Vignette 1

A 75 year-old-man with a history of hypertension was admitted to an acute-care hospital for worsening back pain. While undergoing additional work-up, his pain was managed with opioids. On day 3, he developed urinary retention, for which the clinician ordered the placement of an indwelling urinary catheter. Unfortunately, the patient’s assigned nurse was not properly trained in catheter insertion—particularly for older men with higher risk for difficult urinary insertion due to benign prostatic hypertrophy—resulting in a traumatic hematuria and excessive discomfort for the patient. Due to absence of bacteriuria and fever, and no standard requirements or recommendations for documenting traumatic injuries from urinary catheter use, this adverse event was not included in the hospital’s CAUTI count, was not flagged for inclusion in the hospital’s quality review process (triggered by NHSN CAUTIs), and was not reported to the state health department or CMS.

Vignette 2

A 60 year old woman was admitted to an acute-care hospital from long-term care facility for management of a fall that caused to a hip fracture. An external urinary collection device was placed on admission due to immobility in the setting of acute fracture pain and chronic urinary incontinence, with the goal of preventing CAUTI by avoiding placement of an indwelling urinary catheter. On day 3 of the hospitalization, a urine culture was obtained for some discomfort with urination, interpreted by clinicians as dysuria (in the setting of an external urinary catheter whose placement and movement can irritate the female urethral meatus, particularly in postmenopausal women). A urine sample collected from the 3-day-old external catheter grew >100,000 colony-forming units per milliliter (CFU/mL) of Escherichia coli, for which she received 7 days of oral ciprofloxacin. The case did not meet the NHSN CAUTI definition due to absence of indwelling urinary catheter. This case was not reported, yet this was an instance of inappropriate urine testing. The patient had another likely and reversible cause of urethral meatus irritation than UTI, urine was collected from an external catheter that had been in place for days, from this postmenopausal older female patient with a high baseline likelihood of asymptomatic bacteriuria. Ideally, this inappropriate antibiotic treatment—by initial antibiotic selection as well as starting an antibiotic in response to a positive urine culture collected by inappropriate method and indication—should have been flagged and reported for the purposes of quality improvement.

Catheter utilization

Standardized utilization ratio (SUR) and device utilization ratio (DUR) are objective measures that capture overall catheter use and allow for some estimation of infectious and noninfectious harms. DUR is the ratio of catheter days to patient days for a specified period. SUR is the ratio of observed to predicted catheter days, is compared to a national benchmark, and is risk adjusted to allow comparisons across different populations and multiple hospitals. ^{19–Reference Abrantes-Figueiredo, Ross and Banach21}

Urine test utilization

Although efforts to identify symptomatic UTIs continue, a hospital’s diagnostic performance can be evaluated by measuring urine-culture utilization rates (or urinalysis rates in outpatient settings), which can reflect urine test use in both catheterized and noncatheterized patients. Urine-culture utilization rates can be extracted from electronic medical records and can be risk adjusted, similar to blood-culture utilization rates. ^{Reference Bates, Goldman and Lee22} Furthermore, electronic identification of patients with hospital-onset bacteriuria (similar to hospital-onset bacteremia) is possible.

Urine-culture contamination

Urine-culture contamination is usually reflected by the rate of mixed flora in urine cultures, the incidence of which is increasing in inpatient and outpatient settings (>40%). ^{Reference Whelan, Nelson and Kim23} Contaminated or mixed-flora (usually defined as ≥3 species in a urine culture) urine-culture rates often reflect specimen collection, transport, and storage practices. They can pose a diagnostic challenge to clinicians due to false-positive or false-negative test results. Measuring urine-culture contamination is important for the same reasons as measuring blood-culture contamination: to improve collection, transport, and diagnostic accuracy and to reduce overuse of additional tests and antibiotics. ^{Reference Alahmadi, Aldeyab and McElnay24,Reference Garcia, Spitzer and Beaudry25}

Composite measure of catheter harm

Catheter harm encompasses both infectious complications (eg, catheter-associated bacteriuria, infection) and noninfectious catheter-related complications (eg, urethral injury, pain, falls, catheter obstruction, deep vein thrombosis). ^{Reference Patel, Advani and Kofman26} Future research is needed to develop and validate a composite measure for catheter harm that reflects a comprehensive picture of catheter care and urine testing while allowing for electronic capture of data elements (Fig. 1). ^{Reference Fakih and Advani27}

Figure 1. Full spectrum of catheter harm.

Ventilator-associated harm

In the realm of ventilator-associated harm, the Centers for Disease Control and Prevention (CDC) developed the ventilator-associated event (VAEs) metric. The VAE metric was specifically designed to broaden the scope of surveillance to include noninfectious harms in addition to pneumonia. ^{Reference Klompas9} Indeed, pneumonia only accounts for ∼33% of VAEs. The rest are mostly attributable to volume overload, acute respiratory distress syndrome (ARDS), and atelectasis. Comprehensive programs to prevent VAEs consequently include measures designed to avoid noninfectious harm from ventilators such as avoiding mechanical ventilation when possible, minimizing sedation, facilitating early extubation, maintaining euvolemia, and using low-tidal-volume ventilation, in addition to pneumonia prevention measures such as elevating the head of the bed, providing comprehensive oral care including toothbrushing, and maintaining ventilator circuits. ^{Reference Klompas28,Reference Klompas, Branson and Cawcutt29}

Nonventilator pneumonia

The CDC is currently exploring novel metrics to capture nonventilator hospital-acquired pneumonia (NV-HAP). NV-HAP accounts for ∼65% of all hospital-acquired pneumonia. It is associated with morbidity and mortality rates similar to VAP, yet hospital surveillance programs and prevention guidelines traditionally have not addressed NV-HAP. The CDC has sponsored the ongoing development of a potentially automatable surveillance definition for NV-HAP to facilitate widespread, objective, and efficient surveillance. ^{Reference Ji, McKenna and Ochoa30,Reference Jones, Sarvet and Ying31} The latest version of the Compendium: 2022 Updates on prevention of hospital-acquired pneumonia now includes a section on preventing NV-HAP, highlighting the importance of rigorous oral care, mobilizing patients, and identifying patients with dysphagia so that additional measures to prevent aspiration can be implemented. ^{Reference Klompas, Branson and Cawcutt29}

Vascular device-associated infections and harms

The NHSN has a forthcoming metric on hospital-onset bacteremia that will broaden bloodstream infection surveillance to include all hospital-onset bacteremia and fungemia cases, not just those associated with central lines. This metric considers additional indwelling vascular devices that may serve as foci for bacteremia besides central lines, including arterial catheters, midline catheters, and peripheral intravenous catheters. ^{Reference Buetti, Marschall and Drees32} More broadly, some HAIs may lead to secondary bacteremia independent of an intravascular catheter, and they are also important sources of morbidity and mortality that merit attention and prevention. As with CAUTI, contamination of culture is a risk with the potential for triggering unnecessary and harmful treatments. ^{Reference Doern, Carroll and Diekema33} Noninfectious risks, such as catheter thrombosis, may lead to obstruction and malpositioning that can result in vascular injuries. These noninfectious risks are more appreciated with vascular catheters than with urinary catheters and also can increase the risk for infection. ^{Reference Jumani, Advani, Reich, Gosey and Milstone3} Lastly, although only 1 urinary catheter or 1 endotracheal tube is usually in place, many patients may have 1 or more concurrent lines for vascular access. ^{Reference Jumani, Advani, Reich, Gosey and Milstone3} This can further increase the risk of harms to patients from vascular catheters.

Hospital-acquired sepsis

Similar considerations described below have informed the NHSN’s surveillance definition for adult sepsis events. ^{Reference Rhee, Dantes, Epstein and Klompas34} Sepsis is present at some time during hospitalization in 35%–50% of hospital deaths and costs Medicare alone >$22 billion per year. ^{Reference Rhee, Dantes and Epstein35} Notwithstanding its outsized impact on patient outcomes and costs, there is currently no systematic reporting of sepsis overall or hospital-acquired sepsis in particular to public health authorities. An advantage of surveillance for hospital-acquired sepsis in particular is 2-fold: (1) by definition, it focuses surveillance on a subset of patients with severe HAIs and (2) it captures many serious infections that are currently not-reportable including non–device-associated UTIs that lead to secondary sepsis, NV-HAP, surgical-site infections (both those that are currently reportable to CMS and those that are not), and hospital-onset bacteremia cases. The scope of hospital-acquired sepsis surveillance is broader than hospital-onset bacteremia insofar as only 15%–20% of patients with sepsis or septic shock are bacteremic. ^{Reference Rhee, Dantes and Epstein35}

The CDC adult sepsis event definition is designed to enable automated surveillance using electronic health record (EHR) data alone. It defines a sepsis event as the combination of suspected infection (as suggested by a blood culture draw, initiation of antibiotics, and continuation of antibiotics for at least 4 days) and concurrent organ dysfunction (initiation of vasopressors or mechanical ventilation, rise in creatinine or bilirubin, or drop in platelets). A side-by-side comparison of hospital-onset adult sepsis event surveillance with traditionally reportable HAIs in 3 hospitals revealed that hospital-onset adult sepsis events detected twice as many infections compared to currently reportable HAIs and identified more serious events than currently reportable HAIs insofar as reflected by higher mortality rates. ^{Reference Page, Klompas and Chan2}