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