CAUTI CRUSHERS

ELIMINATING THE RISK FOR CATHETER-ASSOCIATED URINARY

TRACT INFECTIONS

· Describe risk factors associated with urinary tract infections

· Identify catheter-associated urinary tract infection (CAUTI) reduction strategies in order to implement into clinical practice.

• Demonstrate setting up a sterile field for urinary catheterization.

• Demonstrate the use of proper aseptic technique when inserting a urinary catheter.

OBJECTIVES

Ignaz SemmelweisFather of Infection Control

Florence NightingaleFounder of Modern Nursing

Evidence-Based, Best Practice

CAUTI CRUSHERS 101

• Why is this important?

• How will this benefit our patients?

• Give me the facts!

What Are CAUTIs?

• A urinary tract infection (UTI):

– Infection involving any part of the urinary system, including the urethra, bladder, ureters and kidneys.

– Most common type of healthcare-associated infection (HAI) reported to the National Healthcare Safety Network (NHSN)

Urinary tract infections account for more than 30% of infections reported by acute care hospitals in the United States. What percentage of those are associated with a urinary catheter?

a. 25%b. 50%c. 75%d. 90%

ANSWER

C. Approximately 75% are associated with a urinary catheter – tube inserted into the bladder through the urethra to drain urine

Clinical Manifestations

• Vary Greatly• Asymptomatic bacteriuria → overwhelming

sepsis• Symptomatic UTI:– Lower abdominal, suprapubic, or flank pain– Systemic symptoms:• Nausea• Vomiting• Fever

Burden of Illness

• Of patients who receive urethral catheters:– Bacteriuria rate is ≈ 5% per day

• Among those with bacteriuria:– ≈ 10% will develop symptoms of UTI– Up to 3% will develop bacteremia

• Direct medical costs:– Symptomatic UTI: $600-$1,000– Catheter-associated bacteremia: ≈ $3,000 per

episode

CAUTI Facts

• CAUTIs can result in increased:– Morbidity– Mortality– Hospital costs – Length of Stay

What percentage of patients who are hospitalized receive a urinary catheter?

a. 5-10%b. 15-25%c. 30-35%d. 40-45%

ANSWER

B. 15-25% of hospitalized patients receive urinary catheters during their hospital stay

What is the most important risk factor for developing a catheter-associated UTI?

A. Insertion technique (sterile field, aseptic technique)

B. Peri-care; daily cleansing of perineal area surrounding the catheter

C. Prolonged use of the urinary catheterD. Patient’s age, gender and mobility

status

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Prolonged use

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Patient’s

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Answer

• C. Prolonged use of the urinary catheter

CAUTI Stats• 3% increase in CAUTIs nationally from 2009-2012• 12% of Texas hospitals have a Standardized

Infection Ratio (SIR) worse than the national SIR of 1.03 (2013)

Ruling by CMS• Hospital-acquired conditions (HACs): conditions that

patients did not have when they were admitted to the hospital, but which developed during their hospital stay.

• Centers for Medicare & Medicaid Services (CMS) now holds U. S. hospitals accountable for not preventing certain HACs.

• 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.• CMS chose 10 conditions, and CAUTI was one of them.

Essential Hospitals Engaging Network (EHEN)

• Formerly the National Association of Public Hospitals, EHEN initiated a program in 2012 for public hospitals– Goal: Reduce certain infections and conditions by 40% by

the end of 2013 when compared to 2010 data– CAUTIs were selected as one of the target infections

• UMC joined that initiative. Although we met goal for central line-associated bloodstream infections, we did not meet goal for CAUTIs.

• We are committed to closing this Professional Practice Gap!

CAUTI RATES AT UMC

2010 2011 2012 20130

10

20

30

40

50

60

27

54

37

29

CAUTIs in Combined ICUs at UMC2010-2013

2010201120122013

7% increase inCAUTIs from 2010

2010 2011 2012 20130

5

10

15

20

25

30

35

15

1918

8

12

35

1921

Total CAUTIs for Trauma & Med-Surg ICU at UMC 2010-2013

Trauma ICUMedical-Surgical ICU

Challenge for 2014

• Same challenge has been presented to UMC for 2014: reduce CAUTIs by 40% compared to our 2010 data

Mariam Yazdi, RN, BSN

Cindy Hernandez, RN, BSN

CINDY HERNANDEZMARIAM YAZDI

CAUTI REDUCTION GOAL

• Reduce incidence of CAUTIs by 15% in 2014.

• Reduce incidence of CAUTIs by 30% in 2015.

CAUTI ELIMINATION ACTION PLAN

• Cultivate enthusiasm• Increase Awareness• Provide Ongoing Education• Institute PI Tool – Immediate

Removal of foley• In-service Proper Catheter

Maintenance• Ensure Intradepartmental

Collaboration

When is it appropriate to use an indwelling urinary catheter ?

a. Need for strict, accurate output measurement as per MD ordersb. For end of life issues regarding comfort when requestedc. Strict prolonged immobilization (as in pelvic fracture)d. To help promote healing of Stage III and Stage IV sacral or coccyx pressure ulcers

A. all of the above; B. a & b only; C. c & d only

a) all o

f the above

;

b) a &

b only;

c) c

& d only

33%33%33%

When Is a Catheter Appropriate?

A. All of the aboveIn addition, the following conditions may warrant using an indwelling urinary catheter:• Bladder Injury• Acute Urinary Retention• Acute bladder outlet obstruction• Select peri-operative needs

Catheter Insertion Components

• Hand Hygiene prior to and after insertion

• Proper sterile field set up• Aseptic Technique • Remember, inserting a foley is a component of

evidence-based practice, no matter what the discipline. It requires careful attention and is not just a “task” to be completed

UTI Bundle

Approach

AWARENESS!

LABEL THE FOLEY BAGS

In report, what Foley day is this?

KEEP URINE FLOWING FREELY

No kinks in tubing or

Securement Device

URINE FLOW BAG

BLADDER

BAG

Securement Device

MORE HOUSEKEEPING

Empty Foley bag frequently; avoid allowing the spigot to

touch the collection container

KEEP FOLEY UNIT OFFFLOOR.

FOLEY CARE• Foley/Perineal Care frequency –

EVERY 12 HOURS!

Tools

Don’t Forget! • Bathe patients with product containing

Chlorhexidine Gluconate (CHG), avoiding mucosal areas

• Place CUROS cap on sampling port• Maintain a closed system • Collect urine sample from sampling port

closest to insertion site. • DO NOT COLLECT URINE FROM

DRAINAGE BAG.

Early Removal of Indwelling Catheters

• 14 studies have evaluated urinary catheter-reminders and stop-orders – Written, computerized, or nurse-initiated

• Summary of the Evidence:– Significant reduction in catheter use (≈ 2.5 days)– Significant reduction in infection (≈ 50%)– No evidence of harm (i.e., re-insertion if

necessary)

IMMEDIATE CATHETER REMOVAL

Catheter removed

Review hospital policy and practice

Foley removal

CAUTI ELIMINATION ACTION PLAN

• Educate nurses and nursing support staff– Nurse Technicians– CNAs– Unit Council and Staff Meetings– Quarterly Education: for new hires;

maintaining Unit competence

DATA COLLECTION

• PI Monitoring Tool – Covers all areas of foley management, including

the UTI Bundle

• Collaboration with Quality Management–Nurse residents round 2 times per week.– Quality Management rounds 1-2 times per

week.

• Rounding started on 8/18/14.

Alternatives to the Indwelling Catheter

– Bladder Ultrasound

– Intermittent Catheterization

– Condom Catheter for males

– Area for Research: female external catheters

ReferencesEliminating Catheter-Associated Urinary Tract Infections. Health Research &

Educational Trust, Chicago: July 2013. Accessed at www.hpoe.org. Educational Trust, Chicago: July 2013. Accessed at www.hpoe.org

Educational Tools | catheterout.org. (2014, January 1). Retrieved August 15, 2014.

Health and Research Educational Trust; CUSP, Eliminating CAUTI: A National Patient Safety Imperative. (2013). Interim Data Report on the National On the CUSP: Stop CAUTI Project. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/cusp/using-cusp-prevention/cauti-interim/cauti-interim.pdf

Martinez-Resendez, MD, M., et al. (2014). Impact of daily chlorhexidine baths and hand hygiene compliance on nosocomial infection rates in critically ill patients. American Journal of Infection Control, 42, 713-717.

Rebmann, T., & Greene, L. (2014). Preventing Catheter-associated Urinary Tract Infections: An Executive Summary Of The Association For Professionals In Infection Control And Epidemiology, Inc, Elimination Guide. American Journal of Infection Control,644-646

Strategies to Prevent Catheter‐Associated Urinary Tract Infections in Acute Care Hospitals. (2008). Infection Control and Hospital Epidemiology, Vol. 29(S1). Retrieved August 1, 2014, from http://www.jstor.org/stable/10.1086/591066.

PREVENTION TEAM

WILL YOU BE A CAUTI CRUSHER?

And They All Came Tumbling Down

The Whole Bundle – Gotta Have It!