Prevention of Catheter Associated Urinary Tract Infections

Connie Garrett MSN, RN, CNOR & James A. Haley Veteran Hospital Operating Room Staff

Introduction

• 600,000 patients develop hospital acquired urinary tract infections (UTIs) every year.

• 80% of these infections are from a urinary catheter.

• About half of the patients with a urinary catheter do not have a valid indication for placement.

• Each day the urinary catheter remains in place the risk of urinary infection (CAUTI) increases 5% per day.

Intro

• Most common hospital-acquired infection: 40% of all HAIs1 million cases annually (hospitals & nursing

homes)• 12-25% of all hospitalized patients receive a

urinary catheterHalf of these found to not have valid indication

Introduction

• Increased length of stay 0.5 – 1 day• Estimated cost per case of CA-UTI ranges from

$500-$3,000• Cost to health care system up to $450 million

annually according to CMS• CA-UTI not documented as present on

admission can no longer code patient to higher reimbursement DRG for Medicare

Background

• Urinary catheters in the operating room have historically been a problem during assembly of the three part system.

• Assembly during urinary catheter insertion is an unacceptable practice that results in catheter contamination and urine spills on the operating room bed.

• Staff nurses in the operating room need a voice to make a standard of care change for current urinary foley catheters.

Problem Statement

• Current urinary foley catheter for hospital is not aligned with standard of care

• Continuous “closed”urinary catheters are available which can prevent break in sterile technique during insertion and cross contamination of body fluids.

Goals/Outcomes

• Research one part continuous “closed”urinary foley catheter

• Consider silver alloy gel coated catheter (community standard).

• Research available catheter securing devices• Perform cost analysis • Implement “closed” system urinary foley

catheter

Plan

• Collaborate with peers in community hospitals and assess current practice and standard of care for urinary foley catheter

• Perform a literature review• Contact local vendor that supplies continuous

“closed” catheter and 3-way temperature sensing foley catheter for cardiac surgery

• Contact local vendor to discuss cost analysis of standard urinary catheter used in local community hospitals

Plan

• Collaborate with infection control practitioner to communicate concern of current urinary foley catheter system• Meet with chief of general surgery to

present current community standard of care, current evidence, and cost analysis comparing current and future foley catheter system.

Plan

• Chief of general surgery performs independent literature review of evidence presented by OR and references provided from literature

• Objective evidence is presented to Chief of Surgery• Evidence is presented to Infection Control Committee

with request to pilot one piece continuous silver alloy urinary catheter

• Chief of surgery requests quality management to perform OR cost analysis conversion for urinary foley system.

Do

• Use community standard and evidence supporting silver alloy catheter to perform pilot project in OR

• Collaborate with vendor to stock necessary foley catheters including temperature sensing foley catheter for cardiac procedures and latex free catheters

Do

• Communicate pilot project with OR nurses• Educate OR staff on collection/data tool for

urinary foley pilot• Provide prevention pack education to OR staff• Distribute education brochure for CAUTI

prevention • Prompt surgeon for order to remove urinary

catheter prior to transfer of patient from OR

Do

• Ensure education includes securing device is implemented for urinary catheter patients

• Educate documentation must specify which foley catheter is inserted during pilot and “closed” system maintained

• Educate documentation must include foley catheter securing device was used/not used and explanation when not used

Study

• Collect foley insertion and evaluation tool daily for 3 months on unit

• Review evaluation tool daily and submit copy to infection control practitioner

• OR nurses will peer review foley insertion by medical staff and document accordingly in the electronic health record

• Infection control practitioner includes ICU in urinary foley pilot

Act

• Select evidence based model for change• Form interdisciplinary team and involve OR

direct care nurses• Pilot one piece continuous catheter• Collect data tool• Review data tool and evaluations

IOWA Model

• Identification of problem• Topic is a priority for organization• Form team

MDs, RNs, Unit educator/CNL-Project champion Infection control practitioner-Process owner

• Literature review and community standard critiqued for use in practice

• Sufficient research base

Pilot Change in Practice

• Select Outcomes to be Achieved• Collect Baseline Data• Design Evidence-Based Practice (EBP)

Guideline(s)• Implement EBP on Pilot Units• Evaluate Process & Outcomes• Modify the Practice Guideline

Institute Change in Practice

• Monitor and analyze structure, process, and outcome data– Environment – Staff– Cost– Patient and Family

Disseminate Results

• Insertion prep kit includes all necessary components pre-assembled

• Securing device included in kit• Elimination of cross contamination during

insertion • Elimination of urine spills on OR bed • Elimination of potential splash to health care

provider

Disseminate Results

• Pilot initiated January 2008 with data collection for 6 months on unit

• Data collected and analyzed for UTI rates in acute care July 2009

• UTI rates decreased from 3.0% to 1.7% after implementation of silver alloy catheter for Qtr 1, 2009

• Urinary catheter secured prior to transferring to receiving unit

Foley UTI Results

2008 3-part silicone 2009 silver alloy "closed system"

0

0.5

1

1.5

2

2.5

3

3.5

3

1.7

UTI Rates

Qtr 3/4 Qtr 1

Literature Review Results

• Support for one piece continuous enclosed system

• Silver coating evidenced to reduce biofilm around catheter tip up to 7 days

Favorable Data

• AM J Infect Control 2002;30:221-5• U Mass Med Center evaluated 5 months using

silver-impregnated foley on all patients and compared to data from previous year using non-silver foleys. Rate of CAUTIs for noncoated catheters was 4.9/1000 patient-days compared to 2.7/1000 patient-days with silver-hydrogel catheters. A reduction of 45% (P=.1). The estimated cost savings rained from $12,563.52-$142,314.72.

Favorable Data

• American Journal of Medicine 105(3):236-41,1998 Sep.

• Meta-analysis U of Washington. 8 trials with 2,355 patients. OR UTI was 0.59 (95% CI, 0.42-0.84) indicating a significant benefit to silver-coated catheters. Silver alloy catheters (OR=0.24; 95% CI, 0.11-0.52) were significantly more protective against bacteriuria than silver oxide catheters (OR=0.79;955 CI, 0.56-1.10).

Favorable Data

• Arch Intern Med.2000;160:2670-2675• U Michigan cohort of 1000 patients

(medical,surgical,ICU,etc.) with silver or standard foley. Silver-coated catheters led to 47% relative decrease in incidence of symptomatic UTI from 30-16 cases/1000 patients compared with standard catheters. Silver-coated catheters provided clinical benefits over standard catheters in all cases and cost savings in 84% of cases.

Opposing Data

• Infection Control & Hospital Epidemiology, 27(1):38-43,2006 Jan.

• Johns Hopkins & Wake Forest prospective study of 3,036 patients with catheters, 1.165 (38%) of silver impregnated, and 1,871 (62%) not impregnated. The rate of UTIs/1000 foley days was 14.29 in silver catheter group, compared with 16.15 nonsilver catheter group (IR ratio, 0.88; 95% CI, 0.70-1.11; P=.29. In a multivariate survival analysis silver catheters were not statistically protective against UTI.

• **Note- Study groups not identical-more men, and shorter duration of catheterization, & fewer urine cultures/1,000 catheter-days in the silver catheter group.

Unit Pilot of Bard Prevention Pack

• Bard foley catheter system evaluated and chosen for standard of care change

• Silver alloy coated foley catheter selected for pilot• All in one prep kit consisting of a #16 Fr. foley

catheter, bacteriostatic drainage bag, and stat-lock securing device

• Use as small a catheter as possible that is consistent with proper drainage, to minimize urethral trauma. Therefore, #14 Fr. Foley catheter recommended in place of #16 during evaluation of size comparison

Pearls of Wisdom for OR

• Documentation received from Bard to exclude practice of balloon inflation prior to insertion

• Maintain a sterile, continuously “closed” drainage system.

• Keep catheter properly secured to prevent movement and urethral traction.

• Keep collection bag below the level of the bladder at all times.

• Maintain unobstructed urine flow.

CAUTI Update

• CAUTI prevention is now a VHA initiative• CDC updated guidelines 2009 are available• APIC -CAUTI guidelines updated• Evidence based guidelines in production by

process owner

EBP References

• APIC CA-UTI Elimination Guidewww.apic.org/CAUTIGuide

• SHEA-IDSA Compendiumhttp://www.shea-online.org/about/compendium.cfm

• CDC Guidelinehttp://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html#N.b. An update to CDC guidelines is expected in early 2009.***Note- Pilot research and project performed in 2008

References

• AM J Infect Control 2002;30:221-5• American Journal of Medicine 105(3):236-

41,1998 Sep.• Arch Intern Med.2000;160:2670-2675• Infection Control & Hospital Epidemiology,

27(1):38-43,2006 Jan.