Beyond Infection: Device Utilization Ratio as a Performance Measure for Urinary Catheter Harm

Beyond Infection: Device Utilization Ratio as a Performance

Measure for Urinary Catheter Harm

Mohamad G. Fakih, MD, MPH

1,2

, Carolyn V. Gould, MD, MSCR

, Barbara W. Trautner, MD,

PhD

4,5

, Jennifer Meddings, MD, MSc

, Russell N. Olmsted, MPH, CIC

, Sarah L. Krein, RN,

PhD

, and Sanjay Saint, MD, MPH

8,9

St. John Hospital and Medical Center, Detroit, Michigan;

Wayne State University School of Medicine, Detroit, Michigan;

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta,

Georgia;

Houston VA Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E.

DeBakey Veterans Affairs Medical Center, Houston, Texas;

Section of Infectious Diseases, Department of Medicine and Department of Surgery, Baylor

College of Medicine, Houston, Texas;

Department of Internal Medicine, Division of General Medicine, University of Michigan Medical

School, Ann Arbor, Michigan;

Infection Prevention and Control, Unified Clinical Organization, Trinity Health, Livonia, Michigan;

VA Ann Arbor Healthcare System, Ann Arbor, Michigan;

Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan.

Abstract

Catheter-associated urinary tract infection (CAUTI) is considered a reasonably preventable event

in the hospital setting, and it has been included in the US Department of Health and Human

Services National Action Plan to Prevent Healthcare-Associated Infections. While multiple

definitions for measuring CAUTI exist, each has important limitations, and understanding these

limitations is important to both clinical practice and policy decisions. The National Healthcare

Safety Network (NHSN) surveillance definition, the most frequently used outcome measure for

CAUTI prevention efforts, has limited clinical correlation and does not necessarily reflect

noninfectious harms related to the catheter. We advocate use of the device utilization ratio (DUR)

as an additional performance measure for potential urinary catheter harm. The DUR is patient-

centered and objective and is currently captured as part of NHSN reporting. Furthermore, these

data are readily obtainable from electronic medical records. The DUR also provides a more direct

reflection of improvement efforts focused on reducing inappropriate urinary catheter use.

Address correspondence to Mohamad G. Fakih, MD, MPH, Medical Director, Infection Prevention and Control, St. John Hospital and

Medical Center, 19251 Mack Ave, Suite 190, Grosse Pointe Woods, MI 48236 ([email protected]g).

HHS Public Access

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Infect Control Hosp Epidemiol

. Author manuscript; available in PMC 2019 May 06.

Published in final edited form as:

Infect Control Hosp Epidemiol

. 2016 March ; 37(3): 327–333. doi:10.1017/ice.2015.287.

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

BACKGROUND

Preventing catheter-associated urinary tract infection (CAUTI) is a national safety priority

and has been adopted as a metric by the Centers for Medicare and Medicaid Services to

optimize outcomes.

1–3

The risk of developing a CAUTI starts upon insertion and increases

daily until catheter removal; this risk is also affected by patient characteristics.

4,5

In addition

to urinary tract infection (UTI), the presence of the urinary catheter may lead to unnecessary

urine cultures, associated inappropriate use of antimicrobials,

colonization and outbreaks of

multidrug-resistant Gram-negative organisms,

7,8

and

Clostridium difficile

infection.

Noninfectious complications such as urethral and bladder trauma

and impaired mobility

are also salient patient harms related to the catheter. Our objectives are to discuss the current

outcome measures used to evaluate CAUTI events and to address their strengths and

limitations in the context of both clinical practice and healthcare policy. We conclude by

emphasizing the benefits of using the device utilization ratio (DUR) as an additional

performance measure that reflects the risk of both infectious and noninfectious harm

associated with the catheter.

Outcomes Currently Used to Evaluate CAUTI

Several different definitions of CAUTI are currently in use for epidemiological surveillance,

clinical diagnosis, and billing (Table 1).

Surveillance-based criteria for CAUTI.—The most frequently used surveillance

definition of CAUTI comes from the Centers for Disease Control and Prevention (CDC)

National Healthcare Safety Network (NHSN).

The NHSN CAUTI definition applies to

patients with an indwelling urinary catheter in place for >2 calendar days on the day of the

event and who have the catheter in place on the day of or the day before the event. The

catheter-associated symptomatic UTI (SUTI) definition requires the application of different

algorithms to identify CAUTI events that draw on a combination of clinical symptoms or

signs, the result of the urine culture, and the temporal use of an indwelling urinary catheter.

The algorithms rely on the presence of no more than 2 species of microorganisms in the

urine, in addition to other elements such as fever (regardless of the cause) or localized

findings. Starting in January 2015, the SUTI definition excluded urine analysis findings,

nonbacterial organisms, and any quantitated urine cultures with < 100,000 colony-forming

units (CFUs) per milliliter.

CAUTI as defined by clinical practice guidelines.—The clinical definition of CAUTI

published by the Infectious Diseases Society of America (IDSA) is based on clinical and

laboratory findings, with the exclusion of other sources of infection.

The IDSA clinical

definition incorporates patients with a urinary catheter (including indwelling and

nonindwelling catheters) or those who have had a catheter discontinued within 48 hours

prior to signs or symptoms. The clinical definition has 3 components: (1) significant amount

of bacteriuria defined as ≥10

CFU/mL; (2) signs or symptoms of a urinary tract infection

(as defined below); and (3) no other identified source of infection.

Signs and symptoms

that may be compatible with CAUTI include new fever, chills, altered mentation, or malaise

with no other recognized cause. In addition, flank pain, costovertebral angle tenderness,

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acute hematuria, and pelvic discomfort are considered local findings compatible with the

diagnosis. Urinary frequency, dysuria, and urgency are included if the catheter has been

removed within 48 hours. Many of these signs and symptoms are non-specific and make the

clinical CAUTI definition a diagnosis by exclusion.

Furthermore, the IDSA guidelines

exclude both the urinalysis results and the type of organism from the diagnosis of CAUTI.

Claims-based diagnosis of CAUTI.—CAUTI events are also defined using

administrative discharge data, which are submitted as claims to request payment. These data

are used to identify UTIs as hospital-acquired and catheter-associated and thus not eligible

as payable comorbidities.

14,15

Administrative data-derived hospital-acquired CAUTI rates

are much lower than expected (0.14% of hospitalizations) according to medical record

reviews and epidemiologic surveillance for CAUTIs.

16,17

A recent systematic review on the accuracy of administrative code data reported low

sensitivity but high specificity for diagnosing CAUTI.

Although UTIs are commonly listed

as diagnoses in discharge data, very few are identified in administrative data as CAUTIs

because the documentation generated by clinicians that hospital coders must rely upon for

generating diagnosis codes rarely includes explicit descriptions of UTIs as being catheter-

associated.

Clinician-based diagnosis of CAUTI.—In clinical practice, clinicians often obtain

urine cultures based on findings that are not consistent with evidence or guidelines, such as

urine color, cloudiness, and odor.

These findings are non-specific for the presence or

absence of organisms in the urine. Furthermore, clinicians often do not distinguish between

asymptomatic bacteriuria and symptomatic CAUTI in their catheterized patients.

6,20

Pyuria

in particular often drives inappropriate antimicrobial use and misdiagnosis of asymptomatic

bacteriuria as CAUTI.

6,21

Many clinicians treat patients with asymptomatic bacteriuria,

even in patient groups with high risk for developing

Clostridium difficile infection

Results from the Medicare Patient Safety Monitoring System, which captures adverse events

in a sample of patients admitted to US hospitals, were recently reported regarding clinician-

diagnosed CAUTI for patients with specific diagnoses or surgeries over the period 2005–

2011.

Clinician-diagnosed CAUTI was defined as an event in a patient who either had an

indwelling catheter or underwent intermittent catheterization during their inpatient stay,

where the physician made the diagnosis of UTI and ordered antimicrobials.

Physicians

diagnosed CAUTI in ~5% of patients exposed to urinary catheterization for different

primary diagnoses, whereas the NHSN CAUTI rate in the medical–surgical units in acute

care hospitals averaged <1.5 events per 1,000 catheter days during a similar time period.

With a national inpatient average length of stay of 4–5 days, CAUTI events are much more

prevalent based on a clinician-diagnosis compared to the NHSN-based definition.

Limitations of the Outcomes Currently Used to Measure CAUTI

The optimal definition for CAUTI used in quality improvement efforts is one that only

captures true instances of disease for which treatment is recommended, thus serving both

clinical and surveillance needs. At present, all of the available definitions suffer from

substantial limitations. For example, the IDSA definition is based on excluding other sources

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of potential infection and relies on subjective criteria.

Clinician practice often does not

follow these guidelines and may be driven instead by perceived risks, such as patient

characteristics (older age), types of organisms (Gram-negative organisms on urine culture),

and the presence of pyuria.

6,21

Clinicians often treat asymptomatic bacteriuria as a UTI,

6,20

as a positive urine culture is a strong trigger for antimicrobial use even without evidence of

infection.

Claims-based CAUTI is associated with very poor sensitivity, underestimating

the number of events. Only the NHSN definition, a national measure used for quality

improvement initiatives, is based on objective criteria, which makes it attractive for public

reporting and comparison over time.

Limitations of the NHSN CAUTI definition, criteria, and summary measure in

evaluating outcomes.—Although the NHSN CAUTI measure is the measure most

widely used to evaluate CAUTI nationally, it also has several limitations. First, case finding,

using the previous NHSN CAUTI definition, is restricted by low positive predictive value

when compared with clinical CAUTI diagnoses.

In one study, only 35% and 62% of cases

fitting the NHSN definition were considered CAUTIs when evaluated by infectious diseases

specialists and treating physicians, respectively.

Moreover, some NHSN-defined CAUTIs

may not merit clinical treatment, particularly those diagnosed on the basis of fever alone, as

the fever might actually be caused by a nonurinary etiology. Refinements in the NHSN

criteria enacted January 2015, excluding funguria and lower urine-culture colony counts,

may improve the positive predictive value of the definition for detecting clinically relevant

events. A more clinically relevant NHSN definition will be more accepted and thus support

efforts to reduce CAUTI.

A second limitation of the surveillance definition is the potential for underreporting of

CAUTI events. Validation of reported CAUTI outcomes by CMS is also in progress, a

process that has its own constraints,

but may result in improved compliance by hospitals

reporting these to NHSN. The Healthcare Infection Control Practices Advisory Committee

(HICPAC) acknowledges the limitations of surveillance definitions when evaluating clinical

disease and recommends that reported data be systematically validated.

Developing

electronic means to capture NHSN CAUTI would reduce reporter subjectivity and also

eliminate the inherent bias of self-reporting.

An electronically accessible definition could

be based upon urinary catheter presence, associated bacteriuria, and fever; such a definition

would capture more than 90% of the currently identified NHSN CAUTI cases.

Third, NHSN-defined CAUTI events may be influenced by the prevalence of fever and the

frequency of urine culture collection in a given location, both of which are critical elements

for case identification.

For example, the NHSN reported that the pooled mean CAUTI rate

for neurosurgical intensive care units (ICUs) (high fever prevalence) is 5.3 per 1,000 catheter

days, 3 times greater than the mean CAUTI rate of medical–surgical ICUs with >15 beds.

Furthermore, seasonal influenza, often associated with admissions to ICUs for febrile

patients with severe infection, may lead to an increase in NHSN-defined CAUTI rates. In

addition to patient-specific risk factors (eg, fever prevalence or duration of catheter use),

provider- or facility-specific practices (eg, reflex urine culturing triggered by fever or

abnormal urinalysis) may result in higher NHSN-defined CAUTI rates.

26,31

The presence of

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fever leads clinicians to obtain urine cultures,

resulting in an increase in detection of

patients with asymptomatic bacteriuria who may not have clinical CAUTI.

Fourth, the NHSN reliance on catheter days as the denominator for CAUTI rates makes it

challenging in some situations to measure the impact of specific quality improvement efforts

focusing on reducing device use. Interventions mainly focusing on device avoidance, such as

an intervention in the emergency department to prevent inappropriate placement,

may lead

to selecting a smaller population with higher risk for infection, resulting in a paradoxical

increase or no change in NHSN CAUTI rates.

34,35

A population-based CAUTI rate

(calculated as the number of CAUTI events divided by the total number of patient days

multiplied by 10,000) factors in the effect of catheter avoidance on the entire population and

may better reflect the success of such efforts, especially for the same unit or facility over

time, as it accounts for both the change in device use and the change in device infection risk.

Despite the limitations of the NHSN measure, this measure is especially useful for

evaluating CAUTI over time, particularly for units with stable device utilization and urine

culturing practices. This measure is enhanced by using the standardized infection ratio,

which adjusts for patient mix by type and size of patient care location, and hospital

affiliation with a medical school. However, following trends nationally over time has been

challenged by successive definition modifications, refinements, and clarifications as well as

uptake in reporting as a result of state and national reporting mandates. Further refinements

to the NHSN CAUTI measure to improve standardization of reporting, along with

implementation of electronic surveillance, will facilitate monitoring of infectious

complications associated with the urinary catheter. In addition to monitoring CAUTI,

monitoring a device-use performance measure might serve as a useful way to capture the

broader potential for catheter harm.

What is the Ideal Performance Measure to Assess Potential Catheter Harm?

To date, the majority of interventions leading to a successful reduction in CAUTI (with

different definitions used) have focused on reducing urinary catheter use, either by

shortening duration or avoiding placement.

The main outcome focus has been CAUTI

reduction, rather than avoiding catheter-associated harm. Other infection-related events (eg,

inappropriate antimicrobial use, antimicrobial resistance, and

Clostridium difficile

infection)

and noninfectious complications,

such as urethral damage, pain, or inadvertent catheter

removal, have received limited attention. Importantly, the catheter may act as “a 1-point

restraint,” limiting the patient’s mobility.

While the urinary catheter use measure has traditionally been regarded as a process measure

when evaluating CAUTI risk, it serves as a performance measure (both process and outcome

measure) for potential “catheter harm” (Table 2). The urinary catheter device utilization

ratio, calculated by dividing the number of indwelling catheter-days by patient days on the

same unit, may be adjusted for variables currently reported to NHSN, including hospital

demographics, such as size and teaching status, as well as unit type. The CDC is evaluating

methods for risk adjustment of the device utilization ratio in an effort to develop a quality

metric that may be amenable to interfacility comparisons. These efforts may also facilitate

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development of target device utilization ratios for different patient care locations. The device

utilization ratio provides additional benefits in evaluating the population at risk for device-

related infection.

34,35

The current NHSN defined CAUTI rate uses catheter days for a

denominator and does not distinguish between a hospital with a low or a high device

utilization ratio for the same rate. A unit with a high device utilization ratio may have the

same CAUTI rate as one with a lower ratio, despite having more CAUTI events. Finally, the

device utilization ratio is easily obtainable from electronic medical records

and is less

susceptible to reporting bias. The device utilization ratio is the most patient-centered

measure (in contrast to being event centered) because it has the potential to evaluate the

overall risks to the patient associated with the catheter.

While device utilization provides a global measure of potential catheter harm, it does have

limitations. The device utilization ratio does not distinguish between the number of catheter

insertions and the duration of catheterization. The risk of urinary tract infection is likely not

evenly spread throughout the life cycle of the catheter,

with a greater risk the longer the

catheter is in place. The incidence of bacteriuria is related to duration of catheter use

; for

example, the risk of bacteriuria in a patient with an indwelling catheter for 10 days may not

be the same as the risk to 5 patients with catheter use of 2 days each. A potential

complementary measure, also easily captured using data entered into electronic medical

records, is to assess the rate of catheter insertions per patient admission. Furthermore, the

device utilization ratio does not predict the proportion of appropriately used catheters,

although a reduction over time is likely correlated with improvement.

Prior to

implementation, evaluation of a proposed risk-adjusted device utilization metric with regard

to usability as a quality metric and association with appropriateness is needed.

With all of the changes in the national approach to patient safety, it is important to consider a

measure that reflects the multiple risks and harms associated with urinary catheters,

including CAUTI. Expanding beyond traditional surveillance that is event-specific to

additional performance measures may enable the evaluation of multiple risks to patient harm

and is consistent with the statement by Fridkin and Olmsted: “Surveillance systems must be

able to evolve in response to ever changing needs of the communities and society they

serve.”

A standardized measure of device utilization can serve as a performance metric

that is objective, amenable to electronic reporting, and correlates with risk of both infectious

and non-infectious harms associated with the urinary catheter.

ACKNOWLEDGMENTS

Financial support

. This project was supported by a contract from the Agency for Healthcare Research and Quality

(grant no. HHSA290201000025I/HHSA29032001T).

Potential conflicts of interest

. M.G.FS., S.S., S.K., and J.M. report receiving support for involvement in the “On the

CUSP: Stop CAUTI” initiative. M.G.F. reports receiving support from the Ascension Health Hospital Engagement

Network effort to prevent healthcare-associated infections; and support from Michigan Health and Hospital

Association Hospital Engagement Network to reduce CAUTI. C.V.G. reports no conflicts of interest. B.W.T. reports

support from the Department of Veterans Affairs (grant no. VA RRP 12–433) and the National Institutes of Health

(grant no. NIH DK092293), and the Agency for Healthcare Research in Quality (AHRQ Safety Program for Long-

Term Care: Preventing CAUTI and Other HAIs). J.M.’s research is funded by grants from the Agency for

Healthcare Research and Quality (grant nos. 1K08HS019767 and 1R010HS018344. R.N.O. receives honor-aria

from Health Research & Educational Trust as extended faculty and as a member of Ethicon, Inc., Speakers’ Bureau.

He also is a consultant to Joint Commission Resources and Premier, Inc. S.K. reports support from the Department

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of Veterans Affairs (grant no. 1 I01 HX001101–01). Additionally, S.S. reports that he is on the medical advisory

boards of Doximity and Jvion.

DISCLAIMER: The findings and conclusions in this report are those of the authors and do not necessarily represent

the official position of the Agency for Healthcare Research and Quality, the Centers for Disease Control and

Prevention, or the Department of Veterans Affairs.

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table 1.

The National Health Safety Network and Infectious Diseases Society of America Claims-Based Definitions for Catheter-Associated Urinary Tract

Infections (CAUTI) and Clinician Diagnosis

Source Criteria Catheter Types Use Advantages Limitations

National Healthcare

Safety Network

(NHSN) 2015

Bacteriuria (≥10

CFU/mL);

algorithm-based including the

presence of 1 of 3 clinical findings:

fever, suprapubic tenderness,

costovertebral angle pain or

tenderness; if catheter is removed,

urgency, frequency, dysuria are also

options.

Indwelling CAUTI surveillance for

public reporting and

performance metrics

Objective criteria, reproducible,

universally used for quality

improvement initiatives

Does not correlate with clinical CAUTI

or clinician practice; heavily dependent

on fever even if alternate source present;

limited in evaluating improvements in

reducing CAUTI events when efforts

focus on avoiding device placement

Clinical Practice

Guideline: Infectious

Diseases Society of

America (IDSA)

Bacteriuria (≥10

CFU/mL); signs

or symptoms of a urinary tract

infection, and no other identified

source of infection

Indwelling, suprapubic,

external (condom), and

intermittent

Clinical diagnosis; to

distinguish CAUTI from

asymptomatic bacteriuria

Clinical; independent of

urinalysis results; the diagnosis

by exclusion minimizes

overdiagnosing CAUTI in

patients with asymptomatic

bacteriuria

Not easy for a clinician to follow or

apply to a specific patient; runs counter

to ingrained diagnostic biases (pyuria

not used)

Claims-based Administrative claims data for the

purposes of identifying UTIs as

hospital-acquired and catheter-

associated

Indwelling Billing; to identify

hospital-acquired CAUTIs

as a diagnosis that is

ineligible for generating

additional hospital

payment as a comorbidity

Identified by diagnosis codes

submitted by hospital coders

routinely in the process of

generating and submitting

administrative data to request

hospital payment

Low sensitivity to capture clinical

CAUTIs (ie, many CAUTIs that occur

are identified simply as UTIs but not

CAUTIs in claims data)

Clinician diagnosis Informal but common criteria based

on presence of bacteriuria, pyuria,

and many subjective findings

Unclear; physicians

often are not aware of

the presence of the

urinary catheter or the

type

Deciding whether to treat

with antimicrobial agents;

to explain clinical

symptoms

Based on clinician evaluation;

influenced by the type of

organism; directly affects

patient care

Subjective findings used for diagnosis,

including urine color, smell and

consistency; pyuria often equated to

infection; high potential for

inappropriate antimicrobial use

NOTE. CFU/mL, colony-forming units per milliliter.

Infect Control Hosp Epidemiol

. Author manuscript; available in PMC 2019 May 06.

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Fakih et al. Page 11

table 2.

Infectious and Noninfectious Harms Associated with Urinary Catheters

Immediate Complications Downstream Consequences

Infectious Complications

Catheter-associated urinary tract infections (lower urinary tract involvement) Complicated infection (upper urinary tract involvement, bacteremia)

Asymptomatic bacteriuria associated with inappropriate antimicrobial use Multidrug-resistant organisms (infection, reservoir, and transmission)

Clostridium difficile

infection

Antimicrobial side effects

Non-infectious Complications

Trauma Urethral trauma with insertion or manipulation

Hematuria

Bladder injury including perforation

Pressure ulcers, device related

Immobility (1-point restraint) Pressure ulcers related to immobility

Deconditioning, frailty

Venous thromboembolism

Falls

Patient suffering Discomfort, pain

Loss of dignity

Societal loss Increased length of stay

Unnecessary resource use

Infect Control Hosp Epidemiol

. Author manuscript; available in PMC 2019 May 06.