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National Patient Safety Goal 07.06.01

Preventing Catheter-Associated Urinary Tract Infections

(CAUTI)

Catheter-Associated Urinary Tract Infection (CAUTI)

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OBJECTIVES

• Describe appropriate screening for UTI • Describe appropriate treatment of asymptomatic

bacteriuria • Describe the criteria for diagnosing a CAUTI • List the appropriate versus inappropriate use of

indwelling urinary catheters • Identify the risk factors that contribute to CAUTI • List the bundles involved in prevention of CAUTI

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The pathway of pathogens to the urinary tract

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Clinician Practice

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Screening Urine

The practice: “screening culture on admission”, “standing orders” or “reflex orders” for urine cultures based on urinalysis results: • May increase utilization of unnecessary antibiotics, testing, consults • May adversely affect patients exposing them to inappropriate testing and

treatments.

Clinician Practice

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Clinician Practice

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Clinician Practice

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Clinician Practice

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Clinician Practice

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Clinician Practice

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Clinician Practice

If a urinary tract infection is suspected indwelling urinary catheter should be replaced before urine collection obtained.

• It is important to identify a true UTI.

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Urine Specimen

Catheter-Associated

Urinary Tract Infection (CAUTI)

• UTI causes ~ 35% of hospital-acquired infections

• Most due to urinary catheters

• ~20% of inpatients are catheterized

• Leads to increased morbidity and healthcare costs

• CMS does not reimburse for the additional costs of hospital-acquired CAUTI

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What is CAUTI (CDC defined) UTI: Patient has at least one of the following signs or symptoms: fever (>38.0°C), suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency, urinary frequency, dysuria

Patient has a urine culture with no more than two species of organisms

identified, at least one of which is a bacterium of ≥10˄5 CFU/ml

Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place for >2 calendar days 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 > 2 calendar days and then removed, the date of event for the UTI must be the day of discontinuation or the next day for the UTI to be catheter-associated.

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• Signs and symptoms “new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain, costovertebral angle tenderness; acute hematuria; pelvic discomfort”

Clinician Practice

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Clinician Practice

1. Extended use of foley

2. Microbial colonization of the drainage bag

3. Female gender

4. Diabetes

5. Errors in catheter insertion

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Risk Factors for CAUTI

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• Studies have shown that initial catheterization was inappropriate 21% to 50% of the time, and that continued catheter use was inappropriate almost half of the days that patients are catheterized.

• A common reason for inappropriate continued catheter use is that physician is not aware that catheter is in place.

• Physicians should assess daily whether or not their catheterized

patient still requires the catheter.

Indwelling Urinary Catheters

References • Am J Med 2000 Oct 15;109(6):476-80. Are physicians aware of which of their patients have indwelling urinary catheters? Saint S,

Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, Lipsky BA, Hofer TP. • http://catheterout.org/?q=physician-engagement%20

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Expert Consensus of Appropriate Versus Inappropriate Use of

Urinary Catheters

Annals of Internal Medicine, 2015, Website: http://annals.org/article.aspx?articleid=2280677

Satisfaction survey of 100 catheterized VA patients:

• 42% found the indwelling catheter to be uncomfortable

• 48% stated that it was painful

• 61% noted that it restricted their ADLs

• 2 patients provided unsolicited comments that their catheter “hurt like hell”

(Saint et al. JAGS 1999)

Patients perspective

• Most urinary catheters do contain latex

• This provides the pliable soft consistency.

• EIRMC does have latex free catheters if needed.

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Latex and Urinary Catheters

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Interventions should be employed to encourage spontaneous voiding: Early mobilization Toilet or bedside commode to allow for upright position Bladder scan for:

Bladder discomfort

Urge to void but is unable to do so

Incontinent

Post Removal Orders

Lippincott Procedures for Bladder ultrasonography, and urinary incontinence care.

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Reduce the Risk of CAUTI

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Reduce the Risk of CAUTI

• Hand Washing

• Aseptic technique during insertion

• Daily peri-care/bathing

• Bag below the bladder

• Secure in place

• Closed system

• Avoid contamination when emptying

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Nurses Role/CAUTI Bundles

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Nurses Role/CAUTI Bundles

No Dependent Loop. Go with the Flow

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• Despite the small increase in the CAUTI rate, initial evidence from 2014 indicates this rate could be declining. • Despite the marked decreases in most HAI categories, the U.S. did not meet 2013 goals.

Source: CDC, "Healthcare-associated Infections (HAI) Progress Report,” January 13, 2015

How does CAUTI compare?

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Clinician Practice

1. Avoid placing urinary catheter not indicated

2. Order removal when not clinically indicated • Consider alternatives: External catheters, frequent

toileting, and briefs

3. Avoid ordering urine cultures unless clinical signs of UTI present or other reasons prevail

4. Don’t treat aseptic bacteriuria except for selected conditions

5. If catheter is necessary, educate patient about risk of UTI

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Summary

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1. Acute urinary retention 2. Perioperative use in selected surgeries 3. Assist in skin healing for incontinent patient 4. Palliative care 5. Gross hematuria/irrigation 6. Prolonged immobilization for trauma or surgery 7. Hourly I/O in the setting of critically ill patient

Criteria for a Continuous Foley Catheter

does your patient Why

need that catheter?

Summary

Lippincott; care of patient with indwelling foley catheter Carolyn V. Gould, MD, MSCR ; Craig A. Umscheid, MD, MSCE ; Rajender K. Agarwal, MD, MPH; Gretchen Kuntz, MSW, MSLIS ; David A. Pegues, MD and the Healthcare Infection Control Practices Advisory Committee (HICPAC) The Joint Commission. (2014). Standard NPSG.07.06.01. Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: The Joint Commission. (Level VII) Healthcare Infection Control Practices Advisory Committee. (2010). "Guideline for prevention of catheter-associated urinary tract infections, 2009" [Online]. Accessed September 2014 via the Web at http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf (Level I) Institute for Healthcare Improvement. (2012). How-to guide: Prevent catheter-associated urinary tract infection. Cambridge, MA: Institute for Healthcare Improvement. (Level VII) Association of Professionals in Infection Control and Epidemiology (APIC). (2014). "APIC implementation guide: Guide to preventing catheter-associated urinary tract infections" [Online]. Accessed September 2014 via the Web at http://apic.org/Resource_/EliminationGuideForm/6473ab9b-e75c-457a-8d0f-d57d32bc242b/File/APIC_CAUTI_web_0603.pdf (Level IV)

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References