Discussion

Overall, there was a significant decrease in catheter days in all hospitalized patients, but we did not observe a significant change in the CAUTI rate. During the course of this study, a CAUTI reduction performance improvement project was active, and we hypothesized that the decrease in catheter days observed in men was a result of the ongoing project. We did observe a downward trend in CAUTI in women when expressed as CAUTI per 1,000 patient days. We believe this is due to a decrease in indwelling catheter use at least partially due to the introduction of the EUCD as well as the ongoing project. As expected, when the CAUTI rate for women was expressed per 1,000 catheter days a decrease in the rate associated with the introduction of the EUCD was not observed because the EUCD would not prevent a CAUTI in a woman with a need for an indwelling catheter. However, when the rate of indwelling catheter use was examined more closely, the rate of decline after EUCD introduction did not vary significantly from the pre-introduction period (Fig. 1).

Multiple strategies have been utilized to reduce CAUTI rates, including implementing practice bundles with a focus on catheter avoidance and early catheter removal^{Reference Allen, Culbertson, Eyherabide and Geca3} and utilization of external catheter devices for men.^{Reference Gray, Skinner and Kaler4} Urinary management with an EUCD for women has been described previously,^{Reference Beeson and Davis5} but overall, data regarding EUCD use and their effect on indwelling catheter utilization and CAUTI are limited. EUCD implementation has been associated with decreased catheter days as well as decreased female CAUTI rates in smaller hospitals and specific units. Eckert et al⁶ introduced an EUCD in a 60-bed telemetry unit followed by use throughout the hospital (386 total beds). A decrease in CAUTI was observed in the first year that was not sustained.^{Reference Eckert, Mattia, Patel, Okumura, Reynolds and Stuiver6} Several studies have also demonstrated a decrease in urinary catheter utilization,^{Reference Dublynn and Episcopia7–Reference Mueller9} with variable effect on CAUTI rates. Beeson et al^{Reference Beeson, Davis and Vollman8} demonstrated a decrease of 27% in CAUTIs over 6 months in a surgical intensive care unit and Dublynn et al^{Reference Dublynn and Episcopia7} noted a 51.7% decline in CAUTIs over 1 year. Mueller et al^{Reference Mueller9} demonstrated a significant decrease in the urinary catheter standardized utilization ratio, but the CAUTI standardized infection ratio increased nonsignificantly. However, data were reported in total with no breakdown between men and women, so it was difficult to assess whether there was separate improvement in the CAUTI rate among women only.^{Reference Mueller9}

This was a single-center study at an academic medical center, which limits the generalizability of our results. Adverse events were reported via nursing incident reports which may have led to underreporting and may have limited patient perspective on EUCD use. Furthermore, the retrospective nature and lack of a concurrent control group may have resulted in selection bias (ie, patients receiving the EUCD were not randomized or rigorously selected) and confounding (eg, uncontrolled concurrent interventions). Additional prospective studies to more precisely determine whether the EUCD is associated with changes in UTI (both CAUTI and noncatheter UTI) and to define the cost implications of EUCD are warranted.

In summary, introduction of a female EUCD was associated with a decrease in indwelling catheter use and a trend toward a decrease in the CAUTI rate when expressed as infection per 1,000 patient days in women.