Prevention of Catheter Associated Urinary Tract

Infections (CA-UTI)Patti G. Grota PhD, RN, CNS-M-S, CIC

Nurse EpidemiologistAssistant Professor, UTHSCSA SON

Assistant Professor, Schreiner University

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Objectives• Explore the epidemiology of CA-bacteriuria.• Discuss national guidelines and recommendations

that impact prevention of CA-UTI.• Describe the pathophysiology of CA bacteriuria.• List the differences in asymptomatic CA bacteruria

and CA-UTI.• Describe how bundles prevent CA-UTI.• Explain appropriate documentation of indication

insertion and maintenance of indwelling urinary catheters.

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EpidemiologyProblems with Urinary Catheters

• Urinary tract infection• Mechanical trauma to urethra and

bladder• Immobility (restraining patient)*

*Saint S, Ann Intern Med 2002; 137: 125-7**Saint S, Am J Infect Control 2000;28:68-75

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EpidemiologyMore Problems

• Discomfort and pain to patient• Add to direct costs of hospitalization:

$500 to $1,000. If bacteremia present, cost up to $3,800.**

• Increased length of stay

*Saint S, Ann Intern Med 2002; 137: 125-7**Saint S, Am J Infect Control 2000;28:68-75

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Epidemiology of CAUTI

•

Most common type of healthcare-associated infection.

75% diagnosed in a hospital are associated with a urinary catheter*CDC, 2009

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EpidemiologyBurden of CA-UTI

•The risk of CA-UTI increase 5% every day that an indwelling urinary catheter remains in place.(AACN, 2009)• More than 30 million Foley catheters are inserted annually in the United States, and probably contribute to 1 million CAUTIs . (APIC.org, 2008)• A complications of CA-UTI can increase a patient’s hospital length of stay from 0.4 days to 2 days. (APIC.org, 2008)•An additional average expense of $3,803 per episode, as reported in an ICU CAUTI study. (APIC.org, 2008)

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Epidemiology• Indwelling urinary catheters may not always be

appropriate– 288 physicians were unaware of the presence of

indwelling catheters in 28% of their patients who had catheters.

– Less than half of urinary catheters in teaching hospital were indicated.

– Catheterization was 3.7 times more likely to be inappropriate if the physician was unaware a catheter was in place.

– Approximately 74% US hospitals reported not monitoring how long a catheter had been in place.

Saint et. Al Am J Med 2000Tambyah, Infect Control Hosp Epidemiol 2002;23:27-31

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Pathophysiology Risk Factors for CA-UTI

• Method of catheterization• Duration of catheter• Quality of catheter care• Host susceptibility

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Pathophysiology: Key PointThe risk of CA-UTI increases

proportionally with the duration of the indwelling catheter.

If you have to use an indwelling catheter, get it out as soon as

possible! pgg/02-22-12

• Short-term catheterizationRemains indwelling ≤ 2 weeksCommonly used in acute or critical care

• Long-term catheterizationRemains indwelling ≥ 2 weeks

Gray M et al. Best practices in managing the indwelling catheter. Perspectives 2007 (Supp 1)

Indwelling CatheterizationShort term vs Long term

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PathophysiologyCommon Pathogens

• Endogenous intestinal flora– E. coli– Proteus– Enterobacter– Enterococci

• Nonintestinal or environmental pathogens– Pseudomonas– Candida– Staph coag neg– MRSA– Acinetobacter

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CAUTIFrequency of Common Pathogens

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APIC elimination guidepgg/02-22-12

Pathophysiology

Ascension of microbes

.

External (extraluminal) Bacterial Ascension ●Microorganisms colonize the external catheter surface, most often creating a biofilm.

●Bacteria tend to ascend early after catheter insertion suggesting a lack of asepsis during initial insertion.

●Bacteria can also ascend 1-3 days after catheterization, usually due to capillary action.

Guide to the Elimination of CAUTIs. APIC, 2008.

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PathophysiologyAscension of microbes

Internal (intraluminal) Bacterial Ascension ●Bacteria tend to be introduced when opening the otherwise closed urinary drainage system. ●Microbes ascend from the urine collection bag into the bladder via reflux. ●Biofilm formation occurs, and damage to bladder mucosa facilitates biofilm on this surface.

*APIC.2008. Guide to the Elimination of CAUTIs

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Intraluminal Extraluminal

Detrusor spasm Shedding of cells Bacteremia

Leakage Obstruction Fever (+) UA Hypotension

Bladder infection with inflammation

CAUTI: Pathophysiology

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National Guidelines

• Who makes the national guidelines and recommendations?– CDC/NHSN– Infectious Disease Society of America– Joint Commission NPSG 7– Association of Professionals in Infection

Prevention and Control (APIC)– Medicare and Medicaid Regulations

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National Guidelines● Why national guidelines and recommendations?

Clinical indicator of quality of care

Contributes to increased morbidity, mortality, and costs

Increased length of hospital stay

Increased patient discomfort

Increased risk for hospital readmission

*CDC, 2009

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Deficit Reduction Act P.L. 109-171

• Secretary of HHS must identify high cost, high volume preventable conditions that result in higher payment

• October 1, 2008 CMS denied payments for 10 hospital acquired conditions (HACs), 3 of which were HAIs

Selected surgical site infectionsVascular catheter associated infectionsCatheter associated urinary tract infections

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Joint Commission NPSG 07.07.01(adults only)

• Implement evidence-based practices to prevent indwelling catheter associated UTI (CAUTI)

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CAUTI BundleComponents

InsertionMaintenance Surveillance

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What is a bundle?

• A collection of best practices identified by evidence-based science as necessary to provide optimum care for patients in certain circumstances involving particular risks to achieve the goal of improved outcome.

• Keep It Smart but Simple Aseptic technique

Secure the catheter

Hand hygiene

Closed drainage system

Appropriate indication

Check daily for removal

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“Life Cycle” of the Indwelling Urinary Catheter

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Disrupting the Life Cycle of the Indwelling Urinary Catheter

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What does the evidence say?

Category 1 Strongly Recommended*• Educate personnel in correct techniques• Catheterize only when necessary• Leave catheter in the least amount of time possible• Hand washing principles• Sterile technique • Secure catheter properly• Maintain closed sterile drainage• Obtain urine samples aseptically• Maintain unobstructed urine flow

CDC, 2009pgg/02-22-12

Appropriate Indications for Insertion

• Hospice Care• Neurogenic bladder• Obstruction/retention• Stage 3 or 4 pressure ulcer• Selected surgical procedures• Critically ill pt to monitor urine output• Prolonged immobilization~Indications based on expert consensus

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Inappropriate Indications

• Nursing care of incontinent patients• A means of obtaining a urine specimen when

the patient can voluntarily void• Prolonged postoperative duration without

indications

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Alternatives To Insertion

External Urinary Catheter Devices

Intermittent catheterization

Bladder scanners

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Advantages of Suprapubic Catheterization

• Lower risk of CA-bacteriuria• Reduced risk of urethral trauma and stricture• Ability to attempt normal voiding without the

the need for recatheterization• Less interference with sexual activity (Cochran Review of 14 trials that compared indwelling with

suprapubic)

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CAUTI BundlesMaintenance

• Maintain sterility of closed urinary drainage• Maintain unobstructed urinary flow• Keep collection bag below the bladder and off the

floor• Do not change indwelling catheters or collection

bags routinely• Wash hands prior to handling the urinary drainage

system and catheter

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Maintain Proper Care• Hand hygiene immediately before and after

insertion and before any manipulation of the catheter device

• Use smallest bore catheter possible• Indwelling urinary catheter must be properly

secured to prevent movement or urethral traction.

• Date the Foley collection bag with permanent marker or label

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CAUTI BundlesMaintenance

• Check the skin condition around the securement device at least daily. Relocate if irritation of skin is noted.

• Use port for urine collection-Do no break catheter system to collection specimen.

• For long-term indwelling catheters, change the catheter prior to specimen collection.

• Remove the catheter as soon as possible.

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Strategies for Monitoring Catheter Use by Setting

Setting Strategies References

Emergency Department Indication checklists, tagging of catheter bags

Gokula, 2005

ICU Daily checklists for indication

Huang, 2004Jain, 2006Reilly, 2008

Peri-procedure Aseptic procedures for catheter placement, Automatic stop orders

Stephen, 2006

General Admissions Reminders vs stop orders, daily checklists for indication

Saint, 2005Topal, 2005Crouzet, 2007Fakih, 2008

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Early Removal of Indwelling Catheters: Summary of the Evidence

• 14 studies have evaluated urinary catheter reminders and stop-orders (written, computerized, nurse-initiated)

– Significant reduction in catheter use

– Significant reduction in infection

– No evidence of harm (ie, re-insertion)

(Meddings J et al. Clin Infect Dis 2010)

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Removal of catheters: Additional principles

• Remove as soon as possible after insertion• Use a portable ultrasound device to assess

urine volume in patients before catheterizing to determine need.

• Use a portable ultrasound device to assess for retention after removal of indwelling catheter and prior to reinsertion.

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CAUTI Bundle

CautionC-Closed System, Catheter Selection, Consider AlternativesA-Aseptic ManagementU-Universal/Standard PrecautionsT-Tie/Secure Catheter to patient/Tubing to bedI-Indications for Use AND to DiscontinueO-Obstruction Free, Specimens from Sampling PortN-No Dependent Loops

*CDC, 2009

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Cochrane Review of Antimicrobial Catheters (2008)

• 23 trials involving 5236 hospitalized adults in 22 parallel group trials met inclusion criteria

• Conclusion #1: “…Silver alloy (antiseptic) coated or nitrofurazone impregnated (antibiotic) urinary catheters might reduce infections in hospitalized adults…..but the evidence is weak.

• Conclustion #2: “Larger, more scientifically rigorous, trials are needed on whether catheters impregnated with antibiotics or antiseptics reduce infections.

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Antimicrobial Catheter Recommendations (CID, 2010:50)

• Short-term indwelling urethral catheters: May reduce onset of CA-bacteriuria but data is insufficient to support reduction of CA-UTI

• No trial has compared antibiotic-coated versus silver alloy-coated catheters

• No indication supported in long term indwelling urethral catheters.

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CA-bacteruria or CA-UTIHow do you know?

• CA-UTI will be accompanied by signs and symptoms with no other probable cause– Fever– Suprapubic tenderness– Acute hematuria– Altered mental status– Dysuria– Urgency

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NHSN CA-UTI Surveillance DefinitionsCriterion 1a

Indwelling urinary catheter in place at the time of specimen collection or removed within the 48 hours prior to specimen collection

Positive urine culture with no more than 2 pathogens

At least one sign or symptom with no other cause

Costa vertebral angle pain or tendernessSuprapubic tendernessFever> 38 degrees C

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NHSN CA-UTI Surveillance DefinitionsCriterion 2a

Indwelling urinary catheter in place at the time of specimen collection or removed within the 48 hours prior to specimen collection

At least one sign or symptom with no other cause

A positive urinalysis demonstrated by at least 1 of the following:

A positive urine culture of > 103 and < 10 5 colony-forming units/ml with no more than 2 species of microorganisms

Costa vertebral angle pain or tenderness

A + dipstick for either leukocyte esterase or nitrites

Suprapubic tenderness Pyuria

Fever> 38 degrees C Microorganisms seen on Gram stain of unspun urine

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Pyuria alone is NOT

indicative of a CA-UTI.

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Foley Data Collection Tool

4/14/24/34/44/54/64/74/84/9

4/104/114/124/134/144/154/164/174/184/194/204/214/224/234/244/254/264/274/284/294/30

SI/CTICU Census

EXAMPLE 1111 4/1/10 OR X X X X D/C

Location of Foley

Insertion (if known)

Patient's Last Name

Patient's Last 4 of

Social Security Number

Foley Insertion

Date

LEGEND: X - Foley Present; BLANK CELL - No Foley Present; D/C - Foley Discontinued; R - Foley Replaced; R 24 - Foley discontinued but replaced due to retention within 24 hours

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Please print clearly.Indicate date of insertion with a “V”.Please mark each day of catheter with an “X”Please indicate “DC” on the date catheter is discontinued.

EP: CAUTI Rates

• Metric #1: Number of foley catheters per unit per day (nursing)

• Metric #2: Number of foley catheter days per unit per month (nursing)

• Metric #3: Number of CA-UTI per unit (IC)

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IPECData Entry Symptomatic CAUTI

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IPEC Compliance Reporting

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Documentation: Procedure Note• Note title: INSERTION OF INDWELLING URINARY CATHETER (Template note)• Bladder scan prior to insertion: Yes ____________

No____________________• If yes, amount of urine return: (free text)• Type of procedure: Intermittent (In and Out)____

Indwelling________• Type of insertion: Initial ________ Reinsertion_______• Catheter description: Type (use drop down box)• Size (use drop down box)• Hand hygiene and aseptic technique were used by inserter. Yes

No• Catheter was properly secured. Yes No• Collection bag placed below the level of the bladder. Yes No• Inserted without difficulty. Yes No If No, describe process• Amount of urine return: (free text)

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DocumentationDaily Maintenance Note (new)

• Note title: Urinary catheter Daily Care (Daily assessment note for units who do PIE notes)

• Urinary drainage device Yes No• If yes, what type (drop down box):

IUD_________ ICC__________ Suprapubic________EUD_________ Dialysis________

• Other(free text)_________• Sterile, continuously closed drainage system maintained (if appropriate) Yes

No• If indwelling urinary catheter or EUD, catheter properly secured Yes No• Unobstructed urine flow maintained. Yes No• Drainage spigot not allowed to touch the collection container. Yes No• Meatal care provided with routine hygiene. Yes No

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DocumentationNursing Admission Assessment

• Bladder elimination: Denies problems Unable to assess. Urinary catheter device

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Has urinary catheter device• If checked, urinary catheter template opens up (see below)What type of device(drop down box):

IUD_________ ICC__________Suprapubic_______ EUD_________

Dialysis__________ Other(free text)_________• Catheter changed on admission using aseptic technique: Yes No• Sterile, continuously closed drainage system maintained (if appropriate)

Yes No• If indwelling urinary catheter or EUD, catheter properly secured Yes

No• Description of urine: (drop down box) clear, turbid, hematuria• Signs of CA-UTI: (drop down box). (Check all that are appropriate)

oliguria, dysuria, hematuria, suprapubic pain, intervertebral coastal pain, fever , confusion

HOW ARE YOU DOING?Example compared to NHSN Mean

National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued November 2008. pgg/02-22-12

HOW ARE YOU DOING?Example compared to NHSN 10 per

centile

National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued November 2008. pgg/02-22-12

PROMOTING COST SAVINGS AND IMPROVED PATIENT CARE

• Direct predicted costs of one CAUTI= $3800• Predicted Direct Costs for CAUTI annually= N X

$3800; where N = number of CAUTI• Indirect costs= lost work time, patient suffering

etc.

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What can you do?

• Staff Education and Competencies• Nurse Champions• Policies and Procedures• Documentation• Team Ownership

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Thank you!!

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