Among her group’s interventions, a patient safety checklist has been built, with questions about catheter use entered into a daily electronic progress note used by all services on the inpatient wards. One particularly successful strategy empowered nurses to determine whether continued catheter use seems justified and to ask physicians whether an “idle” CVC could be removed.
With a decline in CLABSI rates in ICUs and a shift in focus to the medical wards, Dr. Chernetsky Tejedor says, hospitalists are in a prime position to help reduce the inappropriate use of catheters and other invasive devices. More broadly, hospitalists may be well-suited to help change the culture of medicine toward a wider acceptance of proven interventions, such as central-line checklists.
Dr. Kavanagh argues that the slow and arduous process to move past what he calls “a huge resistance to checklists” and win universal adoption of such protocols “is not a good chapter in medicine.” He isn’t laying the blame at the feet of doctors alone, however. “In some institutions,” he says, “there needs to be a change from a profit-driven to a patient-centered culture.”
Greg Maynard, MD, MSc, SFHM, director of the University of California at San Diego Center for Innovation and Improvement Science and senior vice president of SHM’s Center for Hospital Innovation and Improvement, acknowledges the integral role of checklists in improvement efforts. He cautions, however, that they should be viewed as only one part of a multipronged approach.
As with hand hygiene, Dr. Maynard concedes that some facilities are still facing resistance from medical staff in integrating checklists into their routines, though he argues that an ingrained anti-checklist medical culture may not be solely at fault. “If you insert a checklist in such a way that it’s very inconvenient, that stops the flow of work,” he says, “you’re not going to have as much success as if you’ve thoughtfully designed it so that the checklist is called into play when it makes sense to bring it into play and made it easy to do, as opposed to difficult and awkward to do.”
In Focus: Catheter-Associated UTIs
Catheter-associated urinary tract infections (CAUTIs) account for roughly 1 in 3 healthcare-associated infections, according to the CDC. And yet many researchers say the “Rodney Dangerfield of HAIs” has long been overlooked.
A frequently cited study led by Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center, found that nearly 40% of attending physicians were unaware that their patients even had an indwelling urinary catheter.6
Dr. Saint has dubbed the phenomenon “immaculate catheterization” to highlight the glaring discrepancy. “Because we also found, in a significant number of patients, there was no documentation anywhere in the medical record that the catheter existed,” he says. “It’s not in the physician’s notes, it’s not in the nursing notes, but we knew it was there because we could see it coming out of the patient.” Catheters that were inappropriately placed, he found, were more often “forgotten” than appropriate ones.
Perhaps more than anything else, the startling observation underscores the intense need for basic awareness of the two biggest UTI risk factors: whether a catheter is used, and how long it’s left in place. “You can get marked reductions by just taking care of those two factors,” Health Watch USA’s Dr. Kavanagh says.
At the Ann Arbor VA Hospital, one unit’s presence of a “Patient Safety Professional” to help ensure better oversight virtually brought the inappropriate use of indwelling catheters to a standstill. Dr. Saint and his colleagues are now gathering data to determine whether that decrease has translated to a drop in infections.