STANDARDIZATION OF URINARY CATHETERIZATION GUIDELINES TO REDUCE PAEDIATRIC PERIOPERATIVE URINARY TRACT INFECTION RATES: A QUALITY IMPROVEMENT INITIATIVE

According to the Canadian Patient Safety Institute nosocomial urinary tract infections (UTIs) are the fourth leading cause of healthcare associated infections1. 80% of these are attributable to indwelling urethral catheters2. Nosocomial infections have been shown to often be preventable as well as negatively impact patient outcomes and healthcare costs3,4. As per the Canadian Institute for Health Information the cost of a UTI can range from $3,444 to $5,377 and the average length of stay increases by 3.4 to 5.3 days. Specific to paediatric nosocomial UTIs, increased rates of readmission and reoperation have been demonstrated5. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) – Paediatric semi-annual reports demonstrated consistently elevated paediatric UTI rates in our institution's paediatric surgical program, with an odds ratio of 1.9x compared to the predicted rate. The purpose of the quality improvement initiative was to reduce the rate of paediatric perioperative UTIs at our institution, with a specific project aim of achieving a 30% reduction in paediatric perioperative UTIs within 1 year of program initiation. A multidisciplinary working group was formed, with broad stakeholder involvement. Audits were performed to assess current perioperative catheterization practices and identify areas for improvement. A ‘permissive list’ was developed of paediatric surgical procedures for which catheters may be required. Consensus was achieved to standardize early urinary catheter removal except for urologic procedures. Educational campaigns focused on proper catheter insertion and maintenance techniques were developed. Standardization of urinary catheterization equipment, technique and maintenance was achieved. Electronic Medical Record order sets were developed to implement the above as a standardized ‘forcing function’. Project implementation was delayed due to the COVID-19 pandemic and secondary changes to elective surgery, leading to a two year project duration. By project completion, a 47% reduction in perioperative UTI rate was achieved. Additionally, 96% adherence to the ‘permissive lists’ was seen. Performance in the NSQIP-Paediatric program improved from ‘Needs Improvement’ to ‘Exemplary’ Status. Standardization of urinary catheterization indications, management and removal helped achieve a substantial decrease in UTI rates at a tertiary care Children's Hospital across all paediatric surgical services. The involvement of a diverse multidisciplinary team and broad stakeholder engagement helped achieve early buy-in to interventions. The use of forcing functions helped promote consistent early discontinuation of urinary catheters.