Mount Sinai Embraces Hospitalists’ Choosing Wisely Advice
By implementing one of the Society of Hospital Medicine’s Choosing Wisely recommendations, a team of physicians at New York’s Mount Sinai Hospital virtually eliminated the inappropriate use of urinary catheters and catheter-associated infections in five hospitalist medicine units.
Launched by Dr. Hyung (Harry) Cho, Chair of Mt. Sinai’s High Value Care Committee, and Dr. Steve Khalil, a third-year resident in medicine, the project, “Lose the Tube,” relied on a simple intervention. Hospitalist medical directors used EMRs to determine which patients had Foley catheters. They then used daily multidisciplinary rounds to ask clinicians caring for those patients: “Does this patient need the Foley?” According to Dr. Cho, the clinicians were often unaware their patient even had a catheter, as they are often placed when patients are being treated in the emergency room and little thought was given to removing them after patients were transferred.
“Using a simple, non-threatening question avoided a culture of blame or a ‘top-down’ stewardship approach,” Dr. Cho said. “Instead, we fostered a lateral approach of encouraging ownership and responsible decision-making. This lends itself to a sustainable process.”
As clinicians’ awareness grew around whether their patients needed catheterization, catheter use in general and, more importantly, catheter-associated urinary tract infection (CAUTI) rates dropped dramatically. Working in five hospitalist medicine units over five months, usage decreased from 2.85 CAUTI/1,000 catheter days to 0.23. Over the course of those five months, only one infection was reported. Usage overall declined from 948.5 catheter days per month in the six months preceding the intervention to 877 catheter days per month in the five months following the intervention. Dr. Cho calculated that the annual cost savings from avoided infections would range from $28,641 to $120,226, based on the average cost of treating a UTI (at the low end) and the average cost of treating a resultant blood stream infection (at the high end).
Dr. Cho said there was little physician pushback about the campaign to reduce unnecessary catheterization, and no major educational campaign was required to bring about change. Reminders about the initiative were given at monthly orientation meetings, and Drs. Cho and Khalil developed a mnemonic device, “NO TUBE,” to highlight the CDC recommendations for appropriate urinary catheter usage:
- Neurologic (spinal/pelvic) trauma
- Obstruction/Retention
- Tenuous (critically ill congestive heart failure/acute kidney injury)
- Urological surgery
- Bed sores and incontinence
- End of life
The mnemonic was shared with the medical directors and included on a small number of flyers that were posted publicly.
“I’m a believer that simpler is better,” Dr. Cho said. “There were no additional pages, emails, phone calls or additional meetings. We came up with a simple mnemonic and it stuck.”
Dr. Cho and his colleagues plan to expand the program to other medicine and surgical units at Mount Sinai next year.
