Postoperative Urinary Tract Infection Is Impacted by Routine Foley Catheter Placement in Bariatric Surgeries

General Information 

Institution Name: Stony Brook University Hospital

Submitter Names and Titles: Stella T. Tsui, BS, Medical Student; Talar Tatarian, MD, Clinical Instructor of Surgery; and Aurora D. Pryor, MD, FACS, Professor of Surgery

Name of the Case Study: Postoperative Urinary Tract Infection Is Impacted by Routine Foley Catheter Placement in Bariatric Surgeries

What Was Done? 

Global Problem Addressed 

Urinary tract infection (UTI) accounts for up to 40 percent of health care- associated infection and up to 80 percent of UTIs are catheter-associated (CAUTI).¹ Routine use of indwelling urinary catheters (IUCs) in the perioperative setting contribute to CAUTI.² CAUTI commonly leads to unnecessary antimicrobial use, prolonged hospitalization, bacteremia, and increased health care costs.³

In bariatric patients undergoing surgery at an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) hospital, UTI accounts for 17 percent of all postdischarge complications.⁴ IUC use was independently found to be significantly associated with UTI following laparoscopic bariatric surgery, regardless of the duration of catheterization.⁵

CAUTI is therefore a preventable complication leading to morbidity in bariatric surgery patients.

Identification of Local Problem 

Incidence of UTI is used as a marker of bariatric surgical outcomes by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). When comparing our institution’s outcomes with national benchmarks, we found that we had a relatively higher rate of UTI in the bariatric patient population. Given our institution’s commitment to delivering quality patient care, we felt that measures needed to be taken to improve these outcomes.

How Was the Quality Improvement (QI) Activity Put in Place? 

Context of the QI Activity 

Stony Brook University Hospital is a tertiary academic medical center with more than 600 beds providing care to a suburban community in Long Island, NY. The surgical volume is 24,000 cases per year. Stony Brook University Hospital was named one of Healthgrades “America’s 100 Best Hospitals” for 2019 based on actual clinical outcomes. The Stony Brook Bariatric Surgery Center has been an accredited bariatric center with MBSAQIP accreditation since 2013. This quality QI project was undertaken in 2015 in order to address our high rate of CAUTI. There was no hospital-wide oversight in the project.

Planning and Development Process 

The Centers for Disease Control and Prevention guidelines suggest using IUCs only when absolutely necessary and removing them as soon as possible. The guidelines advise against use for the convenience of patient-care personnel.⁶ This indicates that the most effective primary prevention of CAUTI is to limit the use of IUCs to when it is clinically indicated and necessary. There are currently no published guidelines regarding the placement and removal of IUCs in patients undergoing bariatric surgery.

Our bariatric group is comprised of four attending surgeons, all of whom would routinely place IUCs intra-operatively prior to initiation of this QI study.

IUCs would be removed on the morning of postoperative day one. We first organized multiple team meetings to review our post-surgical outcomes related to CAUTI. This review led to a consensus among all surgeons that routine use of IUCs was not clinically necessary for all bariatric operations. The surgical group subsequently met with the anesthesia team to achieve consensus on perioperative catheter use.

Description of the Quality Improvement Activity 

Based on the incidence of UTI in the MBSAQIP report, we felt that a patient outcome improvement measure was required. A urinary catheter avoidance protocol was constructed to address the problem. With this new protocol, IUCs were no longer placed intraoperatively in adult patients undergoing bariatric surgery. Instead, IUCs were only placed for postoperative urinary retention (in other words, patient is unable to void within 6 hours postoperatively). This catheter avoidance protocol was first implemented July 1, 2014. Data were prospectively collected after implementation of the catheter avoidance protocol and were compared with pre-protocol outcomes.

Resources Used and Skills Needed

Staff

We used four bariatric surgeons, two anesthesiologists, one minimally invasive and bariatric surgery fellow, one physician assistant, one nurse practitioner, and three nursing and 10 ancillary staff from the bariatric office, preoperative units, postoperative recovery units, medical surgical units, and operating room.

Costs

No additional costs were required beyond normal hospital operations to implement and maintain the QI program. No additional funding sources were necessary.

What Were the Results?

Overall Results 

Sixty months of pre- and post-protocol UTI rates were compared. We identified 171 patients in the pre-catheter avoidance protocol group and 523 patients in the post-protocol group (Table 1). There was a significant difference in the average incidence rates of postoperative UTI in pre-protocol (2.924%) and post- protocol (0.574%) groups (p=0.0009) (Figure 1). Discontinuation of routine IUC placement resulted in an 80.4 percent relative risk reduction in postoperative UTI compared with routine IUC placement.

Avoiding routine urinary catheter placement led to a reduction in postoperative UTI for patients undergoing bariatric surgery. These data support the discontinuation of routine urinary catheter placement in best practices protocols.

Setbacks

There was initial hesitation by our anesthesia colleagues, as perioperative IUCs are used as a method of perioperative monitoring. However, after a multidisciplinary meeting and a review of clinical outcomes, we were able to reach a consensus in an effort to improve outcomes.

Cost Savings

No money was invested in implementing the QI project. The per-patient cost to the hospital for a symptomatic UTI is approximately $911, and the cost of an IUC is approximately $17.7 Given the 80.4 percent relative risk reduction due to the protocol change, the estimated costs savings of catheter avoidance is approximately $6,704/year ($3,644 for UTI treatment, $3,060 IUC cost assuming 180 cases/year). Additionally, the hospital operating room fee is about $66 per minute.8 Assuming it takes approximately two minutes to place an IUC, catheter avoidance saves an additional $23,760 annually. This is an estimated total cost savings of $30,464 annually.

Tips for Others 

While funding is not necessary, multidisciplinary buy-in is imperative to implementing a new protocol. We recommend a review of institutional CAUTI outcomes to determine if there is room for improvement. With the data at hand, a meeting can be organized with surgeons, anesthesiologists, and other care team members to determine how best to implement change at a given institution. By initiating collaboration between departments, it brings more attention and awareness to the problem at hand. Moreover, if positive change is seen, new practices may be adopted hospital-wide to further reduce the incidence of CAUTI.

References

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6. Stamm WE. Guidelines for Prevention of Catheter-Associated Urinary Tract Infection. Ann Intern Med. 1975;82(3):386- 390. 
7. Kennedy EH, Greene MT, Saint S. Estimating Hospital Costs of Catheter-Associated Urinary Tract Infection. J Hosp Med. 2013;8(9):519-522. 
8. Shippert RD. A Study of Time-Dependent Operating Room Fees and How to save $100000 by Using Time-Saving Products. Am J Cosm Surg. 2005;22:25-34.