Infection Control Approach on Catheter-Associated UTI Rates
Infection Control Approach on Catheter-Associated UTI Rates
This before-after prospective cohort study was conducted in 10 PICUs in 10 hospitals that were members of the INICC in the following 6 countries: El Salvador, Colombia, India, Mexico, Philippines, and Turkey. Each hospital had been actively participating in the INICC Surveillance Program for at least 3 months and has an infection control team (ICT) comprised of a medical doctor with formal education and background in internal medicine, infectious diseases, and/or hospital epidemiology and infection control professionals (ICPs). The study period was from June 2003 through December 2010 and was divided into a baseline period (phase 1) and an intervention period (phase 2). Each participating hospital's institutional review board agreed to the study protocol, and patient confidentiality was protected by codifying the recorded information and making it identifiable only to the ICT. Other hospital and PICU characteristics are summarized in Table 1.
The intervention period was initiated after 3 months of participation in the INICC Surveillance Program. The mean length of the intervention period (± standard deviation) was 13.6 ± 10.4months (range, 4–34 months). The INICC multidimensional infection control approach includes the following components: a bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on DA-HAI rates, and performance feedback on infection control practices.
The INICC Surveillance Program includes the following 2 components: outcome surveillance (DA-HAI rates and their adverse consequences, including mortality rates) and process surveillance (adherence to hand hygiene and other basic preventive infection control practices).
The INICC chairman trained the principal and secondary investigators at hospitals from Argentina, Colombia, India, Mexico, and Turkey. In the remaining countries, investigators were self-trained by means of a manual and training tool that described how to perform surveillance and complete surveillance forms. Investigators have continuous e-mail and telephone access to a support team at the INICC central office in Buenos Aires, Argentina, which is in charge of responding to all inquiries within 24 hours. The INICC chairman also reviews all queries and responses.
Each month, participating hospitals submit the completed surveillance forms to the INICC central office, where the validity of each case is checked and the recorded signs and symptoms of infection and the results of laboratory studies, radiographic studies, and cultures are scrutinized to assure that the NNIS system criteria for DA-HAI were fulfilled. The forms used for surveillance of each ICU patient permit both internal and external validation, because they include every clinical and microbiological criterion for each type of HAI. The ICT member who reviews the data forms filled in at the participating hospital can verify that adequate criteria for infection were fulfilled in each case. Moreover, the original patient data form can also be validated at the INICC Central Office before data on the reported infection are entered into the INICC database.
The methods and definitions for DA-HAI developed by the US Centers for Disease Control and Prevention for the NNIS/NHSN program are applied in outcome surveillance. However, INICC methods have been adapted to the setting of developing countries because of their specific resource limitations and different socioeconomic status.
Outcome surveillance includes rates of CAUTI per 1,000 UC-days, ventilator-associated pneumonia per 1,000 ventilator-days, central line–associated bloodstream infection per 1,000 central line–days, microorganism profile, bacterial resistance, length of stay, and mortality in their ICUs.
Process surveillance was designed to assess compliance with easily measurable key infection control practices, such as surveillance of compliance rates for hand hygiene practices and specific measures for the prevention of DA-HAI.
Hand hygiene compliance by healthcare workers (HCWs) is determined by measuring the frequency with which hand hygiene is performed when clearly indicated, and such practices are monitored by the hospital infection control practitioner during randomly selected 1-hour observation periods 3 times per week. Although HCWs know that hand hygiene practices are regularly monitored, they are not actually aware of the precise moment at which observations are taking place.
Contacts are monitored through direct observation, and the ICPs record the hand hygiene opportunities and compliance before contact with each patient. ICPs are trained to detect hand hygiene compliance and record it on a form specifically designed for the study. In particular, the INICC direct observation comprises the "Five Moments for Hand Hygiene" as recommended by the World Health Organization.
The concept of using performance feedback on outcome surveillance and process surveillance as a valuable control measure in resource-limited hospitals was based on its effectiveness as proved in previous INICC studies.
On a monthly basis, upon processing the hospital surveillance data, the INICC Headquarters team prepares and sends to each participating hospital a final report on that hospital's institutional rates of DA-HAIs, microorganism profile, bacterial resistance, length of stay and mortality in their ICUs, and compliance with hand hygiene, central line, and UC care as well as measures to prevent ventilator-associated pneumonia. The participating ICU staff receive feedback on their performance at monthly meetings by means of the review of charts showing a running record of DA-HAI rates compiled by the INICC headquarters team, which are also posted in a prominent location in the ICU.
The bundle consisted of the following interventions:
The data were collected from PICUs with standardized forms that included information on the bundle components. These components were based on the practical recommendations for acute care hospitals published by the SHEA and IDSA in 2008.
For the diagnosis of CAUTI, the patient must meet 1 of 2 criteria. The first criterion is satisfied when a patient with a UC has a positive urine culture result yielding 10 colony-forming units (CFU) per mL or more with no more than 2 microorganisms isolated and has 1 or more of the following symptoms with no other recognized cause: fever (temperature, ≥ 38°C), urgency, or suprapubic tenderness. The second criterion is satisfied when a patient with a UC has at least 2 of the following criteria with no other recognized cause: positive results of a dipstick analysis for leukocyte esterase or nitrate and pyuria (≥10 leukocytes/mL).
Patient characteristics during baseline and during the last 3 months of the intervention period in each PICU were compared using Fisher exact test for dichotomous variables and unmatched Student t test for continuous variables. We calculated 95% confidence intervals (CIs) using VCStat (Castiglia). Relative risk (RR) ratios with 95% CIs were calculated for comparisons of rates of CAUTI using EPI Info, version 6. P values less than .05 by 2-sided tests were considered significant. In addition, we explored the change in CAUTI rates after an ICU joined INICC by looking at the follow-up period stratified by 3-month periods over the first year of follow-up, 6-month periods over the second and third years of follow-up, and then yearly (to allow somewhat for fewer subjects in ICUs with longer periods of follow-up). We calculated crude stratified rates and, using random-effects Poisson regression to allow for clustering by ICU, calculated incidence rate ratios (IRRs) for each time period, compared with the 3-month baseline period. Device days were included in the model as an offset with the coefficient constrained to be 0 (patients without UC during hospitalization were excluded). We performed an additional regression considering "time since ICU started the intervention period" as a continuous variable (excluding the baseline period) and calculated the IRR for reduction in HAI for each 3-month period of follow-up.
Methods
Setting and Study Design
This before-after prospective cohort study was conducted in 10 PICUs in 10 hospitals that were members of the INICC in the following 6 countries: El Salvador, Colombia, India, Mexico, Philippines, and Turkey. Each hospital had been actively participating in the INICC Surveillance Program for at least 3 months and has an infection control team (ICT) comprised of a medical doctor with formal education and background in internal medicine, infectious diseases, and/or hospital epidemiology and infection control professionals (ICPs). The study period was from June 2003 through December 2010 and was divided into a baseline period (phase 1) and an intervention period (phase 2). Each participating hospital's institutional review board agreed to the study protocol, and patient confidentiality was protected by codifying the recorded information and making it identifiable only to the ICT. Other hospital and PICU characteristics are summarized in Table 1.
Intervention Period (Phase 2)
The intervention period was initiated after 3 months of participation in the INICC Surveillance Program. The mean length of the intervention period (± standard deviation) was 13.6 ± 10.4months (range, 4–34 months). The INICC multidimensional infection control approach includes the following components: a bundle of infection control interventions, education, outcome surveillance, process surveillance, feedback on DA-HAI rates, and performance feedback on infection control practices.
INICC Methodology
The INICC Surveillance Program includes the following 2 components: outcome surveillance (DA-HAI rates and their adverse consequences, including mortality rates) and process surveillance (adherence to hand hygiene and other basic preventive infection control practices).
Training, Validation, and Reporting
The INICC chairman trained the principal and secondary investigators at hospitals from Argentina, Colombia, India, Mexico, and Turkey. In the remaining countries, investigators were self-trained by means of a manual and training tool that described how to perform surveillance and complete surveillance forms. Investigators have continuous e-mail and telephone access to a support team at the INICC central office in Buenos Aires, Argentina, which is in charge of responding to all inquiries within 24 hours. The INICC chairman also reviews all queries and responses.
Each month, participating hospitals submit the completed surveillance forms to the INICC central office, where the validity of each case is checked and the recorded signs and symptoms of infection and the results of laboratory studies, radiographic studies, and cultures are scrutinized to assure that the NNIS system criteria for DA-HAI were fulfilled. The forms used for surveillance of each ICU patient permit both internal and external validation, because they include every clinical and microbiological criterion for each type of HAI. The ICT member who reviews the data forms filled in at the participating hospital can verify that adequate criteria for infection were fulfilled in each case. Moreover, the original patient data form can also be validated at the INICC Central Office before data on the reported infection are entered into the INICC database.
Outcome Surveillance
The methods and definitions for DA-HAI developed by the US Centers for Disease Control and Prevention for the NNIS/NHSN program are applied in outcome surveillance. However, INICC methods have been adapted to the setting of developing countries because of their specific resource limitations and different socioeconomic status.
Outcome surveillance includes rates of CAUTI per 1,000 UC-days, ventilator-associated pneumonia per 1,000 ventilator-days, central line–associated bloodstream infection per 1,000 central line–days, microorganism profile, bacterial resistance, length of stay, and mortality in their ICUs.
Process Surveillance
Process surveillance was designed to assess compliance with easily measurable key infection control practices, such as surveillance of compliance rates for hand hygiene practices and specific measures for the prevention of DA-HAI.
Hand Hygiene Compliance
Hand hygiene compliance by healthcare workers (HCWs) is determined by measuring the frequency with which hand hygiene is performed when clearly indicated, and such practices are monitored by the hospital infection control practitioner during randomly selected 1-hour observation periods 3 times per week. Although HCWs know that hand hygiene practices are regularly monitored, they are not actually aware of the precise moment at which observations are taking place.
Contacts are monitored through direct observation, and the ICPs record the hand hygiene opportunities and compliance before contact with each patient. ICPs are trained to detect hand hygiene compliance and record it on a form specifically designed for the study. In particular, the INICC direct observation comprises the "Five Moments for Hand Hygiene" as recommended by the World Health Organization.
Performance Feedback
The concept of using performance feedback on outcome surveillance and process surveillance as a valuable control measure in resource-limited hospitals was based on its effectiveness as proved in previous INICC studies.
On a monthly basis, upon processing the hospital surveillance data, the INICC Headquarters team prepares and sends to each participating hospital a final report on that hospital's institutional rates of DA-HAIs, microorganism profile, bacterial resistance, length of stay and mortality in their ICUs, and compliance with hand hygiene, central line, and UC care as well as measures to prevent ventilator-associated pneumonia. The participating ICU staff receive feedback on their performance at monthly meetings by means of the review of charts showing a running record of DA-HAI rates compiled by the INICC headquarters team, which are also posted in a prominent location in the ICU.
Components of Practice Bundle to Prevent CAUTI
The bundle consisted of the following interventions:
Education and training on insertion, care, and maintenance of indwelling catheters, alternatives to indwelling catheters, and procedures for catheter insertion, management, insertion, and removal.
Insertion of UCs only when needed and the removal of such catheters when they are not necessary.
Use of indwelling urethral catheters for perioperative procedures and for selected surgical procedures; urine output monitoring for critically ill patients; management of acute urinary retention and urinary obstruction; assistance in pressure ulcer healing for incontinent residents.
Consideration of other methods for management, including condom catheters or in-and-out catheterization, when appropriate.
Hand hygiene before insertion and manipulation of the catheter.
Use of as small a catheter as possible.
Use of gloves, a drape, and sponges; a sterile or antiseptic solution for cleaning the urethral meatus; and a single-use packet of sterile lubricant jelly for insertion.
Insertion of catheters by use of aseptic technique and sterile equipment.
Appropriate management of indwelling catheters, including properly securing indwelling catheters to prevent movement; maintaining a sterile, continuously closed drainage system; not disconnecting the catheter and drainage tube; replacing the collecting system by use of aseptic technique and after disinfecting the catheter tubing junction when breaks in aseptic technique, disconnection, or leakage occur.
Maintaining unobstructed urine flow.
Keeping the collecting bag below the level of the bladder at all times.
Emptying the collecting bag regularly and avoiding allowing the draining spigot to touch the collecting container.
Cleaning of the meatal area as part of routine hygiene.
Surveillance of CAUTI, using standardized criteria to identify patients with CAUTI, and recording catheter-days as a denominator.
The data were collected from PICUs with standardized forms that included information on the bundle components. These components were based on the practical recommendations for acute care hospitals published by the SHEA and IDSA in 2008.
Definitions
For the diagnosis of CAUTI, the patient must meet 1 of 2 criteria. The first criterion is satisfied when a patient with a UC has a positive urine culture result yielding 10 colony-forming units (CFU) per mL or more with no more than 2 microorganisms isolated and has 1 or more of the following symptoms with no other recognized cause: fever (temperature, ≥ 38°C), urgency, or suprapubic tenderness. The second criterion is satisfied when a patient with a UC has at least 2 of the following criteria with no other recognized cause: positive results of a dipstick analysis for leukocyte esterase or nitrate and pyuria (≥10 leukocytes/mL).
Statistical Methods
Patient characteristics during baseline and during the last 3 months of the intervention period in each PICU were compared using Fisher exact test for dichotomous variables and unmatched Student t test for continuous variables. We calculated 95% confidence intervals (CIs) using VCStat (Castiglia). Relative risk (RR) ratios with 95% CIs were calculated for comparisons of rates of CAUTI using EPI Info, version 6. P values less than .05 by 2-sided tests were considered significant. In addition, we explored the change in CAUTI rates after an ICU joined INICC by looking at the follow-up period stratified by 3-month periods over the first year of follow-up, 6-month periods over the second and third years of follow-up, and then yearly (to allow somewhat for fewer subjects in ICUs with longer periods of follow-up). We calculated crude stratified rates and, using random-effects Poisson regression to allow for clustering by ICU, calculated incidence rate ratios (IRRs) for each time period, compared with the 3-month baseline period. Device days were included in the model as an offset with the coefficient constrained to be 0 (patients without UC during hospitalization were excluded). We performed an additional regression considering "time since ICU started the intervention period" as a continuous variable (excluding the baseline period) and calculated the IRR for reduction in HAI for each 3-month period of follow-up.
