene, aseptic technique during catheter insertion, and proper maintenance of a closed urinary catheter system.5 Nurses and physicians have long been aware of the complications associated with indwelling catheters and have worked diligently to try to prevent CAUTI's.

Unintended Consequences

Evidence-based medicine has reinforced the importance of following strict protocol to prevent HAC's, and CMS has penalized hospitals by non-payment for HAC's. Unfortunately, it has been shown that the incidence of CAUTI's, unlike other HAC's, have not reduced since the CMS non-payment initiation.8

Perhaps, this is an infection that has an element of being non-preventable and hospitals are being penalized unfairly. At the very least, it merits further investigation as to why the prevention of CAUTI's has not been successful while the increased prevention of the other seven HAC's identified by CMS has been successful.

Not only is payment withheld for the care given, but hospitals are spending more money educating the staff in proper catheter procedure, on alternatives to indwelling catheters, and additional nursing hours utilized in providing care to patients who need frequent changing and cleaning due to incontinence.

While no one can fault CMS or hospital administrations to enforce better quality control in regard to CAUTI's, we have to be realistic in achieving the policy goals and be aware of unintended consequences of CMS non-payment.

An unintended consequence in the CMS program to reduce HAC's has been a lack of standardization of CAUTI definitions and data recording as well as incorrect coding and documentation for billing purposes.

All hospitals record their data differently from each other. Often, the only area which documents a patient having an indwelling catheter is the nurses notes. The billing department does not have access to the nurses notes, therefore is unaware that a patient's UTI is a result of an indwelling catheter. This omission loophole allows for the billing department to exclude the coding which identifies the UTI as hospital acquired, not present on admission.

One clinicians' definition of a CAUTI may not be the same as another clinicians'. This difference also leads to different coding for billing purposes. This allows some institutions to be reimbursed for the treatment of a HAC, where another hospital that documents more thoroughly, showing the condition was a secondary diagnosis not present on admission, will not be reimbursed. Are these billing errors or differences intentional or are some institutions instructing their billing departments to be creative by omitting information regarding HAC's? Following such practices as these would be fraudulent.

Another unintended consequence of the mandate is hospitals reporting less time available in the efforts to reduce other non-targeted HAC's.9 Furthermore, the CMS mandate finds hospitals practicing defensive testing on admission to identify UTI's.

Current practice does not include urinalyses and urine cultures on admission, but more and more hospitals are testing for UTI's to document their presence on admission. This leads to increased antibiotic use, which can generate increased antibiotic resistance and C. diff.5 Unfortunately, it may also lead to decreased accessibility to high-risk patients such as the elderly who are most vulnerable to these HAC's.5 If a hospital is not reimbursed for such infections, they may find ways to prevent high risk patients from being admitted.

Increasing Awareness

Advantages of the CMS mandate regarding HAC's encourages hospitals to embrace greater awareness of CAUTI's, increase education of healthcare workers, promote nurse driven identification of early catheter removal, explore alternatives to indwelling catheters, and provide adequate staffing. These actions promote improved overall care of the patient with increased focus on preventing UTI's.

Patients are more comfortable without an indwelling catheter, which leads to greater patient satisfaction in their care. The elimination of an indwelling catheter promotes mobility, which prevents other complications such as venous thromboembolism and pneumonia. Additionally, the reinforcement of aseptic care crosses all aspects of in-patient care which improves health outcomes overall.

The CMS rule changes are paving new avenues in healthcare. At the very least, the attention to CAUTI's promotes increased effort to reduce HAC's. The focus on nurse driven care empowers the nurse to take action immediately instead of waiting for a physician. Careful attention to staffing will help reduce nurse burnout. The involvement of a unit-based quality nurse promotes careful attention to CAUTI's and reduces some of the burden on the individual nurse.

Any effort to reduce infection rates should be utilized which will promote better patient outcomes. The question has to be asked, where will the money come from to pay for CAUTI if not from CMS? If a hospital utilizes appropriate coding and bills correctly for HAC's, therefore is penalized by CMS non-payment, is it fair that there is not specific standardization of documentation, coding, and billing?

A hospital which documents their efforts and does their due diligence in preventing CAUTI's may be unfairly penalized for an infection which possibly should not be considered a never event. Careful follow-up and possible re-visiting from CMS may be necessary to evaluate this mandate and possible changes to the ruling may be in its future.

References for this article can be accessed here.

Hannah Khoury is Medicine/Oncology Clinical Supervisor, The George Washington University Hospital, Washington, D.C.

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