Editor’s note: Hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) use the program’s data and reports to improve performance and surgical outcomes. Sites are invited to share their experiences at the ACS NSQIP Annual Conference—now called the ACS Quality and Safety Conference—through abstract submissions for poster and panel presentations. Hospitals also are encouraged to share their quality improvement (QI) initiatives, so other institutions can learn from their experience and develop their own QI programs.
“ACS NSQIP best practices case studies” is an ongoing look at these experiences. These case studies have been edited to comply with Bulletin style and provide a description of the clinical problem being addressed, the context of the QI project, the planning and development process, a description of the activity, the resources needed, the results, and tips for other case studies.
Accounting for more than one-third of nosocomial infections in U.S. hospitals,1 urinary tract infections (UTIs) are associated with increased morbidity, mortality, and health care costs.2,3 Defined as a nonreimbursable, “reasonably preventable” hospital-associated complication by the Centers for Medicare & Medicaid Services,4 UTI became of particular relevance to surgeons after a study of New York and California registry data showed that 70 percent of nosocomial UTIs involved patients undergoing surgical procedures.5 Moreover, the challenge of nosocomial UTI for the colon and rectal surgeon was recently highlighted in a study using data from the ACS NSQIP, which showed that UTI rates after colon and rectal surgery (CRS) exceed risk-adjusted estimates on the basis of patient factors alone.6
These results echoed the findings of a previous ACS NSQIP study, which also identified CRS as a risk factor for UTI.7 The 2012 designation of UTI prevention as a National Patient Safety Goal emphasizes the importance of UTIs as a target for QI in both surgery overall and CRS.8
The ACS NSQIP studies, as well as a 2012 report of risk factors for UTI after resection of colorectal cancer in the Nationwide Inpatient Sample, delineate a number of patient-related risk factors for UTI, yet fail to identify physician-controlled modifiable risk factors. However, Wald and colleagues, in a study of more than 35,000 Medicare beneficiaries undergoing surgery, demonstrated a 21 percent increase in UTI incidence for postoperative indwelling urinary catheterization (IUC) lasting more than 48 hours.9 These data—in conjunction with a 1999 study by Benoist and colleagues that called into question the long-held belief that pelvic surgery necessitates protracted IUC10—forms the basis for our proposed intervention.
Why was the QI activity undertaken?
Because the perioperative management of IUC may be service- and surgeon-dependent at many institutions, researchers at Beth Israel Deaconess Medical Center, Boston, MA, sought to investigate whether standardized management of IUC placement and duration could reduce the incidence of UTIs in CRS. As part of our ongoing institutional efforts to reduce perioperative morbidity, we found that our UTI rate exceeded both the ACS NSQIP benchmark and the expected rates for UTIs in CRS.5 We analyzed potential contributing factors, including previously identified modifiable and non-modifiable risk factors.
We considered the length of time that the catheter remained indwelling and the method of IUC insertion as modifiable risk factors. We found no outcomes data in the literature on the optimal strategy for placing operative IUCs or the potential impact thereof. Our hospital practice for catheter placement was in line with the 2009 update of the U.S. Centers for Disease Control and Prevention Guideline for Prevention of Catheter-Associated Urinary Tract Infections.11
How was the QI activity put into place?
Based on the January 2012 ACS NSQIP Semiannual Report that placed our CRS UTI rate in the 10th decile, the division chief for colorectal surgery identified the problem, piloted interventions, met with the colorectal team to discuss interventions, engaged all team members, and selected a protocol to standardize and modify provider behavior through simple interventions.
An institutional program of daily reassessment of the need for IUC was instituted at our tertiary care hospital across all service lines in January 2010. However, no specific actions were attached to these guidelines, and we saw no significant decrease in UTIs. This group served as the control population against which subsequent interventions were compared.
Intervention group 1
In response to the persistently elevated UTI rate, a daily electronic order was developed to maintain an IUC for more than 24 hours. Specifically, an electronic health record (EHR) prompt was created such that each time an IUC was ordered to be inserted, a query appeared every 24 hours about the need for continued catheterization. The provider was required to enter clinical justification for the continued need for the IUC for the ensuing 24 hours, and no further orders could be entered until the prompt was addressed.
All of the perioperative IUCs were removed within 48 hours unless there was clinical justification for maintaining use. The clinical notation of pelvic dissection or pelvic surgery was not considered to be sufficient for IUC use beyond 48 hours, as studies have documented the safety of removing IUC on the first postoperative day.12 This EHR order was activated in February 2011.
Intervention group 2
In July 2012, a system of service-specific sterile IUC placement was implemented. All patients who received CRS services were included. Patients who underwent colorectal procedures through general surgery and acute care surgery services were omitted.
Before the intervention, IUCs were placed in the operating room (OR) after perineal antiseptic preparation by a member of the operating team. Team members who performed IUC insertion included nurses, residents, and supervised medical students.
We changed our practice to specify that, for cases done in the lithotomy position, IUC be inserted after the surgeon had prepped the patient, scrubbed and gowned themselves, and then draped the patient.
For cases performed in the supine position, the patient was fully prepped, including the perineum, in the frog leg position with antiseptic prep. The IUC was then placed and the patient was repositioned and draped. The surgeon or resident who placed the IUC changed gloves after placement. The catheter was suspended from the drapes over the inner thigh with a clamp so that it remained away from the anal area in the event of a transanal anastomosis or perineal procedure. We continued our 100 percent compliance with perioperative antibiotic administration.
ACS NSQIP criteria were used to define a UTI.13 Excluded from analysis were patients who had shown signs of a pre-existing UTI. Patients with enterovesical, colovesical, or colon or rectal vaginal fistulae were classified as having a preexisting UTI. The three groups from our institution’s ACS NSQIP abstracted data include the following: between January 2010 and February 14, 2011 (control group); February 15, 2011, to June 2012 (intervention 1 group: electronic order prompt); and July 2012 to December 2012 (intervention 2 group: sterile intraoperative IUC placement) were compared. To identify our cohort, we used the procedural terminology codes described by Ingraham and colleagues.14
We analyzed demographics, patient comorbidities, perioperative morbidity, type of operation (abdominal versus pelvic surgery), and rate of UTI. We analyzed patients who developed a UTI in our population and classified them as having no risk factors (that is, perioperative insertion alone), reinsertion of catheter in the postoperative period, or IUC for more than 48 hours.
What resources were used?
The CRS team, composed of attending surgeons and residents, nurse practitioners, and registered nurses, were involved from the inception of the new practice changes and continue to be engaged in maintaining the sterile IUC protocol.
No funding was allocated to piloting and implementing these changes, and no additional costs were incurred to develop or sustain this practice.
What were the results?
All of the analyses were conducted using IBM statistical package for the social sciences (SPSS) statistics version 21.0.0 for Macintosh. Categorical variables were analyzed using the X2 or Fisher’s exact test where appropriate. Continuous variables were compared using the 2-tailed sample t test or Analysis of Variance (also known as ANOVA) as appropriate. Multiviable logistic regression was performed to determine independent predictors of UTI. All of the variables with a p-value <0.05 on bivariate analysis were included in the model. Forward stepwise selection was used to determine final independent predictors. Throughout all of the analyses, statistical significance was determined by a criterion of p < 0.05.
A total of 811 cases were identified that met inclusion criteria across the three study periods: the control period (January 2010 to February 14, 2011) included 215 cases; intervention 1 (February 15, 2011, to June 2012) included 476 cases; and intervention 2 (July 2012 to December 2012) included 120 cases. Demographics, including patient comorbidities and American Society of Anesthesiologists (ASA) classification, were similar across all of the study periods. Operations without pelvic dissection—that is, segmental colectomy or total abdominal colectomy—comprised 63 percent of the whole. Overall, 37 percent of the cases required pelvic surgery, defined as proctectomy, proctocolectomy, and abdominoperineal resection.
Within intervention group 2, 45 percent of the cases required pelvic surgery. This outcome was attributed to the fact that only colorectal surgeons adopted this intervention. This difference should theoretically bias toward a higher UTI rate in group 2. However, the UTI rate in the control group and intervention group 1 did not differ on the basis of surgeon specialty.
UTI occurred at a rate of 6.9 percent in the control group, dropped to 2.7 percent after intervention 1, and was 0.8 percent in intervention group 2 (See Figure 1). The decrease in UTI across the groups was statistically significant at p < 0.004 (see Table 1). After initiation of sterile intraoperative IUC placement, no ACS NSQIP UTIs were identified on the CRS service during an initial four-month study period (106 cases). In the ensuing two months, one patient developed a UTI after having ureteral reconstruction and double-J stent placement at the time of colorectal operation.
Figure 1. UTI rates
Table 1. 30-day postoperative outcomes
Mean duration of IUC for intervention group 2 was 2.2 days. Overall, 77 percent of the patients in this group had IUC removal by postoperative day two. IUC reinsertion rate in this group was 11 percent. Our practice in the immediate postoperative period is to replace IUC for urinary retention rather than to use intermittent catheterization. For the control patients and patients in intervention group 1, documentation of IUC removal and reinsertion was not consistently available to provide reliable data.
Bivariate analysis was used to further compare patients who developed UTI (n = 29) with those who did not (n = 782). Independent predictors of UTI on multivariable regression are shown in Table 3. Superficial surgical site infection predicted UTI development (OR, 3.7 [95 percent CI, 1.4–9.8]), whereas the study interventions were each protective when compared with controls (group 1: OR, 0.4 [95 percent CI, 0.2–0.8]; group 2: OR, 0.1 [95 percent CI, 0.0–0.8]).
Postoperative 30-day outcomes were notable for this significant decrease in UTIs, as well as an overall decrease in morbidity (p = 0.05). The decreased rate of UTIs contributed to a decrease in overall morbidity in the intervention 2 group to 24 percent compared with 35 percent for the control and intervention 1 groups (see Table 1 above).
All of the UTI patients were stratified as having no risk factors (43 percent), IUC greater than 48 hours (30 percent), reinsertion of IUC (10 percent), and reinsertion of IUC for more than 48 hours (17 percent). Among patients who required IUC reinsertion, IUC for more than 48 hours, or both, 59 percent had pelvic surgery and more than 10 percent had pelvic radiation therapy. The patients who had no risk factors for UTI other than the perioperative placement of the IUC were found solely in the control and intervention 1 groups (see Tables 2 and 3).
Table 2. Comparison of UTI cases with non-UTI cases
Table 3. Independent predictors of UTI
What conclusions did we draw from the findings?
As the authors of this article reported in 2014, the protocol of sterile intraoperative catheter placement alone essentially eliminated UTIs associated with catheter placement.15 The somewhat simple change from preoperative to intraoperative sterile urinary catheterization also had significant impact on reducing UTIs in our CRS patients. This practice change was really a culture change that involved the CRS service. Nursing engagement continues to drive this practice and ensure compliance by all team members. This practice essentially eliminated UTIs that were associated only by the fact that an indwelling catheter was placed under sterile conditions.
- Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166.
- Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28(1):68-75.
- Platt R, Polk BF, Murdock B, Rosner B. Mortality associated with nosocomial urinary-tract infection. N Engl J Med. 1982;307(11):637-642.
- Centers for Medicare & Medicaid Services. U.S. Department of Health and Human Services. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates. Fed Reg. 2007;72:24679-24726.
- Ricciardi R, Baxter NN, Read TE, Marcello PW, Schoetz DJ, Roberts PL. Surgeon involvement in the care of patients deemed to have “preventable” conditions. J Am Coll Surg. 2009;209(6):707-711.
- Regenbogen SE, Read TE, Roberts PL, Marcello PW, Schoetz DJ, Ricciardi R. Urinary tract infection after colon and rectal resections: More common than predicted by risk-adjustment models. J Am Coll Surg. 2011;213(6):784-792.
- Attaluri V, Kiran RP, Vogel J, Remzi F, Church J. Risk factors for urinary tract infections in colorectal compared with vascular surgery: A need to review current present-on-admission policy? J Am Coll Surg. 2011;212(3):356-361.
- The Joint Commission. 2011–2012 National Patient Safety Goals. Available at: http://www.jointcommission.org/mobile/standards_information/national_patient_safety_goals.aspx. Accessed February 14, 2017.
- Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the postoperative period: Analysis of the national surgical infection prevention project data. Arch Surg. 2008;143(6):551-557.
- Benoist S, Panis Y, Denet C, Mauvais F, Mariani P, Valleur P. Optimal duration of urinary drainage after rectal resection: A randomized controlled trial. Surgery. 1999;125(2):135-141.
- Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-326.
- Zmora O, Madbouly K, Tulchinsky H, Hussein A, Khaikin M. Urinary bladder catheter drainage following pelvic surgery–is it necessary for that long? Dis Colon Rectum. 2010;53(3):321-326.
- American College of Surgeons User guide for the 2008 participant use data file. American College of Surgeons. ACS NSQIP. Available at: facs.org/~/media/files/quality%20programs/NSQIP/UG08.pdf. Accessed February 14, 2017.
- Ingraham AM, Cohen ME, Bilimoria KY, et al. Comparison of hospital performance in nonemergency versus emergency colorectal operations at 142 hospitals. J Am Coll Surg. 2010;210(2):155-165.
- Nagle D, Curran T, Anez-Bustillos L, Poylin V. Reducing urinary tract infections in colon and rectal surgery. Dis Colon Rectum. 2014,57(1):91-97.