Discussion

Based on our Connecticut statewide data, the utility of current metrics varied by hospital size. For larger hospitals or hospitals with more CAUTI events, the CAD or SIR was a meaningful metric for assessing hospital-wide CAUTI prevention efforts. However, most hospitals in Connecticut are small hospitals, for which we were either not able to calculate an SIR or reported an SIR of 0 because their predicted number of infections was very low. The CDC recommends against calculating an SIR for hospitals with smaller denominators.³ As a result, small hospitals with high number of CAUTI events may not be identified. Additionally, 40% of small hospitals had a negative CAD, despite at least half of these hospitals reporting high device utilization, likely because the SIR does not adjust adequately to smaller hospitals due to lower exposure. In the absence of a reportable performance metric, these small hospitals may not be incentivized to reduce catheter harm. Similarly, it is difficult to calculate CAD at the unit level for larger hospitals with lower exposure. In such cases, using SUR or DUR may incentivize units to decrease utilization. Because SUR also adjusts for hospital- and unit-level factors, it is a more attractive measure for smaller hospitals and facilities with rare CAUTI events.^{Reference Advani and Fakih4} Additionally, small hospitals may benefit from locally reporting days from the last CAUTI event.

We found that examining different metrics collectively may be a more useful strategy for targeting prevention efforts. For example, hospitals with low SIRs and high SURs may represent low-risk catheter use, better maintenance and care of indwelling catheters, or strict urine-culturing practices. In these scenarios, focusing prevention efforts on decreasing device utilization should be considered to account for noninfectious catheter harm as well. Alternatively, hospitals that have high SIRs and low SURs may represent a population with more high-risk catheter use (ie, catheters in high-risk patients), inadequate catheter care, or indiscriminate urine-culturing practices. These hospitals may benefit from focusing on catheter maintenance and stewardship of culturing. Thus, using a combination of metrics may help hospitals direct their prevention strategies toward reducing overall catheter harm. These data may also be helpful to state HAI programs to target CAUTI prevention efforts on a larger scale.