HAIs can attack from several angles. But two of the most common culprits enabling infections to start are health care鈥檚 most common lines into and out of our bodies: central lines and catheters. Hospitals鈥 tiny tubes often lead to central-line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs).
Dr. Karen Clarke (鈥89) has found a way to significantly reduce those urinary tract infections. Clarke is an assistant professor of medicine at Emory University Hospital in Atlanta, Ga., and a hospitalist at West Georgia Health in LaGrange. 鈥淯sing a bundled approach that included four interventions, she and colleagues reduced CAUTI rates by 70 percent at 276-bed West Georgia Medical Center in LaGrange,鈥 Bryn Nelson wrote for The Hospitalist in January 2012 in an article titled 鈥淎 Winnable Battle鈥.
Those numbers matter. CAUTIs represent a full third of the 1.7 million annual health care-associated infections in the U.S. If Clarke鈥檚 results are replicated nationally, then hospitals could prevent CAUTIs for nearly 400,000 people (or roughly the population of Omaha) each year.
Preventing seven out of 10 infections from ever starting鈥攖hat鈥檚 superhero stuff. But the Freeport, Grand Bahama Island-native (a prodigy who knew she wanted to be a doctor at age 8 and started at SM论坛 when she was just 15) stopped short of flaunting her cape. 鈥淚 was surprised by the significance of the results,鈥 Clarke admitted.
Profile of Champions
Dr. Karen Clarke knows what it takes to champion a cause for patients. Here are four things she says a hospital champion must have:
- Knowledge about the changes that need to be made;
- Authority to make those changes;
- Interest in seeing those changes through; and
- Time and resources to monitor implementation.
Despite their prevalence, CAUTIs hadn鈥檛 exactly garnered much attention in the health care community. (Nelson called them the 鈥淩odney Dangerfield of HAIs.鈥) CAUTIs lack respect, Clarke said, 鈥渂ecause they are associated with significantly less morbidity and mortality than are central line-associated bloodstream infections or ventilator-associated pneumonias. However, CAUTIs are the most common type of HAI, and their sheer number makes them significant.鈥
Something happened in 2008 to make CAUTIs more relevant to hospitals. That was when 鈥淢edicare and other payers stopped reimbursing hospitals for the cost of treating many HAIs,鈥 Clarke said. Once hospitals felt the burn of urinary tract infections in their budgets, the Rodney Dangerfield of HAIs suddenly had hospitals鈥 full attention. 鈥淭here was a financial incentive to reduce the rate,鈥 Clarke said.
Over the next few months, Clarke partnered with Bonnie Norrick, the head of West Georgia Health鈥檚 Infection Control and Prevention Department, to find ways to reduce CAUTIs in their hospital. 鈥淚 must give Bonnie all of the credit for developing and implementing the bundle,鈥 Clarke said.
鈥淭he bundle鈥 is the hospital鈥檚 quartet of interventions that have stopped seven in 10 urinary tract infections. The bundle calls on the hospital to:
- Use silver alloy catheters in the acute areas of the hospital. (Silver possesses antimicrobial properties.)
- Use securing devices to limit movement of catheters after insertion.
- Ensure that catheter tubing has no kinks and that foley bags are off the floor.
- Require documentation before allowing foley catheters to remain in place beyond surgical patients鈥 second postoperative day.
Clarke and Norrick began implementing these interventions at West Georgia Health in early 2009. History suggested to Dr. Atul Gawande, a surgeon, writer and public health researcher, that implementing these changes wouldn鈥檛 necessarily go smoothly. In an August 13 New Yorker article titled 鈥淏ig Med,鈥 Gawande wrote, 鈥淒octors and patients have not had a positive experience with outsiders second-guessing decisions. How will they feel about managers trying to tell them what the 鈥榖est practices鈥 are?鈥
In the case of the team at West Georgia Health, it turned out that they felt just fine. 鈥淭here was no uphill battle, since the hospital had a financial incentive to reduce the CAUTI rate,鈥 Clarke said. 鈥淧robably because the interventions were not costly, and they were clearly well thought out, there was no resistance to implementing the bundle.鈥
By May of the following year, the four interventions were engrained in the hospital culture, and the team observed the 70 percent drop in CAUTIs. You could say the team escorted Rodney Dangerfield (with the utmost respect) straight out of West Georgia Health.
So how soon can we expect hospitals across America to adopt West Georgia Health鈥檚 CAUTI-prevention bundle? Gawande urged patience. 鈥淚n medicine, good ideas still take an appallingly long time to trickle down鈥. One study examined how long it took several major discoveries, such as the finding that the use of beta-blockers after a heart attack improves survival, to reach even half of Americans. The answer was, on average, more than 15 years.鈥
Still, these cost-effective interventions did a lot to protect patients and avoid unnecessary expenses at West Georgia Health. Nelson鈥檚 article in The Hospitalist argued that hospitals can further reduce infection rates by taking a hard look at who is being catheterized and for how long.
A 2000 study in the American Journal of Medicine by Dr. Sanjay Saint at the University of Michigan found that nearly two in five attending physicians didn鈥檛 know their patients were even catheterized. The admittedly private procedure appeared to be not only unmentionable, but also oftentimes undocumented.
Saint told The Hospitalist that he 鈥渇ound in a significant number of patients鈥 no documentation anywhere in the medical record that the catheter existed. It鈥檚 not in the physician鈥檚 notes, it鈥檚 not in the nursing notes, but we knew it was there because we could see it coming out of the patient.鈥
What goes without mentioning and without documenting can easily go on too long. (How can physicians order the timely removal of a device they didn鈥檛 realize had been inserted?) And the longer a catheter remains discreetly in place, the more likely it is to quietly trigger an avoidable CAUTI.
Another factor increasing total CAUTIs is gratuitous catheterization. Saint found that unnecessary catheters were especially problematic because they 鈥渨ere more often 鈥榝orgotten鈥 than appropriate ones,鈥 allowing potential infections additional time to develop.
The existence of unnecessary or neglected catheters indicates a hospital culture in need of strengthening鈥攊n need of champions. Gawande said such a champion is 鈥渘ot telling clinicians what to do. Instead, he鈥檚 trying to get clinicians to agree on precise standards of care, and then make sure that they follow through on them.鈥 Clarke and Norrick are two such champions.
But perhaps 鈥渃hampion鈥 is the wrong word. Clarke and Norrick didn鈥檛 bring West Georgia Health鈥檚 CAUTI rate down by themselves. The team did that. Clarke and Norrick simply kept their eyes open and cared enough to insist that everyone buy into the team鈥檚 way.
In this model, the team is the champion. Clarke and Norrick, they鈥檙e team captains. And the patients? The patients just win.