Abstract
Despite published catheter-associated urinary tract infection (CAUTI) prevention guidelines, inappropriate catheter use is common. We surveyed housestaff about their knowledge of CAUTIs at a teaching hospital and found the majority is aware of prevention guidelines; however, their application to clinical scenarios and catheter practices fall short of national goals.
Keywords: catheter-associated urinary tract infection, healthcare-associated infection, medical education, survey, infection control, practice guidelines
INTRODUCTION
Catheter-associated urinary tract infections (CAUTIs) are a major cause of healthcare-associated infections and contribute to increased morbidity and mortality.1-3 Prevention guidelines recommend limiting catheter placement and duration, but inappropriate utilization is well-described.1,4-7
In many teaching hospitals, housestaff are responsible for ordering catheter placement and discontinuation. We implemented a survey to assess housestaff’s knowledge of CAUTIs and catheter practices, with the goal to identify knowledge deficits to allow for targeted education.
METHODS
Recruitment
We surveyed housestaff in medicine, surgery, medicine-pediatrics, and anesthesiology at Massachusetts General Hospital (MGH) in Boston, Massachusetts. Emergency medicine housestaff who train in a combined residency with MGH and Brigham and Women’s Hospital were also included. The study was approved by the Partners Human Research Committee (#2012P001078). Subjects were notified of the survey via email from their program director. Next they were emailed an invitation to participate on June 26, 2012 with a reminder email sent on July 1, 2012. Entry into a lottery for a twenty dollar gift card was provided to encourage participation.
Survey Design
An anonymous electronic survey was designed in REDCap, a web-based survey tool.8 Although numerous CAUTI-prevention guidelines exist, we used The Society for Healthcare Epidemiology of America guidelines for survey development.4 Subjects were asked to provide demographic information, including post-graduate year (PGY) of training, program, and site of most recent inpatient experience (intensive care unit or floor). Respondents were asked questions regarding knowledge of prevention guidelines and CAUTI risk factors. They were asked to estimate the frequency with which they re-assessed the need for catheter placement in patients under their care. They were instructed to select appropriate indications for catheter placement from clinical scenarios and to identify appropriate timing of catheter removal post-operatively. The complete Survey Instrument is provided (Supplementary Material), including correct responses to questions where appropriate.
Scoring
Only surveys in which respondents answered all questions were included for analysis. For questions with a discrete “correct” response (Questions 2, 3, 7, 9), answers were scored as “correct” if they reflected common knowledge and adhered to consistent guidelines.4 Scoring for question 7, related to catheter placement indications, was determined by adding the number of appropriate indications selected (total possible: 9) with the number of inappropriate indications left unselected (total possible: 6), dividing by the number of scenarios (15) and multiplying by 100.
Statistical Analysis
Comparisons of responses were evaluated for statistical significance using the N-1 two proportion test with a two-tailed p-value.
RESULTS
Response Rate and Respondent Characteristics
A total of 403 subjects -- of which 175 were medicine, 75 surgery, 16 medicine-pediatrics, 81 anesthesia and 56 emergency medicine housestaff -- were invited to participate from June 26-July 3, 2012. One-hundred-and-sixty responses were received and 158 were complete, forming the sample for analysis. Respondent-reported level of training was: PGY1 43/158 (27%); PGY2 51/158 (32%); and PGY3+ 64/158 (41%). Respondent breakdown by training program was: medicine 72/158 (46%); surgery 30/158 (19%); medicine-pediatrics 5/158 (3%); anesthesiology 24/158 (15%); and emergency medicine 27/158 (17%).
Guideline and CAUTI Risk Factor Knowledge
Ninety-five subjects (60%) reported awareness of CAUTI prevention guidelines. When analyzed by PGY level, 44% of PGY 1 subjects reported awareness, compared to 70% of PGY 3+ subjects (p= 0.007). One-hundred-and-forty (89%) responded correctly that duration of catheter placement is the greatest predictor of CAUTI development. Eighty-five respondents (54%) could correctly identify the daily risk of CAUTI per catheter day and analysis by PGY level showed no statistical difference.
Inpatient Urinary Catheter Practices
Seventeen (11%) respondents reported it was easy to find documentation of the presence of a urinary catheter whereas 46 (29%) reported that it was difficult or very difficult. Nursing notes were identified by 83 (52%) as the most likely place to find documentation of a catheter.
Seventy-two (46%) respondents reported at least daily reassessment of the need for catheter placement in patients under their care during their last rotation. Analysis by PGY level was not statistically different. When responses were considered by most recent inpatient experience, intensive care unit or floor, 31/57 (54%) and 41/101 (41%) reassessed catheter need at least daily, respectively.
Knowledge of Appropriate and Inappropriate Catheter Indications
Only 5 (3%) respondents correctly identified the appropriate or inappropriate nature of every clinical scenario for catheter placement, scoring 100%. The majority of subjects, 102 (64%), scored between 75-99% on these 15 clinical scenarios (data not shown). Recognizing an epidural catheter as an indication for urinary catheter placement was the scenario most commonly missed. Of the inappropriate catheter placement scenarios, placing a catheter for a stage II bedsore with incontinence was the most common error. Respondents most reliably recognized that not all surgical patients required catheter placement, and patient preference was not an appropriate indication for catheter placement (Table 1).
Table 1.
Respondents’ ability to identify appropriate or inappropriate indications for urinary catheter use (N= 158)
| Clinical Scenario | N answered correctly (%) |
|---|---|
| Appropriate Indication | |
| Monitoring Urine Output in Critically Ill Patients | 152 (96%) |
| Comfort Measures in Terminally Ill Patients | 116 (73%) |
| Stage III Bedsore with Incontinence | 95 (60%) |
| Stage IV Bedsore with Incontinence | 120 (76%) |
| Urethral Trauma or Post-Radical Prostatectomy | 119 (75%) |
| Epidural Catheter in Place | 75 (47%) |
| Gross Hematuria | 103 (65%) |
| Acute Urinary Retention | 140 (89%) |
| Chronic Urinary Retention and No Alternative | 121 (76%) |
| Inappropriate Indication | |
| Incontinence | 132 (84%) |
| Stage I Bedsore with Incontinence | 147 (93%) |
| Stage II Bedsore with Incontinence | 125 (79%) |
| Limited Mobility | 142 (90%) |
| All Surgical Patients | 154 (97%) |
| Patient Preference | 153 (97%) |
Fifty-four respondents (34%) correctly identified when to remove a catheter post-operatively when other indications for catheterization were absent. When only anesthesia responses were considered, 7/24 (29%) answered correctly (p=0.63); when only the surgical responses were considered, 17/30 (57%) respondents answered correctly (p=0.02).
DISCUSSION
We found that a small majority of housestaff respondents reported awareness of CAUTI prevention guidelines, which increased with training, and the vast majority correctly identified catheter duration as the greatest risk factor for CAUTI development. Despite the high visibility of efforts aimed at CAUTI prevention, only a minority of respondents could correctly identify all appropriate/inappropriate indications for catheterization in common clinical scenarios.1-3 This finding highlights the need to develop and implement educational tools targeting housestaff who frequently manage inpatient catheter orders.
Although published guidelines recommend frequent reassessment, less than half of respondents reported daily reassessment of catheter necessity in their patients.1 Due to the anonymous nature of the survey, the frequency of reassessment cannot be independently verified, however, we believe it is unlikely that respondents would underestimate their practice. While knowledge deficits related to CAUTIs may contribute to infrequent reassessment of catheterization, this deficiency may also reflect the lack of a systems-based approach to recognize the presence of an indwelling catheter, and reassess its necessity. 9
As noted above, when comparing surgery and anesthesia housestaff, the two groups most likely to care for the post-operative patient, surgery housestaff identified appropriate timing for post-operative catheter removal more frequently than anesthesia. This finding highlights the importance of educational initiatives that target specific patient populations most relevant to providers.
This study has several limitations. While the survey response rate was low, thus limiting the generalizability of results, it was similar to those of published surveys regarding other medical topics in this population.10 This was a single site study, again limiting generalizability. Due to the nature of self-reporting, we cannot verify the information provided by respondents, and the results may be subject to social desirability bias. If this bias were present, however, respondents would likely overestimate their CAUTI awareness and positive practices in reassessing urinary catheter placement. Thus, the deficits reported are likely minimum estimates, providing further support for the need for targeted education about guidelines and catheter practices.
We found that housestaff knowledge of CAUTI guidelines, application to clinical scenarios and catheter practices fall short of national goals. As reducing CAUTIs is a healthcare priority, targeted interventions, including educational initiatives, need to be developed and aimed at housestaff who can play a major role in decreasing catheter use and duration.
Supplementary Material
ACKNOWLEDGEMENTS
The authors acknowledge the assistance of the following individuals.
Lynn Simpson, MPH, Enterprise Research Infrastructure and Services at Partners Healthcare
Keith Baker, MD, PhD, Program Director, Anesthesiology Residency, MGH
Hasan Bazari, MD, Program Director Emeritus, Internal Medicine Residency, MGH
Evangeline Galvez, MD, Program Director, Internal Medicine-Pediatrics Residency, MGH
John T. Mullen, MD, Program Director, General Surgery Residency, MGH
Eric Nadel, MD, Program Director, Emergency Medicine Residency, MGH
FUNDING.
This work was supported by a grant from the Doris Duke Charitable Foundation to Harvard Medical School to fund Clinical Research Fellows (HEH), Massachusetts General Hospital Departmental Funds (DCH, ESS), National Institutes of Health Training Grants (Nos. T32 A107061, ESS), and the Harvard Center for AIDS Research (RPW). Support was also received from Harvard Catalyst, The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award No. UL1 TR001102) and financial contributions from Harvard University and its affiliated academic health care centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, or the National Institutes of Health.
Footnotes
CONFLICTS OF INTEREST
MLP: No conflicts of interest to declare.
ESS: No conflicts of interest to declare.
HEH: No conflicts of interest to declare.
RPW: No conflicts of interest to declare.
DCH: No conflicts of interest to declare.
Contributor Information
Molly L. Paras, Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital; Harvard Medical School; Cox 5, 55 Fruit Street, Boston, MA, USA, 02114;.
Erica S. Shenoy, Division of Infectious Diseases, Infection Control Unit and Medical Practice Evaluation Center, Massachusetts General Hospital; Harvard Medical School; Boston, MA, USA.
Heather E. Hsu, Department of Medicine, Boston Children’s Hospital, Harvard Medical School; Boston, MA, USA.
Rochelle P. Walensky, Divisions of Infectious Diseases, Massachusetts General and Brigham and Women’s Hospital; Medical Practice Evaluation Center, Massachusetts General Hospital; Harvard Medical School; Boston, MA, USA.
David C. Hooper, Division of Infectious Diseases, Infection Control Unit, Massachusetts General Hospital; Harvard Medical School; 55 Fruit Street, GRJ 504, Boston, MA, USA, 02114; dhooper@partners.org.
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