An ounce of prevention saves a "bundle" of cure

A hospitalist by training, Dr. Saint discovered early on in his career that preventing infections due to urinary catheters represented an important hole in the evidence base, and devoted his research efforts toward filling this gap. Beginning in the late 1990s, Dr. Saint’s team was the first to find that physicians are often unaware of which patients have urinary catheters, to demonstrate that reminders can limit urinary catheterization, and to conduct a randomized trial comparing indwelling and condom catheters.

The biggest issue I saw when I began my career is still the most important one – routinely providing care to patients that represents the best scientific evidence. As science continues to advance, our goal remains to treat each patient the way we would treat a family member.

This work reinforced the need for a multi-pronged intervention to decrease the use of urinary catheters and increase the use of best practices for infection control, known as the “Bladder Bundle.” These strategies focus on preventing CAUTI by optimizing the use of urinary catheters, with a specific emphasis on continual assessment and catheter removal as soon as possible, especially for patients without a clear indication. The program focuses on both the technical aspects needed for CAUTI prevention, as well as the role that behavior and culture changes play in quality improvement.

In 2005, in collaboration with the Michigan Health and Hospital Association (MHA), Dr. Saint and his team began implementing the Bladder Bundle initiative in most hospitals in Michigan. Using a mixed-methods evaluation of the diffusion, adoption, and implementation of CAUTI prevention practices, Dr. Saint’s team found that the intervention resulted in a 25 percent decrease in CAUTI throughout the state, compared to a 6 percent decrease nationwide.

The recognized success of the Bladder Bundle led to a nationwide effort to reduce CAUTI, funded through the Agency for Healthcare Research and Quality (AHRQ) and the Health Research and Education Trust, with Dr. Saint serving as academic lead on the effort. Modeled after the MHA program, this initiative worked with 926 units (intensive care units [ICUs] and non-ICUs) in 603 hospitals across the country to implement evidence-based CAUTI reduction practices. Results published in a June 2016 New England Journal of Medicine article demonstrated that the intervention reduced catheter use and CAUTI in medical-surgical units by 32 percent. Dr. Saint’s team has projects supported by the CDC and AHRQ focused on adapting the intervention to help reduce CAUTI rates and catheter use in ICUs as well as hospitals where CAUTI rates generally remain persistently high.

These efforts have produced a toolkit for hospitals to apply comprehensive, sustainable CAUTI-prevention measures within their own units, and the intervention has now spread to nearly 1,000 hospitals, or one in five in the country.