Utilization of a lock-out valve to decrease the common, costly, and preventable problem of catheter-associated urinary tract infections, "Beyond the Abstract," by Jennifer L. Young, MD

BERKELEY, CA (UroToday.com) - An estimated 1.7 million health care-associated infections occur in United States hospitals annually.[1] Urinary tract infections are the most common.[2] Approximately 80% of urinary tract infections are associated with the use of urinary catheters.[3] Costs attributable to catheter-associated urinary tract infections (CAUTIs) are estimated at $600 to 1,006 per episode.[4, 5, 6, 7] An episode of urinary tract-related bacteremia costs at least $2,800.[8] In 2002, an estimated 13,088 deaths were associated with urinary tract infections.[2]

"By failing to prepare, you are preparing to fail."
 Benjamin Franklin  (the inventor of the flexible urinary catheter)

Catheter-associated urinary tract infection was chosen by the Centers for Medicare and Medicaid Services (CMS) as one of the complications for which hospitals no longer receive additional payment to compensate for the extra cost of treatment as of October 1, 2008.

This will likely have a significant impact on Medicare payments to hospitals as payment to a hospital is determined by multiplying the hospital base payment by the diagnosis's “relative weight.” Prior to 2008, the payment would increase if the patient had a complication.

For example, a patient admitted to the University of Michigan with pneumonia would yield a payment of $6,072 if uncomplicated, $8,346 if complicated by a minor condition such as a catheter-associated urinary tract infection, and $11,891 if complicated by a major complication such as a renal abscess associated with a urinary catheter.[9]

Under the new rules, however, the hospital will receive payment of $6,072 for pneumonia without additional payment for treatment of catheter-associated urinary tract infection.[9] This is a loss of $2,274 for catheter-associated infection and $5,819 for renal abscess associated with a catheter.

In 2010, the Joint Commission proposed the implementation of evidence-based practices to prevent CAUTIs as one of its 2012 National Patient Safety Goals.[10] Most recently, among proposed changes to the Acute Care Hospital Inpatient Prospective Payment System (IPPS), the CMS announced it plans in 2014 to begin reporting rates of CAUTI publicly for hospitals participating in the Hospital Inpatient Quality Reporting Program, based on data submitted beginning in 2012.[11]

In terms of prevention, the Centers for Disease Control and Prevention proposed recommended practices for preventing catheter-associated urinary tract infection in 1981 that emphasized hand hygiene, aseptic catheter insertion, and proper maintenance using a closed urinary drainage system.[12] In 2008, the Healthcare-Associated Infection Taskforce from the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America provided an evidence-based compendium of the various practices available.[13, 14]

Saint et al made recommendations for hospitals to address the Center for Medicare and Medicaid rule changes regarding catheter-related urinary tract infection:

  1. Develop or adopt protocols[15, 16, 17] to ensure indwelling urinary catheters are used only when medically indicated and that they are inserted and maintained with correct technique.
  2. Create a list of indications for indwelling catheters to limit catheter use. For example: urinary retention, monitoring of urinary output in critically ill patients, urinary incontinence that poses a risks such as skin breakdown or contamination of a surgical site, and some surgical procedures.
  3. Develop training standards for those who insert and mange catheters and drainage bags. Provide necessary supplies for catheter insertion and maintenance.
  4. Develop systems to promote removal of urinary catheters when they are no longer indicated. This could include daily review of catheter necessity during rounds; automated nurse or physician reminders of presence of a catheter; catheter stop-orders entered automatically with each order for catheter insertion so that discontinuation of the catheter becomes the default after a certain period of time.
  5. Educate clinicians about the appropriate use and interpretation of urinalysis and urine culture. Bacteriuria and pyuria are relatively common among patients with indwelling urinary catheters. These findings do not necessarily indicate the presence of infection or the need for treatment in the absence of symptoms. Appropriate education may result in improved accuracy of documentation and more judicious use of antibiotics.[9]

Despite the nationwide initiative and nonpayment by CMS, inaction is common. In study of approximately 600 U.S. hospitals conducted in 2005, 56% reported not having a system for monitoring which patients had catheters and 74% reported not monitoring catheter duration.[18] Only 9% used some type of catheter removal reminder or stop-order.[18] Alternatives to indwelling catheters include intermittent catheterization and condom catheters. These have been shown to be less likely to cause bacteriuria in certain patient populations.[19, 20, 21, 22, 23, 24, 25] Limitations of intermittent catheterization include patient and nursing resistance, limited utility in patients with poor hand function or memory and the risk of catheter trauma due to incorrect technique. Limitations of condom catheters include use in men only, with adequate phallus length, no bladder outlet obstruction, and ability to tolerate the skin adhesive.

The lock-out valve introduced here could be one more tool in the armamentarium we have to decrease the rate of catheter-associate urinary tract infection. A lock-out valve intrinsic to the catheter and drainage bag, would mandate maintenance of a closed drainage system when changing from a large drainage bag to a leg bag. This would be useful in ambulatory patients requiring indwelling catheterization, such as after prostatectomy, urethral trauma, or urethral stricture surgery.

Our hope is that this device could decrease the rate of the common, costly, and preventable problem of catheter-associated urinary tract infection.


  1. Conway JL and Larson EL. Guidelines to prevent catheter-associated urinary tract infection: 1980 to 2010. Heart Lung. 2012;42(3):271-83.
  2. Klevens RM, Edwards JR, Richards CL, Jr, Horan TC, Gaynes RP, Pollock DA, et al. Estimating health care-associated infections and deaths in U.S. hospitals. 2002 Public Health Rep. 2007;122:160–6.
  3. Saint S, Chenoweth CE. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am. 2003;17:411–32.
  4. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28(1):68–75.
  5. Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol. 1996;17(8):552–7.
  6. Tambyah PA, Knasinski V, Maki DG. The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care. Infect Control Hosp Epidemiol. 2002;23(1):27–31.
  7. United States Department of Health and Human Services. Action plan to prevent healthcare-associated infetions. 2009 Available at: http://www.premierinc.com/safety/topics/HAI/downloads/draft-hai-plan-01062009.pdf.
  8. Saint S, Veentra DL, Lipsky BA. The clinical and economic consequences of nosocomial central venous catheter-related infection: are antimicrobial catheters useful? Infect Control Hosp Epidemiol. 2000;21:375–380.
  9. Saint S, Meddings JA, Calfee D et al. Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med. 2009; 150(12): 877-84.
  10. Joint Commission. Proposed 2012 national patient safety goals hospital accreditation program. Available at: http://www.jointcommission.org/assets/1/6/NPSGs_CAUTI-VAP_HAP_20101119.pdf
  11. Centers for Medicare and Medicaid. Medicare Program: proposed changes to the hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2012 rates. Federal Register. 2011;76:2578805. Available at: http://www.federalregister.gov/articles/2011/05/05/2011-9644/medicare-program-proposed-changes-to-the-hospital-inpatient-prospective-payment-system-for-acute#p-4.
  12. Wong ES. Guideline for prevention of catheter-associated urinary tract infections. Am J Infect Control. 1983;11(1):28–36.
  13. Yokoe DS, Mermel LA, Anderson DJ, et al. Executive Summary: A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol. 2008;29(s1):S12–S21.
  14. Lo E, Nicolle L, Classen D, et al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol. 2008;29(s1):S41–S50.
  15. Dumigan DG, Kohan CA, Reed CR, Jekel JF, Fikrig MK. Utilizing national nosocomial infection surveillance system data to improve urinary tract infection rates in three intensive-care units. Clin Perform Qual Health Care. 1998;6(4):172–8.
  16. Topal J, Conklin S, Camp K, Morris V, Balcezak T, Herbert P. Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. Am J Med Qual. 2005;20(3):121–6.
  17. Stephan F, Sax H, Wachsmuth M, Hoffmeyer P, Clergue F, Pittet D. Reduction of urinary tract infection and antibiotic use after surgery: a controlled, prospective, before-after intervention study. Clin Infect Dis. 2006;42(11):1544–51.
  18. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis. 2008;46(2):243–50.
  19. Hirsh DD, Fainstein V, Musher DM. Do condom catheter collecting systems cause urinary tract infection? JAMA. 1979;242(4):340–1.
  20. Ouslander JG, Greengold B, Chen S. Complications of chronic indwelling urinary catheters among male nursing home patients: a prospective study. J Urol. 1987;138(5):1191–5.
  21. Ouslander JG, Greengold B, Chen S. External catheter use and urinary tract infections among incontinent male nursing home patients. J Am Geriatr Soc. 1987;35(12):1063–70.
  22. Saint S, Kaufman SR, Rogers MA, Baker PD, Ossenkop K, Lipsky BA. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc. 2006;54(7):1055–61.
  23. Kuhn W, Rist M, Zaech GA. Intermittent urethral self-catheterisation: long term results (bacteriological evolution, continence, acceptance, complications). Paraplegia. 1991;29(4):222–24.
  24. Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean, intermittent self-catheterization in the treatment of urinary tract disease. J Urol. 1972;107(3):458–61.
  25. Diokno AC, Sonda LP, Hollander JB, Lapides J. Fate of patients started on clean intermittent self-catheterization therapy 10 years ago. J Urol. 1983;129(6):1120–2.

Written by:
Jennifer L. Young, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

The Urology Group, 19415 Deerfield Avenue, Suite 112, Leesburg, VA USA

Lock-out valve to decrease catheter-associated urinary tract infections - Abstract

More Information about Beyond the Abstract