Jennifer Meddings, MD, MSc; Milisa Manojlovich, PhD, RN; Jessica M. Ameling, MPH; Russell N. Olmsted, MPH, CIC; Andrew J. Rolle, MPH; M. Todd Greene, PhD, MPH; David Ratz, MS; Ashley Snyder, MPH; Sanjay Saint, MD, MPH
Disclaimer: The findings and conclusions in this report are those of the authors and do not represent the official position of the CDC, the American Hospital Association, or the Department of Veterans Affairs.
Acknowledgment: The authors thank the Health Research & Educational Trust (HRET) Health Care-Associated Infection team, as well as the National Program Team and all members of the CDC STRIVE collaborative. The authors also thank Rachel Ehrlinger, BA; Jason Engle, BS; Karen E. Fowler, MPH; and Jason Mann, MSA, for assistance with manuscript preparation.
Financial Support: Dr. Meddings' work was partially funded by concurrent support from Agency for Healthcare Research and Quality (AHRQ) (K08 HS19767).
Disclosures: Dr. Meddings, Dr. Manojlovich, Ms. Ameling, Dr. Greene, Mr. Ratz, Ms. Snyder, and Dr. Saint report a contract from the CDC with the HRET, which subcontracted with the University of Michigan to support faculty/staff effort for this contract, during the conduct of the study. Dr. Meddings also reports an AHRQ K08 grant during the conduct of the study; employment by the University of Michigan Medical School (Michigan Medicine), VA Ann Arbor Healthcare System, and the Center for Clinical Management Research; being an investigator on an AHRQ contract with HRET; and receipt of honoraria for presentations from various professional and nonprofit organizations and QuantiaMD outside the submitted work. In addition, Dr. Meddings' research involves development of products to improve patient safety by reducing hospital-acquired complications, and her team has a provisional patent involving one of these products (US20180339133A1). She has no associations with any companies or manufacturers, has no ownership in a commercial entity, and receives no royalties. Mr. Olmsted reports personal fees from the HRET during the conduct of the study and personal fees from Ethicon, Inc., outside the submitted work. Mr. Rolle reports a CDC contract to the HRET during the conduct of the study. Dr. Saint also reports personal fees from Doximity and Jvion during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3534.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Not applicable. Statistical code: Available from Dr. Greene (e-mail, firstname.lastname@example.org). Data set: Not available.
Corresponding Author: Jennifer Meddings, MD, MSc, University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109-2800; e-mail, Meddings@umich.edu.
Current Author Addresses: Drs. Meddings, Greene, and Saint, Ms. Ameling, and Ms. Snyder: University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800.
Dr. Manojlovich: University of Michigan School of Nursing, 400 North Ingalls Building, Room 4306, Ann Arbor, MI, 48109-5482
Ms. Fowler and Mr. Ratz: Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI 48113-0170.
Mr. Olmsted: Integrated Clinical Services, Trinity Health, 20555 Victor Parkway, Livonia, MI 48152.
Mr. Rolle: Health Research & Educational Trust, American Hospital Association, 155 North Wacker Drive, Suite 400, Chicago, IL 60606.
Author Contributions: Conception and design: J. Meddings, J.M. Ameling, R.N. Olmsted, A.J. Rolle, M.T. Greene, S. Saint.
Analysis and interpretation of the data: J. Meddings, M. Manojlovich, R.N. Olmsted, M.T. Greene, D. Ratz, A. Snyder, S. Saint.
Drafting of the article: J. Meddings, J.M. Ameling, M.T. Greene, D. Ratz.
Critical revision of the article for important intellectual content: J. Meddings, M. Manojlovich, J.M. Ameling, R.N. Olmsted, A.J. Rolle, M.T. Greene, D. Ratz, S. Saint.
Final approval of the article: J. Meddings, M. Manojlovich, J.M. Ameling, R.N. Olmsted, A.J. Rolle, M.T. Greene, D. Ratz, A. Snyder, S. Saint.
Provision of study materials or patients: A.J. Rolle.
Statistical expertise: M.T. Greene, D. Ratz, A. Snyder.
Obtaining of funding: S. Saint.
Administrative, technical, or logistic support: J. Meddings, J.M. Ameling.
Collection and assembly of data: A.J. Rolle, M.T. Greene.
Many hospitals struggle to prevent catheter-associated urinary tract infection (CAUTI).
To evaluate the effect of a multimodal initiative on CAUTI in hospitals with high burden of health care–associated infection (HAI).
Prospective, national, nonrandomized, clustered, externally facilitated, pre–post observational quality improvement initiative, for 3 cohorts active between November 2016 and May 2018.
Acute care, long-term acute care, and critical access hospitals, including intensive care and non–intensive care wards.
Target hospitals had a high burden of Clostridioides difficile infection plus central line–associated bloodstream infection, CAUTI, or hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection, defined as cumulative attributable differences above the first tertile in the Targeted Assessment for Prevention (TAP) strategy. Some additional nonrecruited hospitals also joined.
Multimodal intervention, including Practice Change Assessment tool to identify infection prevention and control (IPC) and HAI prevention gaps; Web-based, on-demand modules involving onboarding, foundational IPC practices, HAI-specific 2-tiered approach to prioritize and implement interventions, and TAP resources; monthly webinars; state partner–led in-person meetings; and feedback. State partners made site visits to at least 50% of their enrolled hospitals, to support self-assessments and coach.
Rates of CAUTI and urinary catheter device utilization ratio.
Of 387 participating hospitals from 23 states and the District of Columbia, 361 provided CAUTI data. Over the study period, the unadjusted CAUTI rate was low and relatively stable, decreasing slightly from 1.12 to 1.04 CAUTIs per 1000 catheter-days. Catheter utilization decreased from 21.46 to 19.83 catheter-days per 100 patient-days from the pre- to the postintervention period.
The intervention period was brief, with no assessment of fidelity. Baseline CAUTI rates were low. Patient characteristics were not assessed.
This multimodal intervention yielded no substantial improvements in CAUTI or urinary catheter utilization.
Centers for Disease Control and Prevention.
STRIVE project timeline.
Outcome data were catheter-associated urinary tract infections as reported by participating hospitals to the CDC National Healthcare Safety Network. CDC = Centers for Disease Control and Prevention; ICAR = Infection Control Assessment and Response; PCA = Practice Change Assessment; SHA = state hospital association; STRIVE = States Targeting Reduction in Infections via Engagement; TAP = Targeted Assessment for Prevention.
Study flow diagram.
CAD = cumulative attributable difference; CDC = Centers for Disease Control and Prevention; CAUTI = catheter-associated urinary tract infection; HAI = health care–associated infection; NHSN = National Healthcare Safety Network.
* “States” includes the District of Columbia.
† “Withdrew” defined as hospital and state jointly decided the hospital would stop participating in the program.
‡ 251 hospitals self-reported that they focused on CAUTI prevention during the program.
Table 1. Characteristics of Participating Hospitals That Submitted CAUTI Data*
CAUTI rates per 1000 catheter-days and urinary catheter utilization per 100 patient-days for the 361 hospitals that provided CAUTI data.
Rates are shown by month for the 12-month preintervention (baseline) and 12-month postintervention periods. The solid line represents the monthly rates; dashed lines represent the 95% CIs. B = baseline month; CAUTI = catheter-associated urinary tract infection; M = intervention month.
Appendix Table 1. Aggregated Monthly CAUTI and Urinary Catheter Utilization Data From the 361 Participating Hospitals That Submitted CAUTI Data
Table 2. Pre- and Postintervention CAUTI Data, by Hospital Type
Hospital-level CAUTI rates during the pre- and postintervention periods (n = 355).
In this Sankey bar chart, the connecting segments show how hospitals changed from the pre- to the postintervention periods. The slopes of the connecting segments should be interpreted cautiously because some segments connecting to the same rate category are increasing or decreasing visually but indicate no change in rates in these hospitals. Only segments that connect to a different category indicate changes in rates from the pre- to the postintervention period. CAUTI = catheter-associated urinary tract infection.
Appendix Table 2. Comparison of CAUTI Rates Between the Pre- and Postintervention Periods
Meddings J, Manojlovich M, Ameling JM, et al. Quantitative Results of a National Intervention to Prevent Hospital-Acquired Catheter-Associated Urinary Tract Infection: A Pre–Post Observational Study. Ann Intern Med. 2019;171:S38–S44. doi: https://doi.org/10.7326/M18-3534
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Published: Ann Intern Med. 2019;171(7_Supplement):S38-S44.
Hospital Medicine, Hospital-Acquired Infections, Infectious Disease, Nephrology, Urinary Tract Infection.
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