Catheter-Associated Urinary Tract Infection and the Medicare Rule Changes

By failing to prepare, you are preparing to fail. Benjamin Franklin, inventor of the flexible urinary catheter Catheter-associated urinary tract infection is the most frequent health careassociated infection in the United States (1, 2). Urinary catheter use is common, with approximately 1 in 5 patients admitted to an acute care hospital receiving an indwelling catheter (1, 3), and the rate of catheter use is even higher among Medicare patients (4). Infection frequently occurs after placement of urinary catheters; each day of catheter use is associated with an approximately 5% increase in bacteriuria (5), which is asymptomatic most of the time (3, 6) and usually requires no treatment. Because clinicians must distinguish asymptomatic bacteriuria from symptomatic urinary tract infection to avoid unnecessary administration of antimicrobial therapy, we provide a clinical definition of asymptomatic bacteriuria in Table 1 (7). Each episode of catheter-associated urinary tract infection costs at least $600 (3, 8, 9), and each episode of urinary tractrelated bacteremia costs at least $2800 (3, 10). Because catheter-associated urinary tract infection is common, costly, and believed to be reasonably preventable, the Centers for Medicare & Medicaid Services (CMS) chose it as 1 of the complications for which hospitals no longer receive additional payment to compensate for the extra cost of treatment (as of 1 October 2008). Thus, from a hospital's perspective, catheter-associated urinary tract infection may become an even more costly complication (1113). Table 1. Clinical Definition of Asymptomatic Bacteriuria Because of the possible far-reaching consequences of the CMS rule changes and the high frequency of catheter-associated infection, our aim in this Perspective is to provide practical and timely information and guidance for hospital-based administrators, policymakers, epidemiologists, and clinicians. We first address the preventability of catheter-associated urinary tract infection, then discuss the CMS rule changes about payment for treatment of catheter-associated urinary tract infection. Finally, we offer our assessment of the possible consequences of the rule changes as well as our guidance for hospital administrators and clinicians. How Preventable Is Catheter-Associated Urinary Tract Infection? The Centers for Medicare & Medicaid Services were asked to select hospital-acquired complications that could reasonably be prevented through the application of evidence-based guidelines. Does catheter-associated urinary tract infection fit this criterion? Perhaps. More than 2 decades ago, the Centers for Disease Control and Prevention proposed some recommended practices for preventing catheter-associated urinary tract infection that appropriately emphasize the benefits of hand hygiene, aseptic catheter insertion, and proper maintenance by using a closed urinary drainage system (14). More recently, the Healthcare-Associated Infections Allied Task Force from the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America provided an evidence-based compendium of the various practices available (15, 16). With regard to catheter-associated urinary tract infection, the compendium focused on the importance of maintaining an appropriate infrastructure for infection surveillance and prevention, education, and training of health care personnel about catheter-associated urinary tract infection, appropriate insertion and maintenance of the indwelling catheter, consideration of alternatives to indwelling catheter use (for example, condom and intermittent catheterization), and early removal of the indwelling catheter by using reminders or stop orders (15, 16). Of note, practices also can be bundled together, as demonstrated by the approach used in Michigan intensive care units to reduce the incidence of vascular catheterrelated infection (17). Studies of multimodal interventions include such interventions as educational programs directed at nurses, physicians, or both (included nearly universally in the studies we reviewed for this article); restricting the initial placement of indwelling urinary catheters in various settings (for example, emergency department, intensive care unit or inpatient floor, preoperative area or operative room); systems to remind physicians or nurses of urinary catheter presence, with recommendation for removal; methods to facilitate prompt urinary catheter removal when it is no longer necessary, such as nurse-initiated catheter removal protocols that do not require a physician order; and surveillance and feedback about catheter-associated urinary tract infection rates. Implementing multimodal interventions to prevent hospital-acquired catheter-associated urinary tract infection is not a new idea (18, 19). For example, more than 10 years ago, Dumigan and colleagues (19) used a multidisciplinary team approach to produce guidelines for appropriate catheter placement in addition to a protocol enabling nurses to remove unnecessary catheters without a physician order. When these interventions were implemented in 3 intensive care units, catheter-associated urinary tract infection rates decreased by 17% to 45%, with postintervention catheter-associated urinary tract infection rates of 8.3 to 11.2 per 1000 catheter-days. Several types of reminders to remove urinary catheters have been studied as interventions. Daily reminders from nurses to physicians after a catheter has been in place for a specified interval (such as 3 to 5 days) are part of several multimodal interventions (2022). These before-and-after studies without a concurrent control group demonstrate significantly reduced incidence of catheter-associated urinary tract infection. Other forms of catheter removal reminders include electronic reminders to physicians that a urinary catheter was placed in the emergency department (23) and expiring urinary catheter orders (for example, stop orders) that remind clinicians to remove catheters after prespecified periods. The orders can target physicians (24) or can authorize nurses to remove unnecessary catheters (on the basis of specific criteria) without requiring an additional order from the physician (23, 25, 26). Multimodal studies including stop orders have had mixed results, ranging from no significant changein the only randomized, controlled trial performed to evaluate this intervention (26)to reduced catheter-associated urinary tract infection rates in before-and-after studies, including 2 studies that demonstrated more than a 50% reduction in rates of catheter-associated urinary tract infection (23, 25). Other interventions that decrease inappropriate urinary catheter use include restricting use to acceptable indications for placement, usually by prompting physicians to designate an appropriate indication as part of the catheter placement order (24, 25, 27). The most impressive reductions come from interventions that use a reminder system to aid early removal of unnecessary catheters, often in combination with urinary catheter placement restrictions. Most of these studies, however, excluded patients who needed long-term catheterization, and the reminders did not completely eliminate risk for catheter-associated urinary tract infection. The bulk of the evidence is consistent with the view that multimodal strategies could prevent between 25% and 75% of catheter-associated urinary tract infections. On the basis of these findings, we conclude that reduction (not elimination) of catheter-associated urinary tract infection is possible. Inaction, however, is common. In a national study conducted in 2005 of approximately 600 U.S. hospitals (28), 56% reported having no system for monitoring which patients had urinary catheters placed and 74% reported not monitoring how long a catheter had been in place. Only 9% used some type of catheter removal reminder or stop order (28). Overview of the CMS Rule Changes Value-based purchasing is a quality improvement strategy explicitly linking payment with health care outcomes by paying more for better health care and less for inferior care. Value-based purchasing could improve the quality of hospital care while also lowering health care costs. The current hospital payment system is the antithesis of value-based purchasing, because hospitals can receive additional payments when patients develop complications during their stay, including hospital-acquired infection. One approach is to hold hospitals financially accountable for failing to prevent complications. This strategy underlies the hospital payment rule change, implemented by CMS as the Hospital-Acquired Conditions Initiative, in which CMS will no longer pay hospitals extra when patients develop specified complications after admission (Table 2) (4, 2931). Table 2. Hospital-Acquired Conditions Not Eligible for Additional Payment The Deficit Reduction Act of 2005 (Section 5001c) mandated the Secretary of Health and Human Services to choose at least 2 hospital-acquired complications that meet 3 criteria: complications with high cost, high volume, or both; complications that result in the assignment of the case to a diagnosis-related group that has a higher payment when present as a secondary diagnosis; and complications that could reasonably have been prevented through the application of evidence-based guidelines. For discharges occurring on or after 1 October 2008, hospitals paid by the Inpatient Prospective Payment System will not receive additional payment for the following conditions when acquired during hospitalization: catheter-associated urinary tract infection, decubitus ulcer, vascular catheterassociated infection, serious preventable events (such as blood incompatibility), injury due to fall or trauma, serious glycemic control states, and specific postoperative infections and venous thromboembolic conditions (Table 2). This initiative has 2 main components: mandated use of a code call