Discussion

Reducing inappropriate urethral catheter use is an important method of preventing CAUTI and enhancing patient safety. Our intervention, implemented nearly a decade ago, revealed that a simple set of practices can reduce inappropriate catheter use and can contribute to decreased CAUTI rates: use of a standardized catheter kit with a closed system, a nursing note template facilitating daily nursing review of catheter presence, and a policy prompting removal when no longer indicated.^{Reference Miller, Krein and Fowler1} The results from this study show a continuing decrease in indwelling urethral catheter prevalence and a sustained reduction in inappropriate use over 8 years following the implementation of this multimodal intervention.

Sustainability in quality improvement interventions is a complex phenomenon and represents a key goal for patient safety leaders and policy makers. Sustainability generally consists of 3 elements: effectiveness; routinization and institutionalization of the program; and staff capacity, including having effective program champions.^{Reference Shediac-Rizkallah and Bone3,Reference Scheirer4} Several program features may have contributed to the sustained reductions in inappropriate catheter use revealed in this study. First, some of the elements used in our multimodal intervention had demonstrated effectiveness in prior work.^{Reference Meddings, Rogers, Krein, Fakih, Olmsted and Saint2,Reference Gould, Umscheid, Agarwal, Kuntz and Pegues7,Reference Huang, Wann and Lin8} Thus, we had implemented changes that were evidence-based. Second, the note template in the electronic medical record made catheter assessments a part of the routine daily nursing care and documentation process, which prompted removal of urethral catheters as soon as they were no longer indicated. Third, the focus on appropriate catheter use was institutionalized by making the daily review of urethral catheter presence and need a standard part of nurse hand-off communications. Finally, our facility had effective champions who continued to monitor fidelity to the intervention and infection rates after the initial intervention. When there were increases in infection rates in the facility, a group was convened to determine the cause and address the issue accordingly.

Outside our intervention, national efforts to decrease CAUTI rates during this time may have contributed to the success observed. In 2008, the Centers for Medicare and Medicaid Services stopped payments for the treatment of many hospital-acquired conditions, including CAUTI, which has led to CAUTI prevention efforts in US hospitals nationwide.^{9,Reference Saint, Greene and Krein10} In 2006, the VA developed the Inpatient Evaluation Center to monitor ICU patient outcomes, including CAUTI, which was later expanded to include monitoring infections in acute-care settings around the start of the intervention.

Our study should be interpreted in the context of the following limitations. First, we conducted this study at a single site; therefore, our results may not be generalizable to other healthcare systems. Although the VA Ann Arbor is part of the single largest healthcare system in the United States, the VA has certain characteristics that distinguish it from other nongovernmental healthcare facilities. These include the use of an electronic health record that spans multiple facilities and a financial model that is focused on prevention of illness versus fee for service. Second, we focused on the process measure of urethral catheter use and did not assess outcomes, such as infectious or noninfectious harms. The ultimate goal of this program is to reduce catheter-associated harms; however, we were unable to asses these outcomes for this follow-up study. Finally, our assessments were done sporadically over the 8-year period; variations in urethral catheter use over this period may not have been captured.

Limitations notwithstanding, our findings show sustainability of the initial results of a multimodal CAUTI prevention intervention with an ongoing decrease in catheter use and sustained reduction in inappropriate urethral catheter over an 8-year period. Although additional research to understand how different program elements might contribute to sustainability may be warranted, we expect that such a program can be modified and adapted for use in other healthcare systems.