092211--CAUTI-Thomas

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Palmetto Health Baptist
1501 Sumter St
Columbia, SC
Lendon Thomas, BS, CIC
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Catheter Associated Urinary Tract Infections
are an ongoing issue in health care
Recent changes in the landscape of CAUTI
prevention
Growing interest by many stakeholders

I am an employee of C.R. Bard, Inc., Bard
Medical Division. Any discussion regarding
Bard products during my presentation is
limited to information that is consistent with
Bard labeling for those products.

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Review/update the problem of CAUTI
Outline many newer events within the last
five years
Discuss the latest concepts in prevention
strategy
 From literature and published guidelines
 Locally at Palmetto Health System
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100 million indwelling urethral catheters sold
worldwide anually
24 million in the U.S.
25% of hospitalized patients exposed to
catheters during their stay
UTI = up to 40% of all HAI
Vast majority of UTI are catheter related
Not without increased cost and morbidity
Saint S, Kaufman S, Thompson M, Rogers M, Chenoweth C. A Reminder Reduces Urinary
Catheterization in Hospitalized Patients. Journal on Quality and Patient Safety. 2005 August. (31)8;
455-62
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CAUTI accounts for 36% of all HAI
Incidence of catheter associated bacteriuria is
26% in patients with indwelling catheter for 2
to 10 days
24% of those acquiring bacteriuria will
advance to CAUTI
Approximately 3% will develop bacteremia of
urinary origin
Greene L, Marks J, Oriola S. Association for Professionals in Infection Control. Guide to The
Elimination of Catheter Associated Urinary Tract Infections (CAUTIs). 2008, p. 5.
Federal Agencies/Mandates
CMS
State Involvement
SCIP
Public Reporting of HAI
HICPAC
CDC
CAUTI
Michigan Keystone
AHRQ
Organizations
Private Websites
CatheterOut.org
Workingtowardzero
APIC
SHEA
JCAHO
IDSA
Consumer Groups
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
Original CDC Guidelines for CAUTI
prevention, 1981
HICPAC (Healthcare Infection Control
Practices Advisory Committee)
 Revised the Guidelines for Prevention of CAUTI in
2008
 DHHS Document from CDC = 321 pages
 Abbreviated guidelines issued 2009
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Guideline for Prevention of Catheter
Associated Urinary Tract Infections 2008, DHHS, Centers for Disease Control and Prevention
HICPAC/CDC
Guidelines
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory
Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS,
Centers for Disease Control and Prevention, 2009
•
CMS now holds U.S. hospitals accountable for not
preventing certain hospital-acquired complications
•
CMS required to choose at least 2 conditions that:
– are high cost and/or high volume; and
– could reasonably have been prevented through
the application of evidence-based guidelines
Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice
[Educational Slides] CatheterOut.org website, University of Michigan.
CR5499 Instruction on the CMS web site at http://www.com.hhs.gov/Transmittals/downloads/R
1240CP.pdf
•
•
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•
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•
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Catheter-associated UTI
Vascular catheter-associated infection
Retained object during surgery
Air embolism
Blood incompatibility
Pressure ulcers
Surgical Site Infections after certain surgical procedures
Falls and Trauma
Manifestations of Poor Glycemic Control
DVT or PE following certain orthopedic surgeries
42 CFR Parts 411, 412, 413, and 489; August 2007
Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice
[Educational Slides] CatheterOut.org website, University of Michigan.
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DHHS: Med-Par Data, 2006: 42 CFR Parts 411, 412, 413, and 489; August 2007

Surgical Care Improvement Project1
 11 SCIP Performance Measures
 Reported publically on CMS “Hospital Compare” website
 SCIP-INF-9: Urinary catheter removed on post-operative
day 1 or post-operative day 2 with day of surgery being
day 0.
 PHB showed 96% on Hospital Compare. (Site qualified by
saying small sample, less than a quarter).2
1Hospitals.tmf.org
[Internet]. TMF Health Quality Institute. SCIP Quality Indicators. Available from
http:/hospitals.tmf.org/SCIP/SCIPQuality Indicators/tabid/678/Default.aspx
2HHS.gov
[Internet]. Medicare Hospital Compare Process of Care Measures. Surgical Care Improvement
Project Process of Care Measure. Available from http://www.hospitalcompare.hhs.gov

As of last year, 2010:
 27 states require public reporting of selected HAI
 2 states report “confidentially” to state agencies
 3 states have “voluntary” public reporting
 5 states made laws to study the issue of public
reporting
 13 states and DC have no public reporting laws.
RID—Committee to Reduce Infection Deaths. State Legislation and Initiatives on HealthcareAssociated Infections, [Updated March 2010, cited 2011 Aug 13]. Available from
http://hospitalinfection.org/legislation.shtml
Infectious Disease
Society of America
(IDSA)
Hooton T, Bradley S, Cardenas D, Colgan R, Geerlings S, Rice J, Saint S et. al. Diagnosis, Prevention, and
Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice
Guidelines from the Infectious Disease Society of America. CID 2010:50 (1 March) 000
Association for
Professionals in
Infection Control
Greene L, Marks J, Oriola S. Association for Professionals in Infection Control. Guide to The Elimination
of Catheter Associated Urinary Tract Infections (CAUTIs). 2008
Society for
Healthcare
Epidemiology of
America (SHEA)
Lo E, Nicolle L, Classen D, Arias K, Podgorny K, Anderson D, Burstin, H et. al. Strategies to Prevent
Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infection Control and Hospital
Epidemiology 2008; 29:S41-S50
 JCAHO
 New National Patient Safety Goal
(NPSG.07.06.01)—May 9, 2011
 “Implement evidence based practices to prevent
indwelling catheter-associated urinary tract
infections (CAUTI)”


2012 = Get Ready Year
January 2013—in surveys. Dings included.
JCAHO. 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-Publication
Version. DivSSM, May 9, 2011.

All these guidelines/mandates, etc, point to
the same direction
Care Process
Strategies
Change in the culture of the organization
Medical Staff
Patient Care Staff
Administrative/Management Staff
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Make sure the catheter is indicated
Adhere to general infection control principles
(aseptic insertion, proper maintenance, hand
hygiene, properly trained staff, feedback to
care providers)
Remove the catheter as soon as possible
Consider alternatives to indwelling catheters
Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice
[Educational Slides] CatheterOut.org website, University of Michigan.
Acute urinary retention or bladder outlet
obstruction
 Critical output monitoring in critically ill patients
(hourly output measurement)
 Peri-operatively in selected surgical procedures

 GU tract or its contiguous structures
 Long procedures (remove the catheter in PACU)
 Large volume infusions or diuretics during surgery
 Intra-operative urinary output monitoring
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices
Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract
Infections. DHHS, Centers for Disease Control and Prevention, 2009
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Assist healing of open sacral or perineal
wounds in incontinent patients
Prolonged immobilization [further defined as]
 Unstable thoracic or lumbar spine
 Multiple traumatic injuries

Improve comfort for end of life care
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices Advisory
Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract Infections. DHHS,
Centers for Disease Control and Prevention, 2009
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Incontinence1
Obtaining urine for culture or diagnostic test
(when the patient can void)1
Prolonged post-operative duration (more
than 1 or 2 days)2
1Gould
CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues D. Healthcare Infection Control Practices
Advisory Committee (HICPAC). Guideline for Prevention of Catheter Associated Urinary Tract
Infections. DHHS, Centers for Disease Control and Prevention, 2009
2CMS. Measure ID# SCIP-Inf-9. Specifications Manual for National Hospital Inpatient Quality
Measures, 2009.

Munasinghe et. al, looked at 836 medical
admissions over a 1 month period
 10% of the admissions had indwelling catheter
placed within 24 hours of admission
 38% had no justifiable indication
Munasinge RL, Yazdani H, Siddique M, Hafeez W. Appropriateness of use of Indwelling
Urinary Catheters in Patients Admitted to the Medical Service. Infection Control and
Hospital Epidemiology. 2001 October 22(10), 617

Gardam, et. al, in a similar study reported:
 20% indwelling catheter rate
 Only 50% of the catheters justifiable

Jain, et. al, reported 34% unjustified
catheters
Gardam Ma, Amihod B, Orienstein P, Consolacion N, Miller MA. Overutilization of indwelling
catheters and the development of nosocomial urinary tract infections. Clinical Performance
and Quality Healthcare. 1998, (6) 99-102
Jain P, Parada JP, David A, Smith LG. Overuse of indwelling urinary tract catheter in
hospitalized medical patgients. Arch. Intern. Med. 1995; 155:1425-1429

Caretakers forget to assess the risk
Maki DG, Tambyah PA. CDC. Engineering Out the Risk of Infection with Urinary Catheters. Emerging
Infectious Diseases. 2001 Mar-Apr; 7(2): 1-12.
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Risk Awareness
In patients with indwelling catheters:
 Risk of bacteriuria increases by 5% every day the
catheter remains indwelling
 10% of those becoming bacteruric advance to
symptomatic CAUTI.
 Around 3% will develop urinary associated
bacteremia
Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice
[Educational Slides] CatheterOut.org website, University of Michigan.

Forget the catheter is in place
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Survey of 288 physicians (attending, house
staff, interns and medical students). 469
patients in their care—25% with catheters by
observation
Saint S, Wiese J, Amory JK, Bernstein MI, Patel UD, Zemencut JK, et. al. Are physicians aware of which
of their patients have indwelling urinary catheters? Am. J. Med, 2000 Oct 15; 109 (6): 476-80
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Survey Findings
Percent UNAWARE their patient had
catheter
Medical Students
21%
Interns
22%
Residents
27%
Attendings
38%
31% of the catheters were inappropriate
Saint S, Wiese J, Amory JK, Bernstein MI, Patel UD, Zemencut JK, et. al. Are physicians aware of which of
their patients have indwelling urinary catheters? Am. J. Med, 2000 Oct 15; 109 (6): 476-80
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Appropriateness and Duration
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Insertion checklists
Removal reminder systems
Automatic stop orders
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C.R. Bard, Inc. Bard ADVANCE Foley Tray System [component], 2010

Recent Study, Meddings et. al, 2010
 Systematic review and meta-analysis
 Reviewed published interventional studies that
used reminders to physicians or nurses that
urinary catheter in use or stop orders to prompt
catheter removal in hospitalized patients
Meddings J, Rogers MA, Macy M, Saint S. Systematic Review and meta-analysis: reminder systems to
reduce catheter associated urinary tract infections and urinary catheter use in hospitalized patients.
Clin. Infect. Dis. 2010 Sept 1; 51(5): 550-60

Results:
 CAUTI rate reduced by 52% (p = <0.001) with the
use of reminder or stop order
 Foley duration decreased by 37% (2.6 fewer days
per patient
 Stop orders were more effective than reminders
 Need for re-catheterization not different, control
vs. intervention
Meddings J, Rogers MA, Macy M, Saint S. Systematic Review and meta-analysis: reminder systems to
reduce catheter associated urinary tract infections and urinary catheter use in hospitalized patients. Clin.
Infect. Dis. 2010 Sept 1; 51(5): 550-60
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Use of portable bladder scanners
Straight catheterization vs. indwelling
Condom catheters in male patients
Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing Hospital-Acquired
Urinary Tract Infections in the United States: A National Study. Clinical Infectious Diseases 2008; 46: 243-50
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Accurate for urine volume
Reduce the number of intermittent
catheterizations
One group found that use of bladder scan
decreased catheter related UTI from 87% to
38% in one nursing unit and from 81% to 50%
in another unit over a 12 month period.
Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing
Hospital-Acquired Urinary Tract Infections in the United States: A National Study. Clinical
Infectious Diseases 2008; 46: 243-50

Randomized controlled trial published in
2006 found:
 Condom catheters instead of indwelling catheters
lowered the incidence of bacteriuria in men
[without dementia]
 Men reported condom catheters more
comfortable than indwelling catheters
Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing HospitalAcquired Urinary Tract Infections in the United States: A National Study. Clinical Infectious
Diseases 2008; 46: 243-50

National survey of prevention strategies
 Survey data collected during 2005
 Random sample of non-federal hospitals (n = 600)
 All VA Hospitals (n = 119)
 72% response rate
Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing HospitalAcquired Urinary Tract Infections in the United States: A National Study. Clinical Infectious
Diseases 2008; 46: 243-50
Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing Hospital-Acquired
Urinary Tract Infections in the United States: A National Study. Clinical Infectious Diseases 2008; 46:
243-50

Concluded:
 Despite the strong link between urinary catheters and
CAUTI, we found no strategy to be widely used to prevent
HA-UTI. The most commonly used practices (bladder
ultrasound and antimicrobial catheters) were each used in
fewer than one-third of hospitals
 Urinary catheter reminders, which have proven benefits
were used in <10% of U.S. hospitals.
Saint S, Kowalski C, Kaufman S, Hofer T, Kauffman CA, Olmstead R, et. al. Preventing HospitalAcquired Urinary Tract Infections in the United States: A National Study. Clinical Infectious Diseases
2008; 46: 243-50

Elements of performance (insertion and use)
 Insert indwelling urinary catheters according to
established evidence based guidelines that
address the following:
▪ Limiting use and duration to situations necessary for
patient care
▪ Using aseptic techniques for site prep, equipment and
supplies
JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication
version, May 9, 2011.

Elements of Performance (catheter
management)
 Manage indwelling urinary catheters according to
established evidence based guidelines
▪
▪
▪
▪
Securing catheters
Maintaining sterility of collection system
Replacement when required
Asepsis in urine sample collection
JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, May
9, 2011.

Measure and monitor the processes and
outcomes
 Select measures based on evidence based guidelines or
best practices
 Monitor compliance (ongoing audit or point prevalence)
 Evaluate effectiveness
▪
▪
▪
▪
UTI Surveillance
Decreased indwelling catheter days
Decreased inappropriate use
Improved nursing care practices
JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, May 9,
2011.
Association for Professionals in Infection Control. Guide to the Elimination of Catheter-Associated
Urinary Tract Infections, 2008. Washington DC.
Number of Observations
Securement = Yes
% Securement Compliant
*TES Intact = Yes
% TES Compliant
Dependent Loop Compliant
% Loop Compliance
Below Bladder Level Compliant
% Bladder Level Compliant
Not Touching Floor Compliant
% No Touch Floor Compliant
Not Over-filled Compliant
% No Overfill Compliant
MSU
10
2
20.0
10
100.0
5
50.0
9
90.0
10
100.0
10
100.0
SCU
8
1
12.5
3
37.5
4
50.0
7
87.5
6
75.0
8
100.0
JSC
2
0
0.0
2
100.0
1
50.0
2
100.0
2
100.0
2
100.0
GSU
6
1
16.7
6
100.0
3
50.0
6
100.0
6
100.0
6
100.0
5N
4
1
25.0
4
100.0
2
50.0
2
50.0
3
75.0
4
100.0
30
5
16.7
25
83.3
15
50.0
26
86.7
27
90.0
30
100.0
Unit
Overall
Ref: Bard Medical Division: Foley Catheter Observation Survey. Compliance Document # 1007-02, 7-14-10
Lo E, Nicolle L, Classen D, Arias K, Podgorny K, Anderson D, Burstin, H et. al. Strategies to Prevent CatheterAssociated Urinary Tract Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008;
29:S41-S50
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
Active CAUTI Prevention Team
Developed successful implementation
bundles:
 Indwelling catheter insertion bundle
 Catheter care and maintenance bundle

CAUTI prevention education
 Nurses
 Physicians
Palmetto Health Baptist Catheter-Associated Urinary Tract Infection (CAUTI) Team. AIM Statement,
2011.

Foley Removal Protocols
 Tested in several critical care units at Palmetto

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
Richland
Reduced catheter days
Reduced CAUTI
Currently in pilot at PHB in PCU and ICU
Target date, full implementation: Oct. 1, 2011
Palmetto Health Baptist Catheter-Associated Urinary Tract Infection (CAUTI) Team. AIM
Statement, 2011.
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Stop order pop-up reminders in the electronic
medical record
EHR enhancements will allow Physician to:
 Utilize a Foley removal guideline OR
 Require Physician to justify in record why
continuing catheter

If catheter continued, must provide
justification in the record.
Palmetto Health Baptist Catheter-Associated Urinary Tract Infection (CAUTI) Team. AIM Statement, 2011.
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Realize this is a common initiative in hospitals
throughout the U.S.—not just at PH. It is evidence
based medicine.
Participate
Be supportive
Think about these measures as a way to reduce
patient risks and improve patient care/outcomes
Be a part of the success story when it happens.
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