One of the most common preventable healthcare-acquired infections is the urinary tract infection (UTI), most often acquired because of issues around urinary catheterization. Hundreds of thousands of preventable UTIs occur in patients every year, but there is a great deal of clinical and process complexity around trying to improve the rate of UTI infections in hospitals.
One thing is clear: programs aimed at aggressively reducing the incidence of urinary tract infections can be successful, given the right types of care delivery process analysis and change, as well as the appropriate and timely use of clinical information systems by front-line clinicians. That point was brought home recently when a group of University of Michigan physician researchers examined the problem and published a meta-study of the issue, entitled “Systematic Review and Meta-Analysis: Reminder Systems to Reduce Catheter-Associated Urinary Tract Infections and Urinary Catheter Use in Hospitalized Patients,” along with co-authors Mary A.M. Rogers, M.D., Michelle Macy, M.D., and Sanjay Saint, M.D., in the September issue of Clinical Infectious Diseases.
Jennifer Meddings, M.D., of the University of Michigan Health System, led the research. A practicing physician with a background in both internal medicine and pediatrics, Meddings practices within the UM Health System and also does regular clinical research. She spoke recently with HCI Editor-in-Chief Mark Hagland regarding what was learned in the study, and the implications of the research for the healthcare clinical IT audience.
Healthcare Informatics: One of the core process problems, it seems, is that clinicians-both physicians and nurses-tend to leave urinary catheters in place too long, and at risk to patients, for a variety of reasons. Can you discuss some of the clinical and process reasons for this problem?
WE FIND THAT WE HAVE TO EXAMINE WHY IT'S SO TEMPTING FOR NURSES AND PHYSICIANS TO PLACE URINARY CATHETERS EVEN WHEN IT'S NOT CLINICALLY CALLED FOR.
Jennifer Meddings, M.D.: Yes, the current default is for the urinary catheter to stay in place, unless several steps happen. The first step is that the doctor has to realize the catheter is still in place; step two is that the doctor has to decide to take it out; then, in step three, the doctor has to write an order for the catheter to be taken out; and step four is that the nurse has to work it into her or his daily work schedule in order for it to come out. Our team of researchers was interested in what studies had been done around interventions such as reminders and stop orders in this area. There are two flavors of reminders: one is a simple reminder; and flavor number two is an actual stop order, in which the catheter will come out unless the doctor wishes for it to stay in; and that's analogous to restraint orders. So our research involved a literature review of what researchers had found. And then we were able to pool the data, and the results were a meta-analysis.
HCI: And, importantly, you and your colleagues found that when reminder and/or stop-order systems are put in place, 52 percent of the time, an infection was averted, right?
HCI: That's quite significant. But you also found that the culture of clinical practice has to be examined in an organization, in order for change to take place, correct?
Meddings: Exactly. In June, I spoke to a national conference of wound, ostomy and continence nurses, called the WOC Conference, in Phoenix. I spoke to them at great length, and whenever I speak with people about these types of reminders, I tell them that the reminders themselves will not likely be successful unless organizations address issues such as the convenience of putting in urinary catheters as a substitute for continence care.
In fact, nurses and physicians are often very well-meaning in placing urinary catheters. And there are some cases where urinary catheterization is very appropriate, such as when a patient has an open wound on their backside that has to be guarded against moisture. But often, that's not the case. So we find that we have to examine why it's so tempting for nurses and physicians to place urinary catheters even when it's not clinically called for, when such catheterization takes place, for example, because these patients will require more linen changes and more baths. So you have to give nurses more power.