Catheter Associated Urinary Tract Infection Prevention

Nursing Care for Urinary Catheter Associated Infections

Catheter associated health issues. Chatterer caused urinary tract infection.Assessment and indications of infection.Nursing strategies and interventions.

Catheter infection Associated Infection as Health Issue

    Health care-associated infections (HAIs) have received increasing scrutiny over the last decade and are now widely recognized as largely preventable adverse events related to medical care. CAUTIs are the single most common HAI, accounting for 34% of all HAIs ( Klevens et al., 2007) and associated with significant morbidity and excess health care costs (Saint, 2000). 

    CAUTI is disproportionately reported among older adults (Fakih et al., 2010). Although once largely overlooked as part of the price of doing business in hospitals, a significantly changed regulatory environment has emerged that will bring increased scrutiny to HAIs in general and CAUTIs in particular. 

    Examples of this oversight include process and outcome measurement and reporting and financial incentives to improve these measures. Since 2008, the Centers for Medicare and Medicaid Services (CMS) no longer reimburses for additional costs required to treat hospital-acquired urinary tract infections (UTIs, CMS, Department of Health and Human Services [DHHS], 2007). 

    Long-term care facilities also follow CMS regulatory guidance and their federal regulations (F-315 Tag) mandate that IUC use must be medically justified and care rendered to reduce infection risk in all residents with or without an IUC (CMS, DHHS, 2005) , Enhanced public reporting and financial incentives figure prominently in the Patient Protection and Affordable Care Act of 2010;HAIs are singled out for inclusion in both types of initiatives (Patient Protection and Affordable Care Act, 2010). 

    Therefore, it is imperative that health care professional staff in various settings develop strategies and interventions to reduce IUC duration and prevent CAUTIs, thus benefitting both patient and financial outcomes.

    This paradigm shift occurs as the evidence base for the prevention of CAUTI is evolving. After 25 years of stasis in the field, multiple stakeholder organizations including the Centers for Disease Control and Prevention (CDC) and several major professional societies have critically examined the literature on CAUTI prevention.

    Between 2008 and 2010, at least six evidence-based practice strategies, recommendations, and/ or guidelines for preventing CAUTI in hospitals and long-term care have been published ( Cottenden et al., 2005; Gould et al., 2009; Greene, Marx, &Oriola , 2008; Hooton et al., 2010; Joanna Briggs Institute [JBI], 2000; Lo et al., 2008; see Resources section). 

    Prior to this proliferation of recommendations, the last evidence synthesis for CAUTI prevention in the United States occurred in 1981. In addition, in 2009, the CDC's National Healthcare Safety Network significantly revised the surveillance definition for CAUTI (CDC, National Healthcare Safety Network, 2009 ). 

    In the light of these rapid changes in the field, the review of policies, procedures, practices, and products is imperative for all health care facilities. In this chapter, we will review the rationale for CAUTI prevention strategies, suggest an approach to implementing a comprehensive CAUTI prevention program, and catalog the most important CAUTI prevention strategies.

Catheter Related Health Issues

    Health care-associated UTIs are frequent and costly, resulting in increased morbidity and possible mortality in hospitalized older adults (Saint, 2000). There are more than 500,000 hospital-acquired UTIs in the United States annually (Gould et al., 2009; Klevens et al., 2007). 

    At a mean cost of $589 per episode, this epidemic results in $250 million of excess health care costs each year ( Tambyah , Knasinski , & Maki, 2002). Five percent of UTIs lead to bacteremias , with significantly increased mortality and costs.

    The vast majority of UTIs are associated with the ubiquitous IUC, also known as a Foley catheter named after urologist Frederick Foley who developed the modern device. Urinary catheters are among the most widely used medical devices. 

    Despite their utility in acutely ill patients, they have many downsides, including the CAUTI. Other complications include delirium (Inouye, 2006), local trauma, encrustation, and restriction of mobility (Saint, Lipsky, &Goold , 2002). 

    Therefore, the benefits of managing urinary output with an IUC must be weighed against the many risks.

    Unfortunately, the indiscriminate use of IUCs is widespread. IUCs are used in up to 25% of hospital admissions (Weinstein et al., 1999) and are more commonly used in the older patient (Fakih et al., 2010). 

    Thirty percent of Medicare patients have IUCs during their hospital stay (Zhan et al., 2009) and older women are disproportionately likely to have no clear indication for catheterization (Fakih et al., 2010). Of Medicare patients undergoing elective surgery, 86% have an IUC (Wald, Ma, Bratzler , & Kramer, 2008) and nearly 50% continue to have a catheter in place beyond 48 hours postoperatively (Wald, Epstein, & Kramer, 2005). 

    According to the Infectious Diseases Society of America (IDSA), 21%-54% of all IUCs are inappropriately placed and are not medically indicated (Hooton et al., 2010). Only 25% of attending physicians in teaching hospitals are aware that their patients have urinary catheters, and few hospitals have systematic methods for tracking which patients have catheters placed (Saint et al., 2000; Saint et al., 2008). 

    Clearly, interventions aimed at evidence-based use of catheters are needed to prevent CAUTIs. To better understand the potential approaches to prevention of CAUTIs, an understanding of CAUTI pathogenesis is essential.

Catheter Related Urinary Tract Infection Pathogenesis

    The urinary tract is normally a sterile body site; therefore, any positive urine culture (defined in Table 19.1) can be considered a UTI. The IDSA distinguishes between two categories of UTIs: the benign asymptomatic bacteriuria (ASB) and the clinically important symptomatic UTI. 

    Either of these conditions can occur in the presence of an IUC (Hooton et al., 2010).When a patient has an IUC, microorganisms can gain access to the urinary tract on either the extraluminal surface of the IUC or intraluminal surface through breaks in the catheter system. 

    Extraluminal infection can occur early if bacteria are introduced during insertion, but more commonly, extraluminal infection occurs later (Maki &Tambyah , 2001). Once they gain access to the urinary tract, microorganisms can thrive in a “biofilm” layer on either the extraluminal or intraluminal surface of the IUC. 

    The biofilm, made up of bacteria, host proteins, and bacterial slime, is thought to be important in the development of late CAUTIs. Because the formation of a biofilm and colonization with bacteria takes time, most CAUTI occurs after 48 hours of catheterization and increases approximately 5% per day (Schaeffer, 1986; Stamm , 1975).

    The mechanisms described previously provide the rationale for evidence-based care of IUCs and highlights three potential opportunities for intervention during the use of IUCs. 

    The first opportunity is avoidance of catheters at the time of the decision for insertion, the second is evidence based product selection and care practices regarding IUCs (including insertion and maintenance), and the third is minimizing duration through timely removal. 

    A fourth set of additional strategies for CAUTI prevention includes education of providers and surveillance of processes and outcomes. This set of strategies can be applied at any of the opportunities for intervention. A comprehensive program to eliminate CAUTIs includes elements of each of the aforementioned strategies.

Assessment 

    Surveillance Definition of Catheter-Associated Urinary Tract Infection Pathogenesis A CAUTI is a UTI that occurs while a patient has an IUC or within 48 hours of its removal. Although the clinical diagnosis of CAUTI is in the eye of the clinician, the CDC has developed explicit surveillance criteria for CAUTI for use by infection control practitioners. In brief, the patient must have the following symptoms:

1. A positive urine culture sent more than 48 hours after admission to the health care facility.

2. An IÚC at the time of or within 48 hours prior to the culture

3. One of the following: suprapubic tenderness, costovertebral angle pain or tenderness, or a fever higher than 38 °C without another recognized cause; or a positive blood culture with the same organism as in the urine. The CAUTI diagnosed within 48 hours of arrival to a location is attributed to the prior location.

    In nonbacteremic cases, this surveillance definition requires the patient to have symptoms referable to the urinary tract or a fever without another cause. ASB is of questionable clinical significance and should not be treated except in pregnant patients or those undergoing urologic surgery (Nicolle et al., 2005). 

    For the purposes of infection control surveillance, new alterations in mental status do not meet the diagnostic criteria for CAUTI.

    CAUTIs are generally reported as infections per 1,000 catheter days on a given patient care unit. More than half of all states require public reporting of hospital-acquired infections, among them, many specify reporting of CAUTIs. Such reporting of CAUTI rates is likely to increase.

Additional process measures that may be of interest include catheter days or hospital     days, catheter duration per episode of catheterization (may also be referred to as dwell time), and proportion of catheterized or admitted patients from the emergency department (ED) or operating room ( OR). 

    Since October 2009, the Surgical Care Improvement Project collects a measure of postoperative catheter removal on post-operative Day 1 or 2 and, as of October 2010, has expanded this measure to catheter removal on catheterization Day 1 or 2 for all surgical patients (Surgical Care Improvement Project, nd).

Indications for Indwelling Urinary Catheters

    Avoidance of unnecessary IUCs may reduce CAUTI incidence with subsequent decreases in length of stay, costs of hospitalization, and costs associated with CAUTI ( Apisarn - thanarak et al., 2007). Elpern et al. (2009) evaluated the inappropriate use of IUCs among inpatients and found them to be more common in female, non-ambulatory, and medical ICU patients. 

    Explicit criteria for appropriate insertion may result in significant reductions in catheter duration and CAUTI prevalence. The University of Colorado Hospital developed and disseminated an algorithm for appropriate insertion of IUCs in the ED based on guidance from the published literature. Similar criteria can also be developed specifically for the OR and postoperative period. 

    At the University of Colorado Hospital, a protocol for early postoperative removal was developed and disseminated. An IUC should not be used for routine care of patients who are incontinent, as a means to obtain urine culture or other diagnostic tests in a patient who can void, for prolonged postoperative duration without appropriate indications, or routinely in patients receiving epidural anesthesia and analgesia.

Nursing Interventions and Strategies

    It is estimated that 20%-69% of CAUTIs are preventable (Gould et al., 2009). Specific interventions to prevent CAUTIs are summarized in the subsequent text and organized regarding the four strategies. Many of these recommendations are supported by low quality evidence and expert opinion. Further study may impact these recommendations. A proposed approach to a comprehensive CAUTI intervention follows.

Strategy 1: Avoidance

    To reduce the incidence of CAUTI, it is important to rethink practice systems and examine “why” behind the clinical indication for the IUC. Clearly identifying the need for the IUC can assist in the avoidance of inserting an IUC when other options for elimination are available. The use of an algorithm to guide the insertion decision may be of assistance. 

    To avoid catheterizations, alternative strategies for man-aging urine output are necessary. Completing a systems evaluation of available equipment to provide alternatives to IUC for urinary elimination is an important first step in reducing use. Developing toileting schedules incorporated with frequent nursing staff rounding is another strategy that can be used to reduce urgency and incontinence episodes.

    If the patient is mobile or has limited mobility, alternatives to an IUC include the use of a bedside commode with a toileting schedule (Gray, 2010), condom catheters for male patients (Dowling-Catronovo & Bradway, 2008; Saint et al . , 2006), moisture wicking incontinence pads ( BioRelief , nd; Cottenden et al., 2005; Medline UltrasorbUnderpad , nd), intermittent straight catheterization with the use of a bladder scanner to determine bladder urine volume (Hooton et al., 2010; Saint et al., 2006; Saint et al., 2009), as well as urinals and bedpans. 

    Careful consideration of products and how and where they are stocked is essential to success. For instance, commodes need to be available in multiple sizes and need to include stable (not easy to tip) and bariatric commodes; urinals need to fit snugly on bedrails.

    For less mobile male patients, the condom catheter is an effective alternative to an IUC. Research by Saint and colleagues (2006) found that the use of condom catheters for elimination were effective in reducing CAUTIs (p=.04). In addition, the patients in this study reported condom catheters to be more comfortable (p=.02) and less painful (p=.02) than an IUC. 

    The authors did not report an increase in adverse skin breakdown associated with the use of the condom catheter. Moisture absorbing or wicking under pads for incontinence management are a newer alternative for the acute care environment. Incontinence under pad products pull effluent moisture and urine away from the skin and can absorb up to 2 L of fluid before becoming saturated ( Junkin &Selekof , 2008; Padula , Osborne, & Williams, 2008). 

    For a full discussion of incontinence management, please refer to Chapter 18, Urinary Incontinence.Urinary retention post-surgery or after initial IUC removal may pose clinical care challenges. To prevent IUC insertion or reinsertion, intermittent catheterization should be considered as an avoidance strategy. 

    The bladder scanner, which utilizes ultrasound technology, is clinically beneficial in determining urinary retention, reducing unnecessary intermittent catheterizations, enhancing patient comfort, and saving costs associated with inappropriate catheterizations and possible CAUTIS (Lee, Tsay , Lou. & Dai. 2007; Palese ( Buchini , Deroma , &Barbone , 2010; Sparks et al., 2004).

Strategy 2: Evidence-Based Product Selection, Insertion, and Routine Care

    If an IUC is determined to be clinically indicated, selection of the right catheter, proper technique during insertion of the device, and evidence-based ongoing care management are needed to reduce infection.

     Catheter material remains in area of ongoing debate. Although antimicrobial catheter materials have been shown to reduce catheter-associated bacteriuria (Johnson, Kuskowski , & Wilt, 2006), the impact of antimicrobial catheters on symptomatic CAUTIs remains unproven. 

    Research syntheses have failed to conclusively demonstrate the effectiveness of silver-coated or antibiotic-impregnated catheters on prevention of CAUTIs for short-term catheterization of adult patients versus standard materials. 

    There is also insufficient evidence to determine whether selection of a latex catheter, hydrogel coated latex catheter, silicone-coated latex catheter, or all-silicone catheter influences CAUTI risk ( Cottenden et al., 2005; Hooton et al., 2010; Parker et al al., 2009; Patient Protection and Affordable Care Act, 2010; Schumm & Lam, 2008). 

    The decision to use a silver-coated or antibiotic-impregnated catheter should be made with the understanding that it does not substitute for a comprehensive CAUTI prevention program. Selecting the smallest IUC size, when possible, is an additional consideration to reduce the risk of infection (Gould et al. 2009; Greene et al., 2008; Hooton et al., 2010). 

    The selection of a smaller catheter (eg, less than 18 French) reduces irritation and inflammation of the urethra and reduces risk of infection (Gray, 2010).Placing an IUC is a fundamental skill for nurses; however, current evidence supporting sterile versus aseptic technique for the procedure is inconclusive (Greene et al., 2008; JBL, nd). 

    Strict sterile technique involves using a sterile gown, mask, prolonged hand washing (more than 4 minutes), opening and using a sterile insertion kit, donning sterile gloves, cleansing the urethral meatus and perineal area with an anti-septic solution, and inserting the catheter using a no-touch technique (Gray, 2010). 

    Willson and colleagues (2009) reviewed the literature and found that most clinicians employ an aseptic technique, which was most frequently defined as the use of sterile gloves, sterile barriers, perineal washing using an antiseptic cleanser, and no-touch insertion. 

    Current recommendations suggest an IUC insertion be placed under aseptic technique with sterile equipment (Gould et al., 2009; Greene et al., 2008; Hooton et al., 2010). Once an IUC is placed, optimal management includes care of the urethral meatus according to "routine hygiene" (eg, daily cleansing of the meatal surface during bathing with soap and water and as needed (eg, following a bowel movement: Gould et al. , 2009: Greene et al., 2008; Hooton et al., 2010; Jeong et al., 2010; JB1, nd). the risk of infection (Jeong et al., 2010; Willson et al., 2009).

    Securing the IUC after placement to reduce friction from movement is an important element of catheter management supported by current guidelines, researchers, and expert opinion panels ( Darouiche et al., 2006; Gould et al., 2009; Hooton et al., 2010; Society of Urologic Nurses and Associates Clinical Practice Guidelines Task Force, 2006).

     Maintaining a closed catheter system is also supported by current guidelines (Gould et al., 2009; Greene et al., 2008; Hooton et al., 2010) to eliminate the introduction of microbes that occurs when breaking the prepackaged seals on the IUC A systems analysis should be conducted to purchase and stock the most commonly needed IUC insertion and drainage bag kits to optimize the maintenance of a closed system.

    Similarly, maintaining the urine collection bag below the level of the bladder minimizes reflux into the catheter itself preventing retrograde flow of urine (Gould et al., 2009; Greene et al., 2008; Hooton et al., 2010). Establishing work flow protocols to routinely empty the drainage bag frequently and prior to transport are important in reducing urine reflux and opportunities for CAUTI.

Strategy 3: Timely Removal

    Developing systems that prompt health care providers to review the need for the IUC and encourage early removal have been found to reduce IUC use and CAUTI rates ( Apisarnthanarak et al., 2007; Fernandez, Griffiths, &Muric , 2003; Loeb et al., 2008; Meddings , Rogers, Macy, & Saint, 2010). 

    Meddings and colleagues (2010) conducted a systematic review and meta-analysis and found that urinary catheter removal reminders and stop orders appeared to reduce CAUTI rates. 

    Implementing systems that provide physicians and nurses with routine reminders to evaluate the need for the IUC were found to reduce the CAUTI rate by 56% (p=.005). In this study, automatic stop orders were found to reduce the rate of CAUTI by 41% (p < .001). 

    Overall, urinary catheter use and mean duration of catheterization were also decreased in several studies analyzed ( Meddings et al., 2010).

    Other valid approaches to reducing catheter days include audit and feedback (Goetz, Kedzuf , Wagener, &Muder , 1999) and nurse-prompted reminders to recommend re -evaluation of the need for the IUC and early removal ( Apisarnthanaraket al. 2007; Greene et al., 2008). Some hospitals have explored nurse-driven catheter removal protocols (Wenger, 2010).

    Multiple studies have examined outcomes associated with early removal of IUCS after surgery. Early removal of IUCs after uncomplicated hysterectomy decreased first ambulation time and length of hospital stay ( Alessandri , Mistrangelo , Lijoi , Ferrero, &Ragni , 2006). 

    Dunn, Shlay , and Forshner (2003) found that early removal post-surgery was not associated with adverse events in patients and subjective pain was significantly less. Keeping the IUC as long as thoracic epidural analgesia is maintained may result in a higher incidence of CAUTI and increased hospital stay. 

    IUC removal on the morning after surgery while the thoracic epidural catheter is still in place does not lead to urinary retention, infection, or higher rates of catheterizations (Basse, Werner, &Kehlet , 2000; Chia, Wei, Chang, & Liu , 2009; Ladak et al., 2009; Zaouter , Kaneva , & Carli, 2009).

Strategy 4: Surveillance and Education

    Ensuring leadership of organizations and systems are in place to effectively evaluate and sustain practice change are essential to improving patient outcomes ( Kabcenell . Nolan, Martin, & Gill, 2010; Reinertsen , Bisognano , & Pugh, 2008). In particular, surveillance is key to an effective infection control program. 

    Metrics that are amenable to performance measurement and feedback are discussed in the Assessment of the Problem section and include process measures as well as outcomes. A 2005 survey demonstrated that only a minority of hospitals track urinary catheter use (Saint et al., 2008).

    Measurement must be accompanied by provision, knowledge, and skills to front-line providers through appropriate education and training, which may be central to a multicomponent CAUTI intervention. Huang et al. (2004) found that a multifaceted educational intervention incorporating the use of algorithms, automated stop orders, and physician reminder prompts needed to be critically evaluated to effectively decrease CAUTIs in all patients. 

    Ongoing system evaluation, nursing reeducation, practice reminders, and public reporting of unit-based CAUTI rate data are strategies to inform the health care team of current practice outcomes and effectiveness of CAUTI prevention strategies. 

    Implementing systems that encompass the whole health care team to question the need for the IUC and, when indicated, ensuring proper care and early removal can be pivotal in reducing CAUTI rates (Wenger, 2010). Approach to a Comprehensive Catheter-Associated Urinary Tract Infection Intervention

    Evidence-based practice guidelines derived from valid, current research and other evidence sources can successfully improve patient outcomes and quality care. 

    However, simply disseminating scientific evidence is often ineffective in changing clinical practice. Learning how to implement findings is critically important to promoting high quality and safe care ( Drekonja , Kuskowski , & Johnson, 2010). 

    To effectively facilitate the translation of best evidence into practice, processes enhancing practice change must be embraced by the health care provider ( Wallin , Profetto -McGrath, & Levers, 2005). 

    Understanding health care provider decisions, experiences, practice processes, and barriers are considered essential elements that must be explored to successfully implement practice change based on best evidence ( Titler & Everett, 2006).

    Developing an interdisciplinary champion team and creating a multifaceted intervention to implement evidence-based procedures for IUC insertion and maintenance must be a priority in all practice settings. 

    The ultimate goals are to reduce routine catheter insertions, provide evidence-based catheter care, and prompt early removal when possible, thus decreasing the risk of and prevention of CAUTI.

    Steps used for protocol development at the University of Colorado Hospital are highlighted in the subsequent text. Improved patient outcomes (decreased catheter days, decreased CAUTIs) and decreased costs have been realized.

Protocol Development

1. Recruit an interdisciplinary champion team to include nurses (clinical educators, OR registered nurses (RNs), ED RNs); physicians (hospitalists, infectious disease ED medical doctors [MDs), surgeons, anesthesiologists); rehabilitation therapists and transport personnel; infection control preventionists; and quality improvement, central supply, and clinical informatics representatives. 

2. Examine and synthesize the evidence (search, review, critique, and hold journal clubs in various care areas to present the evidence). 3. Identify and understand product use, availability, and costs in your health care setting. Refine product use based on the best evidence and cost analysis. Examine the following: Urinary catheter materials, sizes, kits, and drainage bags

Catheter Security Device

1.     Urinals and bedpan availability Commodes (availability and size)

2.     Bladder scanners

3.     Alternatives (incontinence pads, condom catheters, etc.)

4.     Identify barriers to optimal IUC care practices by surveying staff or holding focus groups throughout your health care setting.

5.     Update your policy and procedures related to inwelling catheter insertion and care based on the evidence.

6.     Consider breaking the project into manageable phases. Avoidance strategies may require a different approach than care or removal strategies. For instance, avoidance starts in the ED and OR, whereas removal occurs on inpatient floors.

7.     Develop and use algorithms, decision aids, and factoid posters displaying evidence-based caveats.

8.         Update patient and family educational materials on the importance of prompt and early removal of indwelling catheters.

9.             Educate staff (including radiology, transport, rehabilitation therapy staff [PT, physical therapist; OT, occupational therapist]) focusing on policy and procedure revision, insertion indication guidelines, insertion procedures, maintenance and care, catheter bag placement, removal prompts, and bladder scanner use and procedures.

              Work with infection control and clinical informatics staff to audit and measure outcomes. Provide feedback to staff. Potential measurable outcomes include the following:

CAUTIs/1,000 Catheter Days

Catheter days and hospital days

Postoperative catheter days and patient days

Proportion of catheterized and admitted patients from ED or OR

Continually evaluate and update practice changes