ACKNOWLEDGEMENT
First of all, let we thank Almighty Allah for unending love, care and blessing especially
during the tenure of this study. In performing our PDSA study, we had to take the help
and guideline of some respected person, who deserve our greatest gratitude. The
completion of this PDSA study gives us much pleasure. We would like to show our
gratitude Madam Wan Norazi Binti Meor Ismail and Madam Marina Binti Idi, tutors in
Infection Control Post Basic, also our Clinical Instructor Sister Haslinda Binti Haplus.
Institut Kementerian Kesihatan Malaysia(ILKKM) Sungai Buloh for giving us a good
guideline for assignment throughout numerous consultations.
We would like to take this opportunity to express our sincere thanks to many people
especially our family, classmates and team members itself, have made valuable
comment suggestions on this proposal which gave us an inspiration to improve our
assignment.
We would also like to expand our deepest gratitude to all staff of Intensive Care
Unit(ICU) and Sungai Buloh Hospital Infection and Control Unit for helped for complete
this study. We also want to thank for those who have directly and indirectly guided us
in writing this assignment
CHAPTER ONE
1.1 BACKGROUND
Urinary catheterization is one of the most common procedures performed in hospitals
especially in intensive care units. The urinary catheter is considered as a single
biggest risk factor for acquired urinary tract infections (UTIs), and more than 80% of
all acquired UTIs are attributable to catheter use. Indwelling urinary catheters are
frequently used in critically-ill patients worldwide. Hospital-acquired infections from
indwelling urinary catheters are associated with increased morbidity, length of stay,
and healthcare costs (World Health Organization [WHO], 2016). Urinary tract
infections acquired during a hospitalization account for 40% of all hospital-acquired
infections (HAIs) with 80% of UTIs being associated with use of urinary retention
catheters (Quinn, 2015). HAIs from indwelling urinary catheters are associated with
more than 113,000 deaths annually in the United States (Ternavasio-de la Vega et al.,
2016). The purpose of this study was to assess nurses' knowledge and practices
toward prevention of CAUTI in intensive care unit at Hospital Sungai Buloh. This study
also sought to implement specific opportunities for improvement in CAUTI rates in an
ICU unit through reduction of urinary catheters used, implementation of urinary
catheter insertion and maintenance best practices, and timely nursing assessment for
need leading to urinary catheter removal if indicated through a structured educational
strategy. Evidence-based protocols designed to decrease urinary catheter associated
infections may not capture point of care practices contributing to this significant
problem. In response to this significant issue for critically ill patients, a targeted
education intervention was developed and implemented by the infection prevention
CAUTI to ICU staff.
1.2 INTRODUCTION
The use of indwelling catheters in the Critical Care Units (CCUs) has a major role in
determining the incidence and the morbidity as well as mortality from hospital-acquired
urinary tract infections (UTIs). A UTI is an inflammatory response to colonization of the
urinary tract, most commonly by bacteria or fungi. A UTI should be differentiated from
the mere detection of bacteria in the urinary tract. This condition, referred to as
asymptomatic bacteriuria, is common and does not require treatment, especially in the
patient with an indwelling urinary catheter. A CAUTI occurs when a patient with an
indwelling urinary catheter develops 2 or more signs or symptoms of a UTI such as
hematuria, fever, suprapubic or flank pain, change in urine character, and altered
mental status. CAUTI is classified as a complicated UTI. The current review highlights
the important management issues in critical care patients having CAUTI.
The urinary catheter is considered as a single risk factor for acquired urinary tract
infections (UTIs), and more than 80% of all acquired UTIs are attributable to catheter
use. It an infection involving any part of the urinary system, including urethra, bladder,
ureters and kidney. UTIs are the most common type of healthcare – associated
infection reported to the National Healthcare Safety Network (NHSN). Among UTIs
acquired in the hospital, approximately 75% are associated with a urinary catheter,
which is a tube inserted into the bladder through the urethra to drain urine. Between
15 – 25 % of hospitalized patients receiving urinary catheter during their hospital stay.
The National Healthcare Safety Network (NHSN) in 2013 reported that CAUTI pooled
means were ranged from 1.2 to 4.1 per 1,000 urinary catheter days in medical-surgical
and intensive care units (ICUs). While for Non-ICU rates ranged from 1.3 to 1.5 per
1,000 urinary catheter days in medical-surgical units (APIC, 2014). In Egypt, a national
surveillance of HAIs program was conducted for ninety-one ICUs in 28 hospitals on
three phases from April 2011 to February 2016, and the results show that there were
2,688 HAIs, in which about 15% of HAIs were UTIs (Talaat et al., 2016). Al Nasser et
al. (2016) conducted a study in three Arabian Gulf Countries: Saudi Arabia (SA),
Oman, and Bahrain for a six-year surveillance from 2008 to 2013. Their study findings
revealed there were 140 CAUTI events in SA, 145 CAUTI events in Bahrain, and only
one CAUTI event in Oman. Another study conducted in SA examining deviceassociated healthcare associated infection (DA-HAI) in 12 general Ministry of Health
hospitals, among ICU patients between 2013- 2016. This study found that there were
13,492 DA-HAIs, in which about 28.4% of DA-HAIs was CAUTI (Gaid, Assiri, McNabb,
& Banjar, 2017). According to Mukakamanzi (2017), UTI cases are mostly related to
the presence of urinary catheter although many catheters are used unnecessarily and
for prolonged periods of time. Extended use of urinary catheter and inappropriate
management increase the risk of infections (Shehab, 2017). The Association for
Professionals in Infection Control (APIC) (2014) also indicated that CAUTI has been
reported to be associated with increased morbidity, mortality, hospital cost, and length
of hospital stay. Nurses play an important role in urinary catheter insertion,
maintenance, and removal (Sobeih & Nasr, 2015). Therefore, nurses should have
adequate knowledge regarding infection control in the use of urethral catheters and
their practice must be adhered to healthcare setting's guidelines on infection control
(Opina & Oducado, 2014). Catheter-associated urinary tract infection is considered as
the most frequent and preventable infections, if nurses take into consideration the
recommended catheter placement indications and evidenced-based practice of
catheter maintenance (Mukakamanzi, 2017). Thus, avoidance of unnecessary
catheterizations and remove catheters as soon as possible are the most effective
preventive measures of CAUTI (Tenke, Mezei, Bőde, & Köves, 2017). On the other
hand, device-associated healthcare associated infection DA-HAI data and published
studies to certain devices are limited in SA (Gaid et al., 2017). Therefore, this study
was conducted to assess the current knowledge and practices of nurses toward
prevention of CAUTI at Hospital Sungai Buloh. The study's findings may provide some
evidence about areas of strengths and weakness of nurses regarding CAUTI
prevention. This study may also be a guide for developing education and training
programs on issues related to CAUTI.
Catheters can be inserted into a body cavity, duct, or vessel. Functionally, they allow
drainage, administration of fluids or gases, access by surgical instruments, and also
perform a wide variety of other tasks depending on the type of catheter. The process
of inserting a catheter is called catheterization. In most uses, a catheter is a thin,
flexible tube (catheter) though catheters are available in varying levels of stiffness
depending on the application. A catheter left inside the body, either temporarily or
permanently, may be referred to as an indwelling catheter. But in this PDSA, we going
to based our studies more on the indwelling urinary catheter also known as a Foley
catheter and how disease come about from the use of indwelling urinary catheters.
Indwelling urinary catheters (IUCs) are semi-rigid, flexible tubes. They drain the
bladder but block the urethra. IUC shave double lumens, or separate channels,
running down it lengthwise. One of the lumen is open at both ends and allows for urine
drainage by connection to a drainage bag. The relative size of a Foley catheter is
described using French units (Fr). In general, urinary catheters range in size from 8Fr
to 36Fr in diameter. 1 Fr is equivalent to 0.33 mm = .013inch = 1/77 inch in diameter.
The distal end of most urinary catheters contains two ports (lumen or channel or dual
lumen). One is a funnel shaped drainage channel to allow efflux of urine once the
catheter is placed and the other is the inflation/deflation channel for infusion of water
into the retention balloon. The infusion port for the balloon is usually labelled with the
size of the balloon (5cc or 30 cc) and the size of the catheter. Three-way catheters are
available with a third channel to facilitate continuous bladder irrigation or for instillation
of medication. This catheter is primarily used following urological surgery or in case
of bleeding from a bladder or prostate tumour and the bladder may need continuous
or intermittent irrigation to clear blood clots or debris. The most important risk factor
for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary
catheter. Therefore, catheters should only be used for appropriate indications and
should be remove as soon as they are no longer needed.
Various intermittent catheters (a): the upper five are male catheters, the lowest one is
a female catheter. Two indwelling catheters with retention balloons inflated (b).
1.3 DEFINATION
Urinary tract infections (UTI) are defined using Symptomatic Urinary Tract
Infection (SUTI) criteria, and Asymptomatic Bacteremic UTI (ABUTI). (See Table
1). UTI cannot be considered secondary to another site of infection.
Indwelling catheter: A drainage tube that is inserted into the urinary bladder
through the urethra, is left in place, and is connected to a drainage bag (including
leg bags). These devices are also called Foley catheters. Indwelling urinary
catheters that are used for intermittent or continuous irrigation are also included in
CAUTI surveillance. Condom or straight in-and-out catheters are not included nor
are nephrostomy tubes, ileoconduits, or suprapubic catheters unless an indwelling
urinary catheter (IUC) is also present.
Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter
was in place for more than two consecutive days in an inpatient location on the
date of event, with day of device placement being Day 1*, AND an indwelling
urinary catheter was in place on the date of event or the day before. If an indwelling
urinary catheter was in place for more than two consecutive days in an inpatient
location and then removed, the date of event for the UTI must be the day of device
discontinuation or the next day for the UTI to be catheter-associated.
CAUTI needs to be defined with some caution. Urine sampling for microbiological
workup needs to be done carefully avoiding contamination, either routinely once a
week, or at the beginning of a new episode of sepsis. CAUTI is usually deemed
present if there are at least 103 colony-forming units (cfu)/mL of 1 or 2 micro-organisms
identified by urine culture. While 'significant’ bacteriuria is defined as >10 5 cfu/mL,
once micro-organisms are detected in the urine, in the absence of anti-microbials, it is
almost inevitable to reach the 105 cfu/mL level quite rapidly, which is why the level of
103 cfu/mL is believed to be indicative of true CAUTI. An ICU-acquired UTI refers to
those patients who develop a positive urine culture first identified on ICU Day 3 (48 h)
or later. Patients developing positive urine cultures within 48 h of being discharged
from an ICU, could also be defined as having ICU-acquired UTI. The Centers for
Disease Control and Prevention (CDC) defines CAUTI for those patients who have an
indwelling catheter in place for 48 h or more. For diagnosing UTI, the CDC requires
that the patient should be manifesting symptoms such as fever or chills, new onset of
burning pain, urgency or frequency if not catheterized at that point of time, change in
urine character, flank or suprapubic pain or tenderness or change or decrease in
mental or functional status in patients older than 65 years. In patients who do not have
compelling laboratory evidence such as positive urine culture, the CDC gives credence
to a positive dipstick test for leucocyte esterase and/or nitrate, pyuria and visualization
of organisms on Gram stain of unspun urine, if these are associated with two or more
clinical symptoms of UTI. The CDC guidelines therefore, help distinguish
asymptomatic catheter-associated bacteriuria or candiduria, which are rarely
associated with adverse outcomes and generally do not require treatment with
antimicrobials, from true CAUTI.
1.3.1 RISK FACTOR FOR CAUTI
Multiple factors have been identified as potential risk factors for CAUTI. Many of them
are relevant for patients managed in ICUs including prolonged catheterization, use of
systemic antibiotics, other active sites of infection, diabetes mellitus, and elevated
creatinine. Females have much higher risk compared to males, and pre-existing
conditions such as malnutrition also put the patient at increased risk. Insertion of the
indwelling catheter outside the protected environments of the operating room, ureteric
stenting and assiduous monitoring of urine output using the catheter are all
independent risk factors for CAUTI. A most important and potentially modifiable risk
factor is the duration of catheterization, and hence indwelling urinary catheters need
to be used for the shortest periods of time feasible. By the 30 th day of catheterization,
infection rates are about 100%. Closed drainage, dependent drainage including proper
positioning of the drainage tubing and collection bag and protection of the drainage
port could go a long way in reducing the burden of CAUTI. Antimicrobial drug therapy,
while protective for short-duration catheterizations, carries the risk of selective
colonization with multi-drug-resistant organisms such as Pseudomonas aeruginosa,
other resistant Gram-negative bacilli, enterococci and yeasts. ICU-acquired CAUTI
was not found to be an independent risk factor of in-hospital death, although it
contributes to significant morbidity.
1.3.2 PATHOGENESIS
Barring hematogenous seeding, almost exclusively, of Staphylococcus aureus,
causing pyelonephritis, almost all micro-organisms implicated in endemic CAUTI
are either part of the patient's colonic or perineal flora, or derived from the hands
of medical and paramedical personnel during insertion of indwelling catheters or
improper handling of the collection system. Organisms may cause CAUTI in one
of two ways. Extra luminal ascending infection may be caused either during the
time of indwelling catheter insertion, or later on by organisms from the perineal
areas moving upward by capillary action in the thin mucous film that coats the
external surface of the catheter. Intraluminal infection is caused by organisms
gaining access to the lumen of the catheter either from failure of closed drainage
or the urine in the collecting bag getting contaminated. While extra luminal
ascension of micro-organisms may be the more common means of causation of
CAUTIs, both routes are important.
1.4 PROBLEM STATEMENT
2
The single most important manoeuvre which can reduce the incidence of CAUTI is to use
indwelling urinary catheters only when justified. It should never be used for management
of urinary incontinence, and alternatives to urethral catheterization should be explored for
such situations.[28] Sterile techniques should be strictly followed for insertion of
indwelling urinary catheters.[27] Pre-connected closed drainage systems might reduce
the risk of disconnection of the closed system,[29] although there is no conclusive data
that these can reduce the incidence of CAUTI.[30] The collection system should always
be placed below the level of the bladder and not be allowed to touch the floor.[31]
Aseptic techniques should be employed for emptying the drainage system,[27] and the
same collection system should never be used for more than one patient. Other preventive
practices include removal of the catheter as soon as possible,[32] avoiding opening the
system, encouraging fluid intake and avoiding irrigation of the bladder. Anti-infective
catheters can be employed if indicated, in patients who are judged to be at a high risk for
development of CAUTI.[33]
Recent studies have shown the effectiveness of the implementation of multidimensional
urinary tract infection prevention strategies and bundles in critical care
units.[34,35,36,37] Such approaches include a specific bundle of interventions for
CAUTI prevention, education, outcome surveillance, process surveillance, feedback of
CAUTI rates and performance indices of infection control practices. These strategies
have been successfully employed in both adult and pediatric critical care areas. These
multidimensional infection control programs for CAUTI prevention have shown
reduction in the CAUTI rates of CCUs, which were associated with improvement in hand
hygiene, as an integral component of a multi-faceted strategy, and as a result of providing
education and training on CAUTI prevention measures by means of introducing bundles
of interventions. Thus, improvements in processes of care can lead to a reduction n in the
risk of CAUTI, and their adverse consequences, especially in CCUs of resource-limited
countries like India. There is also a continuous need to foster sustained improvements in
practices.
3
Healthcare Infection Control Practices Advisory Committee’s (HICPAC) guidelines
Objectives
1.Clinician will demonstrate understanding of the device indications,
contraindications, warnings and precautions.
2.Clinician will demonstrate competency in the proper insertion and removal of an
indwelling urinary catheter.
Foley Catheter Insertion
Task
Completed
Confirm patient meets the CDC Guidelines for Appropriate
1.Indications for Indwelling Urethral Catheter Use:
Patient has acute urinary retention or bladder outlet obstruction
Need for accurate urine output measurements
Use for selected surgical procedures
To assist in healing of open sacral or perineal wounds
Patient requires prolonged immobilization
To improve comfort for end of life care
Select the smallest Foley catheter possible, consistent with good drainage
2.Preparation
Conduct a 15-30 second antiseptic hand wash and don clean gloves
Open outer packaging, remove tray and open CSR wrap
Position patient
Place underpad beneath patient, plastic or “shiny” side down
Use provided castile soap wipes to cleanse patient’s peri-urethral area
using downward strokes from anterior to posterior
Discard gloves. Perform hand hygiene with provided alcohol hand sanitizer
gel
3.Insert Foley Catheter using aseptic technique and sterile equipment:
Maintain aseptic technique and don sterile gloves
Position fenestrated drape on patient appropriately
Use the syringe with the green plunger to deposit lubricant into tray
-top for Foley catheter lubrication
Remove top tray and place next to bottom tray (keep on CSR wrap)
Attach the water-filled syringe to the inflation port
Note: It is not necessary to pre-test the Foley catheter balloon
Remove Foley catheter from wrap and lubricate catheter
Prepare patient with packet of pre-saturated antiseptic swab sticks:
a.Female Patient:
with a downward stroke cleanse the right labia minora and
discard the swab. Repeat for left labia minora. Use the last swab stick
cleanse the area between the labia minora
Trainer
Initials
b.Male Patient:
Cleanse the penis in a circular motion starting at the urethral
meatus and work outward
Proceed with catheterization until urine is visible in the drainage tube
a.Female Patient:
Advance catheter two more inches
(or according to hospital protocol)
b.Male Patient: Advance catheter 6-10 inches(or according to hospital
protocol)
Inflate catheter balloon using entire 10mL of sterile water provided in the prefilled
syringe
Note: Use of less than 10mL can result in improperly inflated balloon
Once the balloon is inflated, ease the catheter back by gently pulling on the
catheter until slight tension is detected indicating that the balloon is in place at the
neck of the bladder
If proper catheterization is not accomplished, use a new catheter for future
attempts
After inserting the Foley catheter, discard all materials in accordance with the
hospital protocol and remove contaminated gloves
4.If provided, secure the Foley catheter to the patient using the Foley device lock
Note: Please ensure patient is appropriate for use of STAT LOCK®Foley device
5.Position hanger on bed rail at the foot of the bed and use green sheeting clip to secure
drainage tube to sheet, confirm tube is not kinked
6.Indicate time and date of catheter insertion on provided labels and place designated
labels on patient chart and drainage system
CDC HICPAC Guideline for Prevention of Catheter
NAME AND TITLE
UNIT
DATE
TRAINER NAME
Insertion and Removal Skills Training Checklist
Foley Catheter Removal
1.Follow hospital protocol for the removal of a urinary catheter
2.Explain the procedure to the patient and ensure privacy
3.Conduct a 15-30 second antiseptic hand wash
4.Don clean gloves
5.Remove STATLOCK®Foley device
6.Position patient and place waterproof pad under patient
7.Deflate catheter balloon:
a. Back off syringe to 0.5mL and insert into the inflation port
b. Allow the water to naturally flow back into the syringe
to deflate the balloon
c. Remove all 10mL of water
d. Do not use vigorous aspiration as this may cause the inflation lumen to
collapse, preventing balloon deflation
e. Use only gentle aspiration to encourage deflation if needed
f. Allow approximately 30 seconds for the pressure within the balloon to
force the plunger back and volunteer its water into the syringe
- If slow or no deflation is noticed, reseat the syringe
- If balloon will not deflate and if permitted by hospital protocol, the valve
arm may by severed.
- If this fails, contact adequately trained professional
for assistance, as directed by hospital protocol
- If balloon rupture occurs, care should be taken to assure that all balloon
fragments have been removed from the patient
8.Remove the catheter and discard it according to hospital policy
9.Document procedure according to hospital protocol
Guidelines for preventing CAUTI
The single most important manoeuvre which can reduce the incidence of CAUTI is to use
indwelling urinary catheters only when justified.[27] It should never be used for management
of urinary incontinence, and alternatives to urethral catheterization should be explored for
such situations.[28] Sterile techniques should be strictly followed for insertion of indwelling
urinary catheters.[27] Pre-connected closed drainage systems might reduce the risk of
disconnection of the closed system,[29] although there is no conclusive data that these can
reduce the incidence of CAUTI.[30] The collection system should always be placed below
the level of the bladder and not be allowed to touch the floor.[31] Aseptic techniques should
be employed for emptying the drainage system,[27] and the same collection system should
never be used for more than one patient. Other preventive practices include removal of the
catheter as soon as possible,[32] avoiding opening the system, encouraging fluid intake and
avoiding irrigation of the bladder. Anti-infective catheters can be employed if indicated, in
patients who are judged to be at a high risk for development of CAUTI.[33]
Recent studies have shown the effectiveness of the implementation of multidimensional
urinary tract infection prevention strategies and bundles in critical care units.[34,35,36,37]
Such approaches include a specific bundle of interventions for CAUTI prevention, education,
outcome surveillance, process surveillance, feedback of CAUTI rates and performance
indices of infection control practices. These strategies have been successfully employed in
both adult and pediatric critical care areas. These multidimensional infection control
programs for CAUTI prevention have shown reduction in the CAUTI rates of CCUs, which
were associated with improvement in hand hygiene, as an integral component of a multifaceted strategy, and as a result of providing education and training on CAUTI prevention
measures by means of introducing bundles of interventions. Thus, improvements in processes
of care can lead to a reduction n in the risk of CAUTI, and their adverse consequences,
especially in CCUs of resource-limited countries like India. There is also a continuous need
to foster sustained improvements in practices.
Methods: The intervention of a targeted, evidence-based educational program was implemented
to raise nursing staff awareness and uptake of evidence-based protocol and point of care
practices designed to decrease risks of catheter-associated urinary tract infections (CAUTI) in
CICU patients. A descriptive design was used. Sampling was made at the unit and not the
individual level. The CICU was selected by infection prevention CAUTI team members to
implement specific nursing staff education focused on urinary catheter insertion hands-on
training using low fidelity simulation, daily catheter care best practices, and timely nursing
assessment of early urinary catheter removal. Targeted education and training was initiated
December 2015. One hundred percent of CICU staff nurses (N = 76) received hands on training
for insertion and care of urinary retention catheters. Periodic rounding in CICU by infection
prevention CAUTI team members was performed to assess 100% of patients with an indwelling
urinary catheter. The infection prevention team checked for daily care compliance by nursing
staff, nurse assessment for necessity of continued urinary catheter placement, proper urinary
catheter securement devices in use, and appropriate positioning of closed drainage units. “Just in
time” coaching and recognition was provided by the assessment team as needed.
Results: Catheter induced infection rates dropped significantly after training was initiated for the
CICU staff. For FY2015, a total of 16 CAUTIs were recorded for the CICU with a rate of 3.91 per
1,000 device days and 2.22 per 1,000 patient days. For FY2016, the current total for CAUTIs
reported in CICU is 4, reflecting a 75% reduction in the number of CAUTIs for CICU. The
infection rate per 1,000 device days is currently at 1.15 and the rate per 1,000 patient days is
0.69. The incidence of improper care was reduced significantly with the periodic rounding by the
infection prevention CAUTI team nurses.
Conclusion: With regular use of urinary retention catheters in ICU settings, patients are at
increased risk for developing a CAUTI. Working in partnership with experts outside nursing units
improved collaboration across disciplines in this CICU. Use of an infection prevention CAUTI
team aided in increasing staff education and awareness of CAUTI nurse-led prevention
strategies in this ICU. With targeted evidence-based education for the nursing staff and routine
rounding by the infection prevention CAUTI team, a reduction in the number of CAUTIs have
resulted in this ICU setting. The significance of this project to nursing practice and patient clinical
outcomes is demonstrated in the reduction of CAUTIs through nurse-driven monitoring and
processes. Further research is recommended to fully demonstrate the impact of targeted
evidence-based clinician education and nurse-led protocols on CAUTI rates in the CICU setting