Hey Doc, Do I Still Need This Catheter?

About 25 percent of hospital patients at any given time have urinary catheters -- and a substantial proportion of patients have them much longer than they really need them, experts say. This greatly raises their risk of getting a painful urinary tract infection or even a blood infection.

But a new University of Michigan Health System study, funded by a patient safety grant from the Blue Cross Blue Shield of Michigan Foundation, shows that simply having nurses flag patients' records with a written reminder can jog the memory of busy doctors, prompt them to consider removing the catheter, and lead to a much shorter time with a catheter for many patients. The study is published in the August issue of the Joint Commission Journal on Quality and Patient Safety.

The written-reminder system isn't expensive, and in fact the study finds that its cost equals or is less than the savings that a hospital could achieve by reducing infections among patients. An estimated 40 percent of infections developed by patients during their hospital stay are urinary tract infections, and most of these infections are due to urinary catheters. The cost of treating each infection that causes symptoms is estimated to be at least $500.

"Doctors are responsible for ordering the removal of catheters, but research has shown that many of them forget which patients have catheters and how long they have them," says lead author Sanjay Saint, M.D., M.P.H., a hospitalist at the VA Ann Arbor Healthcare System and an associate professor of internal medicine at the U-M Medical School. "Our reminder system helps doctors do the right thing," he adds.

"Catheter reminders may become automatic as hospitals implement computerized doctors-orders systems. But since about 90 percent of American hospitals still don't have such systems, our study suggests that written reminders should be used in their place," says Saint, the director of the UMHS/VA Patient Safety Enhancement Program, which researches ways to prevent patient injuries and adverse events during hospital care. He is also a member of the Patient Safety Committee that oversees clinical patient safety improvement efforts at UMHS.

Ira Strumwasser, Ph.D., president and CEO of BCBSM Foundation, says, "This is a terrific example of how a simple change in a process can make a real difference in lessening the risk of infection for thousands of patients, as well as reduce costs associated with treating infections."

The controlled trial, carried out for 16 months in four wards of the U-M's University Hospital, involved patients who had been admitted for surgery or with general ailments including kidney and lung problems. Two of the wards used the reminder system and two did not, but a nurse checked the records of every patient each day.

The first eight months of the study gathered baseline data on catheter use. Then, for the next eight months on the two wards where reminders were used, the nurse attached a pre-written order and a sign-here sticker to each patient's chart every day after the catheter had been in place for 48 hours. After about four months, she began paging doctors who didn't fill out the order to either continue the catheter or remove it. The medical director of the Infection Control & Epidemiology division, Carol Chenoweth, M.D., began e-mailing doctors as they started their one-month rotations on the wards.

The data were then analyzed and adjusted for the differences in age, sex and length of hospital stay among the patients on the different wards.

In all, the proportion of each patient's hospital stay that involved a catheter went down by 7.6 percent on the reminder wards compared with baseline, and went up by 15.1 percent in the no-reminder wards. The researchers measured this proportion as a percentage of each patient's total days in the hospital -- if a catheter was used for three of six days, that was a 50 percent proportion.

About two-thirds of the doctors on the reminder wards routinely filled out the daily order after the paging reminders began. When the researchers excluded the one-third of doctors who ignored the reminders, the numbers got even better: The percentage of patient days spent on a catheter went down by 25.7 percent in the reminder group.

The cost of the reminder system, including the nurse's time and the printing of reminders, would be about $53,200 per year, the researchers estimated. The savings, based on conservative estimates of the number of catheterized days, the proportion of doctors who would comply, the risk of urinary tract infection (5 percent for each day on a catheter) and the cost of treating symptomatic infection, would be about $53,449. That means the system would pay for itself with $249 left over.

If all doctors in a hospital complied fully, the savings could be in the tens of thousands, Saint says.

The nurse who checked the records for the entire study period, Maureen Thompson, R.N., M.S.N., notes that catheter reminders are now a routine part of patient care in UMHS intensive care units. "Through our involvement with the Keystone statewide initiative to improve patient safety within ICUs, we have made the daily consideration of invasive line discontinuation a key element of our daily patient safety review," she says.

Saint says that his team has applied for funding to extend the program into more non-ICU wards until the U-M Health System begins using a computerized physician order-entry system in 2006.

In the meantime, he says, hospitals everywhere may be able to institute their own reminder system of written reminders and pages, and thereby reduce the number of days patients are catheterized. "A major way for health care facilities to reduce hospital-acquired infections is to get rid of unnecessary devices, including catheters," he says. "Rather than just relying on the memories of over-worked doctors who are focusing on a patient's medical condition and not their catheter status, we may be able to reduce both the morbidity and mortality associated with urinary tract infections. It's a systems-based solution, and could even be used for other applications."

Saint emphasizes that a successful reminder system, like the one implemented in the study, needs to be interdisciplinary, involving infection control professionals, nurses, and physicians. In addition to Saint, Chenoweth and Thompson, the new paper's authors are research associate Samuel Kaufman, M.A., and research assistant professor of internal medicine Mary A.M. Rogers, Ph.D., M.S. The study was sponsored by a patient safety grant from the Blue Cross Blue Shield of Michigan Foundation.

For more information on patient safety research at UMHS, visit www.med.umich.edu/psep
For more on patient safety at UMHS, visit www.med.umich.edu/opm/newspage/2004/patientsafety.htm
For more on the Keystone ICU project, visit www.mha.org/mha/keystone/icu