Preventing Catheter-Associated Urinary Tract Infections

0 downloads 0 Views 81KB Size Report
Sep 29, 2016 - Ascension Health. St. Louis, MO. Since publication of their article, the authors report no fur- ther potential conflict of interest. 1. Damschroder LJ ...
The

n e w e ng l a n d j o u r na l

of

m e dic i n e

C or r e sp ondence

Preventing Catheter-Associated Urinary Tract Infections To the Editor: We were surprised by the results reported by Saint et al. (June 2 issue)1 regarding the lack of success of the Comprehensive Unitbased Safety Program (CUSP) in reducing urinarycatheter use and catheter-associated urinary tract infections (UTIs) in the intensive care unit (ICU) setting. During a similar period, from January 2012 to December 2014, and using strategies very similar to those that the authors detail in Table 1 of their article, we were able to reduce the use of urinary catheters in our medical ICU from 92% to 20%.2 We have been able to maintain this practice, and our catheter utilization rate remains at approximately 25%. We have had only one documented catheter-associated UTI since January 2015. Our institution is a large urban teaching hospital, and our medical ICU has 20 beds. The key component to our success is the enthusiastic collaboration by our physicians and nurses in implementing and maintaining this strategy. Culture change is difficult. We believe that more can be done to reduce catheter-associated UTIs in ICU patients. Yizhak Kupfer, M.D. Richard Savel, M.D. Maimonides Medical Center Brooklyn, NY ykupfer@​­maimonidesmed​.­org No potential conflict of interest relevant to this letter was reported. 1. Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med 2016;​374:​2111-9. 2. Irukulla P, Kupfer Y, Seneviratne C, et al. A stepwise strategy significantly reduced medical intensive care unit urinary catheter utilization rates. Chest 2015;​148:​488-A. abstract. DOI: 10.1056/NEJMc1609988

has sought to lower the rate of catheter-associated UTIs at our facility using a modified version of the Keystone bladder bundle.1,2 We observed a pattern similar to the results presented by Saint et al.: an initial decline in hospital-wide rates of catheter-associated UTIs followed by a period of continued infections in ICUs, manifested as high rates due to the “small numbers” problem as overall catheter use declined. We agree that ICU patients are more prone than non-ICU patients to have a fever of unknown origin and thus reportable infections; however, the sustainability of organizational culture change is also a factor. The bundle is a high-involvement intervention that requires oversight, repeat training, and feedback cycles with dedicated staff participation over time. Furthermore, departures of safety champions from academic centers limit the potential for culture change to spread from a specific intervention to this week’s letters 1297 Preventing Catheter-Associated Urinary Tract Infections 1299 Body-Mass Index in Adolescence and Cardiovascular Death in Adulthood 1301 Sudden Cardiac Death in Children and Young Adults 1302 Ankylosing Spondylitis and Axial Spondyloarthritis 1303 Viral Load Kinetics of MERS Coronavirus Infection 1305 Stellar Quake

To the Editor: Since 2013, the Tulane CatheterAssociated Urinary Tract Infection Workgroup

 e29 Crystallopathies

n engl j med 375;13 nejm.org  September 29, 2016

The New England Journal of Medicine Downloaded from nejm.org on January 29, 2018. For personal use only. No other uses without permission. Copyright © 2016 Massachusetts Medical Society. All rights reserved.

1297

The

n e w e ng l a n d j o u r na l

other areas of patient safety, a challenge that we imagine is greater in nonacademic facilities with limited staff and that may explain attrition among rural, nonacademic participants in CUSP. Andrew L. Wickerham, M.P.H. Tulane University School of Medicine New Orleans, LA awickerh@​­tulane​.­edu

Christina Waggaman, M.S., C.I.C. Tulane Medical Center New Orleans, LA

Geraldine E. Ménard, M.D. Tulane University School of Medicine New Orleans, LA No potential conflict of interest relevant to this letter was reported.

of

m e dic i n e

necessary insertion in emergency and acute care departments. Todd C. Lee, M.D., M.P.H. Emily G. McDonald, M.D. McGill University Health Centre Montreal, QC, Canada todd​.­lee@​­mcgill​.­ca No potential conflict of interest relevant to this letter was reported. 1. Soong C, Leis JA, Okrainec K, McDonald EG, Lee TC. A point prevalence study of urinary catheter use among teaching hospitals with and without reduction programs. J Hosp Med 2016 June 17 (Epub ahead of print). 2. Schwartz BC, Frenette C, Lee TC, Green L, Jayaraman D. Novel low-resource intervention reduces urinary catheter use and associated urinary tract infections: role of outcome measure bias? Am J Infect Control 2015;​43:​348-53. DOI: 10.1056/NEJMc1609988

1. Wickerham AL, Hoerger J, Teja N, et al. Implementation of a

nurse-driven Foley catheter removal protocol. Presented at the 25th Annual National Forum of the Institute for Healthcare Improvement, Orlando, FL, December 10, 2013. 2. Wickerham AL, Lockhart D, Jones K, Waggaman C, Eichler BA, Ménard G. From pilot to policy: house-wide expansion of a nurse-driven Foley catheter removal protocol. Presented at the 26th Annual National Forum of the Institute for Healthcare Improvement, Orlando, FL, December 9, 2014. DOI: 10.1056/NEJMc1609988

To the Editor: Quality-improvement studies can be criticized for focusing on process measures rather than outcomes. It is therefore commendable that Saint et al. found a 14% relative reduction in catheter-associated UTIs across all participating units, coupled with an absolute reduction of 1.3 percentage points in catheter-days in non-ICUs, in their national, multipronged intervention. Without detracting from this, we believe that two points merit discussion. First, despite considerable effort, nearly 20% of patient-days in non-ICUs involved a urinary catheter. We wish to caution against using this as a performance benchmark; for certain acutely ill medical populations, lower catheter use may still be achievable. In a point-prevalence study of Canadian medical teaching hospitals, units with active interventions had 8.8-percentage-point fewer catheter-days than those without (9.8% vs. 18.6%, P = 0.03).1 Second, catheter-associated UTI has a time-limited definition, and catheter removal may actually simply reclassify would-be catheter-associated UTIs into nosocomial UTIs.2 In order to have an effect on overall UTI rates, we suggest that in addition to quality catheter care and prompt removal, future efforts focus on the prevention of un-

1298

The authors reply: We commend Kupfer and Savel for their success in reducing catheter use and catheter-associated UTIs in their medical ICU. The most impressive reduction in terms of catheter use in any ICU participating in our study was an approximately 90% relative reduction. The challenge is scaling up these findings and learning how the approach used by these “positive deviants” can be applied more broadly. We acknowledge that successfully implementing and sustaining infection-prevention efforts depends on organizational context, effective leadership, and committed champions.1 We agree that culture change is difficult. Furthermore, the precise relationships between safety-culture measures and infections are not fully understood. Meddings and colleagues examined the influence of changes in safety culture — as quantified by the Hospital Survey on Patient Safety Culture (HSOPS) — on changes in rates of catheter-associated UTI and catheter-related bloodstream infection and found no significant relationships across all HSOPS domains for either type of infection.2 We currently have a project focusing on ICUs that have higher-thanaverage rates of infection. Wickerham et al. point out that their experience is similar to what we report. This finding — a reduction in catheter-associated UTI rates on general wards but not in the ICUs — was also seen in a seven-hospital Veterans Affairs study.3 A study by Damschroder and colleagues has shown the importance of intrinsically motivated and enthusiastically committed champions and

n engl j med 375;13 nejm.org  September 29, 2016

The New England Journal of Medicine Downloaded from nejm.org on January 29, 2018. For personal use only. No other uses without permission. Copyright © 2016 Massachusetts Medical Society. All rights reserved.

Correspondence

organizational connectedness in successfully im- Sanjay Saint, M.D., M.P.H. plementing infection-prevention efforts and be- M. Todd Greene, Ph.D., M.P.H. havioral change.1 How best to sustain effective Veterans Affairs Ann Arbor Healthcare System Ann Arbor, MI interventions — perhaps by institutionalizing saint@​­umich​.­edu the interventions — is an area of ongoing inves- Mohamad G. Fakih, M.D., M.P.H. tigation. Ascension Health We agree with Lee and McDonald that a cath- St. Louis, MO Since publication of their article, the authors report no fureter utilization rate of 20% should not necessarther potential conflict of interest. ily be used as a performance benchmark in non1. Damschroder LJ, Banaszak-Holl J, Kowalski CP, Forman J, ICU settings. Currently, there are no national Saint S, Krein SL. The role of the champion in infection preventargets for urinary-catheter utilization, although tion: results from a multisite qualitative study. Qual Saf Health the Centers for Disease Control and Prevention Care 2009;​18:​434-40. 2. Meddings J, Reichert H, Greene MT, et al. Evaluation of the asis working on establishing a standardized de- sociation between Hospital Survey on Patient Safety Culture (HSOPS) vice-utilization ratio. We have advocated that measures and catheter-associated infections: results of two national urinary-catheter use be reported as a quality and collaboratives. BMJ Qual Saf 2016 May 24 (Epub ahead of print). 3. Saint S, Fowler KE, Sermak K, et al. Introducing the No Preperformance metric,4 given that urinary cathe- ventable Harms campaign: creating the safest health care systers may have both infectious and noninfectious tem in the world, starting with catheter-associated urinary tract harms. We have not formally evaluated the poten- infection prevention. Am J Infect Control 2015;​43:​254-9. 4. Fakih MG, Gould CV, Trautner BW, et al. Beyond infection: tial misclassification of catheter-associated UTI device utilization ratio as a performance measure for urinary as nosocomial UTI, an interesting concept that catheter harm. Infect Control Hosp Epidemiol 2016;​37:​327-33. requires further study. We completely agree that 5. Fakih MG, Heavens M, Grotemeyer J, Szpunar SM, Groves C, Hendrich A. Avoiding potential harm by improving appropriateavoiding the indwelling catheter — whether it ness of urinary catheter use in 18 emergency departments. Ann 5 is in the emergency department or the operat- Emerg Med 2014;​63(6):​761-8.e1. ing room — is important. DOI: 10.1056/NEJMc1609988

Body-Mass Index in Adolescence and Cardiovascular Death in Adulthood To the Editor: The study by Twig and colleagues (June 23 issue)1 adds to our understanding of the long-term adverse effects of obesity in adolescents. However, this observational study cannot establish causation; moreover, the authors did not take into account the potential effects of changes in bodymass index (BMI) over time or during adulthood. This latter point is important, because a reduction in BMI in overweight or obese persons has been shown to improve clinical outcomes.2 Furthermore, the authors were not able to adjust for confounders, including physical activity, during the teen years or adulthood, which may markedly affect prognosis.3 Simple anthropometric variables of central obesity, such as waist circumference and waist-to-hip ratio, which have been shown to be more closely related to the degree of adiposity and cardiovascular outcomes than BMI alone,4 were not assessed. However, despite the limitations, the results of this study are important, because the current prevalence of obesity and physical inactivity among adolescents in the United States is

considerably greater than that noted in Israel three to five decades ago and could lead to worse cardiovascular outcomes in the future.3 Abhishek Sharma, M.D. State University of New York Downstate Medical Center New York, NY abhisheksharma4mamc@​­gmail​.­com

Carl Lavie, M.D. Ochsner Clinical School New Orleans, LA No potential conflict of interest relevant to this letter was reported. 1. Twig G, Yaniv G, Levine H, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med 2016;​374:​2430-40. 2. Becque MD, Katch VL, Rocchini AP, Marks CR, Moorehead C. Coronary risk incidence of obese adolescents: reduction by exercise plus diet intervention. Pediatrics 1988;​81:​605-12. 3. Lavie CJ, McAuley PA, Church TS, Milani RV, Blair SN. Obesity and cardiovascular diseases: implications regarding fitness, fatness, and severity in the obesity paradox. J Am Coll Cardiol 2014;​63:​1345-54. 4. Oliveros E, Somers VK, Sochor O, Goel K, Lopez-Jimenez F. The concept of normal weight obesity. Prog Cardiovasc Dis 2014;​ 56:​426-33. DOI: 10.1056/NEJMc1609415

n engl j med 375;13 nejm.org  September 29, 2016

The New England Journal of Medicine Downloaded from nejm.org on January 29, 2018. For personal use only. No other uses without permission. Copyright © 2016 Massachusetts Medical Society. All rights reserved.

1299