December 2009

SCIP-9, Preventing Healthcare Associated Infections – Urinary Catheter Removal

By Roxanne Semmens, RN

Since the beginning of 2009 Q4, new measure sets have been included in the Surgical Care Improvement Project (SCIP).  The first of the additions in SCIP is Inf-9 – Urinary Catheter Removal on Postoperative Day 1 (POD1) or Postoperative Day 2 (POD2), with the day of surgery being Day 0.

Each year 16 to 25 percent of hospitalized patients in the United Sates have an indwelling catheter placed; which is approximately five million annually.  Approximately 1.5 million, or 29 percent, of these catheters are placed in the operating room.  This is a significant number that needs to be recognized. The risks of acquiring a urinary tract infection (UTI) depend on multiple factors including the method and duration of catheterization, the quality of catheter care and the patient’s susceptibility. Controlling these factors in the surgical patient can significantly decrease the potential for a urinary tract infection, control costs and lead to better patient outcomes.

Over the past several years, many studies have documented that the insertion of a urinary catheter can increase the daily risk of developing urinary tract infections from three to seven percent.  If a catheter remains in place for a full week, then the risk increases to approximately 25 percent.  An episode of catheter associated UTI (CA-UTI) can prolong hospital stays an average of almost a full day.  With more than one million cases annually, the Centers for Medicare and Medicaid Services (CMS) concluded that the annual cost of nosocomial UTI due to indwelling catheters is between $424 and $451 million. 

Beginning October 1, 2008, CMS put into effect a new rule designed to eliminate payment for “preventable hospital acquired complications”, including CA-UTI.  Further data collection will begin with:

New Date Elements

• Urinary Catheter
• Catheter Removed
• Reason for Continuing Urinary Catheterization

Inclusions – indwelling catheter

• 3 way catheter
• Coude catheter
• Council tip catheter
• Foley
• Indwelling

Exclusions

• External
• Texas

Data Element: Reasons for Continuing Urinary Catheterization

• Allowable Value “1” – there is documentation that the patient was in the ICU and receiving diuretics.

• Notes for abstraction – Allowable Value “1” does not require physician/ANA/PA documentation; however it must be documented that the patient was in the ICU on POD1 or POD2 AND that they were receiving diuretics.

• Allowable Value “2” – there is a physician/advanced practice nurse/physician assistant documentation of reasons for not removing the urinary catheter postoperatively.

• Notes for abstraction – Allowable Value 2 REQUIRES physician/ANA/PA documentation of the specific reason the catheter is not being removed.  An order to “continue catheter” will not suffice.  This documentation can ONLY be found on POD1 or POD2.

• Important Reminders

• Allowable Value “1” must have both ICU documentation AND documentation that the patient is receiving diuretics.
• Physician order cannot be used as diuretic documentation – you need to show administration.
• The physician must document specifically why the catheter is to remain after POD2.

• Suggested Data Sources – Allowable Value “2”: Physician/ANA/PA documentation only.

• Physician order
• Operative report
• Progress notes

How does this new quality measure impact patient care?  It is important to remember that the quality measure is evidence-based medicine.  In a recent survey, *researchers found that 56 percent of responding hospitals did not have systems in place for monitoring which patients had urinary catheters. This can serve as a helpful metric in assessing the usefulness and compliance with insertion criteria and identifying possible education opportunities for clinical staff on appropriate use.

Many strategies have been deployed to reduce catheter duration and should be used in conjunction with daily review.  Some of these include automatic stop orders, mandatory renewal orders that include documentation of indication, nurse driven instruments, development of new protocols, and quality improvement methodology.

Although hospitals will not be able to successfully implement all preventative elements or eliminate all catheter associated urinary tract infections overnight, a successful program involving careful planning, assessment to determine if the process is successful, modification and testing when necessary, and implication is a positive step in the right direction to reducing the rate of CA-UTIs.

*Saint S, Kowalski, CP et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis. 2008 Jan, 15, 46(2):243-250.

Editor’s Note: Roxanne Semmons, RN is a contributing consultant in Cary, NC for Clinical-Insights

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