Routine Foley catheter placement affects postoperative UTIs in bariatric surgery patients

Urinary tract infection (UTI) accounts for up to 40 percent of health care-associated infection, and up to 80 percent of UTIs are catheter-associated (CAUTI).¹ Routine use of indwelling urinary catheters (IUCs) in the perioperative setting contribute to CAUTI,² which, in turn, commonly leads to unnecessary antimicrobial use, prolonged hospitalization, bacteremia, and increased health care costs.³

In bariatric surgery patients at Stony Brook University Hospital, Long Island, NY, an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP^®) institution, UTI accounts for 17 percent of all postdischarge complications.⁴ IUC use was independently found to be significantly associated with UTI following laparoscopic bariatric surgery, regardless of the duration of catheterization.⁵ CAUTI, therefore, has been identified as a preventable complication leading to morbidity in bariatric surgery patients.

In fact, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) uses incidence of UTI as a marker of bariatric surgical outcome. When comparing Stony Brook University Hospital’s outcomes to national benchmarks, we found that our institution had a relatively higher rate of UTI in the bariatric patient population. Given the hospital’s commitment to delivering quality patient care, we felt that measures needed to be taken to improve these outcomes.

Putting the QI activity in place

Stony Brook University Hospital is a tertiary academic medical center with more than 600 beds that provides care to a suburban community. The surgical volume is 24,000 cases per year. Stony Brook University Hospital was named one of Healthgrades’ “America’s 100 Best Hospitals” for 2019 based on actual clinical outcomes. The Stony Brook Bariatric Surgery Center has been an MBSAQIP-accredited bariatric center since 2013. This QI project was undertaken in 2015 to address the hospital’s high rate of CAUTI.

The Centers for Disease Control and Prevention (CDC) guidelines suggest using IUCs only when absolutely necessary, removing them as soon as possible, and has advised against their use for the convenience of patient-care personnel.⁶ The CDC indicates that the most effective primary prevention of CAUTI is to limit the use of IUCs to when it is clinically indicated and necessary. No guidelines have been published regarding the placement and removal of IUCs in patients undergoing bariatric surgery.

Our bariatric group is composed of four attending surgeons, all of whom would routinely place IUCs intraoperatively before this QI activity was implemented. IUCs would be removed the morning of postoperative day one. We first organized multiple team meetings to review our postoperative outcomes related to CAUTI. This process then led to a consensus among all surgeons that routine use of IUCs was not clinically necessary for all bariatric operations. The surgical group subsequently met with the anesthesia team to achieve consensus on perioperative catheter use.

Description of the QI activity

Based on the incidence of UTI in the MBSAQIP report, the team concluded that a patient outcome improvement measure was required. A urinary catheter avoidance protocol was constructed to address the problem. With this new protocol, IUCs were no longer placed intraoperatively in adult patients undergoing bariatric surgery. Instead, IUCs were only placed for postoperative urinary retention (that is, if the patient is unable to void within six hours postoperatively). This catheter avoidance protocol was first implemented July 1, 2014. Data were collected prospectively after implementation of the catheter avoidance protocol and were compared to preprotocol outcomes.

Staff involved in this activity included four bariatric surgeons, two anesthesiologists, one minimally invasive and bariatric surgery fellow, one physician assistant, one nurse practitioner, and three nursing and 10 ancillary staff from the bariatric office, preoperative units, postoperative recovery units, medical surgical units, and operating room. Initially, our anesthesia colleagues hesitated to implement the new protocol because they use perioperative IUCs as a method of perioperative monitoring. However, after a multidisciplinary meeting and a review of clinical outcomes, we were able to reach a consensus in an effort to improve outcomes.

No additional costs were required beyond normal hospital operations to implement and maintain the QI program, and no additional funding sources were necessary.

Results

Five years of pre- and postprotocol UTI rates were compared. We identified 171 patients in the precatheter avoidance protocol group and 523 patients in the postprotocol group (see Table 1). The average incidence rates of postoperative UTI differed significantly in the preprotocol (2.924 percent) versus postprotocol (0.574 percent) groups (p = 0.0009) (see Figure 1). Discontinuation of routine IUC placement resulted in an 80.4 percent relative risk reduction in postoperative UTI compared with routine IUC placement.

Table 1. Incidence of postoperative UTI by year

Figure 1. Incidence of postoperative UTI before and after discontinuation of routine IUC placement by year

Avoiding routine urinary catheter placement led to a reduction in postoperative UTI for patients undergoing bariatric surgery. These data support the discontinuation of routine urinary catheter placement in best practices protocols.

The per-patient cost to the hospital for a symptomatic UTI is approximately $911⁷ and the cost of an IUC is approximately $17. Given the 80.4 percent relative risk reduction experienced after the protocol change, the estimated cost savings of catheter avoidance is approximately $6,704 per year ($3,644 for UTI treatment, $3,060 IUC cost, assuming 180 cases annually). In addition, the hospital operating room fee is approximately $66 per minute.⁸ Assuming it takes approximately two minutes to place an IUC, catheter avoidance saves an additional $23,760 annually, making an estimated total cost savings of $30,464 annually.

Tips for others

While additional funding is unnecessary, multidisciplinary buy-in is imperative to implementing a new protocol. We recommend a review of institutional CAUTI outcomes to determine room for improvement. With the data at hand, a meeting can be organized with surgeons, anesthesiologists, and other care team members to determine how best to implement change at a given institution. Collaboration between departments brings more attention and awareness to the problem at hand. Moreover, if positive change is seen, new practices may be adopted hospitalwide to further reduce the incidence of CAUTI.

References

1. Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166.
2. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(5):625-663. Available at: https://academic.oup.com/cid/article/50/5/625/324341. Accessed August 27, 2019.
3. Oman KS, Makic MBF, Fink R, et al. Nurse-directed interventions to reduce catheter-associated urinary tract infections. Am J Infect Control. 2012;40(6):548-553.
4. Chen SY, Stem M, Schweitzer MA, Magnuson TH, Lidor AO. Assessment of postdischarge complications after bariatric surgery: A National Surgical Quality Improvement Program analysis. Surgery. 2015;158(3):777-786.
5. Helmen ZM, Helm MC, Helm JH, et al. Predictors of postoperative urinary tract infection after bariatric surgery. Obes Surg. 2018;28(7):1950-1954.
6. Stamm WE. Guidelines for prevention of catheter-associated urinary tract infection. Ann Intern Med. 1975;82(3):386-390.
7. Kennedy EH, Greene MT, Saint S. Estimating hospital costs of catheter-associated urinary tract infection. J Hosp Med. 2013;8(9):519-522.
8. Shippert RD. A study of time-dependent operating room fees and how to save $100,000 by using time-saving products. Am J Cosm Surg. 2005;22(1):25-34.