Rethinking Quality Programs: Near-Perfect Compliance with the Joint Commission’s Scip-9 Had No Effect on Catheter Utilization, Urinary Tract Infections, or Urinary Retention at a Major Academic Medical Center

Background:

The Joint Commission’s Surgical Care Improvement Project (SCIP)-9 recommended removing indwelling urinary catheters (IUC) before postoperative day 2 to decrease urinary infection (UTI) risk. Our center implemented a best practice alert (BPA) in the electronic health record to enforce SCIP-9 with near-100% compliance.  We sought to study the effect of the BPA on catheter utilization, urinary tract infection (UTI), and postoperative urinary retention (POUR) as well as study the relationship between UTI, POUR, and length of stay (LOS). 

Methods:

This was a retrospective case control study of all general surgery patients hospitalized for at least 48 hours postoperatively with indwelling urinary catheters (IUC) placed at the time of surgery at a single academic center. We compared two 7 month periods before and after the BPA for catheter removal went into effect. Logistic regression was performed to identify risk factors for POUR and UTI as well as negative binomial regression to examine risks for prolonged length of stay.

Results:

1012 patients were studied (527 before the BPA, 635 after). There was no difference in days with an IUC (1.8 vs. 1.8 days, p=0.9), UTI rate per 1000 catheter days (8.2 vs. 10.4, p=0.7), or POUR (15% vs. 17%, p=0.4). On multivariate analysis, risk factors for UTI included female gender (OR 3.1, p=0.01) and catheter time over 4 days (OR 3.2, p=0.02). Independent risk factors for POUR included male gender (OR 1.9, p<0.001), catheter time 2 days or less (OR 2.7, p=0.001), and age (10-year increase OR 1.2, p<0.001). Both POUR and UTI were independent risk factors for prolonged length of stay, POUR was associated with an average of 7 days longer stay (p<0.001) and UTI with 4 additional days (p=0.003). 

Conclusions:

Near-perfect compliance with SCIP-9 did not affect the rate of UTI, POUR, or device utilization.  POUR has a larger adverse effect on LOS than UTI. These results call into question the value of process measures in improving actual outcomes, as well as the negative impact of POUR on clinical outcomes.