13th May 2009

In the next 45 minutes...In the next 45 minutes...

What is a UTI?

The scale of the problem

Strategies to reduce risk

Is a catheter necessary?

ANTT catheter insertion

Ongoing education

Discussion

2

Problem Number 1Problem Number 1What is a UTI?What is a UTI?

Lots of conflicting definitions Google 753,000 (in 0.33 seconds!)

Bacteria in urine

Symptoms

3

Problem number 2Problem number 2What is a CAUTI?What is a CAUTI?

UTI associated with a urinary catheter! How long after insertion?

How long after removal?

Varying definitions = inconsistent findings

4

Acceptable definition?Acceptable definition?

Is it catheter related? The patient has an indwelling urinary

catheter OR has had a urinary catheter during the previous 7 days .

There is no evidence that a urinary tract infection was present or incubating before catheterisation.

The infection became evident 48 hours or more after catheterisation.

Third Prevalence Survey of Healthcare Associated Infections in Acute Hospitals5

SymptomsSymptoms Criterion 1:

Patient has at least one of the following signs or symptoms with no other recognised cause: fever (>38oC), urgency, frequency, dysuria, or suprapubic tenderness

and

patient has a positive urine culture, that is, ≥105 microorganisms per cm3 of urine with no more than two species of microorganisms.

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Or...criterion 2Or...criterion 2

Patient has at least two of the following signs or symptoms with no other recognised cause: fever (>38oC), urgency, frequency, dysuria, or suprapubic tenderness

and...

7

at least at least one one of the followingof the following::

positive dipstick for leukocyte esterase and/or nitrate Pyuria (urine specimen with ≥10 WBC/mm3 or 3

WBC/high power field of unspun urine) Organisms seen on Gram stain of unspun urine At least two urine cultures with repeated isolation of the

same uropathogen (gram negative bacteria or S. saprophyticus) with 102 colonies / ml in nonvoided specimens

105 colonies/Ml or a single uropathogen (gram negative bacteria or S. saprophyticus) in a patient being treated with an effective antimicrobial agent for a urinary tract infection

Physician diagnosis of a urinary tract infection Physician institutes appropriate therapy for a urinary

tract infection8

How common?How common? 12.6% of acute patients are catheterised

20 - 30 % of acute catheterised patients will develop bacteruria

8-10% of acute catheterised patients will develop symptoms of urinary tract infection

A UTI increases the length of patient hospitalisation by 75% (8 to 14 days)

A single UTI costs £1327

Plowman et al 1999 9

HCAI Comparison 2000HCAI Comparison 2000

Socio-Economic Burden of Hospital Acquired Infection-PHLS report 2000

Incid

en

ce %

(n

ati

on

al

UK

)

UTI

LRTISWI

Skin BSI

Other

Multiple(may inc. UTI)

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Cost Estimate 2000Cost Estimate 2000

Socio-economic Burden of Hospital Acquired Infection-PHLS report 2000

UTI

LRTI

SWISkin

BSI

Other

£ m

illio

ns

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What about...What about...

Urethritis

Prostatitis

Nephritis

Epidydimitis

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UrethritisUrethritis

4 papers

Mean 9%

Range 1-18%

FU Up to 3 years

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ProstatitisProstatitis

Cuckier et al 19765%

Perrouin Verbe et al 199533%

Mean 19% FU 5yrs

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NephritisNephritis

No studies in live patients

But

Evidence of nephritis in 33% of long-term catheterised patients at post mortem

Gomlin & McCue 2000

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EpididymitisEpididymitis

7 papers

Mean 10%

Range 1-28%

FU up to 5 yrs

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Reducing Risk!Reducing Risk!

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EducationEducation

Need for catheter?

Early removal 5% risk per day

Correct products

Correct insertion

Correct care

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Catheter should be MDT decisionCatheter should be MDT decision No routine catheterizations

Individualized decision Discuss with patient

Alternative management Drugs Surgery

MITs CISC Sheath Pads

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Other toolsOther tools Standardize available products

Use national initiatives www.dh.gov.uk/publications HII Saving Lives

Top-down approach Management IC&P Team Urology

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Do you have a catheter formulary?Do you have a catheter formulary?

21

ANTT Catheter InsertionANTT Catheter Insertion

Standardized insertion training using ANTT principles

ALL relevant clinical staff

Management engagement

Training

Assessment

Annual updates22

ANTT Catheter InsertionANTT Catheter Insertion Embedded with ANTT for other procedures

Vascular Access

IV therapy

Intubation

Blood cultures

Insertion using EAUN guidelines

www.uroweb.org/fileadmin/user_upload/EAUN/EAUN2.pdf

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Manchester ANTT ImplementationManchester ANTT Implementation

ANTT included as a part of Trust IP&C strategy

Implementation process started September 2006

Education and training provided to all clinical staff

Individual assessment of staff

Weekly reporting of staff trained to director

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Audit Results – ANTT Compliance

72%

83%

65%68%

84%81%

77%

94%92%

95%

80%

97%

86%

91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Children's MREH/Dental Surgery CSS St Mary's Medicine Total

Original Audit

Re-Audit

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MRSA BacteraemiaMRSA Bacteraemia 12 Month Pre & Post ANTT

0

1

2

3

4

5

6

7

8

9

1 2 3 4 5 6 7 8 9 10 11 12

Month

Nu

mb

er Pre ANTT

Post ANTT

Pre ANTT Trend

Post ANTT Trend

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ANTT – Effect on UTIANTT – Effect on UTI

Not measured in isolation

Audit 2005 - 16%

Audit 2008 – 9.6%

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ConclusionsConclusions

Multifaceted catheter policy needed Insertion policy

ANTT

Product formulary

Education

Assessment

Audit

Much of the work has already been done EAUN

BAUNwww.baun.co.uk

HII

SIGN (Scotland)

www.sign.ac.uk

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DiscussionDiscussion

1. Coello R et al., J Hosp Inf 2003

2. Rowley S, Nursing Times 2001

3. Dodgson K et al., SHEA conference 200929