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Impact of a Multidisciplinary Infection Prevention Initiative on Central Line and Urinary Catheter Utilization in a Long-term Acute Care Hospital

Impact of a Multidisciplinary Infection Prevention Initiative on Central Line and Urinary... Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Open Forum Infectious Diseases MAJOR ARTICLE Impact of a Multidisciplinary Infection Prevention Initiative on Central Line and Urinary Catheter Utilization in a Long-term Acute Care Hospital 1 1 2 1 3 1 Suganya Chandramohan, Bhagyashri Navalkele, Ammara Mushtaq, Amar Krishna, John Kacir, and Teena Chopra 1 2 3 Division of Infectious Diseases and Department of Internal Medicine, Detroit Medical Center/Wayne State University, Detroit, Michigan; Kindred Hospital, Detroit, Michigan Background. Prolonged central line (CL) and urinary catheter (UC) use can increase risk of central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). Methods. This interventional study conducted in a 76-bed long-term acute care hospital (LTACH) in Southeast Michigan was divided into 3 periods: pre-intervention (January 2015–June 2015), intervention (July–November 2015), and postintervention (December 2015–March 2017). During the intervention period, a multidisciplinary infection prevention team (MIPT) made weekly recommendations to remove unnecessary CL/UC or switch to alternate urinary/intravenous access. Device utilization ratios (DURs) and infection rates were compared between the study periods. Interrupted time series (ITS) and 0-inflated poisson (ZIP) regression were used to analyze DUR and CLABSI/CAUTI data, respectively. Results. UC-DUR was 31% in the pre- and postintervention periods and 21% in the intervention period. CL-DUR decreased from 46% (pre-intervention) to 39% (intervention) to 37% (postintervention). The results of ITS analysis indicated nonsignificant decrease and increase in level/trend in DURs coinciding with our intervention. The CAUTI rate per catheter-days did not decrease during intervention (4.36) compared with pre- (2.49) and postintervention (1.93). The CLABSI rate per catheter-days decreased by 73% during intervention (0.39) compared with pre-intervention (1.45). Rates again quadrupled postintervention (1.58). ZIP analysis indicated a beneficial effect of intervention on infection rates without reaching statistical significance. Conclusions. We demonstrated that a workable MIPT initiative focusing on removal of unnecessary CL and UC can be easily implemented in an LTACH requiring minimal time and resources. A rebound increase in UC-DURs to pre-intervention levels aer ft intervention end indicates that continued vigilance is required to maintain performance. Keywords. catheter-associated urinary tract infection; central line–associated blood stream infection; device utilization ratio; infection prevention; long-term acute care. Long-term acute care hospitals (LTACHs) have become a novel both of which will increase the number of patients with chronic model for continued medical care in the US health care system [1]. critical illness [3]. e n Th ational number of LTACHs has increased from 277 in It has been reported that utilization of central lines (CLs) 2003 to 407 in 2016, and the number of hospital discharges to and urinary catheters (UCs) in LTACHs approaches that of these facilities also increased from 1.9% in 2004 to 4.9% in 2009 intensive care units (ICUs) in acute care hospitals [4]. This is [2, 3]. The LTACH population is mainly comprised of patients not surprising as the high acuity of care delivered in LTACHs recovering from critical illness who continue to require inpa- necessitates the use of these devices. However, studies in acute tient/intensive care unit (ICU) level care [1]. These facilities will care hospitals and ICUs note that most of these devices are left continue to play an important role in health care delivery due in place longer than necessary and physicians are oen un ft a- to the aging of the US population and advances in critical care, ware of their presence in patients [5, 6]. Prolonged use of these devices increases the risk of infection, which in turn leads to extended hospital stays, morbidity, mortality, and excess hos- pital costs [7–12]. Received 14 February 2018; editorial decision 25 June 2018; accepted 19 July 2018. Although several studies have looked at central line–asso- Correspondence: S. Chandramohan, MD, 4201 St. Antoine St, University Health Center 2 C, ciated blood stream infection (CLABSI) and cather-associated Detroit, MI 48201 (schandra@dmc.org). ® urinary tract infection (CAUTI) reduction through reduction Open Forum Infectious Diseases © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases of unnecessary device use in acute care hospitals, there is a Society of America. This is an Open Access article distributed under the terms of the Creative scarcity of similar interventions in an LTACH setting [13–16]. Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any Interventions that incorporate the unique characteristics of this medium, provided the original work is not altered or transformed in any way, and that the work health care setting are urgently needed. Therefore, the goals of is properly cited. For commercial re-use, please contact journals.permissions@oup.com our study were 2-fold: (1) to introduce a workable infection DOI: 10.1093/ofid/ofy156 Infection Prevention Rounds in an LTACH • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 prevention initiative that focused on reducing unnecessary use Table  1 [5, 19–21]. When indication for a central line was no of central lines and urinary catheters in an LTACH and (2) to longer present or when alternate intravenous access (midline study the impact of this intervention in reducing device utiliza- or peripheral venous catheter) could be used to instill medica- tion ratio (DUR) and rates of CLABSI and CAUTI. tions, the recommendation was made to discontinue the central line or switch from the central line to a midline or peripheral METHODS line. When indication for a urinary catheter was no longer pres- ent or when alternative methods could be used to drain urine, Study Setting and Study Periods the recommendation to discontinue or switch to an alternative This interventional study was performed at a 76-bed LTACH method, such as condom catheters or intermittent catheter- in the greater Detroit area. A  Multidisciplinary Infection ization, was made. The final recommendations of the MIPT Prevention Team (MIPT) consisting of an infectious disease were communicated to the physician in charge of the patient consultant (employed part-time to oversee infection prevention by phone or email. The team continued rounding from July and antibiotic stewardship), pharmacist, and registered nurse to November 2015. The MIPT intervention was suspended in (RN) trained in infection control was formed. The MIPT team November 2015 due to completion of the infection disease con- was active from July 1, 2015, to November 30, 2015 (interven- sultant’s contract with the facility and not related to the inter- tion period). The impact of the MIPT intervention was assessed vention itself. by comparing predefined outcomes during the intervention period with those during the pre-intervention (January 1, Outcome Assessment 2015–June 30, 2015) and postintervention periods (December The primary outcomes were (1) to ascertain the impact of MIPT 1, 2015–March 31, 2017). The study was approved by the rounds on the total urinary catheter–days, central line–days, LTACH ethics committee. and DURs and (2) to analyze the effect of MIPT intervention on LTACH-onset CLABSI and CAUTI rates. The effectiveness Data Collection and Definitions of the program was determined by comparing these outcomes Patient-days, central line–days, and urinary catheter–days were between the 3 study periods. obtained from the facility administrative database. LTACH- onset CAUTI and CLABSI were defined using 2015 National Statistical Analysis Healthcare Safety Network [17] criteria throughout the study The monthly rates were combined to calculate the CAUTI rate, period. CLABSI and CAUTI rates were calculated for 1000 cen- CLABSI rate, central line utilization ratio (CL DUR), and uri- tral line–days and 1000 urinary catheter–days, respectively. In nary catheter utilization ratio (UC DUR) during the 3 study addition, CLABSI and CAUTI rates were calculated for 10 000 periods. patient-days. Surveillance of CLABSI and CAUTI was con- Segmented regression analysis of interrupted time series ducted by the same RN trained in infection control during all (ITS) was used to evaluate the changes in level and trend in 3 study periods. Other members of the MIPT team were not DURs during the intervention and postintervention periods. As involved in infection surveillance. Central line and urinary our series had 2 change points corresponding to the start and catheter device utilization ratios (DUR) were calculated by end of the intervention period, we used the following model, as dividing the number of catheter-days by number of patient- suggested by Wagner et al. [22]. days during each study period. Infections with symptom onset within 48 hours of admission were excluded to study only LTACH-acquired infections. Table  1. Acceptable Indications for Urinary Catheter and Central Line Intervention Period The MIPT was rounded weekly during the intervention period Urinary Catheter and was available for remote consultation for remainder of the Open sacral wound for incontinent patients Urinary obstruction/neurogenic bladder week. Before the MIPT weekly rounds, the RN collected details Accurate intake and outake monitoring on all patients with indwelling medical devices including patient Urology surgery medical history, current clinical status, available test results, Comfort care in patients with terminal illness device indications, device start date, and any device-related Central Venous Catheter adverse events. This information was reviewed by MIPT dur- Total parentral nutrition administration ing weekly rounds to access device appropriateness. The weekly Dialysis Irritant and vesicant medication including intravenous vancomycin rounds, which combined infection prevention with antibiotic Use of vasopressor and inotrope stewardship, lasted about 1 to 1.5 hours (antibiotic steward- Use of any intravenous medication in patients with difficult vascular access ship portion of the study has been published previously [18]). The table shows the checklist created by the infection prevention team based on the Criteria for appropriateness of central line and urinary cathe- various consensus guidelines [5, 9, 20, 21]. These criteria were used during our weekly ters were based on previously published data and are noted in rounds to check for the appropriateness and necessity of both foley and central lines. 2 • OFID • Chandramohan et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 the Vuong test, which further confirmed that a ZIP model was Yt =+ ββ ´+ imei ββ ´+ ntervention start tt 0 12 t 3 superior compared with a plain poisson model. The ZIP model ´time after interve ention start + β t 4 has 2 components, a logistic model that predicts the occurrence ´+ intervention end β t 5 of having a 0 CLABSI/CAUTI rate (certain 0s) and a poisson ´time after intervent tion end + e , tt model to generate count data. Catheter-days, patient-days, and where Y is the dependent variable (DUR); time is a continuous t intervention/no intervention were used as variables in the model variable indicating time in months (coded as 1 when the study to evaluate their effects on infection rates. We noticed a possi- started and then increasing by 1 for each month thereafter); ble lagged effect of our intervention in the month of December intervention start is a dummy variable coded as 0 (pre-interven- 2015; therefore, this month was included as yes to intervention. tion period) and 1 (intervention and postintervention periods); In addition, our CLABSI and CAUTI rates data did not indicate time after intervention start is the number of months after the first-order autocorrelation, seasonality, or nonstationarity. start of the intervention period with a value of 0 before the start A P value <.05 was considered statistically significant. All sta- of the intervention period and then increasing by 1 for each tistical analyses were performed using SAS software, version 9.4 month thereafter; intervention end is a dummy variable coded (Cary, NC). as 0 (pre-intervention and intervention period) and 1 (postint- ervention period); time after intervention end is the number of RESULTS months after the end of the intervention period with a value of The total patient-days, total central line–days, and total urinary 0 for each month until November 31, 2015, and then increasing catheter–days for the entire study duration were 32 099, 12 969,     by 1 for each month thereafter; e is the random variability at and 9338, respectively. time t not explained by the model. Furthermore, the coefficient β estimates the baseline level of Urinary Catheter and Central Line Utilization Ratio the dependent variable (DUR); β estimates the baseline trend The device utilization ratios for UC and CL during the 3 study (slope) before the intervention; β estimates the level change periods are given in Figure 2 and Table 2. in DURs aer in ft tervention, that is, from the end of the pre-in- e Th average UC DUR decreased from 31% (pre-interven- tervention period; β estimates the change in trend following tion and postintervention period) to 21% during the inter- the intervention; β estimates the level change in DURs from vention period. At the end of the intervention period, the UC the end of the intervention period to the first postintervention DUR was at 15%. It decreased further to 6% in the month aer ft period; β estimates the change in trend aer t ft he end of the stopping the intervention. The CL DUR decreased from 46% intervention period. (pre-intervention period) to 39% (intervention period) to 37% We checked our time series data for nonstationarity (aug- (postintervention). mented Dickey-Fuller test) and autocorrelation (Durbin- ITS analysis indicated no significant trend (β ) in UC DUR Watson statistic and stepwise auto-regression). Autoregressive during the pre-intervention period (Table  3). Aer b ft eginning parameters were set to account for seasonality, but there was the intervention, we noticed nonsignificant decreases in level none present in either of our DUR models. UC DUR data indi- and trend in UC DURs. When the intervention was stopped, we cated nonstationarity; therefore, first-order differencing was noticed an increase in level (β ) that was close to statistical sig- done to convert the data to a stationary series. nificance (P = .06). Increased trend (β ) in UC DURs aer s ft top- We used 0-inflated poisson (ZIP) regression to analyze our ping the intervention was not significant (P = .99). With regards CLABSI and CAUTI rates. This model was used to account to CL DUR, there was no significant baseline trend (β ) noted. for excess 0s in our CLABSI and CAUTI data. We performed Although we noticed decreases and increases in level and trend Table 2. Device Utilization Ratios—Interrupted Time Series UC DUR CL DUR Estimate P Value Estimate P Value Baseline level (β ) –0.0442 .61 0.5033 <.0001 Baseline trend (β ) 0.0101 .63 –0.007024 .7 –0.0403 .65 –0.0965 .11 Change in level after intervention start (β 2) Change in trend after intervention start (β ) –0.0160 .56 –0.000288 .99 0.1118 .06 0.0787 .12 Change in level after intervention end (β ) Change in trend after intervention end (β ) 0.0000300 .99 0.005098 .74 Table  2 shows interrupted time series analysis looking at changes in levels and trend in urinary catheter device utilization ratio and central line device utilization ratio before and after intervention. Abbreviations: CL DUR, central line utilization ratio; UC DUR, urinary catheter utilization ratio. Infection Prevention Rounds in an LTACH • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Table 3. Results of 0-Inflated Poisson Model on Association Between Different Variables on CAUTI and CLABSI Rates Estimate Wald 95% Confidence Limits P Value CAUTI, Poisson model Intervention –0.1408 –0.8465 0.5649 .69 Patient-days 0.0009 –0.0003 0.0021 .14 Catheter-days –0.0055 –0.0081 –0.0029 <.0001 CAUTI, 0 model Intercept –0.2041 –1.1131 0.7048 .65 Intervention –1.4060 –3.7387 0.9267 .23 CLABSI, Poisson model Intervention –0.0803 –2.0496 1.8890 .93 Patient-days –0.0014 –0.0043 0.0014 .31 Catheter-days 0.0010 –0.0041 0.0060 .7 CLABSI, 0 model Intercept –1.2487 –2.8668 0.3694 .13 Intervention 2.5734 –0.3839 5.5308 .08 Table 3 shows the results of the 0-inflated Poisson model on the association between different variables on central line–associated blood stream infection and catheter-associated urinary tract infection rates. Abbreviations: CAUTI, catheter-associated urinary tract infection; CLABSI, central line–associated blood stream infection. coinciding with our intervention, statistical significance was not as the total urinary catheter–days per month decreased, the achieved (Table 3). We repeated the analysis aer in ft cluding the CAUTI rates increased significantly (P < .0001). month of December 2015 in the intervention period to account We noticed a 73% reduction in CLABSI rate per catheter-days for lagged effects from the intervention. Changes in level or during the intervention period. When the intervention was trend in this analysis were not significantly different compared stopped, CLABSI rate per catheter-days quadrupled. Results of with our previous analysis without accounting for lagged effect ZIP analysis indicated that our intervention was associated with (data not shown). a decrease in CLABSI rate per catheter-days and predicted the occurrence of 0 CLABSI; however, statistical significance was CLABSI and CAUTI Rates not achieved (P = .93 and .08, respectively). In addition, neither CAUTI and CLABSI rates during the 3 study periods are given patient-days nor catheter-days was significantly associated with in Figure 1, Figure 3, and Table 3. increase or decrease in CLABSI rates. e in Th crease in CAUTI rates differed based on the denomin- ator used (patient-days: 19.9% increase; vs catheter-days: 75% DISCUSSION increase). Results of ZIP analysis indicated that the interven- tion was not significantly associated with a decrease in CAUTI Despite the high device utilization and increased burden rate per catheter-days, or predicted the occurrence of 0 CAUTI. of CLABSI and CAUTI in LTACHs, studies that focus on e Th patient-days variable was not significantly associated with device-associated infection prevention are rarely done in this decrease in CAUTI rates either. ZIP analysis also indicated that setting [3, 23–25]. We came across 2 studies that focused on Pre-intervention Intervention 20.61 Postintervention 18 15.7 15.77 15.18 14.48 14.1 14.18 11.18 10.41 12 9.9 8.77 6.89 6.23 6.71 5.89 5.46 4.97 4.6 4.59 6 4.16 4.2 3.49 3.62 3.16 2.32 1.73 00 00 CAUTI per 1000 catheter-days CAUTI per 10 000 patient-days Figure 1. Catheter-associated urinary tract infection (CAUTI) rate measured as rate per catheter-days and patient-days during the 3 study periods. Only selected months of data from the postintervention phase are reported in the figure. 4 • OFID • Chandramohan et al Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Ayg-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 0.65 0.6 Pre-intervention Intervention Postintervention 0.6 0.55 0.49 0.5 0.44 0.43 0.45 0.42 0.42 0.4 0.39 0.38 0.38 0.38 0.38 0.38 0.38 0.38 0.4 0.36 0.34 0.33 0.35 0.32 0.3 0.29 0.29 0.28 0.3 0.27 0.27 0.26 0.26 0.26 0.25 0.21 0.2 0.16 0.15 0.15 0.1 0.06 0.05 Urinary Catheter Utilization Ratio Central Line Utilization Ratio Figure 2. Urinary catheter and central line device utilization ratio during the 3 study periods. reducing CLABSI and CAUTI rates in an LTACH setting [24, 25]. time and resources and is feasible in an LTACH setting where One study primarily focused on reducing CLABSI through resources and staff availability are limited. In addition, this ini- implementation of CL maintenance bundle [24]. This study did tiative can be combined with antibiotic stewardship to further not change catheter removal practices in the LTACHs. Another improve patient care. study focused on reducing CAUTI rates and DUR through a Our infection prevention initiative primarily focused on nurse-driven protocol to promote appropriate discontinuation reducing unnecessary use of urinary and central lines. Current of urinary catheters [25]. evidence-based strategies including focused education, elec- To our knowledge, ours is the only study specifically focusing tronic medical record alerts, computerized order entry, stop on reducing unnecessary CL and UC use with the aim to reduce orders, nurse-driven protocols, reminders by a physician leader, DURs, CLABSI, and CAUTI in an LTACH setting. and medical directives have been used to reduce unnecessary We demonstrated that a “2 in 1” CLABSI and CAUTI preven- urinary catheter use [16, 19, 26–29]. With regards to central tion initiative using an MIPT approach can be readily imple- lines, interventions to reduce unnecessary catheter use have mented in an LTACH setting. Our program requires minimal mostly been implemented as part of a bundled intervention Pre-intervention Intervention Postintervention 19.8 11.09 11.18 10.06 8.51 7.89 7.59 7.24 9 7.05 6.58 4.61 2.42 2.23 2.28 1.88 2.09 1.94 1.3 1.64 1.47 00 0 00 00 CLABSI per 1000 catheter-days CLABSI per 10 000 patient-days Figure  3. Central line–associated bloodstream infection (CLABSI) rate measured as rate per catheter-days and patient-days during the 3 study periods. Only selected months of data from the postintervention phase are reported in the figure. Infection Prevention Rounds in an LTACH • OFID • 5 Jan-15 Jan-15 Feb-15 Feb-15 Mar-15 Apr-15 Mar-15 May-15 Apr-15 Jun-15 May-15 Jul-15 Ayg-15 Jun-15 Sep-15 Jul-15 Oct-15 Nov-15 Ayg-15 Dec-15 Sep-15 Jan-16 Oct-15 Feb-16 Mar-16 Nov-15 Apr-16 Dec-15 May-16 Jan-16 Jun-16 Jul-16 Feb-16 Aug-16 Mar-16 Sep-16 Oct-16 Apr-16 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 involving proper insertion and maintenance practices [30]. CAUTI rate per 1000 catheter-days [19]. This likely occurred Prevention strategies focusing on aseptic insertion of cen- in our patient population as well, as we noted less increase in tral line and urinary catheters are unlikely to be helpful in the CAUTI rates when patient-days was used as the denominator. LTACH setting as most patients have these devices at the time Results of our regression analysis further support the theory of admission. Therefore, we focused on weekly reminders to that a decrease in catheter-days was responsible for the increase reduce unnecessary catheter use as this strategy requires lim- in CAUTI rate in our population. Therefore, when early cath- ited resources and could easily be combined with antibiotic eter removal is the focus of the intervention, programs should stewardship. measure CAUTI rate using patient-days as the denominator. Our primary goal was to reduce DURs by removing unneces- Alternatively, the lack of reduction in CAUTI rates could be sary central line and urinary catheters. In the pre-intervention related to the short duration of our intervention period, as period, UC DUR at our LTACH was at the lower limit of previ- we achieved a 0 CAUTI rate at the end of the intervention ously reported rates (median, 0.55; range, 0.12–0.87) [4]. period, when our DUR was decreased by half. Future studies in Despite the low DUR to begin with, our intervention was suc- LTACHs with longer intervention periods could help provide cessful in reducing DUR by almost half at the end of the interven- more insight into this matter. tion period, and we achieved the lowest DUR of 6% in the month Our CLABSI rates per catheter-days in the pre-intervention aer s ft topping the intervention. Implementing a similar interven- period were comparable to previously reported rates in LTACHs tion in LTACHs with DURs in the higher end of spectrum could (mean, 1.4) [4]. Rates decreased by 73% during the interven- lead to much larger reductions. ITS analysis also demonstrates a tion period, followed by an increase in postintervention period. uc fl tuating UC DUR that coincides with our intervention, with A decrease in CLABSI rates during the intervention period was an increasing level aer ft stopping the intervention (close to sta- likely related to our intervention as, to our knowledge, there tistical significance). This is not surprising as it was a common was no other infection prevention intervention ongoing during culture in our LTACH staff to resist urinary catheter removal due our study period. Results of ZIP analysis also indicated a bene- to the inconvenience of managing their patients without these ficial effect of intervention on CLABSI rate without reaching devices. We were able to overcome this resistance during our statistical significance. We continued to notice a 0 CLABSI for intervention period through repeated reminders. Other LTACHs 4 months aer s ft topping the intervention, which likely caused no planning to implement similar measures should be aware of these significant effect of our intervention, even though we included barriers, which could lead to rebound increase in DUR if con- the month of December as yes to intervention to account for stant reminders are not imparted. Our experience suggested that lagged effects. having a physician or nursing leader will help overcome barri- e m Th ain limitation of our study was the short intervention ers related to removal of urinary catheters. Future studies should period, which precluded attainment of statistically significant evaluate ways to change the existing culture in LTACHs and sus- reductions in DURs, CLABSI rate, and CAUTI rate. The study tain these changes over longer periods. was also conducted in a single LTACH located in an under- We were also able to achieve reduction in CL DUR with our served area, which will limit the generalizability of our findings. intervention. Pre-intervention CL DUR in our LTACH was In addition, it is possible that changes in the patient population comparable to previously reported rates in LTACHs (median, that we did not document might have caused changes in DURs 0.67; range, 0.19–1.0) [4]. CL DUR continued to decrease dur- and infection rates, although these are unlikely to have coin- ing the intervention and postintervention periods. However, cided with the 3 study periods. these differences were not statistically significant on ITS ana- In conclusion, tailored infection prevention initiatives tar- lysis. A  continued decrease in CL DUR during postinterven- geting CLABSI and CAUTI are urgently needed in LTACHs, tion period could be credited to the RN who continued to work where device utilization and infection rates are comparable to in the LTACH during the postintervention period. e Th RN intensive care units. We demonstrated that a workable infection continued to monitor device use and stress the importance of prevention initiative focusing on reducing unnecessary central removing unnecessary central lines and/or switching to alter- line and urinary catheter use can be easily implemented in an nate intravenous access. LTACH, requiring minimal time and resources. Although our Despite the reduction in UC DUR during the intervention study did not show a significant reduction in DURs, CLABSI period, this did not lead to a decrease in CAUTI rates. It is rate, and CAUTI rate, evidence from studies done in ACHs hypothesized that interventions focusing on early removal of clearly indicates that reducing unnecessary use will result in urinary catheters might preferentially target patients at low reduction of DUR and infection rates. Even a simple initiative risk of CAUTI, leaving patients at high risk with catheters who could result in substantial gains in an LTACH with high device will continue to contribute to numerator data while the low utilization. Furthermore, LTACHs implementing these inter- risk patients who had catheters removed cease to contribute ventions should be aware of potential barriers that could ae ff ct to the denominator of catheter-days, leading to an increase in the program’s effectiveness and sustainability. 6 • OFID • Chandramohan et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 14. Marra AR, Cal RG, Durão MS, et  al. 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Am J Infect ment of central venous and pulmonary-artery catheters. N Engl J Med 1992; Control 2012; 40:88–9. 327:1062–8. 7. Gil RT, Kruse JA, Thill-Baharozian MC, Carlson RW. Triple- vs single-lumen 25. Edwards M, Purpura J, Kochvar G. Quality improvement intervention reduces central venous catheters. A prospective study in a critically ill population. Arch episodes of long-term acute care hospital central line-associated infections. Am J Intern Med 1989; 149:1139–43. Infect Control 2014; 42:735–8. 8. Maki DG, Tambyah PA. Engineering out the risk for infection with urinary cath- 26. Schwartz BC, Frenette C, Lee TC, et al. Novel low-resource intervention reduces eters. Emerg Infect Dis 2001; 7:342–7. urinary catheter use and associated urinary tract infections: role of outcome 9. Renaud B, Brun-Buisson C; ICU-Bacteremia Study Group. Outcomes of primary measure bias? Am J Infect Control 2015; 43:348–53. and catheter-related bacteremia. A cohort and case-control study in critically ill 27. Cornia PB, Amory JK, Fraser S, et al. Computer-based order entry decreases dur- patients. Am J Respir Crit Care Med 2001; 163:1584–90. ation of indwelling urinary catheterization in hospitalized patients. Am J Med 10. Blot SI, Depuydt P, Annemans L, et al. Clinical and economic outcomes in crit- 2003; 114:404–7. ically ill patients with nosocomial catheter-related bloodstream infections. Clin 28. Cho HJ, Khalil S, Poeran J, et al. “Lose the tube”: a choosing wisely initiative to Infect Dis 2005; 41:1591–8. reduce catheter-associated urinary tract infections in hospitalist-led inpatient 11. Saint S. Clinical and economic consequences of nosocomial catheter-related bac- units. Am J Infect Control 2017; 45:333–5. teriuria. Am J Infect Control 2000; 28:68–75. 29. Leis JA, Corpus C, Rahmani A, et  al. Medical directive for urinary cath- 12. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated eter removal by nurses on general medical wards. JAMA Intern Med 2016; infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007; 122:160–6. 176:113–5. 13. Huang WC, Wann SR, Lin SL, et al. Catheter-associated urinary tract infections 30. Blot K, Bergs J, Vogelaers D, et  al. Prevention of central line-associated blood- in intensive care units can be reduced by prompting physicians to remove unnec- stream infections through quality improvement interventions: a systematic essary catheters. Infect Control Hosp Epidemiol 2004; 25:974–8. review and meta-analysis. Clin Infect Dis 2014; 59:96–105. Infection Prevention Rounds in an LTACH • OFID • 7 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

Impact of a Multidisciplinary Infection Prevention Initiative on Central Line and Urinary Catheter Utilization in a Long-term Acute Care Hospital

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Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Open Forum Infectious Diseases MAJOR ARTICLE Impact of a Multidisciplinary Infection Prevention Initiative on Central Line and Urinary Catheter Utilization in a Long-term Acute Care Hospital 1 1 2 1 3 1 Suganya Chandramohan, Bhagyashri Navalkele, Ammara Mushtaq, Amar Krishna, John Kacir, and Teena Chopra 1 2 3 Division of Infectious Diseases and Department of Internal Medicine, Detroit Medical Center/Wayne State University, Detroit, Michigan; Kindred Hospital, Detroit, Michigan Background. Prolonged central line (CL) and urinary catheter (UC) use can increase risk of central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). Methods. This interventional study conducted in a 76-bed long-term acute care hospital (LTACH) in Southeast Michigan was divided into 3 periods: pre-intervention (January 2015–June 2015), intervention (July–November 2015), and postintervention (December 2015–March 2017). During the intervention period, a multidisciplinary infection prevention team (MIPT) made weekly recommendations to remove unnecessary CL/UC or switch to alternate urinary/intravenous access. Device utilization ratios (DURs) and infection rates were compared between the study periods. Interrupted time series (ITS) and 0-inflated poisson (ZIP) regression were used to analyze DUR and CLABSI/CAUTI data, respectively. Results. UC-DUR was 31% in the pre- and postintervention periods and 21% in the intervention period. CL-DUR decreased from 46% (pre-intervention) to 39% (intervention) to 37% (postintervention). The results of ITS analysis indicated nonsignificant decrease and increase in level/trend in DURs coinciding with our intervention. The CAUTI rate per catheter-days did not decrease during intervention (4.36) compared with pre- (2.49) and postintervention (1.93). The CLABSI rate per catheter-days decreased by 73% during intervention (0.39) compared with pre-intervention (1.45). Rates again quadrupled postintervention (1.58). ZIP analysis indicated a beneficial effect of intervention on infection rates without reaching statistical significance. Conclusions. We demonstrated that a workable MIPT initiative focusing on removal of unnecessary CL and UC can be easily implemented in an LTACH requiring minimal time and resources. A rebound increase in UC-DURs to pre-intervention levels aer ft intervention end indicates that continued vigilance is required to maintain performance. Keywords. catheter-associated urinary tract infection; central line–associated blood stream infection; device utilization ratio; infection prevention; long-term acute care. Long-term acute care hospitals (LTACHs) have become a novel both of which will increase the number of patients with chronic model for continued medical care in the US health care system [1]. critical illness [3]. e n Th ational number of LTACHs has increased from 277 in It has been reported that utilization of central lines (CLs) 2003 to 407 in 2016, and the number of hospital discharges to and urinary catheters (UCs) in LTACHs approaches that of these facilities also increased from 1.9% in 2004 to 4.9% in 2009 intensive care units (ICUs) in acute care hospitals [4]. This is [2, 3]. The LTACH population is mainly comprised of patients not surprising as the high acuity of care delivered in LTACHs recovering from critical illness who continue to require inpa- necessitates the use of these devices. However, studies in acute tient/intensive care unit (ICU) level care [1]. These facilities will care hospitals and ICUs note that most of these devices are left continue to play an important role in health care delivery due in place longer than necessary and physicians are oen un ft a- to the aging of the US population and advances in critical care, ware of their presence in patients [5, 6]. Prolonged use of these devices increases the risk of infection, which in turn leads to extended hospital stays, morbidity, mortality, and excess hos- pital costs [7–12]. Received 14 February 2018; editorial decision 25 June 2018; accepted 19 July 2018. Although several studies have looked at central line–asso- Correspondence: S. Chandramohan, MD, 4201 St. Antoine St, University Health Center 2 C, ciated blood stream infection (CLABSI) and cather-associated Detroit, MI 48201 (schandra@dmc.org). ® urinary tract infection (CAUTI) reduction through reduction Open Forum Infectious Diseases © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases of unnecessary device use in acute care hospitals, there is a Society of America. This is an Open Access article distributed under the terms of the Creative scarcity of similar interventions in an LTACH setting [13–16]. Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any Interventions that incorporate the unique characteristics of this medium, provided the original work is not altered or transformed in any way, and that the work health care setting are urgently needed. Therefore, the goals of is properly cited. For commercial re-use, please contact journals.permissions@oup.com our study were 2-fold: (1) to introduce a workable infection DOI: 10.1093/ofid/ofy156 Infection Prevention Rounds in an LTACH • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 prevention initiative that focused on reducing unnecessary use Table  1 [5, 19–21]. When indication for a central line was no of central lines and urinary catheters in an LTACH and (2) to longer present or when alternate intravenous access (midline study the impact of this intervention in reducing device utiliza- or peripheral venous catheter) could be used to instill medica- tion ratio (DUR) and rates of CLABSI and CAUTI. tions, the recommendation was made to discontinue the central line or switch from the central line to a midline or peripheral METHODS line. When indication for a urinary catheter was no longer pres- ent or when alternative methods could be used to drain urine, Study Setting and Study Periods the recommendation to discontinue or switch to an alternative This interventional study was performed at a 76-bed LTACH method, such as condom catheters or intermittent catheter- in the greater Detroit area. A  Multidisciplinary Infection ization, was made. The final recommendations of the MIPT Prevention Team (MIPT) consisting of an infectious disease were communicated to the physician in charge of the patient consultant (employed part-time to oversee infection prevention by phone or email. The team continued rounding from July and antibiotic stewardship), pharmacist, and registered nurse to November 2015. The MIPT intervention was suspended in (RN) trained in infection control was formed. The MIPT team November 2015 due to completion of the infection disease con- was active from July 1, 2015, to November 30, 2015 (interven- sultant’s contract with the facility and not related to the inter- tion period). The impact of the MIPT intervention was assessed vention itself. by comparing predefined outcomes during the intervention period with those during the pre-intervention (January 1, Outcome Assessment 2015–June 30, 2015) and postintervention periods (December The primary outcomes were (1) to ascertain the impact of MIPT 1, 2015–March 31, 2017). The study was approved by the rounds on the total urinary catheter–days, central line–days, LTACH ethics committee. and DURs and (2) to analyze the effect of MIPT intervention on LTACH-onset CLABSI and CAUTI rates. The effectiveness Data Collection and Definitions of the program was determined by comparing these outcomes Patient-days, central line–days, and urinary catheter–days were between the 3 study periods. obtained from the facility administrative database. LTACH- onset CAUTI and CLABSI were defined using 2015 National Statistical Analysis Healthcare Safety Network [17] criteria throughout the study The monthly rates were combined to calculate the CAUTI rate, period. CLABSI and CAUTI rates were calculated for 1000 cen- CLABSI rate, central line utilization ratio (CL DUR), and uri- tral line–days and 1000 urinary catheter–days, respectively. In nary catheter utilization ratio (UC DUR) during the 3 study addition, CLABSI and CAUTI rates were calculated for 10 000 periods. patient-days. Surveillance of CLABSI and CAUTI was con- Segmented regression analysis of interrupted time series ducted by the same RN trained in infection control during all (ITS) was used to evaluate the changes in level and trend in 3 study periods. Other members of the MIPT team were not DURs during the intervention and postintervention periods. As involved in infection surveillance. Central line and urinary our series had 2 change points corresponding to the start and catheter device utilization ratios (DUR) were calculated by end of the intervention period, we used the following model, as dividing the number of catheter-days by number of patient- suggested by Wagner et al. [22]. days during each study period. Infections with symptom onset within 48 hours of admission were excluded to study only LTACH-acquired infections. Table  1. Acceptable Indications for Urinary Catheter and Central Line Intervention Period The MIPT was rounded weekly during the intervention period Urinary Catheter and was available for remote consultation for remainder of the Open sacral wound for incontinent patients Urinary obstruction/neurogenic bladder week. Before the MIPT weekly rounds, the RN collected details Accurate intake and outake monitoring on all patients with indwelling medical devices including patient Urology surgery medical history, current clinical status, available test results, Comfort care in patients with terminal illness device indications, device start date, and any device-related Central Venous Catheter adverse events. This information was reviewed by MIPT dur- Total parentral nutrition administration ing weekly rounds to access device appropriateness. The weekly Dialysis Irritant and vesicant medication including intravenous vancomycin rounds, which combined infection prevention with antibiotic Use of vasopressor and inotrope stewardship, lasted about 1 to 1.5 hours (antibiotic steward- Use of any intravenous medication in patients with difficult vascular access ship portion of the study has been published previously [18]). The table shows the checklist created by the infection prevention team based on the Criteria for appropriateness of central line and urinary cathe- various consensus guidelines [5, 9, 20, 21]. These criteria were used during our weekly ters were based on previously published data and are noted in rounds to check for the appropriateness and necessity of both foley and central lines. 2 • OFID • Chandramohan et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 the Vuong test, which further confirmed that a ZIP model was Yt =+ ββ ´+ imei ββ ´+ ntervention start tt 0 12 t 3 superior compared with a plain poisson model. The ZIP model ´time after interve ention start + β t 4 has 2 components, a logistic model that predicts the occurrence ´+ intervention end β t 5 of having a 0 CLABSI/CAUTI rate (certain 0s) and a poisson ´time after intervent tion end + e , tt model to generate count data. Catheter-days, patient-days, and where Y is the dependent variable (DUR); time is a continuous t intervention/no intervention were used as variables in the model variable indicating time in months (coded as 1 when the study to evaluate their effects on infection rates. We noticed a possi- started and then increasing by 1 for each month thereafter); ble lagged effect of our intervention in the month of December intervention start is a dummy variable coded as 0 (pre-interven- 2015; therefore, this month was included as yes to intervention. tion period) and 1 (intervention and postintervention periods); In addition, our CLABSI and CAUTI rates data did not indicate time after intervention start is the number of months after the first-order autocorrelation, seasonality, or nonstationarity. start of the intervention period with a value of 0 before the start A P value <.05 was considered statistically significant. All sta- of the intervention period and then increasing by 1 for each tistical analyses were performed using SAS software, version 9.4 month thereafter; intervention end is a dummy variable coded (Cary, NC). as 0 (pre-intervention and intervention period) and 1 (postint- ervention period); time after intervention end is the number of RESULTS months after the end of the intervention period with a value of The total patient-days, total central line–days, and total urinary 0 for each month until November 31, 2015, and then increasing catheter–days for the entire study duration were 32 099, 12 969,     by 1 for each month thereafter; e is the random variability at and 9338, respectively. time t not explained by the model. Furthermore, the coefficient β estimates the baseline level of Urinary Catheter and Central Line Utilization Ratio the dependent variable (DUR); β estimates the baseline trend The device utilization ratios for UC and CL during the 3 study (slope) before the intervention; β estimates the level change periods are given in Figure 2 and Table 2. in DURs aer in ft tervention, that is, from the end of the pre-in- e Th average UC DUR decreased from 31% (pre-interven- tervention period; β estimates the change in trend following tion and postintervention period) to 21% during the inter- the intervention; β estimates the level change in DURs from vention period. At the end of the intervention period, the UC the end of the intervention period to the first postintervention DUR was at 15%. It decreased further to 6% in the month aer ft period; β estimates the change in trend aer t ft he end of the stopping the intervention. The CL DUR decreased from 46% intervention period. (pre-intervention period) to 39% (intervention period) to 37% We checked our time series data for nonstationarity (aug- (postintervention). mented Dickey-Fuller test) and autocorrelation (Durbin- ITS analysis indicated no significant trend (β ) in UC DUR Watson statistic and stepwise auto-regression). Autoregressive during the pre-intervention period (Table  3). Aer b ft eginning parameters were set to account for seasonality, but there was the intervention, we noticed nonsignificant decreases in level none present in either of our DUR models. UC DUR data indi- and trend in UC DURs. When the intervention was stopped, we cated nonstationarity; therefore, first-order differencing was noticed an increase in level (β ) that was close to statistical sig- done to convert the data to a stationary series. nificance (P = .06). Increased trend (β ) in UC DURs aer s ft top- We used 0-inflated poisson (ZIP) regression to analyze our ping the intervention was not significant (P = .99). With regards CLABSI and CAUTI rates. This model was used to account to CL DUR, there was no significant baseline trend (β ) noted. for excess 0s in our CLABSI and CAUTI data. We performed Although we noticed decreases and increases in level and trend Table 2. Device Utilization Ratios—Interrupted Time Series UC DUR CL DUR Estimate P Value Estimate P Value Baseline level (β ) –0.0442 .61 0.5033 <.0001 Baseline trend (β ) 0.0101 .63 –0.007024 .7 –0.0403 .65 –0.0965 .11 Change in level after intervention start (β 2) Change in trend after intervention start (β ) –0.0160 .56 –0.000288 .99 0.1118 .06 0.0787 .12 Change in level after intervention end (β ) Change in trend after intervention end (β ) 0.0000300 .99 0.005098 .74 Table  2 shows interrupted time series analysis looking at changes in levels and trend in urinary catheter device utilization ratio and central line device utilization ratio before and after intervention. Abbreviations: CL DUR, central line utilization ratio; UC DUR, urinary catheter utilization ratio. Infection Prevention Rounds in an LTACH • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Table 3. Results of 0-Inflated Poisson Model on Association Between Different Variables on CAUTI and CLABSI Rates Estimate Wald 95% Confidence Limits P Value CAUTI, Poisson model Intervention –0.1408 –0.8465 0.5649 .69 Patient-days 0.0009 –0.0003 0.0021 .14 Catheter-days –0.0055 –0.0081 –0.0029 <.0001 CAUTI, 0 model Intercept –0.2041 –1.1131 0.7048 .65 Intervention –1.4060 –3.7387 0.9267 .23 CLABSI, Poisson model Intervention –0.0803 –2.0496 1.8890 .93 Patient-days –0.0014 –0.0043 0.0014 .31 Catheter-days 0.0010 –0.0041 0.0060 .7 CLABSI, 0 model Intercept –1.2487 –2.8668 0.3694 .13 Intervention 2.5734 –0.3839 5.5308 .08 Table 3 shows the results of the 0-inflated Poisson model on the association between different variables on central line–associated blood stream infection and catheter-associated urinary tract infection rates. Abbreviations: CAUTI, catheter-associated urinary tract infection; CLABSI, central line–associated blood stream infection. coinciding with our intervention, statistical significance was not as the total urinary catheter–days per month decreased, the achieved (Table 3). We repeated the analysis aer in ft cluding the CAUTI rates increased significantly (P < .0001). month of December 2015 in the intervention period to account We noticed a 73% reduction in CLABSI rate per catheter-days for lagged effects from the intervention. Changes in level or during the intervention period. When the intervention was trend in this analysis were not significantly different compared stopped, CLABSI rate per catheter-days quadrupled. Results of with our previous analysis without accounting for lagged effect ZIP analysis indicated that our intervention was associated with (data not shown). a decrease in CLABSI rate per catheter-days and predicted the occurrence of 0 CLABSI; however, statistical significance was CLABSI and CAUTI Rates not achieved (P = .93 and .08, respectively). In addition, neither CAUTI and CLABSI rates during the 3 study periods are given patient-days nor catheter-days was significantly associated with in Figure 1, Figure 3, and Table 3. increase or decrease in CLABSI rates. e in Th crease in CAUTI rates differed based on the denomin- ator used (patient-days: 19.9% increase; vs catheter-days: 75% DISCUSSION increase). Results of ZIP analysis indicated that the interven- tion was not significantly associated with a decrease in CAUTI Despite the high device utilization and increased burden rate per catheter-days, or predicted the occurrence of 0 CAUTI. of CLABSI and CAUTI in LTACHs, studies that focus on e Th patient-days variable was not significantly associated with device-associated infection prevention are rarely done in this decrease in CAUTI rates either. ZIP analysis also indicated that setting [3, 23–25]. We came across 2 studies that focused on Pre-intervention Intervention 20.61 Postintervention 18 15.7 15.77 15.18 14.48 14.1 14.18 11.18 10.41 12 9.9 8.77 6.89 6.23 6.71 5.89 5.46 4.97 4.6 4.59 6 4.16 4.2 3.49 3.62 3.16 2.32 1.73 00 00 CAUTI per 1000 catheter-days CAUTI per 10 000 patient-days Figure 1. Catheter-associated urinary tract infection (CAUTI) rate measured as rate per catheter-days and patient-days during the 3 study periods. Only selected months of data from the postintervention phase are reported in the figure. 4 • OFID • Chandramohan et al Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Ayg-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 0.65 0.6 Pre-intervention Intervention Postintervention 0.6 0.55 0.49 0.5 0.44 0.43 0.45 0.42 0.42 0.4 0.39 0.38 0.38 0.38 0.38 0.38 0.38 0.38 0.4 0.36 0.34 0.33 0.35 0.32 0.3 0.29 0.29 0.28 0.3 0.27 0.27 0.26 0.26 0.26 0.25 0.21 0.2 0.16 0.15 0.15 0.1 0.06 0.05 Urinary Catheter Utilization Ratio Central Line Utilization Ratio Figure 2. Urinary catheter and central line device utilization ratio during the 3 study periods. reducing CLABSI and CAUTI rates in an LTACH setting [24, 25]. time and resources and is feasible in an LTACH setting where One study primarily focused on reducing CLABSI through resources and staff availability are limited. In addition, this ini- implementation of CL maintenance bundle [24]. This study did tiative can be combined with antibiotic stewardship to further not change catheter removal practices in the LTACHs. Another improve patient care. study focused on reducing CAUTI rates and DUR through a Our infection prevention initiative primarily focused on nurse-driven protocol to promote appropriate discontinuation reducing unnecessary use of urinary and central lines. Current of urinary catheters [25]. evidence-based strategies including focused education, elec- To our knowledge, ours is the only study specifically focusing tronic medical record alerts, computerized order entry, stop on reducing unnecessary CL and UC use with the aim to reduce orders, nurse-driven protocols, reminders by a physician leader, DURs, CLABSI, and CAUTI in an LTACH setting. and medical directives have been used to reduce unnecessary We demonstrated that a “2 in 1” CLABSI and CAUTI preven- urinary catheter use [16, 19, 26–29]. With regards to central tion initiative using an MIPT approach can be readily imple- lines, interventions to reduce unnecessary catheter use have mented in an LTACH setting. Our program requires minimal mostly been implemented as part of a bundled intervention Pre-intervention Intervention Postintervention 19.8 11.09 11.18 10.06 8.51 7.89 7.59 7.24 9 7.05 6.58 4.61 2.42 2.23 2.28 1.88 2.09 1.94 1.3 1.64 1.47 00 0 00 00 CLABSI per 1000 catheter-days CLABSI per 10 000 patient-days Figure  3. Central line–associated bloodstream infection (CLABSI) rate measured as rate per catheter-days and patient-days during the 3 study periods. Only selected months of data from the postintervention phase are reported in the figure. Infection Prevention Rounds in an LTACH • OFID • 5 Jan-15 Jan-15 Feb-15 Feb-15 Mar-15 Apr-15 Mar-15 May-15 Apr-15 Jun-15 May-15 Jul-15 Ayg-15 Jun-15 Sep-15 Jul-15 Oct-15 Nov-15 Ayg-15 Dec-15 Sep-15 Jan-16 Oct-15 Feb-16 Mar-16 Nov-15 Apr-16 Dec-15 May-16 Jan-16 Jun-16 Jul-16 Feb-16 Aug-16 Mar-16 Sep-16 Oct-16 Apr-16 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 involving proper insertion and maintenance practices [30]. CAUTI rate per 1000 catheter-days [19]. This likely occurred Prevention strategies focusing on aseptic insertion of cen- in our patient population as well, as we noted less increase in tral line and urinary catheters are unlikely to be helpful in the CAUTI rates when patient-days was used as the denominator. LTACH setting as most patients have these devices at the time Results of our regression analysis further support the theory of admission. Therefore, we focused on weekly reminders to that a decrease in catheter-days was responsible for the increase reduce unnecessary catheter use as this strategy requires lim- in CAUTI rate in our population. Therefore, when early cath- ited resources and could easily be combined with antibiotic eter removal is the focus of the intervention, programs should stewardship. measure CAUTI rate using patient-days as the denominator. Our primary goal was to reduce DURs by removing unneces- Alternatively, the lack of reduction in CAUTI rates could be sary central line and urinary catheters. In the pre-intervention related to the short duration of our intervention period, as period, UC DUR at our LTACH was at the lower limit of previ- we achieved a 0 CAUTI rate at the end of the intervention ously reported rates (median, 0.55; range, 0.12–0.87) [4]. period, when our DUR was decreased by half. Future studies in Despite the low DUR to begin with, our intervention was suc- LTACHs with longer intervention periods could help provide cessful in reducing DUR by almost half at the end of the interven- more insight into this matter. tion period, and we achieved the lowest DUR of 6% in the month Our CLABSI rates per catheter-days in the pre-intervention aer s ft topping the intervention. Implementing a similar interven- period were comparable to previously reported rates in LTACHs tion in LTACHs with DURs in the higher end of spectrum could (mean, 1.4) [4]. Rates decreased by 73% during the interven- lead to much larger reductions. ITS analysis also demonstrates a tion period, followed by an increase in postintervention period. uc fl tuating UC DUR that coincides with our intervention, with A decrease in CLABSI rates during the intervention period was an increasing level aer ft stopping the intervention (close to sta- likely related to our intervention as, to our knowledge, there tistical significance). This is not surprising as it was a common was no other infection prevention intervention ongoing during culture in our LTACH staff to resist urinary catheter removal due our study period. Results of ZIP analysis also indicated a bene- to the inconvenience of managing their patients without these ficial effect of intervention on CLABSI rate without reaching devices. We were able to overcome this resistance during our statistical significance. We continued to notice a 0 CLABSI for intervention period through repeated reminders. Other LTACHs 4 months aer s ft topping the intervention, which likely caused no planning to implement similar measures should be aware of these significant effect of our intervention, even though we included barriers, which could lead to rebound increase in DUR if con- the month of December as yes to intervention to account for stant reminders are not imparted. Our experience suggested that lagged effects. having a physician or nursing leader will help overcome barri- e m Th ain limitation of our study was the short intervention ers related to removal of urinary catheters. Future studies should period, which precluded attainment of statistically significant evaluate ways to change the existing culture in LTACHs and sus- reductions in DURs, CLABSI rate, and CAUTI rate. The study tain these changes over longer periods. was also conducted in a single LTACH located in an under- We were also able to achieve reduction in CL DUR with our served area, which will limit the generalizability of our findings. intervention. Pre-intervention CL DUR in our LTACH was In addition, it is possible that changes in the patient population comparable to previously reported rates in LTACHs (median, that we did not document might have caused changes in DURs 0.67; range, 0.19–1.0) [4]. CL DUR continued to decrease dur- and infection rates, although these are unlikely to have coin- ing the intervention and postintervention periods. However, cided with the 3 study periods. these differences were not statistically significant on ITS ana- In conclusion, tailored infection prevention initiatives tar- lysis. A  continued decrease in CL DUR during postinterven- geting CLABSI and CAUTI are urgently needed in LTACHs, tion period could be credited to the RN who continued to work where device utilization and infection rates are comparable to in the LTACH during the postintervention period. e Th RN intensive care units. We demonstrated that a workable infection continued to monitor device use and stress the importance of prevention initiative focusing on reducing unnecessary central removing unnecessary central lines and/or switching to alter- line and urinary catheter use can be easily implemented in an nate intravenous access. LTACH, requiring minimal time and resources. Although our Despite the reduction in UC DUR during the intervention study did not show a significant reduction in DURs, CLABSI period, this did not lead to a decrease in CAUTI rates. It is rate, and CAUTI rate, evidence from studies done in ACHs hypothesized that interventions focusing on early removal of clearly indicates that reducing unnecessary use will result in urinary catheters might preferentially target patients at low reduction of DUR and infection rates. Even a simple initiative risk of CAUTI, leaving patients at high risk with catheters who could result in substantial gains in an LTACH with high device will continue to contribute to numerator data while the low utilization. Furthermore, LTACHs implementing these inter- risk patients who had catheters removed cease to contribute ventions should be aware of potential barriers that could ae ff ct to the denominator of catheter-days, leading to an increase in the program’s effectiveness and sustainability. 6 • OFID • Chandramohan et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy156/5060132 by Ed 'DeepDyve' Gillespie user on 16 October 2019 14. Marra AR, Cal RG, Durão MS, et  al. 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Journal

Open Forum Infectious Diseases – Oxford University Press

Published: Jul 1, 2018

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