Prevention of Catheter-Associated Urinary Tract Infection
Invited Commentary
A Triumph for the Agency for Healthcare Research
and Quality Safety Program for Long-term Care
Moving Beyond “Round Up the Usual Suspects”
Elizabeth G. Turnipseed, MD, MPH; C. Seth Landefeld, MD
Most Americans view nursing homes as a home of last resort,
and few physicians practice in them. Many of us would prefer
to drive by and look away. Yet, the care of nursing home resi-
dents is critically important:
most Americans will either
Related article page 1154 stay in a nursing home dur-
ing the course of serious ill-
ness or will visit a loved one there. In this issue of JAMA
Internal Medicine, Mody et al1 report results that can be used
to improve care in all US nursing homes.
Every nursing home resident deserves competent, kind,
and attentive care that provides the best achievable out-
comes. However, adverse events are common in nursing home
residents, and many may be preventable. In 2014, 22% of Medi-
care beneficiaries discharged from hospitals to skilled nurs-
ing facilities for 35 days or less experienced an adverse event
that harmed the patient, prolonged the nursing home stay, or
led to transfer to a hospital or other health care facility. Phy-
sician reviewers judged that 59% of serious adverse events were
preventable.2 Nosocomial infections are common in nursing
home residents: up to 3 million occur annually, and approxi-
mately 300 000 people die of these infections each year.3 Uri-
nary tract infections (UTIs) are especially common among nurs-
ing home residents with indwelling urinary catheters, occurring
as frequently as once every 100 days of catheterization.4 More-
over, the incidence of reported catheter-associated UTIs in-
creased in US nursing homes from 2009 to 2013.5
Although catheter-associated UTIs were prevented in an
experimental study of a multicomponent intervention that fo-
cused on less use of catheters, better management when cath-
eters are used, and promotion of a culture that engages nurs-
ing home staff, patients, and families in safe care,4 it was
unknown whether these results could be extended broadly
to nursing homes across the United States. Preventing the
preventable is challenging, even when it is possible. We fre-
quently hear calls for accountability, yet calls to “hold them
accountable” may have no more effect than Captain
Renault’s order in Casablanca, “Round up the usual sus-
pects.” Behaviors that lead to preventable adverse outcomes
are often deeply ingrained in habits, cultures, and systems of
health care, and they are difficult to change. For example,
despite a high level of engagement among North Carolina
hospitals in efforts to improve patient safety, the frequencies
of harms and preventable harms did not change substan-
tially from 2002 to 2007.6 In addition, interventions that are
promising initially may be less effective than hoped, as was
recently shown for early, goal-directed resuscitation for sep-
tic shock.7
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© 2017 American Medical Association. All rights reserved.
Original Investigation Research
Mody et al1 report good news for nursing home residents:
in 404 nursing homes in 38 states, a practical intervention re-
duced the frequency of UTIs among residents with urinary
catheters by more than half. Implementation of multimodal
infection prevention strategies that include a combination of
an evidence-based technical bundle and a socioadaptive
bundle led to a 61% reduction in the incidence of catheter-
associated UTIs among nursing home residents over the proj-
ect period—from UTI rates of 6.78 per 1000 catheter-days to
2.63 per 1000 catheter-days. Moreover, 75% of nursing homes
reported reductions of at least 40%, suggesting that the inter-
vention is effective in a broad range of nursing homes nation-
ally.
The multicomponent intervention was created as part of
the Agency for Healthcare Research and Quality (AHRQ) Safety
Program for Long-term Care (https://w w w.ahrq.gov
/professionals/quality-patient-safety/quality-resources/tools
/cauti-ltc/index.html). The intervention included a technical
bundle of efforts to reduce indwelling catheter use, efforts to
reduce the introduction of bacteria by improving catheter care
and maintenance, and antimicrobial stewardship, as well as a
socioadaptive bundle of efforts to improve attitudes and
behaviors related to infection prevention and resident safety.
Although the study did not determine how these efforts
interacted or which ones work, it is likely that the direct cause
of lower rates of catheter-associated UTIs was improved
catheter care and maintenance. Catheter use was low (<5%)
and did not decrease during the intervention, and antimicrobial
stewardship would more likely change the antibiotic
susceptibility of infectious agents than directly affect the
frequency of infection. Although it is impossible to determine
the precise effect of the socioadaptive bundle, it likely increased
the potency of efforts to improve catheter care and it may have
had other benefits (eg, more mobility or decreased falls) not
measured in the study.
The main result, that the catheter-associated UTI inci-
dence rate decreased greatly over the year of the interven-
tion, is likely valid despite the lack of a concurrent control or
comparison group: the results are biologically plausible and
the prospective design, measurement methods, effects over
time, and magnitude and precision of the effect size are com-
pelling. The fact that the results were consistent across so many
nursing homes further increases confidence in the main
conclusion.
This study has special importance beyond the key find-
ing that UTIs were prevented. First and most important, the
results of this study highlight the value of the federal AHRQ,
which created and supported the Safety Program for Long-
(Reprinted) JAMA Internal Medicine August 2017 Volume 177, Number 8 1163
 Research Original Investigation Prevention of Catheter-Associated Urinary Tract Infection

term Care, which supported the development and implemen-
tation of the intervention. The AHRQ has special expertise in
implementation science, which underlies the design and evalu-
ation of the safety program and is not a focus of the National
Institutes of Health. Elimination of the AHRQ, as proposed in
President Trump’s Budget Blueprint to Make America Great
Again, would not be so great for the tens of thousands of Ameri-
cans who benefit from this study and the Safety Program for
Long-term Care.
The results of the Mody et al1 study also indicate that we
likely can do even better. Nonprofit nursing homes had cath-
eter-associated UTI rates approximately half of those in for-
profit nursing homes, and reductions in UTI rates with the in-
tervention were similar in nonprofit and for-profit nursing
homes. Thus, catheter-associated UTI rates would fall to less
than 2 per 1000 catheter-days if all nursing homes could
achieve the rates of nonprofit nursing homes.
An important question is left unanswered: Can the ben-
efit of the Safety Program for Long-term Care be extended to
the 14 652 nursing homes that did not participate in the study?
Although the study is remarkable for the fact that it engaged
404 nursing homes across the United States, these facilities
are not representative. Not only did participating nursing
homes have higher 5-star quality ratings than did nonpartici-
pating nursing homes, they volunteered to participate in the
safety program. While the Safety Program for Long-term Care
was designed pragmatically to be adaptable in every nursing
home, it is possible that nursing homes that volunteered are
more receptive and responsive to the intervention than are non-
participating facilities. Nonetheless, the compelling results of
the evaluation of the Safety Program for Long-term Care in
Mody et al1 provide a solid foundation for their implementa-
tion with support from the Centers for Medicare and Medic-
aid Services.

ARTICLE INFORMATION
Author Affiliations: Department of Medicine,
University of Alabama at Birmingham.
Corresponding Author: Charles Seth Landefeld,
MD, Department of Medicine, University of
Alabama at Birmingham, BDB 420, 1720 2nd Ave
South, Birmingham, AL 35294 (sethlandefeld@uab
.edu).
Published Online: May 19, 2017.
doi:10.1001/jamainternmed.2017.1792
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Mody L, Greene MT, Meddings J, et al. A national
implementation project to prevent
catheter-associated urinary tract infection in
nursing home residents [published online May 19,
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/jamainternmed.2017.1689
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OEI-06-11-00370. https://oig.hhs.gov/oei/reports
/oei-06-11-00370.pdf. February 2014. Accessed
April 28, 2017.
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