Effect of the Implementation of a Urinalysis with Hold Culture on Rates of Catheter-Associated Urinary Tract Infection (CAUTI)

From the 2019 HVPAA National Conference

Dr. Philip Gary (Lankenau Medical Center), Dr. Kriti Pathak (Lankenau Medical Center), Dr. Ralph Tayyar (Lankenau Medical Center), Dr. Suzanne McAndrew (Lankenau Medical Center), Dr. Brett Gilbert (Lankenau Medical Center), Dr. Jonathan Doroshow (Lankenau Medical Center)

Traditionally, the standard for assessment of fever in a hospitalized patient with a current or recently removed indwelling urinary catheter was a urinalysis with reflex culture. As such, we created a new order “urinalysis with hold-culture” to encourage providers to evaluate the urinalysis and determine if culture is indicated before ordering. We hypothesized that the use of this order in all inpatients would reduce the detection of CAUTIs as defined by the CDC or IDSA that would have otherwise been false-positives.

Retrospective chart review was performed on hospitalized patients with documentation of “insertion of an foley catheter” and “urinalysis with hold-culture” during calendar years 2015 and 2016. Catheter insertion date, time, and removal, urinalysis, urine culture, complete blood count, nursing documentation, and progress notes were reviewed. CMS data for our hospital’s CAUTI rates were reviewed. Based on laboratory criteria for “reflexing” to culture, CAUTIs were deemed “potentially prevented” and cost-savings estimated.

Using CMS data, documented CAUTIs at our hospital for calendar years 2015 (pre-intervention) and for 2016 (post-intervention) were 23 and 16 respectively. Using our laboratory’s previous triggers for reflex culture (positive leukocyte esterase or nitrites) we estimated the number of cultures avoided as 56.

There was a decrease in the number of unnecessarily ordered urine cultures in the calendar year reviewed. Given changes in defining criteria for CAUTI (to exclude presence of yeast as a positive culture), we evaluated the 12 months before and after intervention. A decrease in annual CAUTI rates from 23 to 16 after intervention resulted. This reduction meets standards outlined by CMS to reduce CAUTI rates by 25% by 2020. Using 2007 inflation indices, this reduction represents an initial cost-savings to the hospital between $5306 and $7042. Our intervention resulted in a reduction in the number of cultures performed and analyzed. Given an absolute reduction of 56 urine cultures due to the avoidance of a reflex culture (when compared to previous criteria for reflex culture) and using our laboratory’s estimated cost of a urine culture of $92.00, we estimate additional cost-savings of around $5152.00 before reimbursement. Medicare reimbursement for urine culture is estimated to be $9.99. Given the cost of susceptibility testing for one organism of $91.00, further extrapolation of cost-savings could be argued. We feel our intervention led to a reduction in CAUTIs due to a decrease in false-positives with NNT = 30. This intervention represents potential cost-savings and avoidance of lost reimbursement to a hospital or health system. It also avoids unnecessary harm via unnecessary treatment with antibiotics and further morbidity associated with prolonged hospitalization.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog