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Original Investigation
August 2017

A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents

Author Affiliations
  • 1Geriatric Research Education and Clinical Center, Ann Arbor Veteran Affairs Healthcare System, Ann Arbor, Michigan
  • 2Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
  • 3Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
  • 4Center for Clinical Management Research, Ann Arbor Veteran Affairs Healthcare System, Ann Arbor, Michigan
  • 5Medicine Service, Ann Arbor Veteran Affairs Healthcare System, Ann Arbor, Michigan
  • 6Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor
  • 7The Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas
  • 8Section of Infectious Diseases, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas
  • 9Centers for Disease Control and Prevention, Atlanta, Georgia
  • 10Steven J. Schweon, LLC, Saylorsburg, Pennsylvania
  • 11Health Research & Educational Trust, American Hospital Association, Chicago, Illinois
  • 12Trinity Health, Livonia, Michigan
  • 13Agency for Healthcare Research and Quality, Rockville, Maryland
JAMA Intern Med. 2017;177(8):1154-1162. doi:10.1001/jamainternmed.2017.1689
Key Points

Question  Can a multicomponent initiative focusing on technical and socioadaptive interventions reduce catheter-associated urinary tract infection in nursing homes?

Findings  In this large-scale national implementation project that included 404 community-based nursing homes, longitudinal analysis indicated that catheter-associated urinary tract infection rates decreased by 54% and urine culture orders decreased by 15% over the course of the project. Catheter utilization was largely unchanged.

Meaning  A combined technical and socioadaptive catheter-associated urinary tract infection prevention intervention successfully reduced the incidence of catheter-associated urinary tract infection in community-based nursing homes.

Abstract

Importance  Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms.

Objective  To develop, implement, and evaluate an intervention to reduce catheter-associated UTI.

Design, Setting, and Participants  A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016.

Interventions  The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication.

Main Outcomes and Measures  Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist.

Results  In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001).

Conclusions and Relevance  In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

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