Discussion

Intensive care units have deployed different interventions to reduce CAUTIs.^{Reference Shuman and Chenoweth1,Reference Rosenthal, Todi and Alvarez-Moreno15,Reference Menegueti, Ciol and Bellissimo-Rodrigues29,Reference Sampathkumar33,Reference Patel, Gupta, Vaughn, Mann, Ameling and Meddings34} Our study builds on this extensive literature to suggest a relatively low-resource intervention to reduce CAUTIs in the ICU. Following the implementation of the ICU rounding checklist, the CAUTI rate decreased, with a statistically significant decrease between the preintervention period and 1 year in the postintervention period. We detected an initial increase in the catheter utilization ratio during preintervention period I, followed by a decrease in the following 2 postintervention periods. It is unclear why the catheter utilization ratio initially increased; however, the subsequent decrease may be a result of a lag between the implementation of the checklist and a change in practice patterns.

Our checklist completion rate was lower than that reported in prior studies that included checklist completion rates.^{Reference Carlos, Patel, Vannostrand, Gupta, Cucci and Bosslet21,Reference Centofanti, Duan and Hoad23,Reference Siegel, Figueroa and Stockwell31} This finding may reflect differences in the resources allocated to completing the checklist or lack of buy-in with different provider teams that rotate on a weekly or monthly basis with periods of low checklist uptake impacting the overall completion rate. Another explanation for the relatively low checklist completion rate may be a consequence of high patient turnover in the ICU. The checklist was designed to be completed on the patients in the ICU during morning rounds, and therefore would miss patients admitted during the day because only new patients admitted overnight were typically presented during morning rounds. The checklist would also miss patients discharged before morning rounds either as deceased or to floor level of care. Whether a higher checklist completion rate would lead to more dramatic decreases in the catheter utilization ratio or the CAUTI rate remains unknown. Despite the low completion rate, we were able to show decreases in the catheter utilization ratio and CAUTI rate. Part of the success of an ICU rounding checklist may be the way in which it addresses part of the 4 key steps to removing a urinary catheter as outlined by Meddings et al^{Reference Meddings, Rogers, Macy and Saint9}: (1) recognition by the physician that the urinary catheter is in place, (2) recognition by the physician that the urinary catheter is not needed, (3) physician writing an order to discontinue the urinary catheter, and (4) a nurse removing the urinary catheter.

Prior studies report a rate of ~3–8 CAUTIs per 1,000 catheter days in the ICU, which is consistent with our preintervention rate.^{Reference Shuman and Chenoweth1,Reference Mullin, Kovacs and Fatica14} Our results are similar to the results reported by Jain et al,^{Reference Jain, Miller, Belt, King and Berwick30} who used a bundle checklist to reduce CAUTIs. They reported 3.8 CAUTIs per 1,000 urinary catheter days in the preintervention period and 2.4 CAUTIs per 1,000 urinary catheter days in the postintervention period (P = .170).^{Reference Jain, Miller, Belt, King and Berwick30} Menegueti et al^{Reference Menegueti, Ciol and Bellissimo-Rodrigues29} used a multifaceted intervention that included biannual training of all clinical staff and a checklist with a designated infection control nurse who reviewed cases 3 times per week, yielding a reduction in CAUTIs in the ICU.

This study has several limitations. We used a small sample size and a before-and-after study design, which is susceptible to unmeasured confounding variables. Other potential confounders in our results are the simultaneous hospital-wide educational initiatives to reduce CAUTIs during the same period that were primarily focused on nursing training, including peer feedback, which focused on nursing interventions for noncompliant elements of maintenance bundle audits rather than specific feedback from the checklist. In the future, specific feedback related to the checklist could be formally included. In 2016, all urinary catheter insertions required either 2 nurses or, if a physician was placing the urinary catheter, then a nurse present to assist. Another limitation of our study design was the use of patient days and catheter days without specific individual patient characteristics that may have predisposed patients to developing a CAUTI. One important patient characteristic may be the distinction between chronic indwelling urinary catheter and hospital-acquired indwelling urinary catheter. We focused on hospital-acquired CAUTIs. Patients with chronic indwelling urinary catheters may also have been included in the study, although we believe that these patients comprised only a small percentage of the overall ICU patients during the study period.

Our study also has several strengths. Our intervention required few resources to implement and was easily incorporated into busy daily ICU rounds. Whereas other studies have utilized a dedicated staff member to provide feedback and intervene in CAUTIs, our rounding checklist can be incorporated by the existing clinical team without additional personnel.^{Reference Knoll, Wright and Ellingson17}

Our results suggest that utilization of a daily rounding checklist is associated with a decrease in the average number of CAUTIs in ICU patients. Incorporating a rounding checklist is feasible in the ICU and can likely be used to improve other line-related infections. Further research is warranted to understand the effects of rounding checklist on outcomes such as mortality.