Prevention of Catheter Associated Urinary Tract Infections (CA-UTI)

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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

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Objectives

• Explore the epidemiology of CA-bacteriuria.
• Discuss national guidelines and recommendations
  that impact prevention of CA-UTI.
• Describe the pathophysiology of CA bacteriuria.
• List the differences in asymptomatic CA
  bacteruria and CA-UTI.
• Describe how bundles prevent CA-UTI.
• Explain appropriate documentation of indication
  insertion and maintenance of indwelling urinary
  catheters.

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EpidemiologyProblems with Urinary Catheters

• Urinary tract infection
• Mechanical trauma to urethra and bladder
• Immobility (restraining patient)

Saint S, Ann Intern Med 2002 137 125-7 Saint
S, Am J Infect Control 20002868-75
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EpidemiologyMore Problems

• Discomfort and pain to patient
• Add to direct costs of hospitalization 500 to
  1,000. If bacteremia present, cost up to
  3,800.
• Increased length of stay

Saint S, Ann Intern Med 2002 137 125-7 Saint
S, Am J Infect Control 20002868-75
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Epidemiology of CAUTI

• Most common type of healthcare-associated
  infection.
• 75 diagnosed in a hospital are associated with a
  urinary catheter
• CDC, 2009

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EpidemiologyBurden of CA-UTI

• The risk of CA-UTI increase 5 every day that an
  indwelling urinary catheter remains in
  place.(AACN, 2009)
• More than 30 million Foley catheters are
  inserted annually in the United States, and
  probably contribute to 1 million CAUTIs .
  (APIC.org, 2008)
• A complications of CA-UTI can increase a
  patients 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 20022327-31
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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 CatheterizationShort 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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PathophysiologyCommon Pathogens

• Endogenous intestinal flora
• E. coli
• Proteus
• Enterobacter
• Enterococci
• Nonintestinal or environmental pathogens
• Pseudomonas
• Candida
• Staph coag neg
• MRSA
• Acinetobacter

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CAUTIFrequency of Common Pathogens
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APIC elimination guide
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PathophysiologyAscension of microbes

• .

• External (extraluminal) Bacterial Ascension
• ?Microorganisms colonize the external catheter
  surface, most often creating a biofilm.
• ?Bacteria tend to ascend early after catheter
  insertion suggesting a lack of asepsis during
  initial insertion.
• ?Bacteria can also ascend 1-3 days after
  catheterization, usually due to capillary
  action.
• Guide to the Elimination of CAUTIs. APIC, 2008.

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PathophysiologyAscension of microbes

• Internal (intraluminal) Bacterial Ascension
• ?Bacteria tend to be introduced when opening the
  otherwise closed urinary drainage system.
• ?Microbes ascend from the urine collection bag
  into the bladder via reflux.
• ?Biofilm formation occurs, and damage to bladder
  mucosa facilitates biofilm on this surface.
• APIC.2008. Guide to the Elimination of
  CAUTIs

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CAUTI Pathophysiology

• Intraluminal Extraluminal
• Detrusor spasm Shedding of cells Bacteremia
• Leakage Obstruction
  Fever
• () UA Hypotension

Bladder infection with inflammation
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National Guidelines

• Who makes the national guidelines and
  recommendations?
• CDC/NHSN
• Infectious Disease Society of America
• Joint Commission NPSG 7
• Association of Professionals in Infection
  Prevention and Control (APIC)
• Medicare and Medicaid Regulations

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National Guidelines

• ? Why national guidelines and recommendations?
• Clinical indicator of quality of care
• Contributes to increased morbidity, mortality,
  and costs
• Increased length of hospital stay
• Increased patient discomfort
• Increased risk for hospital readmission
• CDC, 2009

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Deficit Reduction Act P.L. 109-171

• Secretary of HHS must identify high cost, high
  volume preventable conditions that result in
  higher payment
• October 1, 2008 CMS denied payments for 10
  hospital acquired conditions (HACs), 3 of which
  were HAIs
• Selected surgical site 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 BundleComponents

• 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
• Aseptic technique
• Secure the catheter

Hand hygiene
Closed drainage system
Check daily for removal
Appropriate indication
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Life Cycle of the Indwelling Urinary Catheter
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Disrupting the Life Cycle of the Indwelling
Urinary Catheter
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What does the evidence say?Category 1 Strongly
Recommended

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

CDC, 2009
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Appropriate Indications for Insertion

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

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Inappropriate Indications

• Nursing care of incontinent patients
• A means of obtaining a urine specimen when the
  patient can voluntarily void
• Prolonged postoperative duration without
  indications

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Alternatives To Insertion

• External Urinary Catheter Devices
• Intermittent catheterization
• Bladder scanners

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Advantages of Suprapubic Catheterization

• Lower risk of CA-bacteriuria
• Reduced risk of urethral trauma and stricture
• Ability to attempt normal voiding without the the
  need for recatheterization
• Less interference with sexual activity
• (Cochran Review of 14 trials that compared
  indwelling with suprapubic)

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CAUTI BundlesMaintenance

• Maintain sterility of closed urinary drainage
• Maintain unobstructed urinary flow
• Keep collection bag below the bladder and off the
  floor
• Do not change indwelling catheters or collection
  bags routinely
• Wash hands prior to handling the urinary drainage
  system and catheter

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Maintain Proper Care

• Hand hygiene immediately before and after
  insertion and before any manipulation of the
  catheter device
• Use smallest bore catheter possible
• Indwelling urinary catheter must be properly
  secured to prevent movement or urethral traction.
• Date the Foley collection bag with permanent
  marker or label

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CAUTI BundlesMaintenance

• Check the skin condition around the securement
  device at least daily. Relocate if irritation of
  skin is noted.
• Use port for urine collection-Do no break
  catheter system to collection specimen.
• For long-term indwelling catheters, change the
  catheter prior to specimen collection.
• Remove the catheter as soon as possible.

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Strategies for Monitoring Catheter Use by Setting
Setting Strategies References
Emergency Department Indication checklists, tagging of catheter bags Gokula, 2005
ICU Daily checklists for indication Huang, 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 BundleCaution

• 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,
201050)

• Short-term indwelling urethral catheters May
  reduce onset of CA-bacteriuria but data is
  insufficient to support reduction of CA-UTI
• No trial has compared antibiotic-coated versus
  silver alloy-coated catheters
• No indication supported in long term indwelling
  urethral catheters.

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CA-bacteruria or CA-UTIHow do you know?

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

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NHSN CA-UTI Surveillance DefinitionsCriterion 1a
Indwelling urinary catheter in place at the time of specimen collection or removed within the 48 hours prior to specimen collection
Positive urine culture with no more than 2 pathogens
At least one sign or symptom with no other cause Costa vertebral angle pain or tenderness Suprapubic tenderness Fevergt 38 degrees C
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NHSN CA-UTI Surveillance DefinitionsCriterion 2a
Indwelling urinary catheter in place at the time of specimen collection or removed within the 48 hours prior to specimen collection Indwelling urinary catheter in place at the time of specimen collection or removed within the 48 hours prior to specimen collection Indwelling urinary catheter in place at the time of specimen collection or removed within the 48 hours prior to specimen collection
At least one sign or symptom with no other cause A positive urinalysis demonstrated by at least 1 of the following A positive urine culture of gt 103 and lt 10 5 colony-forming units/ml with no more than 2 species of microorganisms
Costa vertebral angle pain or tenderness A dipstick for either leukocyte esterase or nitrites
Suprapubic tenderness Pyuria
Fevergt 38 degrees C Microorganisms seen on Gram stain of unspun urine
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Pyuria alone is NOT indicative of a CA-UTI.
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Foley Data Collection Tool
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.
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EP CAUTI Rates

• Metric 1 Number of foley catheters per unit per
  day (nursing)
• Metric 2 Number of foley catheter days per unit
  per month (nursing)
• Metric 3 Number of CA-UTI per unit (IC)

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IPECData Entry Symptomatic CAUTI
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IPEC Compliance Reporting
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Documentation Procedure Note

• Note title INSERTION OF INDWELLING URINARY
  CATHETER (Template note)
• Bladder scan prior to insertion Yes
  ____________ No____________________
• If yes, amount of urine return (free text)
• Type of procedure Intermittent (In and
  Out)____ Indwelling________
• Type of insertion Initial ________ Reinsertion
  _______
• Catheter description Type (use drop down box)
• Size (use drop down box)
• Hand hygiene and aseptic technique were used by
  inserter. Yes No
• Catheter was properly secured. Yes No
• Collection bag placed below the level of the
  bladder. Yes No
• Inserted without difficulty. Yes No If No,
  describe process
• Amount of urine return (free text)

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DocumentationDaily Maintenance Note (new)

• Note title Urinary catheter Daily Care (Daily
  assessment note for units who do PIE notes)
• Urinary drainage device Yes No
• If yes, what type (drop down box)
• IUD_________ ICC__________ Suprapubic________
• EUD_________ Dialysis________
• Other(free text)_________
• Sterile, continuously closed drainage system
  maintained (if appropriate) Yes No
• If indwelling urinary catheter or EUD, catheter
  properly secured Yes No
• Unobstructed urine flow maintained. Yes No
• Drainage spigot not allowed to touch the
  collection container. Yes No
• Meatal care provided with routine hygiene. Yes
  No

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DocumentationNursing Admission Assessment

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

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• Has urinary catheter device
• If checked, urinary catheter template opens up
  (see below)
• What type of device(drop down box)
• IUD_________ ICC__________ Suprapubic_______ E
  UD_________
• 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 November 2008.
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HOW ARE YOU DOING?Example compared to NHSN 10
per centile
National Healthcare Safety Network (NHSN)
Report, data summary for 2006 through 2007,
issued November 2008.
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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!!