I just took a look at the report on the National Stop CAUTI Project (free full text
here). This project uses the Comprehensive Unit-based Safety Program (CUSP) at 850 hospitals, and the report summarizes data from the first year of the project. The results were rather modest--from a baseline CAUTI rate of 2.55/1,000 catheter days there was a decrease to 2.14/1,000 catheter days. This represents a 16% relative reduction and translates to the avoidance of a whopping 0.41 infections per 1,000 catheter days. To provide some perspective, my 850-bed hospital has 49,000 catheter-days per year. An intervention of that magnitude would lead to a reduction of 20 infections yearly. Now 20 is better than nothing, but I would have to classify this as a high-burden, low-benefit intervention. And all of this begs the question: would it make more sense to take all the effort expended on CAUTI and re-direct it elsewhere (maybe hand hygiene)? Just sayin'....
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Well. Let's say your 850 bed hospital has - guessing - 17,000 discharges. That's about 1/2000th of the US total. So the 20 prevented at your hospital would extrapolate to 40,000 CAUTIs if done nationwide. Does it make sense now? Maybe? If I'm off by a factor of 2, would 20,000 still be enough? How many CAUTIs prevented is enough to be worth it? How many CAUTIs does your hospital have now? Preventing 3 per year wouldn't be worth it, OK. Would preventing 50 instead of 20 per year be worth it?
ReplyDeleteNo matter what you extrapolate the rate to, I still think that this is low yield in that the resources could be better spent on infections of higher impact. A lot of resources are being directed to a target for which there are very few effective interventions. Moreover, at my hospital most of the "CAUTIs" in ICUs are due to Candida, and it's not clear that these are really even UTIs.
ReplyDeleteWhat would be a non-low yield? Would 90% prevention of non-Candida CAUTIs be low yield? 20 per year is low yield in your hospital. What would be not low yield on CAUTI? Is the status quo on CAUTI OK? This is not a rhetorical question. It could be OK, is that what you are saying?
ReplyDeleteIt's more problematic than just low yield. It's low yield for a low impact infection. The same risk reduction for an infection of high impact (i.e., high morbidity and morbidity) would be worth it. Infection prevention at most hospitals is a zero sum game--the resources are fixed. I'm simply arguing from a utilitarian perspective that the resources are probably better spent elsewhere.
ReplyDeleteIt doesn't have to be a zero-sum game. The MRSA prevention program in VA Hospitals worked, in part, because it was not a zero-sum game. A person was hired to run the program at each hospital, so that it wouldn't be one more assignment for the infection control professional, and things would actually get done. With the reductions in MRSA and other infections that occurred with that program it isn't out of the question that the program paid for itself. It almost certainly did if one combines it with the concurrent and also very successful work to prevent CLABSI infections in VA Medical Centers. The MRSA work was published by Rajiv Jain and others (although the results are controversial to some) and the CLABSI work was funded by Marta Render and others.
ReplyDeleteAnd don't think that if it is zero-sum that funds will necessarily go where you think would be smarter to put them. They may go to buy a robot to perform prostatectomies or something else that the hospital can brag about - or profits or bonuses...