Strategies to Prevent Catheter

8/18/2019 Strategies to Prevent Catheter

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Strategies to Prevent Catheter‐Associated Urinary Tract

Infections in Acute Care Hospitals

Evelyn Lo , MD; Lindsay Nicolle , MD; David Classen , MD, MS;Kathleen M. Arias , MS, CIC; Kelly Podgorny , RN, MS, CP!;

Deveric" #. Anderson , MD, MP; elen $%rstin , MD; David P. Cal&ee , MD, MS;

S%san E. Co&&in , MD, MP; Eri" R. D%''er"e , MD; (ictoria )raser , MD;Dale N. *erding , MD; )rances A. *ri&&in , RR+, MPA; Peter *ross , MD; Keith S. Kaye , MD;

Michael Klo-as , MD; #onas Marschall , MD; Leonard A. Merel , D, ScM;

David A. Peg%es , MD; +rish M. Perl , MD; San/ay Saint , MD;Cassandra D. Salgado , MD, MS; Ro'ert A. 0einstein , MD; Ro'ert 0ise , MD;

De'orah S. 1o"oe , MD, MP

)ro the 2niversity o& Manito'a, 0inni-eg, Canada 3E.L., L.N.4; the 2niversity o& 2tah, Salt

La"e City 3D.C.4; the Association &or Pro&essionals in In&ection Control and E-ideiology3K.M.A.4 and the National !%ality )or% 3.$.4, 0ashington, D.C.; the #oint Coission,

a"'roo" +errace 3K.P., R.0.4, the Loyola 2niversity Chicago Stritch School o& Medicine

3D.N.*.4 and the Stroger 3Coo" Co%nty4 os-ital and R%sh 2niversity Medical Center 3R.A.0.4,Chicago, and the ines (eterans A&&airs Medical Center, ines 3D.N.*.4, Illinois; the D%"e

2niversity Medical Center, D%rha, North Carolina 3D.#.A., K.S.K.4; the Mo%nt Sinai School o&

Medicine, Ne5 1or", Ne5 1or" 3D.P.C.4; the Children6s os-ital o& Philadel-hia and 2niversity

o& Pennsylvania School o& Medicine, Philadel-hia, Pennsylvania 3S.E.C.4; the 0ashington2niversity School o& Medicine, St. Lo%is, Misso%ri 3E.R.D., (.)., #.M.4; the Instit%te &or

ealthcare I-roveent, Ca'ridge 3).A.*.4, and $righa and 0oen6s os-ital and arvard

Medical School, $oston 3D.S.1., M.K.4, Massach%setts; the ac"ensac" 2niversity Medical

Center, ac"ensac" 3P.*.4, and the 2niversity o& Medicine and Dentistry7Ne5 #ersey MedicalSchool, Ne5ar" 3P.*.4, Ne5 #ersey; the 0arren Al-ert Medical School o& $ro5n 2niversity and

Rhode Island os-ital, Providence, Rhode Island 3L.A.M.4; the David *e&&en School o&Medicine at the 2niversity o& Cali&ornia, Los Angeles 3D.A.P.4; the #ohns o-"ins Medical

Instit%tions and 2niversity, $altiore, Maryland 3+.M.P.4; the Ann Ar'or (eterans A&&airs

Medical Center and the 2niversity o& Michigan Medical School, Ann Ar'or, Michigan 3S.S.4; the

Medical 2niversity o& So%th Carolina, Charleston 3C.D.S.4.

Address re-rint re8%ests to the Re-rints Coordinator, 2niversity o& Chicago Press, 9:< E. =>th

St., Chicago, IL =>=?< 3re-rints@-ress.%chicago.ed%4 or contact the /o%rnal o&&ice

3iche@-ress.%chicago.ed%4.

Acce-ted May >; electronically -%'lished Se-te'er 9=, >>.

Purpose

#%- +o Section...


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Previo%sly -%'lished g%idelines are availa'le that -rovide co-rehensive recoendations &or

detecting and -reventing healthcare‐associated in&ections. +he intent o& this doc%ent is to

highlight -ractical recoendations in a concise &orat designed to assist ac%te care hos-itals ini-leenting and -rioritiBing their catheter ‐associated %rinary tract in&ection 3CA2+I4

-revention e&&orts. Re&er to the Society &or ealthcare E-ideiology o& AericaIn&ectio%s

Diseases Society o& Aerica Co-endi% o& Strategies to Prevent ealthcare‐

AssociatedIn&ections EFec%tive S%ary and Introd%ction and acco-anying editorial &or additional

disc%ssion.

Section 1: Rationale and Statements of Concern

#%- +o Section...

9.

$%rden o& CA2+Is

a.

2rinary tract in&ection is the ost coon hos-ital‐ac8%ired in&ection; >G o&

these in&ections are attri'%ta'le to an ind5elling %rethral catheter.9

'.

+5elve to siFteen -ercent o& hos-ital in-atients 5ill have a %rinary catheter at

soe tie d%ring their hos-ital stay.

c.

+he daily ris" o& ac8%isition o& %rinary in&ection varies &ro ?G to


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?.

Ris" &actors &or develo-ent o& CA2+I

a.

+he d%ration o& catheteriBation is the ost i-ortant ris" &actor &or develo-ent

o& in&ection.9,‐99

Liiting catheter %se and, 5hen a catheter is indicated,iniiBing the d%ration the catheter reains in sit% are -riary strategies &or

CA2+I -revention.

'. Additional ris" &actors incl%de &eale seF, older age, and not aintaining a

closed drainage syste.

:.

Reservoir &or transission

a. +he drainage 'ag o& the 'acteri%ric -atient is a reservoir &or organiss that ay

containate the environent and 'e transitted to other -atients.9

'.

%t'rea"s o& in&ection 5ith resistant gra‐negative organiss attri'%ta'le to

'acteri%ria in catheteriBed -atients have 'een re-orted.9‐9H

Section : Strategies to !etect CAUTI

#%- +o Section...

9.

S%rveillance de&initions

a.

+he National ealthcare Sa&ety Net5or" de&inition o& sy-toatic nosocoial

%rinary tract in&ection9=,9


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.

Methods &or s%rveillance o& CA2+I

a.

S%rveillance -rogras that onitor %rine c%lt%re res%lts thro%gh the

icro'iology la'oratory are generally %sed to detect -atients 5ith -otential%rinary tract in&ections. Patients 5ith -ositive %rine c%lt%re res%lts are then

eval%ated &or the -resence o& an ind5elling %rinary catheter and a CA2+Ide&ined %sing s%rveillance criteria.

i.

In&ection in -atients 5ith an ind5elling %rinary catheter is %s%ally

asy-toatic.?

ii.

Micro'iological diagnosis %s%ally re8%ires the gro5th o& at least 9>H

c&%L o& an organis &ro a %rine s-ecien collected ase-tically&ro the catheter. Lo5er 8%antitative co%nts ay 'e consistent 5ith

'acteri%ria in soe -atients or ay -redict s%'se8%ent develo-ent o&

higher 8%antitative co%nts.9

Section ": Strategies to Prevent CAUTI

#%- +o Section...

9. EFisting g%idelines and recoendations 3see +a'le 94

a.

In 99, the Centers &or Disease Control and Prevention -%'lished g%idelines &or

the -revention o& catheter ‐associated %rinary tract in&ections.9 +hese g%idelines

-rovide recoendations &or catheter %se, catheter insertion, catheter care, -laceent o& catheteriBed -atients, and 'acteriologic onitoring. +he g%idelines

are c%rrently 'eing %-dated &or the &irst tie since 99.

'.

In >>9, the De-artent o& ealth in *reat $ritain -%'lished g%idelines &or

-reventing in&ections associated 5ith the insertion and aintenance o& short‐

ter ind5elling %rinary catheters in ac%te care;> these g%idelines 5ere %-dated

in >>=.9

. 2-dated relevant literat%re

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a.

Cochrane revie5s

i.

Co-rehensive Cochrane revie5s 5ith eta‐analysis eval%ating

interventions to -revent co-lications o& the %se o& short‐ter

ind5elling %rinary catheters have recently 'een -%'lished.‐


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ii.

Silver ‐alloy catheters ay decrease 'acteri%ria '%t have not 'een

sho5n to decrease sy-toatic in&ection or other %ndesira'le

o%tcoes.?9,?

3a4 Soe o& the varia'ility in o%tcoes re-orted in trials o&

silver catheters ay 'e related to 5hether the co-aratorcatheter is silicone or lateF.??

3'4

A recent -ros-ective crossover st%dy co-aring a silver ‐

alloy, silicone‐ 'ased hydrogel7coated catheter 5ith a

silicone‐ 'ased hydrogel7coated catheter re-orted no

di&&erence in sy-toatic or asy-toatic in&ection or in

'loodstrea in&ections attri'%ta'le to a %rinary so%rce.?:

d.

Liiting the d%ration o& catheteriBation

i.

Ind5elling %rethral catheters are &re8%ently %sed 5hen not indicated

or, i& indicated, reain in sit% longer than necessary.?H‐?<

ii. -tial a--roaches to liit catheter %se and d%ration ay 'e

de-endent on &acility characteristics. A--roaches re-orted to 'e

e&&ective incl%de the &ollo5ingJ

3a4 I-leenting -roced%re‐s-eci&ic g%idelines &or

-osto-erative catheter reoval?

3'4

Providing g%idelines to anage -osto-erative retention,

5hich ay incl%de the %se o& 'ladder scanners?

3c4 Providing reinders to -hysicians to revie5 the need &or

contin%ed catheteriBation and to reove catheters -ro-tly5hen they are no longer indicated:>‐:

3d4

Develo-ent o& care -lans directing n%rse reoval o&

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catheters &or -atients 5ho eet -res-eci&ied criteria:?

e.

S%rveillance

i.

Providing &eed'ac" on %nit‐s-eci&ic %rinary in&ection rates to

n%rsing and healthcare sta&& has 'een e&&ective in decreasingin&ection rates.::,:H

+a'le 9. S%ary o& Recoendations )ro P%'lished *%idelines &or Prevention o&In&ections Associated 0ith Short‐+er Ind5elling 2rethral Catheters

Section #: Recommendations for Implementing Prevention and $onitoring

Strategies

#%- +o Section...

Recoendations &or -reventing and onitoring CA2+I9‐9 are s%ariBed in the &ollo5ing

section. +hey are designed to assist ac%te care hos-itals in -rioritiBing and i-leenting their

CA2+I -revention e&&orts. Criteria &or grading the strength o& recoendation and 8%ality o&

evidence are descri'ed in +a'le .

+a'le . Strength o& Recoendation and !%ality o& Evidence

I. $asic -ractices &or -revention and onitoring o& CA2+IJ recoended &or all ac%te care

hos-itals

A. A--ro-riate in&rastr%ct%re &or -reventing CA2+I

9.

Provide and i-leent 5ritten g%idelines &or catheter %se, insertion, and aintenance

3A‐II4.

a.

Develo- and i-leent &acility criteria &or acce-ta'le indications &or the %se o&

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ind5elling %rinary catheters.

'.

Indications &or the %se o& ind5elling %rethral catheters are liited and incl%de

the &ollo5ingJ?H,:<

i.

Perio-erative %se &or selected s%rgical -roced%res

ii.

2rine o%t-%t onitoring in critically ill -atients

iii.

Manageent o& ac%te %rinary retention and %rinary o'str%ction

iv.

Assistance in -ress%re %lcer healing &or incontinent residents

v.

As an eFce-tion, at -atient re8%est to i-rove co&ort

.

Ens%re that only trained, dedicated -ersonnel insert %rinary catheters 3$‐III4.

?.

Ens%re that s%--lies necessary &or ase-tic‐techni8%e catheter insertion are availa'le 3A

‐III4.

:. I-leent a syste &or doc%enting the &ollo5ing in&oration in the -atient recordJ

indications &or catheter insertion, date and tie o& catheter insertion, individ%al 5hoinserted catheter, and date and tie o& catheter reoval 3A‐III4.

a. Incl%de doc%entation in n%rsing &lo5 sheet, n%rsing notes, or -hysician orders.

i.

Doc%entation sho%ld 'e accessi'le in the -atient record and recorded

in a standard &orat &or data collection and 8%ality i-roveent -%r-oses.

'.

Electronic doc%entation that is searcha'le is -re&erred, i& availa'le.

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H.

Ens%re that there are s%&&icient trained -ersonnel and technology reso%rces to s%--ort

s%rveillance o& catheter %se and o%tcoes 3A‐III4.

$. S%rveillance o& CA2+I

9.

Identi&y the -atient gro%-s or %nits in 5hich to cond%ct s%rveillance, on the 'asis o& ris"

assessent, considering the &re8%ency o& catheter %se and the -otential ris" &actors 3eg,ty-es o& s%rgery, o'stetrics, and critical care4 3$‐III4.

.

2se standardiBed criteria to identi&y -atients 5ho have a CA2+I 3n%erator data4 3A‐II4.

?.

Collect in&oration on catheter ‐days 3denoinator data4 &or all -atients in the -atient

gro%-s or %nits 'eing onitored 3A‐II4.

:. Calc%late CA2+I rates &or target -o-%lations 3A‐II4.

H.

Meas%re the %se o& ind5elling %rinary catheters 3$‐

II4, incl%ding the &ollo5ingJ

a. +he -ercentage o& -atients 5ith an ind5elling %rinary catheter inserted d%ring

hos-italiBation

'.

+he -ercentage o& catheter %se 5ith acce-ted indications

c.

D%ration o& ind5elling catheter %se

=.

2se s%rveillance ethods &or case &inding that are a--ro-riate &or the instit%tion and aredoc%ented to 'e valid 3A‐III4.

C. Ed%cation and training


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9.

Ed%cate healthcare -ersonnel involved in the insertion, care, and aintenance o& %rinary

catheters a'o%t CA2+I -revention, incl%ding alternatives to ind5elling catheters and

-roced%res &or catheter insertion, anageent, and reoval 3A‐III4.

D. A--ro-riate techni8%e &or catheter insertion

9.

Insert %rinary catheters only 5hen necessary &or -atient care and leave the in -lace only

as long as indications -ersist 3A‐II4.

.

Consider other ethods &or anageent, incl%ding condo catheters or in‐and‐o%t

catheteriBation, 5hen a--ro-riate 3A‐I4.

?. Practice hand hygiene 3in accordance 5ith Centers &or Disease Control and Prevention or

0orld ealth rganiBation g%idelines4 iediately 'e&ore insertion o& the catheter and

'e&ore and a&ter any ani-%lation o& the catheter site or a--arat%s 3A‐III4.

:.

Insert catheters 'y %se o& ase-tic techni8%e and sterile e8%i-ent 3A‐III4.

H.

2se gloves, a dra-e, and s-onges; a sterile or antise-tic sol%tion &or cleaning the %rethral

eat%s; and a single‐%se -ac"et o& sterile l%'ricant /elly &or insertion 3A‐III4.

=.

2se as sall a catheter as -ossi'le that is consistent 5ith -ro-er drainage, to iniiBe

%rethral tra%a 3$‐III4.

E. A--ro-riate anageent o& ind5elling catheters

9.

Pro-erly sec%re ind5elling catheters a&ter insertion to -revent oveent and %rethral

traction 3A‐

III4.

.

Maintain a sterile, contin%o%sly closed drainage syste 3A‐I4.

?.

Do not disconnect the catheter and drainage t%'e %nless the catheter %st 'e irrigated


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3A‐I4.

:.

Re-lace the collecting syste 'y %se o& ase-tic techni8%e and a&ter disin&ecting the

catheter ‐t%'ing /%nction 5hen 'rea"s in ase-tic techni8%e, disconnection, or lea"age

occ%r 3$‐III4.

H.

)or eFaination o& &resh %rine, collect a sall sa-le 'y as-irating %rine &ro the

sa-ling -ort 5ith a sterile needle and syringe a&ter cleansing the -ort 5ith disin&ectant3A‐III4.

a. Pro-tly trans-ort %rine s-eciens to the la'oratory &or c%lt%re.

=.

'tain larger vol%es o& %rine &or s-ecial analyses ase-tically &ro the drainage 'ag3A‐III4.


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-ersonnel are assigned to the in&ection -revention and control -rogra.

?.

Senior anageent is acco%nta'le &or ens%ring that healthcare -ersonnel, incl%ding

licensed and nonlicensed -ersonnel, are co-etent to -er&or their /o' res-onsi'ilities.

:.

Direct healthcare -roviders 3s%ch as -hysicians, n%rses, aides, and thera-ists4 and

ancillary -ersonnel 3s%ch as ho%se"ee-ing and e8%i-ent‐ -rocessing -ersonnel4 are

res-onsi'le &or ens%ring that a--ro-riate in&ection -revention and control -ractices are

%sed at all ties 3incl%ding hand hygiene, standard and isolation -reca%tions, cleaningand disin&ection o& e8%i-ent and the environent, ase-tic techni8%e 5hen inserting and

caring &or %rinary catheters, and daily assessent o& 5hether an ind5elling %rinary

catheter is edically indicated4.

H. os-ital and %nit leaders are res-onsi'le &or holding their -ersonnel acco%nta'le &or their

actions.

=.

+he -erson 5ho anages the in&ection -revention and control -rogra is res-onsi'le &orens%ring that an active -rogra to identi&y CA2+Is is i-leented, that data on

CA2+Is are analyBed and reg%larly -rovided to those 5ho can %se the in&oration to

i-rove the 8%ality o& care 3eg, %nit sta&&, clinicians, and hos-ital adinistrators4, andthat evidence‐ 'ased -ractices are incor-orated into the -rogra.


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9.

I-leent an organiBation‐5ide -rogra to identi&y and reove catheters that are no

longer necessary, %sing 9 or ore ethods doc%ented to 'e e&&ective 3A‐II4.

a.

Develo- and i-leent instit%tional -olicy re8%iring contin%al, %s%ally daily,revie5 o& the necessity o& contin%ed catheteriBation.

'.

Electronic or other ty-es o& reinders 3see the A--endiF4 ay 'e %se&%l. SoeeFa-les incl%de the &ollo5ingJ

i.

A%toatic sto- orders re8%iring rene5al o& the order &or contin%ation

o& the ind5elling catheter

ii.

StandardiBed reinders -laced into -atient charts 3A--endiF4 or the

electronic -atient record

c. I-leent daily 5ard ro%nds 'y n%rsing and -hysician sta&& to revie5 all

-atients 5ith %rinary catheters and to ascertain contin%ing necessity.

.

Develo- a -rotocol &or anageent o& -osto-erative %rinary retention, incl%ding n%rse‐

directed %se o& interittent catheteriBation and %se o& 'ladder scanners 3$‐I4.

a. I& 'ladder scanners are %sed, indications %st 'e clearly stated, and n%rsing sta&&

%st 'e trained in their %se.

?.

Esta'lish a syste &or analyBing and re-orting data on catheter %se and adverse events&ro catheter %se 3$‐III4.

a.

De&ine and onitor adverse o%tcoes in addition to CA2+I, incl%ding cathetero'str%ction, %nintended reoval, catheter tra%a, or reinsertion 5ithin : ho%rs

a&ter reoval.

'.

)or analysis, strati&y eas%reents o& catheter %se and adverse o%tcoes 'y

relevant ris" &actors 3eg, seF, age, 5ard, and d%ration4. Revie5 data in a tiely

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&ashion and re-ort the to the a--ro-riate sta"eholders.

III. A--roaches that sho%ld not 'e considered a ro%tine -art o& CA2+I -revention

9.

Do not ro%tinely %se silver ‐coated or other anti'acterial catheters 3A‐I4.

. Do not screen &or asy-toatic 'acter%ria in catheteriBed -atients 3A‐II4.

?.

Do not treat asy-toatic 'acter%ria in catheteriBed -atients eFce-t 'e&ore invasive

%rologic -roced%res 3A‐I4.

:.

Avoid catheter irrigation 3A‐I4.

a. Do not -er&or contin%o%s irrigation o& the 'ladder 5ith antiicro'ials as a

ro%tine in&ection -revention eas%re.

'.

I& o'str%ction is antici-ated, closed contin%o%s irrigation ay 'e %sed to -revent

it.

c.

+o relieve o'str%ction d%e to clots, %c%s, or other ca%ses, an interittent

ethod o& irrigation ay 'e %sed.

H. Do not %se systeic antiicro'ials ro%tinely as -ro-hylaFis 3A‐II4.

=.

Do not change catheters ro%tinely 3A‐III4.

I(. 2nresolved iss%es

9. 2se o& antise-tic sol%tion vers%s sterile saline &or eatal cleaning 'e&ore catheter

insertion


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.

2se o& antiicro'ial‐coated catheters &or selected -atients at high ris" &or in&ection

Section %: Performance $easures

#%- +o Section...

I. Internal re-orting

+hese -er&orance eas%res are intended to s%--ort internal hos-ital 8%ality i-roveente&&orts and do not necessarily address eFternal re-orting needs.

+he -rocess and o%tcoe eas%res s%ggested here are derived &ro -%'lished g%idelines, other

relevant literat%re, and the o-inions o& the a%thors. Re-ort 'oth -rocess and o%tcoe eas%res to

senior hos-ital leadershi-, n%rsing leadershi-, and clinicians 5ho care &or -atients at ris" &or

CA2+I.

A. Process eas%res

9.

Co-liance 5ith doc%entation o& catheter insertion and reoval dates

a.

Cond%ct rando a%dits o& selected %nits and calc%late co-liance rate.

i.

N%eratorJ n%'er o& -atients 5ith %rinary catheters on the %nit 5ith -ro-er doc%entation o& insertion and reoval dates.

ii.

DenoinatorJ n%'er o& -atients on the %nit 5ith a %rinary catheter in

-lace.

iii.

M%lti-ly 'y 9>> so that the eas%re is eF-ressed as a -ercentage.

. Co-liance 5ith doc%entation o& indication &or catheter -laceent

a.

Cond%ct rando a%dits o& selected %nits and calc%late co-liance rate.

i.

N%eratorJ n%'er o& -atients 5ith %rinary catheters on the %nit 5ith


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-ro-er doc%entation o& indication.

ii.

DenoinatorJ n%'er o& -atients on the %nit 5ith a %rinary catheter in

-lace.

iii.

M%lti-ly 'y 9>> so that the eas%re is eF-ressed as a -ercentage.

$. %tcoe eas%res

9.

Rates o& sy-toatic CA2+I, strati&ied 'y ris" &actors 3age, seF, 5ard, indication, and

catheter ‐days4

a.

Altho%gh the validity o& the c%rrent Centers &or Disease Control and

PreventionNational ealthcare Sa&ety Net5or" de&inition o& sy-toatic

CA2+I &or co-arison o& &acility‐to‐&acility o%tcoes is not esta'lished,

eas%reent o& rates allo5s an individ%al &acility to ga%ge the longit%dinali-act o& i-leentation o& -revention strategies.

i.

N%eratorJ n%'er o& sy-toatic CA2+Is in each location

onitored.

ii.

DenoinatorJ total n%'er o& %rinary catheter7days &or all -atients in

each location onitored 5ho have an ind5elling %rinary catheter.

iii.

M%lti-ly 'y 9,>>> so that the eas%re is eF-ressed as cases -er 9,>>>

catheter ‐days.

.

Rates o& 'actereia attri'%ta'le to CA2+I

a. 2se National ealthcare Sa&ety Net5or" de&initions o& la'oratory‐con&ired

'loodstrea in&ection.9<

i.

N%eratorJ n%'er o& e-isodes o& 'loodstrea in&ections attri'%ta'le

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to CA2+I.

ii.

DenoinatorJ total n%'er o& %rinary catheter7days &or all -atients in

each location onitored 5ho have an ind5elling %rinary catheter.

iii.

M%lti-ly 'y 9,>>> so that the eas%re is eF-ressed as cases -er 9,>>>

catheter ‐days.

II. EFternal re-orting

+here are any challenges in -roviding %se&%l in&oration to cons%ers and other sta"eholders

5hile -reventing %nintended adverse conse8%ences o& -%'lic re-orting o& healthcare‐associated

in&ections.: Recoendations &or -%'lic re-orting o& healthcare‐associated in&ections have 'een

-rovided 'y the os-ital In&ection Control Practices Advisory Coittee,: the ealthcare‐

Associated In&ection 0or"ing *ro%- o& the #oint P%'lic Policy Coittee,H> and the National

!%ality )or%.H9

$eca%se the validity o& the c%rrent Centers &or Disease Control and PreventionNational

ealthcare Sa&ety Net5or" de&inition o& CA2+I &or co-arison o& &acility‐to‐&acility o%tcoes

is not esta'lished, eFternal re-orting o& CA2+I rates is not recoended.

A. State and local re8%ireents

9.

os-itals in states that have andatory re-orting re8%ireents %st collect and re-ort

the data re8%ired 'y the state. )or in&oration on state and &ederal re8%ireents, chec"5ith yo%r state or local health de-artent.

$. EFternal 8%ality initiatives

9.

os-itals that -artici-ate in eFternal 8%ality initiatives %st collect and re-ort the datare8%ired 'y the initiative.

Ac&no'ledgments

#%- +o Section...

http://www.jstor.org/stable/10.1086/591066#rf48http://www.jstor.org/stable/10.1086/591066#rf48http://www.jstor.org/stable/10.1086/591066#rf49http://www.jstor.org/stable/10.1086/591066#rf49http://www.jstor.org/stable/10.1086/591066#rf50http://www.jstor.org/stable/10.1086/591066#rf51http://www.jstor.org/stable/10.1086/591066#rf48http://www.jstor.org/stable/10.1086/591066#rf49http://www.jstor.org/stable/10.1086/591066#rf50http://www.jstor.org/stable/10.1086/591066#rf51


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)or Potential Con&licts o& Interest stateents and in&oration on &inancial s%--ort, -lease see the

Ac"no5ledgents in the EFec%tive S%ary, on -age S> o& this s%--leent.

Appendi(

#%- +o Section...

3HH K$4
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Strategies to Prevent Catheter

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