Preventing HAI is a patient safety priority in the U.S. and world-wide.24,25
Along with a continuing need to develop new practices to reduce infection, we must also understand the extent to which recommended practices are being used to identify potential gaps and opportunities for enhancing infection prevention activities to protect hospitalized patients.26
This study shows a significant increase in the percentage of U.S. hospitals, both non-federal and VA, reporting use of several key practices to prevent CLABSI, VAP, and CAUTI between 2005 and 2009. The majority of non-federal hospitals report that the CMS policy to no longer pay for the additional cost of some HAIs had a moderate to large increase on the priority of preventing CLABSI, VAP and CAUTI at their facility. Not surprisingly, a majority of VA hospitals report no change in priority related to the CMS rule since they are not directly subject to the payment change. Despite the increased use of many practices, however, there is much variability and the use of practices to prevent CAUTI remains relatively low compared to those for CLABSI and VAP among both groups of hospitals.
Of the 12 practices included in this analysis, reported use increased for 11 of the practices among non-federal hospitals and for 11 of the practices among VA hospitals. Although not all increases were statistically significant, the patterns observed for many of the practices appeared to be similar between the non-federal and VA hospitals particularly those for preventing CLABSI and VAP. Reported use of all of the practices for preventing CLABSI, except antimicrobial central venous catheters, and all of the practices for preventing VAP increased among both non-federal and VA hospitals. Interestingly, more than half of the non-federal hospitals identified a moderate or large increase in the importance of preventing VAP as a result of the CMS payment change. Yet, while VAP was one of the conditions considered when the initial list was established and remains among the conditions discussed for subsequent inclusion, it is not currently affected by the CMS payment rule.27
Perceived importance notwithstanding, the actual direct impact of the reimbursement rule on prevention efforts to date appears to be limited.
Despite 65% of non-federal hospitals indicating a moderate or large increase in CAUTI as a facility priority due to the CMS payment rule and a significant increase in the use of several practices to prevent CAUTI, no practice was used by more than 50% of non-federal hospitals in 2009. Likewise, bladder ultrasound was the only practice used by a majority of VA hospitals. Although the use of urinary catheter reminders or stop-orders doubled since 2005, this relatively simple approach is only used by 1 in 5 U.S. hospitals despite evidence and recommendations supporting this practice.10,20,28,29
Therefore, a nationwide gap in translating evidence-based practices to prevent CAUTI seems to exist. In contrast, over 90% of hospitals report using at least one practice for preventing CLABSI and VAP. Notably, the practices now used by 90% or more of U.S. hospitals, which includes use of maximum barrier precautions and chlorhexidine as a site antisepsis for prevention of CLABSI and semi-recumbent positioning to prevent VAP, are practices that have been promoted as part of practice bundles and through collaboratives, including the Institute for Healthcare Improvement breakthrough collaboratives and the Keystone ICU initiative in Michigan.7,17
Until recently, however, there were no practice bundles or large-scale collaboratives that focused on preventing CAUTI.16
Another issue distinguishing CAUTI prevention from CLABSI and VAP prevention is that the majority of patients with short-term central venous catheters and those on ventilators are in an ICU. Thus, instituting the use of specific prevention practices may be achieved through a focused effort within a relatively defined area. Whereas indwelling urinary catheters, while prevalent in ICUs, are also used in patients located throughout the hospital and the strategies needed to implement key CAUTI prevention practices may not only vary by type of practice but also by unit. For example, implementing a urinary catheter reminder or stop-order on a medical-surgical floor may differ from that of a rehabilitation unit or even from one medical-surgical floor to another depending on how the units are staffed and how care is delivered.
Our findings should be interpreted in the context of some possible limitations. First, non-response bias is a potential issue. Although the overall response rate was approximately 70% in both years, the response among VA hospitals in 2009 was only 62%. Nonetheless, given a nearly 70% response in the non-federal sample in both years we believe these results provide a reasonable estimate of the use of infection prevention practices by U.S. non-federal hospitals with 50 or more beds and an ICU in both 2005 and 2009. In addition, we found no significant differences in academic affiliation or size (i.e., number of hospital beds) between the hospitals that responded versus those that did not for the VA sample. For the non-federal sample there was also no difference in academic status, but larger hospitals were somewhat less likely to respond in 2009. Second, the 2009 survey was conducted only six months after the CMS payment rule went into effect and it may have been too early to capture some of the prevention activities by non-federal hospitals. However, since the non-payment rule was publicized well in advance of the date when it actually took effect, we expect that the time factor did not substantially impact our study results. Lastly, although we have a considerable amount of information about the use of infection prevention practices, we do not have data on actual infection rates. Nonetheless, we focused primarily on practices that have been shown through research to reduce infections and are generally included in published guidelines or recommendations from the CDC and other professional associations. Also, in line with our finding of significantly higher use of practices to prevent CLABSI and VAP compared to CAUTI, data collected by the CDC through the National Healthcare Safety Network (NHSN) and its predecessor the National Nosocomial Infections Surveillance (NNIS) system suggest a sizeable decline in rates of CLABSI and VAP (comparing data from 2002–2004 vs. 2006–2008) but little change in CAUTI rates.1,30,31
Likewise, although information about CAUTI is not currently available, data collected by the VA also show significant decreases in CLABSI and VAP from fiscal year 2005 to fiscal year 2010.32
In conclusion, our findings reveal that the majority of non-federal hospitals report that the CMS payment rule had a moderate to large increase on their priority in preventing CLABSI, VAP and CAUTI compared to no reported change in priority by the majority of their VA counterparts. However, both non-federal and VA hospitals reported significant increases since 2005 in the use of several key practices to prevent CLABSI, VAP, and CAUTI. These findings suggest that while it is perceived as important and may contribute to changes in practice, the CMS payment rule is likely not the primary driver of the increased use of infection prevention practices among US hospitals over the past several years. Additionally, there is still variability in the types of practices used to prevent certain infections and the percent of hospitals using specific practices to prevent CAUTI remains low compared to CLABSI and VAP. This gap indicates that additional strategies may be required to encourage the use of key CAUTI prevention practices to decrease infection risk and enhance patient safety.