Overcoming Challenges to
CAUTI Prevention
By Linda Greene, RN, MS, CIC,
Shannon Oriola, RN, CIC, COHN,
James Marx, RN, MS, CIC
U
rinary tract infections (UTIs) are the most common type of healthcareassociated infection, accounting for more than 30% of infections reported by acute care hospitals.The majority of healthcare-associated
UTIs are caused by instrumentation of the urinary tract. Catheter-associated
urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost, and length of stay. The presence of bacteria in
the urine commonly leads to unnecessary antibiotic use, and urinary drainage systems are often one of the greatest reservoirs for multidrug-resistant
bacteria and can be a source of transmission of these resistant pathogens to
other patients.
An indwelling urinary catheter is a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed
collection system. A number of years ago, guidelines suggested that a closed
collection system was one of the single most important factors in preventing
CAUTI. Despite the fact that today virtually all systems are closed drainage
systems, healthcare providers must be especially cautious in assuring that
these systems do not become accidentally disconnected. Between 15% and
25% of hospitalized patients may receive short-term indwelling urinary catheters. In many cases, catheters are placed for inappropriate indications, and
healthcare providers are often unaware that their patients have catheters,
leading to prolonged, unnecessary catheter use. Patients who have indwelling urinary catheters will develop bacteria in their urine. It is estimated that
the daily risk for bacteruria (the presence of bacteria in the urine) is 3% to
10%, and after 30 days, 100% of patients will develop bacteria in their urine.
Bacteruria is not necessarily indicative of infection, especially in the absence
of other signs and symptoms. This is called “asymptomatic bacteruria.”
Prevention Practices Should Include the Following:
1. Ensure that urinary catheters are used only when indicated.
2. Remove urinary catheters as soon as soon as possible when no longer
indicated.
3. If a patient requires a urinary catheter, assuring that strict aseptic technique is followed during insertion.
4. Maintain urinary catheters to ensure that they are securely fastened,
placed below the level of the bladder, and that they do not become accidentally disconnected.
Removal of Urinary Catheters
Catheters should be removed as soon as possible. Several studies have
shown that catheters are often left in place for long periods of time because
they are often forgotten by physicians. It is critically important that nurses
and healthcare providers assess patients’ need for a urinary catheter on a
Indications for Urinary
Catheters:
1. Hemodynamic monitoring in
critically ill patients
2. Pressure ulcer healing in patients with decubitis
3. In select circumstances, endof-life care
4. Select surgical procedures
5. Urinary retention or obstruction
Overcoming Challenges to CAUTI Prevention
regular basis. Many organizations utilize a daily checklist. There is also recent
evidence to suggest that electronic reminders or automatic stop orders have
value in reducing the duration of catherization and, subsequently, the incidence of UTIs.
Aseptic Technique
Urinary catherization should generally be considered a sterile procedure.
Because the bladder is sterile, it is important that bacteria from the genital
tract not be introduced via the urinary catheter into the bladder. In select
circumstances, such as in patients with chronic indwelling catheters or those
who must self catheterize, a clean procedure may be used. Healthcare providers must wash hands before insertion, and a sterile, single packet of lubricant should be used. Care must be taken to not accidentally contaminate the
catheter during insertion.
Maintenance of Catheters
It is important that catheters be maintained in a manner that prevents accidental disconnection and kept below the level of the bladder to prevent
accidental backflow of urine. Catheters should be properly secured after insertion to prevent movement and urethral traction. Care must be taken to
ensure that the catheter is not accidentally disconnected. Urine specimens
should be collected aseptically and should be sent to the lab as soon as possible. The Clinical and Laboratory Standards Institute (CLSI) Guidelines recommend that the urine specimen be cultured within 2 hours of its collection. Overgrowth of bacteria can readily occur with mishandled specimens,
which will cause a false positive or unreliable culture result. Catheters and
drainage bags should be changed not on a routine basis but based only on
clinical indications such as infection, obstruction, or when the closed system
is compromised. Routine irrigation should be avoided unless obstruction is
suspected
It is vital that only trained personnel insert catheters and that all healthcare
providers who care for patients with urinary catheters understand their role
in the prevention of CAUTI. Likewise, patients and families need to understand their role in prevention as well. Infection prevention is a team effort—
understanding your role in this important initiative is essential for infection
prevention and safe patient care.
Bringing Evidence to the Bedside: Interactive Scenarios
As a care giver, you will be called upon to apply your knowledge to practical
situations and which arise during the course of providing patient care. Taking
evidence and applying it to your everyday practice can be challenging. The
following scenarios represent real life situations and decisions which could
ultimately affect whether or not a patient develops a CAUTI. Read the scenarios and decide which of the options is the best choice. Once you have made
your selection, review the correct answer, rationale, and learning points associated with that section. Remember that bringing evidence to the bedside
requires not only knowledge but the ability to apply that knowledge to your
everyday practice. It will require the combination of knowledge, interpersonal and problem solving skills.
2
It is vital that only
trained personnel insert
catheters and that all
healthcare providers
who care for patients
with urinary catheters
understand their role
in the prevention of
CAUTI.
Overcoming Challenges to CAUTI Prevention
Scenario 1
Learning Points
Angela is a new graduate assigned to a surgical unit. Angela has been asked
to insert a urinary catheter in a patient who will undergo major abdominal
surgery this morning. She has assembled all of her equipment and supplies
and is getting ready to insert the catheter. She uses sterile gloves, drape,
sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion. Angela washes
her hands before the procedure and very carefully sets up the sterile field.
The patient accidently moves, causing Angela to contaminate the catheter.
As Angela is about to ask someone for a new catheter, her charge nurse stops
by to tell her that the surgery schedule has been moved ahead and that
her patient will be going to surgery in the next few minutes. Angela is now
scared and frightened and is faced with a dilemma. A few minutes later, a
transporter arrives to take the patient to surgery. He appears very impatient.
Angela’s patient now has a urinary catheter in place. As the patient is moved
over to the cart, Angela sees the transporter place the urinary catheter on the
patient’s bed. Everyone is in such a hurry that Angela questions whether she
should stop the transporter or just remain silent.
•
Aseptic technique is used when
inserting a urinary catheter.
Hand hygiene is performed
immediately before and after a
urinary catheter insertion.
•
The source of microorganisms
causing CAUTI can be endogenous, typically via meatal,
rectal, or vaginal colonization;
or exogenous, such as via contaminated hands of healthcare
providers or equipment.
•
An estimated 17% to 69% of
CAUTI may be preventable with
recommended infection control
measures, which means that up
to 380,000 infections and 9000
deaths related to CAUTI could
be prevented per year.
•
Contaminating the urinary
catheter may lead to a UTI.
•
Maintain unobstructed urine
flow.
•
Keep the catheter and collecting tube free from kinking.
•
Keep the collecting bag below
the level of the bladder at all
times.
Question:
What is the best course of action for Angela to take regarding insertion of the
catheter?
1. Stop and reinsert a new catheter.
2. Rationalize that it is only a small break in technique and will not affect
the patient.
3. Continue the procedure in the interest of time.
4. Tell the charge nurse that she was unable to insert the catheter and ask
her to do it for her.
Correct answer: 1
Despite the pressure to move quickly, it is important to follow aseptic technique. Microoorganisms
from the patient’s skin could contaminate the catheter and have the potential to lead to a UTI.
Question:
What should Angela do when she sees the transporter lay the urinary catheter bag on the patient’s abdomen?
1. Nothing—this is a brief transport and time is important.
2. Quickly move the bag to its correct position.
3. Offer to help the transporter secure the bag correctly below the level
of the bladder, explaining what she is doing and why this is important.
Correct answer: 3
The urinary catheter should be kept below the level of the bladder to ensure unobstructed flow. Although Angela could do this herself without explanation, talking to the transporter is a learning opportunity that may prevent this from happening again in the future.
3
Overcoming Challenges to CAUTI Prevention
Scenario 2
Learning Points
Tom is working on a medical unit. His patient, Mrs. X, has a urinary catheter and is febrile. The doctor has ordered a urinalysis and urine culture. Tom
collects the specimen and asks that it be transported to the lab. Later that
night, Tom discovers that the specimen has been sitting for 4 hours. He is
very busy and does not have the time to collect another specimen. For a moment, he wonders if he should just send the specimen. He rationalizes that
it really could not make that much of a difference, and he does have several
more pressing priorities. Later that night, he notices that the urine looks very
cloudy, although it is draining well. He is concerned that he may have to replace the catheter. The nursing assistant reports that the catheter came apart
earlier. Rather than replace the catheter, he contemplates whether irrigation
might be necessary.
•
The CLSI Guidelines recommend that a urine specimen
be cultured within 2 hours of
its collection. Overgrowth of
bacteria can readily occur with
mishandled specimens, and this
will cause a false positive or an
unreliable culture result.
•
Unless obstruction is anticipated (eg, as may occur with
bleeding after prostatic or bladder surgery), bladder irrigation
is not recommended.
•
Change catheters and drainage
bags based on clinical indications such as infection, obstruction, or when the closed system
is compromised.
Question:
When Tom finds out that the specimen has not been sent, he should:
1. send the specimen anyway. It does not really make a difference.
2. call the lab and explain so that they can adjust their procedure accordingly.
3. discard the specimen and obtain a new one.
Correct answer: 3
The CLSI Guidelines recommend that a urine specimen be cultured within 2 hours of its collection.
Overgrowth of bacteria can readily occur with mishandled specimens, and this will cause a false positive or an unreliable culture result.
Question:
Should Tom irrigate the urinary catheter when he finds that the urine is
cloudy?
1. He should not irrigate but should change the catheter instead.
2. He should irrigate the catheter, and if it remains cloudy, he should
change the catheter.
3. He should irrigate but not change the the catheter.
Correct answer: 1.
Routine irrigation is not recommended unless obstruction is anticipated. The urine is cloudy but freeflowing with no evidence of obstruction. Because a disconnection was reported and the cloudy urine
may indicate a UTI, it is recommended that the urinary catheter be changed.
4
Overcoming Challenges to CAUTI Prevention
Scenario 3
Learning Points
Rachel is taking care of an elderly woman who has been transferred from
the intensive care unit (ICU). She had been in congestive heart failure. During her stay in the ICU, the woman required close monitoring of her urinary
output and had an indwelling urinary catheter in place. Upon transfer from
the ICU, the catheter was removed. The family approaches Rachel and says
they cannot understand why the catheter has been removed. They point out
that their mother is sometimes incontinent of urine, and they are concerned
about skin breakdown. Rachel quickly reviews the indications for a urinary
catheter. As Rachel reviews the indications for catheter use, she is uncertain
that her elderly patient meets the criteria for a catheter. Although the patient
is incontinent on occasion, there is no skin breakdown.
•
Indications for a Urinary Catheter:
•
Perioperative use for selected
surgical procedures (eg, surgeries involving the genitourinary
tract, anticipated prolonged
surgery, operative patients with
urinary incontinence, need for
intraoperative hemodynamic
monitoring, and patients anticipated to receive large-volume
diuretics during surgery)
•
Urine output monitoring in
critically ill patients
•
Management of acute urinary
retention and urinary obstruction
•
Assistance in pressure ulcer
healing for incontinent residents
•
As an exception, on patient
request to improve comfort (eg,
end-of-life care)
•
Virtually all healthcare-associated UTIs are caused by
instrumentation of the urinary
tract and are most frequently
associated with the presence
of an indwelling catheter. The
Question:
Which is the correct response from Rachel when she is questioned by the
family?
1. Explain that the doctor feels their mother no longer needs a catheter.
2. Discuss with the family why the catheter was removed and how the
presence of a catheter is a risk factor for a UTI. Assure the family that she
will assist their mother to the bathroom on a regular basis.
3. Tell the family that if their mother continues to be incontinent, she will
reinsert the catheter.
Correct answer: 2
It is important to explain to the patient’s family the risk factors for infection and why the presence of
a urinary catheter could lead to infection. Assuring family members that you will attend to personal
care is important.
Question:
If Rachel’s patient is incontinent, should she have a urinary catheter?
1. No, urinary incontinence without skin breakdown is not a criterion for a
urinary catheter.
2. Yes, the fact that the patient is elderly and incontinent necessitates a urinary catheter.
3. Yes, the fact that the patient is elderly and could fall necessitates a catheter.
Correct answer: 1
Urinary catheters are used for assistance in pressure ulcer healing in incontinent residents.
5
Overcoming Challenges to CAUTI Prevention
Scenario 4
Learning Points
•
Many indwelling urine catheters are inappropriate, especially in older, female patients.
Inappropriate urinary catheter
use in acute care hospitals
ranges from 21% to 50%. It
is estimated that 30% of all
indwelling urine catheters are
inserted in EDs.
•
Indications for the use of
indwelling urethral catheters
are limited and include the following:
•
The plan of care must be
individualized for the patient
with incontinence and should
include the following components1:
•
Assessment and management
of incontinence etiology
•
Perineal skin and risk assessment
•
Gentle cleansing and moisturization
•
Application of skin barriers
•
Use of containment devices if
indicated
Nurse Mark is concerned about skin breakdown in an 88-year-old male patient with dementia who is incontinent of urine. The patient was admitted
with a urine catheter from the emergency department (ED). The patient does
not have a condition that would require an indwelling catheter. Mark wants
to ask the physician for an order to remove the catheter, but he expects the
patient to be incontinent of urine. He includes the potential for skin breakdown in the nursing care plan.
Question:
Which action is not correct?
1. Leaving the catheter in place because the physician ordered a urine
catheter (it saves nursing time to monitor and change the bed when the
patient is incontinent).
2. Considering the use of a condom catheter (if the patient is cooperative
with keeping it on).
3. Considering a prompted voiding program, when the patient is stood at
the bedside and assisted to use the bathroom or urinal on a planned
schedule.
4. Considering checking bladder volume with the bladder ultrasound to
assess retention every 6 hours.
Correct answer: 1
The urine catheter should only be used when necessary. The list of appropriate uses does not include
incontinence, nursing convenience, or because the physician wants a catheter. Consider the less invasive alternates to manage incontinence.
Question:
The prevention of skin breakdown in the incontinence patient can be
achieved using the following methods (check all that apply):
1. Using barrier cream to keep the skin dry.
2. Consider the use of an adult brief while the patient is out of bed (do not
use them overnight).
3. Restricting fluid intake.
4. Keeping the patient on strict bed rest.
Correct answers: 1 and 2
Barrier cream and adult briefs will protect the skin if the patient is incontinent of urine. Restricting
fluid intake and immobilization increase the risk of a urinary tract infection.
6
Overcoming Challenges to CAUTI Prevention
Scenario 5
Learning Points
A 65-year-old male patient with urinary retention has a urine catheter. The
catheter is now clogged and not draining. The physician prescribes bladder
intermittent irrigation.
•
If obstruction is anticipated, closed
continuous irrigation is suggested
to prevent obstruction.
•
If obstruction occurs and it is likely
that the catheter material is contributing to obstruction, change
the catheter.
•
Silicone may be preferable to
other materials to reduce the risk of
encrustation in long-term catheterized patients who have frequent
obstruction.
•
Further research is needed on the
benefit of irrigating the catheter
with acidifying solutions or use of
oral urease inhibitors in long-term
catheterized patients who have
frequent catheter obstruction.
•
Unless obstruction is anticipated
(eg, as may occur with bleeding
after prostatic or bladder surgery),
bladder irrigation is not recommended.
•
Further research is needed on the
use of methanamine to prevent
encrustation in patients requiring
chronic indwelling catheters who
are at high risk for obstruction.
•
Use portable ultrasound in patients
with low urine output to reduce
unnecessary catheter insertions
or irrigations (in catheterized
patients).
•
Changing indwelling catheters
or drainage bags at routine, fixed
intervals is not recommended.
Rather, catheters and drainage
bags should be changed based
on clinical indications such as
infection, obstruction, or when the
closed system is compromised.
•
Perform hand hygiene immediately
before and after insertion or any
manipulation of the catheter site
or device.
Question:
What additional actions should the nurse consider? (check all that apply)
1. Check the bladder volume to see how much urine is in the bladder using
a bladder ultrasound device.
2. Consider replacing the catheter with a silicon catheter.
3. Consider increasing fluid intake, if the patient’s condition permits.
4. Irrigate the catheter as a last resort, if replacement does not work.
5. All of the above
Correct answer: 5
The catheter may not be clogged, so always check the volume of urine in the bladder before replacing
it. Latex catheters may develop incrustations more easily than silicone, so think about this option.
Low urine output may be related to edema or kidney failure, increasing fluid may help the urine flow
through the catheter. Irrigation should be considered only after the urine catheter has been replaced.
The risk of infection may be the only solution in rare circumstances.
Question:
If intermittent irrigation is the only measure that keeps the catheter unclogged, what actions will decrease the risk of infection? (check all that apply)
1. The irrigant and syringe should be used once and discarded. Do not reuse the irrigation syringe or store unused irrigant. (Note: Label states to
discard unused portion; past practice was to use until empty or within
24 hours.)
2. Disinfect the connection with an appropriate surface disinfectant before
disconnecting; maintain aseptic technique when handling the tubing.
3. Use vinegar as the bladder irrigant.
4. Raise the drainage bag to allow the urine to flow back into the bladder
prior to irrigation.
Correct answers: 1 and 2
Irrigation supplies should only be used according to the label directions. The catheter-tubing connection may be a source of bacteria, so disinfect it prior to disconnection using aseptic technique
to prevent the tubing from getting contaminated. Vinegar has not been found to be beneficial in
preventing infection. Never allow the urine in the tubing to flow back into the bladder.
7
Overcoming Challenges to CAUTI Prevention
Scenario 6
Learning Points
The patient with an indwelling urine catheter needs to be transported from
his room to the radiology department by stretcher. Prior to moving the urine
catheter, you would perform hand hygiene and observe standard precautions, including the use of gloves and gown as appropriate.
Question:
What are the considerations before, during, and after transport?
1. Empty catheter bag prior to transfer; use a urinal labeled with the patient’s name.
2. Ensure the catheter is secured to the leg or abdomen.
3. Keep the level of the catheter below the bladder at all times.
4. Have an appropriate place to hang the catheter bag during transport
and while in the radiology department.
5. All of the above
Correct answer: 5
All actions are appropriate to prevent urinary tract infection.
1. An empty urine collection bag
reduces the risk of urine flowing
back into the bladder.
2. Properly secure indwelling
catheters after insertion to prevent movement and urethral
traction.
3. Maintain unobstructed urine
flow.
4. Keep the catheter and collecting tube free from kinking.
5. Keep the collecting bag below
the level of the bladder at all
times. Do not rest the bag on
the floor.
6. Empty the collecting bag
regularly using a separate, clean
collecting container for each
patient, avoid splashing, and
prevent contact of the drainage
spigot with the nonsterile collecting container.
7.
8
Overcoming Challenges to CAUTI Prevention
Scenario 7
Learning Points
Ginny, a nurse, has decided to reduce the usage of inappropriate indwelling urinary catheters as a quality improvement project on the medical unit
where she works. She selects this project because of the new Centers for
Medicare & Medicaid Services (CMS) rules related to nonreimbursement of
CAUTI not present on admission. The surgical unit at her facility has reduced
its catheter-associated UTI rate primarily because of the successful implementation of the recent Surgical Care Improvement Project (SCIP) measure,
which states that a urinary catheter must be removed within 24 hours of
surgery unless there are appropriate indications for continued use.
Ginny’s facility has adopted an electronic health record for nursing documentation, physician order sets, and radiologic and laboratory results. She
has proposed that an automatic reminder be sent to the clinician ordering
the urinary catheter, which includes the indications for indwelling urinary
catheterization.
Question:
As a follow-up request to the informatics team, she also requests an additional field in the nursing documentation section asking the clinician to indicate the reason for continued use of the catheter. Which reason would not be
an indication to continue use of an indwelling urinary catheter for patients?
1. The patient has acute urinary retention or bladder outlet obstruction.
2. The patient requests the catheter because he/she does not want to ambulate to the bathroom after his/her recent surgery.
3. The patient has an open sacral wound and is incontinent of urine.
Correct answer: 2
The patient requests the catheter because he/she does not want to ambulate to the bathroom after
his/her recent surgery. By selecting criteria from an approved list of indications, the nurse can document why the urinary catheter is still medically necessary. If the patient does not meet the criteria, the
nurse can then contact the physician for an order to discontinue the catheter. Some facilities have
been successful in obtaining approval from the Medical Executive leadership team to allow nursing
to utilize a protocol for discontinuing the catheter under a standardized protocol. This will allow the
nurse to discontinue the catheter without contacting the physician.
Question:
Ginny will need to measure the effectiveness of the education by evaluating
the reduction in usage of urinary catheters on her unit. How can Ginny measure if the education was effective?
1. She can calculate a device utilization ratio (the number of indwelling
urinary catheters to the number of patient days on her unit per month).
2. Ginny can conduct random audits to determine the compliance rate of
proper documentation of appropriate indication for catheters on her
unit (numerator: number of patients on her unit with proper documentation of indication; denominator: number of patients on her unit with a
urinary catheter in place; multiply by 100).
3. Both A and B.
Correct answer: 3
She can calculate a device utilization ratio or can determine the compliance rate of proper documentation.
9
1. The table below is available
from the Centers for Disease
Control (CDC) Guideline for the
Prevention of Catheter-associated Urinary Tract Infections,
2009,2 and contains examples
for appropriate and inappropriate indwelling urinary catheter
use.
2. Ginny will need leadership support from her nurse manager
and a physician leader to implement this intervention—this
could be the chief of staff for
the hospital. After the informatics team has implemented
the protocol in the electronic
health record, she will need the
assistance of nursing education
or perhaps the clinical nurse
specialist on her unit to assist
with providing education to the
nurses.
Learning Points
1. Evaluating the device utilization
on her unit may be helpful to
assess the usage on her unit.
The rate is often calculated
monthly and trends usage
over time. If the education is
effective, the device utilization
should decline.
2. The nurses should also be
documenting the reason for the
urinary catheter if the indwelling urinary catheter remains
after the initial assessment of
the patient.
3. Evaluating CAUTI rates is another method to determine if
the intervention was helpful.
4. The CAUTI rate can be obtained
a variety of ways. The two most
common are obtaining the
rates from the Infection Prevention department or from the
manager of the Health Information department (medical
records).
Overcoming Challenges to CAUTI Prevention
Scenario 8
Learning Points
A nurse from the medical ICU has noticed that he has had to break the seal
of the urinary catheter drainage system many times because the physician
has ordered hourly urine output and the drainage system does not have a
urimeter attached to the catheter when he receives the patient.
Question:
Should the nurse should break the seal and switch out the regular drainage
bag with a urimeter when this occurs again?
1. Yes
2. No
Correct answer: 2
The CDC Guideline for the Prevention of Catheter-associated Urinary Tract Infections, 2009, states
that if breaks in aseptic technique, disconnection, or leakage occur, the catheter and collecting system should be replaced using aseptic technique and sterile equipment. The strength of evidence is
fairly strong.
1. The CDC Guideline states that
following aseptic insertion of
the urinary
2. catheter, a closed drainage
system should be maintained.
The strength of evidence is
fairly strong.
3. This issue can be discussed
with the director of the ED
and director of supply chain
services. They can be helpful
by evaluating the possibility of
stocking urinary catheter drainage systems with preattached
urimeters rather than a drainage system with the traditional
drainage bag in the ED.
4. If it is not feasible to switch out
the entire department, switching out systems in key areas
may be beneficial.
5. Key areas of the ED where the
likelihood that a patient may be
admitted to an ICU are trauma
or critical decision unit (patients
evaluated for possible myocardial infarction or stroke).
6. A decrease in the number of
unnecessary disconnection or
replacement of urinary catheter
drainage systems can occur by
targeting key areas for placement of appropriate urinary
catheter drainage systems.
10
Overcoming Challenges to CAUTI Prevention
Scenario 9
Learning Points
•
The primary nurse caring for
the patient or the charge nurse
can speak with the physician
during patient care rounds. The
physician can then be notified
that her rationale for continuing the urinary catheter is
not approved by the medical
leadership and that there are
other alternatives to urinary
catheterization that are safe for
patient care.
•
Many hospitals have decreased
patient falls by implementing nursing rounds. The nurse
rounds every 2 hours to assess
his/her patient needs for pain
control and the need to void,
among other factors.
•
By anticipating patient needs,
patient safety and patient satisfaction can be achieved.
Kathy was rounding for compliance with the new bladder bundle that was
implemented on her unit. She noticed what she believed to be an inappropriate indication for indwelling urinary catheter usage on the log documented
by the primary nurse caring for the patient. The reason listed was the physician’s desire to continue the urinary catheter based on his belief that the patient was at risk for falling if she were to ambulate to the bathroom without
asking for assistance. This particular reason for continuing the catheter was
not on their hospital’s list of indications approved by the Medical Executive
Committee, nor is it recommended as a reason for urinary catheterization in
the CDC Guideline for the Prevention of Catheter-Associated Urinary Tract
Infections, 2009.
Question:
What should Kathy do?
1. Note the documentation and continue with her rounds.
2. Speak to the nurse caring for the patient to determine if she has spoken
to the physician regarding her documentation of the indication to continue the urinary catheter.
Correct answer: 2
Often a urinary catheter may be used as a “restraint” or for nursing convenience. Just as it is important for the nurse to understand the need for urinary catheterization, it is equally important for the
physician to understand indications for usage.
11
Overcoming Challenges to CAUTI Prevention
Scenario 10
Learning Points
Rebecca is scheduled to have surgery next week and is being assessed by a
nurse to ensure that she has completed her preoperative requirements and
is ready for surgery. Rebecca has recently read an article in her local newspaper on hospital-acquired infections and is concerned that her physician
has explained to her that she will require indwelling urinary catheterization
for the procedure. Rebecca asks the nurse what she can do to prevent a UTI
from occurring.
Question:
Which would be the correct response from the nurse to Rebecca’s question?
1. Not to worry—if the patient gets a UTI, the doctor can treat the infection
with an antibiotic.
2. It is unlikely that the patient will develop a UTI. 3. It is important that the urinary catheter is removed as soon as it is no
longer necessary, preferably within 24 hours after her surgery to prevent
infection.
Correct answer: 3
Rebecca would like to avoid complications from her surgery. The nurse can take this opportunity to
teach Rebecca how she and the hospital can take steps to prevent a catheter-associate urinary tract
infection from occurring.
12
•
CAUTI is the most frequently
occurring healthcare-acquired
infection.
•
Many healthcare facilities have
created or adopted patient
education tools on the prevention of certain types of healthcare-acquired infections.
•
The Society for Healthcare
Epidemiology of America, in
partnership with other organizations, has created several
documents or “Frequently
Asked Questions” related to
various types of healthcareacquired infections.
•
Patient guides on healthcareassociated infections are available at www.shea-online.org.3
Overcoming Challenges to CAUTI Prevention
Conclusion
CAUTI is the most frequently occurring healthcare-acquired infection and is
associated with increased length of stay, morbidity, mortality, and overuse of
antibiotics. Healthcare providers play an important role in preventing these
infections. It is important to understand that in the course of everyday work,
decisions about care of urinary catheters arise and we will be challenged to
make the best decision consistent with evidence prevention practices.
It is vital that nurses develop the required skills to allow them to assess patients thoroughly before inserting a urinary catheter and to ensure that all
other options have been investigated. Nurses with expertise in urinary catheterization must share their knowledge with new nurses and nursing students and ensure that their practice is based on the best evidence available.
Patients with catheters need to be taught catheter care to minimize the risk
of UTI. The caregivers of dependent patients need to be taught the skills required for catheter care as well.
Some risk reduction strategies that have been successful in many organizations include:
• Implementation of the Bladder Bundle
• Aseptic technique when inserting a catheter
• Bladder ultrasound may avoid unnecessary catheterization
• Condom or intermittent catheterization in select patients
• Do not catheterize unless you must!
• Early removal of the catheter using reminders or stop orders
Nursing Interventions
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•
•
•
Developing nursing protocols that clearly define criteria for insertion
and removal of a catheter
Incorporating prevention practices into order sets or pathways
Having a zero-tolerance policy for adverse events. Reviewing each case
to identify opportunities for improvement.
Creating a culture in which healthcare providers are comfortable reminding each other when any breach in infection prevention practices
is identified and in which we hold each other accountable for good infection prevention practices.
Infection prevention is everyone’s responsibility. Understanding your role in
preventing infections is an important first step in protecting our patients and
ensuring that that we provide safe patient care.
References
1. Nix D. Prevention and treatment of perineal skin breakdown due to incontinence. Ostomy Wound Manage. 2006;52(4):26-28.
2. Guideline for Prevention of Catheter-associated Urinary Tract Infections,
2009. http://www.cdc.gov/hicpac/cauti/001_cauti.html.
3. Society for Healthcare Epidemiology of America (SHEA). Compendium
of Strategies to Prevent Healthcare-Associated Infections in Acute Care
Hospitals. http://www.shea-online.org/about/compendium.cfm.
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Resources
IHI Program to Prevent CAUTI. http://
www.ihi.org/.
APIC CAUTI Elimination Guide.
http://www.apic.org.
Overcoming Challenges to CAUTI Prevention
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