Urinary tract infections (UTIs) increase morbidity, mortality, and health care costs and prolong hospitalizations for patients who require urinary catheters—especially those who undergo long, complex surgeries or procedures to treat urological or gynecological cancers. To reduce the incidence of UTIs, clinicians at The University of Texas MD Anderson Cancer Center developed a quality improvement program for surgical patients at the institution.
Nationwide, postoperative UTIs occur in 2%–5% of surgical patients. In 2011, surgeons at MD Anderson reviewed the records of approximately 800 consecutive surgical patients and found that UTIs occurred within 30 days after surgery in 2.9% of the patients. The surgeons compared this rate with the rates at other member institutions of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP), which maintains a database of patient outcomes. The analysis indicated that although MD Anderson’s postoperative UTI rate was lower than the rates seen at many institutions, there was room for improvement. For that reason, UTIs became the focus of a data-driven quality improvement effort within the Division of Surgery.
“MD Anderson is a remarkable place in terms of being data driven,” said Thomas Aloia, M.D., an associate professor in the Department of Surgical Oncology and the institution’s liaison with the ACS. “When we have presented people at the institution with data that say we can do better, we’ve yet to encounter resistance to improvement from anyone. Our providers want to improve, and they want the best outcomes for our patients.”
Reducing UTI rates
To address the issue of UTIs, the Division of Surgery assembled a team of surgeons, nurses, anesthesiologists, pharmacists, advanced practice providers, trainees, and environmental engineers to examine the institution’s use of urinary catheters, which are used in almost all patients who undergo surgery in the institution’s main hospital. The team instituted a quality assessment and improvement program called S.T.O.P. UTI, which was named for the program’s four aspects of catheter management:
- sterile placement of the catheter,
- timely removal of the catheter,
- optimal positioning of the catheter (i.e., to avoid reflux of urine into the bladder), and
- proper sampling (i.e., obtaining clean urine samples to validate a diagnosis of UTI).
The initial assessment helped the team target areas for improvement, which included changes to nursing protocols and consolidation of materials required for catheter placement. From 2012, when S.T.O.P. UTI was launched, to 2015, postoperative UTI rates at MD Anderson dropped from 2.90% to 0.46%. And there was an added bonus: the UTI rates for patients who had urinary catheters placed but did not undergo surgery also fell, from 2.4% in 2014 to 0.6% in 2015, even though S.T.O.P. UTI was an improvement program specific to the Division of Surgery.
“There were no simultaneous programs in other divisions to explain those results,” Dr. Aloia said. “So we concluded that the lessons learned in the early part of the surgical quality improvement program had diffused to the whole institution. The ACS searched the literature, and as far as they can tell, this is the first instance of a surgical quality improvement program of this type spreading institutionwide. Significant credit needs to be given to the nursing staff, who were involved in the process improvement from the beginning and applied the new nursing protocols to all hospitalized patients with urinary catheters, not just surgical patients. Ultimately, the whole hospital benefitted.”
The initial report on the S.T.O.P. UTI initiative was presented at the 2014 ACS NSQIP Annual Conference; and at the 2016 conference this July, Dr. Aloia and his colleagues gave a follow-up presentation about the program’s institution-wide impact. Since then, institutions around the country have contacted MD Anderson to ask about the program.
“The S.T.O.P. UTI program is a tool that any institution can use to evaluate its procedures for catheter use, find any weak links, and fix them,” Dr. Aloia said. “Hopefully, the word will get out.”
Other quality improvement projects
Since reducing the UTI rate at MD Anderson, Dr. Aloia and his colleagues have turned their attention to other quality improvement projects (see Enhanced Surgical Recovery Programs for Cancer Patients, OncoLog, September 2015). Among the issues addressed by these projects are surgical wound infections and postoperative pneumonia; the rates of both have dropped 30% since the projects were initiated.
“We keep going after any area where we can improve,” Dr. Aloia said. “Our latest report from the NSQIP says MD Anderson is exemplary across the board, and that’s largely because we systematically address issues whenever they arise. Our quality improvement efforts have gone very well.”
For more information, contact Dr. Thomas Aloia at 713-563-0189 or email@example.com or visit the American College of Surgeons National Surgical Quality Improvement Program.
OncoLog, October 2016, Volume 61, Issue 10