First, I hope you were all able to enjoy the holiday and spend time with your loved ones. For those of you who were here caring for patients, thank you so much. Thanksgiving is a time for us to reflect on the many things we are grateful for. I’ve said it before and I’ll say it again, what makes our UI Health Care team amazing is each and every one of you and what you do every day. Because of you, I’m confident we can meet any challenge, and I have great hope for our future.  

For many years, we have struggled to efficiently use our time and our patient’s time during their inpatient stay, and it’s an issue that is not unique to this organization. When we compare ourselves to other health systems across the country, we commonly refer to the Length of Stay Index (LOSI). The LOSI allows us to look at the time it takes us to care for the patient and discharge them based on the patient’s diagnosis. 

This is an area of focus for many reasons: 

• It is a challenge drawing focus from health care organizations across the country. 
• UI Hospitals & Clinicshas experienced sustained high patient volume year over year. 
• Given our high census, we need open beds to provide care to the next patient who needs us, so we must also focus on an early discharge when it is safe and feasible. 

But perhaps the most important reason to focus on length of stay is that it’s the right thing to do for our patients.  If you or a loved one has ever been hospitalized you know  that waiting for discharge can be a difficult experience for the patient and their family. This waiting period is sometimes the last impression our patients have of us on the day of discharge, making it even more important that we try to make it as efficient and easy a process as possible.  

In order to provide high quality and efficient care for our patients and their families, we must: 

• Have strong collaboration and communication across our multi-disciplinary teams 
• Start thinking about and discussing discharge planning when the patient is admitted 
  • Think about the expected day of discharge (ask about it in huddles, and wrench it into your EPIC dashboard)  
  • Know the plan of care for the day and proactively think about the plan of care for each day until discharge 
    • What do we need to accomplish for the patient to prepare for a safe discharge? 
    • Do all members of the team know the plan and what is needed for discharge? 
• Tell the patients and their families when we anticipate discharge and confirm it the day prior whenever possible 
• Discuss with the patient and family the expectation of the 1100 discharge time 
  • If their ride home will be later in the day, let them know they will be sent to our discharge lounge—if they qualify—to await their ride. 
• Engage our nurse navigators early and schedule the follow-up appointments early in the patient’s stay 
• Engage our social workers early if the patient has potential needs for medical equipment at home, or a post-acute facility stay (SNF, rehab, etc.) 
• Complete what you can before the day of discharge (discharge summary, patient education, consults, imaging, prescriptions, final labs, etc.) 
• Prioritize the patients who are going home that day 
  • Physicians should first round on those patients who we anticipate going home that day and write the discharge order by 0930. 
  • Nurses should complete the discharge tasks as soon as the order is written 
• Tell us the barriers that prevent patients from discharging  
  • Are there delays in tests/procedures being completed? 
  • Are consults pending? 
  • Do you feel empowered to escalate concerns and delays? 
  • What are the system challenges? 
    • Remember to put these into the BlindSpots portal so we can look at how these challenges may be overcome. 

We know that a patient’s status may change, and we cannot always predict when they will be healthy and able to discharge, but for those we can predict, let’s do everything we can to be ready. 

By decreasing our patient’s length of stay, not only are you helping your present inpatients, but you are improving access for patients  in our Emergency Department, operating rooms, ambulatory clinics, and outside hospitals who need our help. Lastly, when a patient is efficiently prepared for a safe discharge, you save time for yourself and your colleagues. 

Please keep your eyes open for more communication on length of stay and early discharge as we work to continue improving these processes. We look forward to continuing this journey with all of you! 

Blog contributors: 

• Ami Gaarde, MBA, BSN, RN, OCN, Director, Nursing and Patient Care, Care Coordination (Adult) 
• Theresa Brennan, MD, Chief Medical Officer 
• Evelyn Kinne, MHA, Quality and Operational Improvement Engineer, Office of the Chief Medical Officer 

This blog is part of an ongoing series focused on introducing the current quality initiatives. Thank you to the Quality Improvement Program team for sharing their important work with us, and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.   

Learn more about the other initiatives by viewing the introduction to this series and previous topics.

Why do some people need a urinary catheter? 

Urinary catheters are used for urinary drainage or as a means to collect urine for measurement. Indications for catheterization are as follows: 

• Urinary retention  
• Urine output measurement in ICU patients 
• During surgery to evaluate fluid status  
• During and following specific surgeries of the genitourinary tract 
• Hematuria associated with clots  
• Neurogenic bladder  

Although urinary catheters provide many patient benefits, there are also associated risks. Due to these risks, urinary catheters should be removed as soon as the benefits no longer outweigh the risks. 

Epidemiology 

According to the Centers for Disease Control and Prevention (CDC), between 15 to 25% of hospitalized patients receive urinary catheters during their hospital stay. Bacteriuria (positive bacteria in urine) in patients with indwelling catheters occurs at a rate of approximately 3 to 10% per day. Of those with bacteriuria, 10 to 25% develop symptoms of urinary tract infection (UTI). In the U.S., based on surveillance data reported to the CDC National Healthcare Safety Network (NHSN), the incidence of CAUTI in 2012 was 1.4 to 1.7 per 1,000 catheter days in inpatient adult and pediatric medical/surgical floors. This means if all the patients at UI Hospitals & Clinics had a urinary catheter today, between one and two of them will develop a CAUTI. 

The duration of catheterization is an important risk factor for CAUTI and is a major target of prevention efforts. Other risk factors include female sex, older age, diabetes mellitus, bacterial colonization of the drainage bag, and improper catheter care.  

Issues with CAUTI 

Health care-associated infections cost U.S. hospitals an estimated $40 billion each year. CAUTIs are among the most common types of health care-associated infections. Research suggests CAUTIs are highly preventable and that perhaps as many as 50 to 70% of these episodes can be prevented. Complications associated with CAUTI result in increased length of stay, patient discomfort, excess health care costs, and contribute to increased mortality. The estimated total U.S. cost per year for CAUTI is $340–450 million. Since October 2008, the Centers for Medicare & Medicaid Services no longer reimburses costs associated with hospital acquired CAUTI.  

How do we prevent CAUTI? 

In general, the most important aspects of CAUTI prevention are avoidance of unnecessary catheterization, use of sterile technique when placing the catheter, proper catheter care, and removal of the catheter as soon as possible.  

The need for a urinary catheter should be evaluated for every patient, every day by both physicians and nurses. It is important to insert catheters only for appropriate indications and leave them in place only if needed. The catheter should not be kept solely for the convenience of patient care. It is also important to consider using alternatives to indwelling urethral catheterization in selected patients when appropriate, such as external catheter or intermittent catheterization. If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension. We can use a bladder scanner to assess urine volume in patients undergoing intermittent catheterization and reduce unnecessary catheter insertions. 

Proper technique during catheter insertion is critical. Health care personnel must perform hand hygiene immediately before and after insertion. We need to use aseptic technique and sterile equipment, and properly secure indwelling catheters after insertion to prevent movement and urethral traction.

Ideal catheter care is also instrumental to CAUTI prevention. Meatal care (cleaning around the catheter) once per shift and after every bowel movement is essential. In addition, daily bathing with chlorhexidine is necessary and is reported to reduce CAUTIs.  

The way a urine culture is collected also has a significant impact on CAUTIs. For instance, urine cultures should never be obtained from a catheter that has been in place for more than 24 hours, because urine cultures collected from an existing catheter will almost always come back positive but may not be clinically significant. Once a CAUTI is suspected urinary catheters should be removed and urine specimens should be obtained from either a newly placed urinary catheter or via intermittent catheterization 

CAUTI reduction initiative 

In August 2022, a multidisciplinary CAUTI committee, led by Karen Brust, MD, hospital epidemiologist, was formed in an effort to reduce CAUTI across UI Hospitals & Clinics’ adult units. Members of the CAUTI committee provided feedback on contributing factors from the perspective of leaders and bedside nurses. Their feedback provided a foundation for potential future data collection and process improvement. The discussions and work of the CAUTI initiative led by Brust also aligned with another CAUTI committee led by the Department of Nursing Services and Patient Care. Since its initiation, the nursing-led committee reviewed and updated existing protocols and policies related to CAUTI. The group identified opportunities for additional guiding documents, specifically for bladder scanning and intermittent catheterization protocol, which is actively being developed. The team collaborated with clinicians to understand the current process of ordering urine cultures and how urine specimens are collected after an order is placed. The results of these conversations revealed variation in practice by the ordering provider and the nurse collecting the urine sample. This led to the ongoing development of an “ideal state” for both actions with recommendations brought to the clinical and nursing informatics teams.

Blog contributors:
-Karen Brust, MD, Clinical Associate Professor of Internal Medicine, Infectious Diseases, Hospital Epidemiologist
-Takaaki Kobayashi, MD, MPH, Clinical Assistant Professor or Internal Medicine, Infectious Diseases

Citations: 

• Agency for Healthcare Research and Quality. Overview | Agency for Healthcare Research and Quality (ahrq.gov) 
• Cather-associated urinary tract infection. Centers for Disease Control and Prevention. Catheter-associated Urinary Tract Infections (CAUTI) | HAI | CDC 
• UPTODATE: placement and management of urinary bladder catheters in adults. Placement and management of urinary bladder catheters in adults – UpToDate