Prevention of Catheter
Associated Urinary Tract
Infections (CA-UTI)
Patti G. Grota PhD, RN, CNS-M-S, CIC
Nurse Epidemiologist
Assistant Professor, UTHSCSA SON
Assistant Professor, Schreiner University
pgg/06-18-12
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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Epidemiology
Problems 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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Epidemiology
More 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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Epidemiology
Burden 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 2000
Tambyah, 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 Point
The 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!
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Indwelling Catheterization
Short term vs Long term
• Short-term catheterization
Remains indwelling ≤ 2 weeks
Commonly used in acute or critical care
• Long-term catheterization
Remains indwelling ≥ 2 weeks
Gray M et al. Best practices in managing the indwelling catheter. Perspectives 2007 (Supp 1)
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Pathophysiology
Common Pathogens
• Endogenous intestinal flora
–
–
–
–
E. coli
Proteus
Enterobacter
Enterococci
• Nonintestinal or environmental pathogens
–
–
–
–
–
Pseudomonas
Candida
Staph coag neg
MRSA
Acinetobacter
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CAUTI
Frequency of Common Pathogens
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APIC elimination guide
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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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Pathophysiology
Ascension 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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CAUTI: Pathophysiology
Intraluminal
Extraluminal
Bladder infection with inflammation
Detrusor spasm
Leakage
Shedding of cells
Obstruction
(+) UA
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Bacteremia
Fever
Hypotension
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 infections
Vascular catheter associated infections
Catheter 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 Bundle
Components
Insertion
Maintenance
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 Hand hygiene
Aseptic technique
Secure the catheter
Check daily for removal
Closed drainage
system
Appropriate indication
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“Life Cycle” of the Indwelling
Urinary Catheter
Catheter
Placement
Catheter
Replacement
Catheter
Care
Catheter
Removal
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Disrupting the Life Cycle of the
Indwelling Urinary Catheter
Prevent
unnecessary
placement
Maintain
proper
care
Prevent
catheter
replacement
Promptly
remove
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
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CDC, 2009
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 Bundles
Maintenance
• 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 Bundles
Maintenance
• 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, 2004
Jain, 2006
Reilly, 2008
Peri-procedure
Aseptic procedures for
catheter placement,
Automatic stop orders
Stephen, 2006
General Admissions
Reminders vs stop orders,
daily checklists for
indication
Saint, 2005
Topal, 2005
Crouzet, 2007
Fakih, 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
Caution
C-Closed System, Catheter Selection, Consider Alternatives
A-Aseptic Management
U-Universal/Standard Precautions
T-Tie/Secure Catheter to patient/Tubing to bed
I-Indications for Use AND to Discontinue
O-Obstruction Free, Specimens from Sampling Port
N-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-UTI
How 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 Definitions
Criterion 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 tenderness
Suprapubic tenderness
Fever> 38 degrees C
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NHSN CA-UTI Surveillance Definitions
Criterion 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:
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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A positive urine culture of >
103 and < 10 5 colonyforming units/ml with no
more than 2 species of
microorganisms
Pyuria alone is
NOT
indicative of a CA-UTI.
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Foley Data Collection Tool
LEGEND: X - Foley Present; BLANK CELL - No Foley Present; D/C - Foley Discontinued; R - Foley Replaced;
4/30
4/29
4/28
4/27
4/26
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4/25
X X X X D/C
4/24
OR
4/23
EXAMPLE 1111 4/1/10
4/22
C ensus
4/21
4/20
4/19
4/18
4/17
4/16
4/15
4/14
4/13
4/12
4/11
4/10
4/9
4/8
4/7
4/6
4/5
4/4
4/3
4/2
4/1
Location R 24 - Foley discontinued but replaced due to retention within 24 hours
Patient's
of Foley
Last 4 of Foley Insertion
Patient's Last
Social Insertion (if known)
Name
Security Date
Number
SI/ C T IC U
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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IPEC
Data 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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Documentation
Daily 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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Documentation
Nursing 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
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HOW ARE YOU DOING?
Example compared to NHSN Mean
National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued
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November 2008.
HOW ARE YOU DOING?
Example compared to NHSN 10 per centile
National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued
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November 2008.
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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