REMOVING indwelling urinary catheters within 48 hours after surgery is an evidence-based strategy for preventing catheter-associated urinary tract infection (CAUTI), a complication that can result in patient distress as well as decreased hospital reimbursement from Centers for Medicare & Medicaid Services (CMS). Approximately 75% of urinary tract infections acquired in a hospital are associated with the presence of an indwelling urinary catheter.1 In 2008, the CMS hospital-acquired condition initiative prevented hospitals from recovering patient care costs incurred as a result of never events, including postoperative CAUTI. Studies suggest that this initiative has been associated with a 10% reduction in the rate of change in CAUTI,2 although others suggest that withholding reimbursement is not always justifiable, as when nonmodifiable patient risk factors contribute to postoperative CAUTI.3
Despite agreement that removal of catheters in the postoperative period reduces CAUTI, little is known about factors that predict compliance with the practice. We sought to examine potential correlates of timely postoperative catheter removal by analyzing data from the American Hospital Association (AHA) Survey of Hospitals, the Hospital Consumer Assessment of Healthcare Providers and Systems, and the CMS performance outcome measures in 59 nonfederal hospitals in Massachusetts. Specifically, we evaluated relationships between the percentage of urinary catheters removed by the second postoperative day and each of the following: rate of falls, rate of serious preventable complications, proportion of Medicare days, nurse-patient communication, and licensed nurse staffing.
REVIEW OF LITERATURE
Indwelling urinary catheters are commonly inserted during surgery to prevent postoperative bladder complications that might result from anesthesia, analgesia, and immobility. In 2008, Wald and colleagues4 demonstrated that the probability of developing a urinary tract infection doubled in patients who still had urinary catheters 2 days postoperatively. Postoperative catheter removal may be delayed because of patient factors, staff preferences, and long-held assumptions. In some cases, surgical patients present emergently with nonmodifiable risk factors such as hypertension, diabetes, coronary artery disease, dependent functional status, open wounds, and hypoalbuminemia3 that add to the risk for urinary tract infection or contribute to delayed removal. In another study,5 semistructured interviews of staff in US hospitals were used to determine factors affecting timely removal of catheters. A number of themes emerged, including competing priorities with other ongoing safety initiatives, the notion that using catheters prevents falls, and the convenience of catheters on busy units.
Misinformation or misconceptions among staff account for some delays in catheter removal. Apisarnthanarak and colleagues6 reported an increase in the percentage of unnecessary catheters that were removed after face-to-face reminders to medical staff. They also found that 55% of their sample cited urinary incontinence without skin breakdown as the indication for retaining the catheter and concluded that more education is needed to dispel that belief. Lynch and colleagues7 studied factors associated with successful removal of urinary catheters in patients undergoing hip replacement surgery in an Australian hospital. One factor of interest to those researchers was the common practice of keeping the catheter in place until the patient had a bowel movement; based on their data, the authors concluded that an empty bowel was not required before removal of the catheter.
Much of the attention on reducing CAUTI has been focused on standard guidelines that suggest appropriate use, aseptic technique for insertion, a closed urinary drainage system with the collection bag below the level of the bladder, and early discontinuation of the catheter.8 Despite well-accepted guidelines to reduce CAUTI, a survey of 250 hospitals9 revealed a lack of consistently applied strategies, and found that high-level organizational leadership and engagement in infection control correlated with having at least 1 policy aimed at reducing CAUTI. Leadership engagement that focuses on identifying communication gaps among staff can also result in CAUTI reduction.10 These findings suggest that organizational and/or unit level leadership may play a role in staffing and practice initiatives to improve CAUTI rates.
There is some evidence that adequate nurse staffing may be an essential element of CAUTI prevention programs. In a study in Brazil,11 excessive nursing workload was the top risk factor for health care–associated infection, followed by severity of the patient's condition. Cimiotti and colleagues12 studied 161 acute care hospitals in Pennsylvania and found that, for each additional patient assigned to a nurse, there was an increase of nearly 1 per thousand in the rate of CAUTI. A more recent study13 matched patients with cardiac surgery in low-staffing hospitals with patients in high-staffing hospitals and found that patients with cardiac surgery in high-staffing hospitals were significantly less likely to develop CAUTI, although the costs for patients with hospital-acquired conditions were greater in high-staffing hospitals.
National campaigns, nurse-driven initiatives, and hospital-mandated programs for decreasing catheter use or shortening the time a patient is catheterized have been developed. Many of these guidelines have demonstrated successful outcomes.14,15 For example, the Comprehensive Unit-based Safety Program (CUSP): Stop CAUTI, sponsored by the Agency for Healthcare Research and Quality, addresses behavioral and decision-making barriers to CAUTI reduction through multidisciplinary efforts that focus on communication and attention to failure points.16 Saint and colleagues17 reported that the CUSP reduced CAUTI rates from 2.28 to 1.54 infections per 1000 catheter-days in non-ICUs.
In a review of the 8 guidelines to reduce CAUTIs developed between 1981 and 2010, the authors reported that there was variation in the definition of CAUTI.8 Although all guidelines acknowledged that CAUTI might be asymptomatic, some guidelines required the presence of urgency, pelvic pain, fever, or bacteremia for a diagnosis of CAUTI. More recently, Huang16 suggested that routine culturing of urine for catheterized patients with a fever might have influenced the high rate of CAUTI reported between 2007 and 2012. That practice often resulted in the treatment of asymptomatic bacteremia with antibiotics, when in fact the fever may have been from multiple sources, and catheter removal without antibiotic use would have been the more appropriate treatment.
Although the Centers for Disease Control and Prevention report no change in overall CAUTI between 2009 and 2014,18 those findings reflect a prior CAUTI definition. The more recent definition from the National Hospital Safety Network19 defines CAUTI as having a higher bacterial colony count (≥105 colony-forming unit [CFU]/mL) than the prior definition (≥103 CFU/mL).16 This suggests that the results of more recent work such as the CUSP initiatives that are using the more recent definition will reflect better outcomes. It also adds confusion to prior work that may have been more effective than initially realized. The findings of these studies may in fact reflect both effective initiatives with improved outcomes if the newer definition of CAUTI had been applied to the data. Given the availability of aggregate data collected through mandated reporting to the CMS, it is now possible to assess other correlates of undesirable outcomes such as CAUTI. This study examined some previously unreported systems-level variables that may explain or predict timely catheter removal and give rise to novel interventions that address the problem.
Fifty-nine nonfederal Massachusetts hospitals that reported the rate of postoperative urinary catheter removal were included in the initial sample and therefore a power analysis was not performed.
This cross-sectional study of Massachusetts hospitals examined factors associated with the CMS Surgical Care Improvement Performance Measure postoperative urinary catheter removal (SCIP Inf_9). That measure was developed and endorsed by a technical panel that included the American Association of Perioperative Nurses.20 SCIP Inf_9 describes the percentage of surgical patients whose urinary catheter is removed postoperatively on day 1 or day 2 with the day of surgery classified as day 0. The measure is designed for application in hospitals and is not specific to a health care profession.20
The publicly available data sources used in this study included the following CMS measures: the percentage of surgical patients whose urinary catheter was removed on the first or second day after surgery,21 falls per 1000 discharges,22 and the rate of serious complications, termed Patient Safety Indicator 90 (PSI 90).23 The technical specification of the PSI 90 composite measure is described in detail elsewhere.24 Additional publicly available data were used from the Massachusetts Hospital Association Healthcare Provider Data report of registered nurse (RN) staffing plans in medical-surgical and ICUs/CCUs from 2014 to 2015.25
In the AHA Annual Survey of Hospitals,26 the staffing domain includes full-time, part-time, and full-time equivalent (FTE) staffing for hospital personnel. Full-time employees are defined as working 35 or more hours a week and part-time employees as working less than 35 hours a week.26 FTEs are defined as equal to the sum of full-time workers plus 0.5 of the part-time workers.26 Employee hours per patient day (HPPD) were calculated by multiplying full-time and full-time equivalent employees by 2080 (40 h/wk × 52 wk) and dividing by adjusted patient days.27 Total licensed nurse FTE HPPD was calculated by summing RN and licensed practical nurse FTE HPPD. Medicare days were calculated by dividing the total Medicare days in the 2014 AHA Survey of hospitals by the adjusted patient days.
Patient perception of nurse communication was measured through the Hospital Consumer Assessment of Healthcare Providers and Systems survey.28 Specifically, the percentage of patients who self-reported that RNs sometimes or never communicated well to them was included in the data analysis. Data measures were merged using the CMS hospital identifier number with the AHA Annual Survey of Hospitals released for 2014.26 This study is exempt from an institutional review board approval, as the data are available from public sources.
Data analysis was performed at the hospital level, so individual covariates such as age, diagnosis, or complexity of case cannot be explored. Frequencies, correlations, and a stepwise linear regression were conducted using IBM SPSS version 23.0 (IBM Corp, Armonk, New York). Variables were computed in the AHA dataset to permit comparisons across hospitals in the stepwise linear model analysis. The data file was examined for random or systematic missing data and marked skewness. No systematic missing data or marked skewness was found in the variables included in the data analysis. Scatterplots of the candidate predictors were examined for applicability of the linear model, outliers, or unusual distributional shapes.
Covariates that were significantly positively or negatively correlated with postoperative urinary catheter removal were included in the stepwise linear regression analysis. All terms were initially placed in the model and then eliminated by stepwise modeling if they remained associated at P = .05 and were removed at P = .10. This was determined by stepwise procedures and likelihood ratio tests.
Five variables significantly correlated with postoperative urinary catheter removal were included in the linear regression (Table 1). Positive correlations were found between timely catheter removal and (1) Medicare days/adjusted patient days and (2) licensed nurse FTE HPPD. Inverse correlations were found between timely catheter removal and (1) patient falls with trauma, (2) score on the serious complications scale (PSI 90), and (3) patient self-report that the nurses sometimes or never communicated with them. In the regression analysis, 3 factors explained 36% of the variance in timely catheter removal (Table 2): fewer falls and trauma per 1000 discharges, better nurse-patient communication, and a greater percentage of Medicare patients. More specifically, the percentage of timely postoperative catheter removals decreased by −0.482 standard deviations (SDs) for each increase of 1 SD in the rate of falls and by −0.301 SDs for each increase in 1 SD in the percentage of patients reporting nurses sometimes or never communicated with them. The postoperative catheter removal increased by 0.257 SDs for each 1 SD increase in the proportions of Medicare days to total adjusted patient days.
The likelihood ratio test from the analysis of variance (α = .05) was used to further examine postoperative urinary catheter removal by low, average, and high numbers of licensed nurse FTE HPPD. The results of the analysis of variance indicated that the assumption of homogeneity of variance was violated (Levene = 4.398, P = .017); therefore, Welch tests were performed. Welch tests showed a significant difference in postoperative urinary catheter removal by licensed nurse FTE HPPD (Welch = 3.422, P = .047). Specifically, there was a 2% increase in postoperative catheter removal with 3 additional hours of licensed nurse FTE hours per patient day. Three additional licensed nursing hours per patient day increased the percentage of urinary catheter removal from ≤97% to ≥99% (Figure). A 2-tailed Pearson correlation was computed to assess the relationship between nurse communication and RN staffing. Higher percentages of patients reporting nurses sometime or never communicated well to them were significantly associated with higher numbers of patients assigned to RNs on medical-surgical units (r = 0.274, P = .029) and ICU/CCUs (r = 0.290, P = .025).
In this study of publicly available data from 59 Massachusetts hospitals, 2 factors were found to decrease the percentage of urinary catheters removed by the second postoperative day (Table 2): a higher rate of patient falls and poorer nurse-patient communication. Conversely, hospitals with a higher proportion of Medicare days increased the percentage of urinary catheters removed by the second postoperative day. Moreover, 3 additional licensed nursing hours per patient day was also significantly associated with the percentage of urinary catheter removed by the second postoperative day.
The finding that positive patient ratings of nurse communication correlate with timelier postoperative catheter removal has not been previously reported. This confirms the importance of nurse-patient relationships in the quality of care. Poor nurse communication may be a result of insufficient staffing and organizational leadership/priorities. The findings suggest that 3 additional licensed nursing hours per patient day resulted in timely removal of urinary catheters, and poorer nurse communication was associated with higher numbers of patients cared for by RNs. Along this line, and consistent with the findings of others,9,11 responsive leadership and organizational safety priorities may impact important quality indicators such as nurse staffing and nurse-patient communication. Interestingly, a higher rate of Medicare days/adjusted patient days also correlated with the urinary catheter being removed within 2 days, which may support the positive impact of CMS Value Based Purchasing Programs on CAUTI rates.
The relationship between higher rates of patient falls when postoperative urinary catheters are left in place for a longer time illustrates the interrelatedness of patient safety initiatives. In addition to preventing CAUTI, nurses must attend to preventing falls, pressure ulcers, delirium, and medication errors. On some units, numerous patient safety initiatives are implemented concurrently. This situation may force nurses to prioritize multiple desirable goals, and research suggests that there are differences of opinion on the interrelationships among patient safety initiatives. For example, conflicting perceptions about the relationship between urinary catheters and patient falls were explored in a qualitative study by Harrod and colleagues.5 On one hand, urinary catheters were seen as a fall-prevention strategy, because patients at risk for falls were less likely to get up without help with a catheter in place. In some hospitals, the primary focus of nurses was fall prevention, because falls are classified as never events. On the other hand, some nurses believed that catheters could cause falls when the patient who is experiencing agitation and a feeling of needing to urinate climbs out of bed. Further research is needed to clarify the interrelationships among patient safety initiatives.
A limitation of this study is that the sample consisted of Massachusetts hospitals, so the findings may not be generalizable to other states. The data analyzed in this study did not account for individual patient factors, comorbid medical diagnoses, psychiatric conditions, or socioeconomic factors that may also impact the postoperative catheter removal rate. More importantly, this study reflects the prior NHSN definition of CAUTI, so the actual rates may be lower than those reported here.16 It is unlikely, however, that the new definition would impact the 3 factors that explained 36% of the variance for timely catheter removal. The number of hospitals instituting any 1 type of initiative aimed at improving CAUTI rates, such as Nursing Improving Care for Healthsystem Elders and the American Nurses Credentialing Center Magnet Program, is not large enough to determine the impact of these programs on CAUTI rates in this study.
The study findings identify nursing-specific factors that correlate with decreased catheter removal. These include poor nurse-patient communication, decreased staffing, and increased falls. These findings begin to suggest that, despite the myriad of nurse-led initiatives to improve the timely removal of urinary catheters, there are factors that require a more in-depth exploration. More research is needed to understand factors that contribute to poor nurse-patient communication, educational initiatives focused on nurses' knowledge about the importance of timely catheter removal, and how staffing effects nurses' adherence to catheter removal within 48 hours of insertion.
Given that this study examined patients on Medicare, it has important implications for the care of older adults. Other competing safety concerns such as falls and pressure ulcers require further more holistic studies to determine how they correlate. Although not directly evident in these study findings, it may be important to look at how organizational leadership impacts patient safety initiatives, staffing, and nurse-patient communication.
In general, the higher the rate of falls and the poorer communication with nurses, the less likely urinary catheters are removed by the second postoperative day. It is important to note that the percentage of postoperative urinary catheter removal was higher in hospitals with a greater proportion of Medicare days to total patient days, suggesting that the CMS Value-Based Purchasing Program is having a positive impact in promoting best practices in nursing care. Importantly, the 3 additional licensed nursing hours per patient day also increased by 2% the percentage of urinary catheters removed by the second postoperative day. Future initiatives to improve timely removal of catheters to improve outcomes in patients should focus on developing and testing interventions that promote timely catheter removal in patients deemed at the highest risk for CAUTI (older adults and those at high risk for falls).
1. Centers for Disease Control and Prevention. Healthcare-Associated Infections (HAI) Progress Report. https://http://www.cdc.gov
/hai/surveillance/progress-report/. Published March 2016. Accessed April 20, 2017.
2. Waters TM, Daniels MJ, Bazzoli GJ, et al Effect of Medicare's nonpayment for hospital-acquired conditions: lessons for future policy. JAMA Intern Med. 2015;175(3):347–354.
3. Zielinski MD, Thomsen KM, Polites SF, Khasawneh MA, Jenkins DH, Habermann EB. Is the Centers for Medicare & Medicaid Service's lack of reimbursement for postoperative urinary tract infections in elderly emergency surgery patients justified? Surgery. 2014;156(4):1009–1017.
4. Wald HL, Ma A, Bratzler D, Kramer AM. Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data. Arch Surg. 2008;143(6):551–557.
5. Harrod M, Kowalski CP, Saint S, Forman J, Krein SL. Variations in risk perceptions: a qualitative study of why unnecessary urinary catheter use continues to be problematic. BMC Health Serv Res. 2013;13(1):151.
6. Apisarnthanarak A, Khusuwan S, Leethong P, Thongsong N, Techawaleekul P, Khawcharoenporn T. Factors associated with not removing urinary catheter after reminder. Infect Control Hosp Epidemiol. 2012;33(08):860–861.
7. Lynch G, Bell K, Long D, Burmeister L. Factors associated with the successful removal of indwelling urinary catheters post-operatively in the fragility hip fracture patient. Int J Orthop Trauma Nurs. 2016;23:25–31.
8. Conway LJ, Larson EL. Guidelines to prevent catheter-associated urinary tract infection
: 1980 to 2010. Heart Lung. 2012;41(3):271–283.
9. Conway LJ, Pogorzelska M, Larson E, Stone PW. Adoption of policies to prevent catheter-associated urinary tract infections in United States intensive care units. Am J Infect Control. 2012;40(8):705–710.
10. Purvis S, Kennedy GD, Knobloch MJ, et al Incorporation of Leadership Rounds in CAUTI Prevention Efforts [published online ahead of print November 21, 2016]. J Nurs Care Qual. doi:10.1097/NCQ.0000000000000239.
11. Daud-Gallotti RM, Costa SF, Guimarães T, et al Nursing workload as a risk factor for healthcare associated infections in ICU: a prospective study. PLoS One. 2012;7(12):e52342.
12. Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care-associated infection. Am J Infect Control. 2012;40(6):486–490.
13. Li X, Bowman SM, Smith TC. Effects of registered nurse staffing level on hospital-acquired conditions in cardiac surgery patients: a propensity score matching analysis. Nurs Outlook. 2016;64(6):533–541.
14. Galiczewski JM. Interventions for the prevention of catheter associated urinary tract infections in intensive care units: an integrative review. Intensive Crit Care Nurs. 2016;32:1–11.
15. Gray D, Nussle R, Cruz A, et al Effects of a catheter-associated urinary tract infection
prevention campaign on infection rate, catheter utilization, and health care workers' perspective at a community safety net hospital. Am J Infect Control. 2016;44(1):115–116.
16. Huang SS. Catheter-associated urinary tract infections—turning the tide. N Engl J Med. 2016;374(22):2168–2169.
17. 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(22):2111–2119.
18. Centers for Disease Control and Prevention. Catheter-associated urinary tract infections. https://http://www.cdc.gov
/hai/ca_uti/uti.html. Published October 2015. Accessed April 20, 2017.
19. Scalise E. NHSN Catheter-associated urinary tract infection
surveillance in 2016. Centers for Disease Control and Prevention. https://http://www.cdc.gov
/nhsn/pdfs/training/2016/uti-event-scalise.pdf. Published March 2016. Accessed April 20, 2017.
20. Agency for Healthcare Research and Quality. Surgical care improvement project: percent of surgical patients with urinary catheter removed on postoperative day 1 or postoperative day 2 with the day of surgery being day zero. https://http://www.qualitymeasures.ahrq.gov
/summaries/summary/16275/surgical-care-improvement-project-percent-of-surgical-patients-with-urinary-catheter-removed-on-postoperative-day-1-or-postoperative-day-2-with-the-day-of-surgery-being-day-zero. Published April 2010. Accessed April 20, 2017.
21. Medicare.gov. Timely and Effective Care. Postoperative urinary catheter removal. https://data.medicare.gov/data/hospital-compare. Data from November 30, 2012, to December 1, 2015. Accessed April 20, 2017.
22. Medicare.gov. Hospital Acquired Conditions Measures. Rate of falls per 1,000 discharges, 2014. https://data.medicare.gov/data/hospital-compare. Data from October 20, 2011, to July 17, 2013. Accessed April 20, 2017.
23. Medicare.gov. Serious Complications. Patient Safety
Indicator (PSI90Safety). https://data.medicare.gov/data/hospital-compare. Data from July 2, 2013, to June 30, 2015. Accessed April 20, 2017.
24. Alvarado Hospital. Patient Safety
Indicators 90, Technical Specifications. Agency for Healthcare Research and Quality. http://http://www.alvaradohospital.com
/documents/psi_90_patient_safety_for_selected_indicators_v45a.pdf. Published July 2014. Accessed April 20, 2017.
25. Massachusetts Hospital Association. PatientCareLink Staffing Plans and Reports, 2014-2015. http://http://www.patientcarelink.org
/Healthcare-Provider-Data.aspx. Accessed February 1, 2016.
26. American Hospital Association. The AHA Annual Survey Database; Washington, DC: American Hospital Association; 2014.
27. Jiang HJ, Stocks C, Wong CJ. Disparities between two common data sources on hospital nurse staffing. J Nurs Scholarsh. 2006;38(2):187–193.
28. Medicare.gov. CMS Hospital Consumer Assessment of Health Care Providers System (HCAHPS). https://data.medicare.gov/data/hospital-compare. Data from October 1, 2014, to September 30, 2015. Accessed April 20, 2017.
Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved
nursing staff; patient safety; postoperative care; urinary catheterization; urinary tract infection