Two Decades of Progress, Yet Hospitals Still Fall Short on Preventing Catheter Infections

Urinary catheters are among the most common medical devices used in hospitals, and among the most deceptively risky. A thin tube inserted into the bladder to drain urine can become a highway for bacteria, allowing microbes that would normally be flushed out of the body to colonize the device, ascend into the bladder, and in severe cases enter the bloodstream. Catheter-associated urinary tract infections, known as CAUTIs, have been a central target of patient safety campaigns for a quarter of a century, and yet a new study published in JAMA Network Open reveals that many hospitals across the United States still have not adopted the most effective, evidence-based strategies to prevent them.

The research, conducted by a team from the University of Michigan Medical School and VA Ann Arbor Healthcare System, draws on twenty years of surveys of hospital infection prevention staff, carried out every four years since 2005. This unusually long observational window allows the researchers to chart not just the current state of practice but the trajectory of improvement over two decades, a period during which CAUTI prevention became a national priority, a subject of federal financial penalties, and a fixture of hospital quality improvement programs.

The findings are a study in partial success. The percentage of non-VA hospitals using at least one of the three most strongly evidence-supported practices rose from roughly 23 percent fifteen to twenty years ago to nearly 70 percent today. That represents a genuine transformation in how hospitals think about urinary catheters, which were once treated as routine, low-consequence equipment. But the data also show that this progress has plateaued, or even slipped slightly, in recent years, suggesting that the remaining hospitals are the hardest to reach and that momentum has stalled without sustained external pressure.

The three practices with the strongest evidence behind them are strikingly simple. The first is a system that reminds physicians that their patient has a catheter in place, or requires them to proactively renew the catheter order after a set period, forcing a fresh decision about whether the device is still needed. The second is an automatic stop order that ends the catheter order unless a clinician actively renews it. The third is nurse-initiated removal, which empowers nurses to take out a catheter without a physician’s order when they judge that a patient can attempt to urinate independently. Yet according to the study, only 49 percent of general hospitals and just 32 percent of VA hospitals have a reminder or renewal system in place. Nurse-initiated removal fares somewhat better, available in 58 percent of general hospitals and 38 percent of VA facilities.

Jennifer Meddings, Professor of Internal Medicine and Pediatrics at the U-M Medical School and a Research Investigator at VA Ann Arbor, expressed surprise at the stagnation. Reminders prompting clinicians to reassess whether a catheter is still necessary are low-cost, demonstrably effective, and straightforward to embed in electronic medical record workflows that many health systems already operate. In her view, hospitals can go further by using their electronic ordering systems to restrict catheter placement to a list of clinically appropriate indications, and by prompting clinicians at the moment of ordering with alternatives such as external catheter devices. Such just-in-time prompts serve as continuous education, which is particularly valuable because trainee physicians place the majority of catheter orders in many hospitals.

Sanjay Saint, Professor Emeritus of Internal Medicine at U-M, now at Northwell Health and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, framed the two-decade arc with measured optimism. He noted that hospitals have come a long way in recognizing that urinary catheters are not benign devices and in building systems to use them more thoughtfully. At the same time, he cautioned that progress is not self-sustaining: the most effective strategies, including prompting clinicians to reassess catheter necessity and empowering nurses to remove devices when appropriate, must be woven into the fabric of everyday care rather than treated as one-time campaigns.

The study also documents growth in hospitals’ capacity to monitor which patients have catheters and how many days those devices have been in place, a foundational data infrastructure for any prevention effort. Here the VA hospitals lagged behind non-VA facilities, but the researchers point to the VA-wide electronic health record modernization now rolling out as a mechanism that could close the gap. Another widely adopted technology is portable bladder ultrasound, in which a bedside scanner estimates urine volume and guides decisions about whether catheterization is truly necessary; more than 70 percent of both VA and non-VA hospitals now use these scanners, making it one of the most universal practices in the CAUTI prevention toolkit.

The financial stakes are considerable. Medicare penalizes non-VA hospitals when patients covered by traditional Medicare experience high rates of catheter-associated urinary tract infections under the Hospital-Acquired Condition Reduction Program, and the program does not reimburse hospitals for the cost of treating these infections when they occur. Hospital CAUTI rates are publicly reported, allowing patients to compare facilities on Medicare’s Care Compare website. This combination of payment consequences and public transparency has been a powerful driver of the improvements seen over the past two decades, and the plateau in adoption suggests that hospitals without these practices may now face mounting pressure to catch up.

To accelerate that catch-up, the Michigan and VA team has consolidated decades of research and quality improvement work into a free public resource. The website bladdersafe.org offers evidence-based tools for hospitals seeking to prevent CAUTIs in medical and surgical patients, including a mobile app called BladderSafe that helps clinicians decide when to use or avoid common devices for managing adult patients’ urinary needs. The site also features a cost calculator that lets hospitals estimate how the expense of implementing prevention programs is offset by reductions in catheter-associated bacteriuria, symptomatic urinary tract infection, and bloodstream infection, turning the business case for prevention into concrete numbers administrators can act on.

The team’s credentials in this field run deep. Epidemiologist M. Todd Greene of the U-M Division of Hospital Medicine and VA Ann Arbor noted that through numerous local, regional, and national implementation projects, the group has demonstrated how collaborative efforts improve both process measures and outcome measures such as infection rates, including work that drove down CAUTI rates in hospitals and nursing homes across Michigan and nationwide. Looking ahead, Greene argued that tracking systems should expand beyond infections to monitor and prevent non-infectious device-related complications, capturing the full spectrum of catheter harms. The researchers also highlight a human vulnerability in the system: infection prevention staff face high job stress and turnover, and better support for them could preserve continuity in data collection and prevention efforts. The study’s authors, members of the U-M/VA Patient Safety Enhancement Program, the U-M Institute for Healthcare Policy and Innovation, and the VA Center for Clinical Management Research, include Sarah Krein, Kristin Chrouser, Karen Fowler, and David Ratz, alongside Saint, Meddings, and Greene. Saint’s contributions were recently recognized with the John M. Eisenberg Patient Safety and Quality Award for Individual Achievement from the Joint Commission and the National Quality Forum. The survey project was funded by the Department of Veterans Affairs, with additional support from the National Institutes of Health, the Agency for Healthcare Research and Quality, and Blue Cross Blue Shield of Michigan through the Collaborative Quality Initiatives based at the University of Michigan. The message for hospitals that have not yet acted is unambiguous: the tools exist, they are free, and the evidence says they work.

Subject of Research: Prevention of catheter-associated urinary tract infections in US hospitals

Article Title: Many hospitals still don’t do enough to prevent UTIs from catheters

Article References: Many hospitals still don’t do enough to prevent UTIs from catheters. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: catheter-associated urinary tract infection, CAUTI, hospital infection prevention, urinary catheters, patient safety, JAMA Network Open, University of Michigan, VA Ann Arbor, electronic health records, bladder ultrasound, Medicare penalties, quality improvement