Assassination of Myths: Evidence Based Practices in

CAUTI prevention

Monica N. Tennant, MSN, APRN, CCNS

What is Evidence Based Practice?

Trust the publication or the expert?

What’s the big deal?

• up to25% of hospitalized patients

– 5-10% NH residents

• Often placed for inappropriate indications

• Physicians frequently unaware pt has a catheter

• Initial insertion unjustified in 21% of patients

– Continued use unwarranted for >50% of days catheter remained

Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155:1425.-9 Weinstein JW et al. ICHE 1999;20:543-8 Munasinghe RL et al. ICHE 2001;22:647-9 Warren JW et al. Arch Intern Med 1989;149:1535-7 Saint S et al. Am J Med 2000;109:476-80 Benoit SR et al. J Am Geriatr Soc 2008;56:2039-44 Jain P et al. Arch Intern Med 1995;155:1425-9 Rogers MA et al J Am Geriatr Soc 2008;56:854-61 Saint S. et al. Clin Infect Dis 2008;46:243-50

What’s the risk?

• Daily risk is up to 10%, approaching

–100% after 30 days

• Between 75% to 90% of patients with asymptomatic bacteriuria do not develop systemic inflammatory response or infectious signs or symptoms

Garibaldi, Mooney, Epstein, & Britt, 1982; Saint, Lipsky, & Goold, 2002 http://www.cdc.gov/hicpac/cauti/005_background. html

EBP can be fun!

Quote from the article Indwelling Urinary Catheters: A One-Point Restraint?:

• “Beyond the health and financial burden of inappropriate catheter use is the substantial patient discomfort caused by catheters. In a recent prospective study,

– 42% of catheterized patients reported that the indwelling catheter was uncomfortable,

– 48% reported that it was painful, and

– 61% noted that it restricted their activities of daily living

– 2 respondents provided unsolicited comments that their indwelling catheter “hurts like hell”

Evidence Based Risk Factors for CAUTI

http://www.cdc.gov/hicpac/cauti/001_cauti.html

What is your hospital monitoring?

• In a recent survey of U.S. hospitals:

– > 50% did not monitor which patients catheterized

– 75% did not monitor duration and/or discontinuation

Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155:1425.-9 Saint S, Lipsky BA, Baker PD, McDonald LL, Ossenkop K. Urinary catheters: what type do men and their nurses prefer? J Am Geriatr Soc. 1999;47:1453.-7

Core Prevention Strategies

• Insert catheters only for appropriate

indications • Leave catheters in place only as long as

needed • Ensure that only properly trained persons

insert and maintain catheters • Insert catheters using aseptic technique

and sterile equipment (acute care setting)

• Following aseptic insertion, maintain a closed drainage system

• Maintain unobstructed urine flow • Hand hygiene and Standard (or

appropriate isolation) Precautions

• Right Reason • Right precautions

• Right insertion

• Right maintenance

• Right flow

(all Category IB) http://www.cdc.gov/hicpac/cauti/001_cauti.html

When can I insert a foley?

• Inserting an Indwelling urinary catheter is an invasive procedure requiring an MD order

http://www.cdc.gov/hicpac/cauti/001_cauti.html

“But my patient is different!”

We’re in the ICU/Critical Care

• 95% of UTIs occurring in the ICU develop in patients with indwelling urinary catheters (70% outside ICU)

• 50% of these patients qualify for condom catheters

It’s more convenient

• Urinary catheter-related infection leads to an almost threefold increase in the risk for death, independent of other

comorbid conditions

• Each CAUTI costs up to $2836

Platt R, Polk BF, Murdock B, Rosner B. Mortality associated with nosocomial urinary-tract infection. N Engl J Med. 982;307:637.-42

Platt R, Polk BF, Murdock B, Rosner B. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1983;1:893.-7

“But my patient is . . . “

Incontinent?

• Patients with indwelling urinary catheters are less mobile – Considered a 1-point restraint

• Patients without indwelling urinary catheters are more frequently repositioned, decreasing risk for pressure ulcers – Assist to bedpan, BSC, or

changing of linens

Going to Surgery?

• Procedures less than ___? time do not require indwelling urinary catheters

• Remove catheters ASAP postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use

Saint, S., Lipsky, BA., Goold, SD. (2002). Indwelling Urinary Catheters: A One-Point Restraint? Annals of Internal Medicine. 137(2):125-127. Gotelli, JM et al. (2008). A Quality Improvement Project to Reduce the Compincations Associated with Indwelling Urinay Catheters. Urol Nurs; 28(6); 465-467.

“But I didn’t break sterile technique!”

• Formation of biofilms on the surfaces of catheters and collecting systems

• Bacteria within biofilms resistant to antimicrobials and host defenses

• Some novel strategies have targeted biofilms (silver)

Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp

Evidence on breaking the seal

Maintain a closed drainage system

• If breaks in aseptic technique, disconnection, or leakage occur, replace catheter and collecting system using aseptic technique and sterile equipment

• – Consider systems with preconnected, sealed catheter-tubing junctions (II)

• – Obtain urine samples aseptically

CDC, IHI, and the procedure your hospital uses in Lotus Notes, Lippincott, that old binder . . .

No Dependant Loop: Go with the flow • Maintain unobstructed urine flow • Keep catheter and collecting tube free from kinking • Keep collecting bag below level of bladder at all times

– do not rest bag on floor

• Empty collecting bag regularly using a separate, clean container for each patient. – Ensure drainage spigot does not contact nonsterile container.

http://www.cdc.gov/hicpac/cauti/001_cauti.html

The urine in this line will never overcome the pressure of the air in this line to jump into the drainage bag.

This is called a “dependant loop.”

The bladder will expand with urine preventing drainage into the bag as long as there’s a dependant loop in the catheter tubing.

Core Recommendations from CDC to prevent CAUTI

• Implement quality improvement programs to enhance appropriate use of indwelling catheters and reduce risk of CAUTI

Examples:

– Alerts or reminders

– Stop orders

– Protocols for nurse-directed removal of unnecessary catheters

– Guidelines/algorithms for appropriate perioperative catheter management

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Supplemental Prevention Strategies: Examples

• Consideration of alternatives to indwelling

urinary catheterization (II)

• Use of portable ultrasound devices for assessing urine volume to reduce unnecessary catheterizations (II)

• Use of antimicrobial/antiseptic-impregnated catheters

(IB, after first implementing core recommendations for use, insertion, and maintenance and ensuring compliance with core recommendations )

Newton et al. Infect Control Hosp Epidemiol 2002;23:217-8

• Intermittent Catheterization

– Patients with neurogenic bladder

• Condom catheters

– Males without obstruction or retention

• Bladder Ultrasound Scanners

– 2 research studies of Neurogenic bladder patients with intermittent cath had fewer catheterizations per day but no reported differences in UTI

Supplemental Prevention Strategies: Examples

Polliak T et al. Spinal Cord 2005;43:615-19 Anton HA et al. Arch Phys Med Rehab 1998;79:172-5

All recommendations in HICPAC guidelines http://www.cdc.gov/hicpac/cauti/001_cauti.html

• Healthcare Infection Control Practices Advisory Committee (HICPAC)

– Federal committee provides advice and guidance to CDC and Secretary of DHHS

– 14 external infection control experts

• Other non-voting members from professional societies, consumer groups, public health organizations

– Expert opinion can and does change:

(With your help!)

What is NOT evidence based practice?

• Changing catheters or drainage bags at routine, fixed intervals

• Irrigation of bladder with antimicrobials • Routine antimicrobial prophylaxis • Cleaning of periurethral area with antiseptics

while catheter is in place • Routine screening for asymptomatic bacteriuria • Instillation of antiseptic/antimicrobial solutions

into drainage bags • Antiseptic releasing cartridges in drain ports of

catheters

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Now is the time to put EBP into practice and

Additional References/resources

• GouldCV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, and HICPAC. Guideline for Prevention of Catheter‐associated Urinary Tract Infections 2009.http://www.cdc.gov/hicpac/cauti/001_cauti.html

• IHI Program to Prevent CAUTI http://www.ihi.org/ • APIC CAUTI Elimination Guide http://www.apic.org/ • IDSA Guidelines (Clin Infect Dis 2010;50:625‐63) • SHEA/IDSA Compendium (ICHE 2008;29:S41‐S50) • National Quality Forum (NQF) Safe Practices for Better • Healthcare – Update April 2010 . CDC/Medscape

collaboration http://www.cdc.gov/hicpac/ • All references and slide are available from

Monica.tennant@emoryhealthcare.org

Where did Monica find all of that?

Click on the Ask a Librarian Link:

The Librarian will research it for you!

Or on the same Woodruff Library link:

Do we have time for CAUTI Rock? • CAUTI Block Video • http://www.youtube.com/embed/Ct1StTQHuYs

• And the winner is... In honor of National Patient Safety Awareness Week Mar. 5-9, creative JPS team members entered a video contest with submissions promoting The Joint Commission National Patient Safety Goals. This year's winner...ICU and the "CAUTI Block", the new patient safety goal for 2012. Published March 23, 2012 Credits: Lisa Temple, RN - lyrics Albert Trevino and Randy Valdez, MSTs - music video mixing and recording Holly Hatchett, Laci Brown and Stacy Nicholson, RNs - props Paula Bauman, Ann Wynne and Bryan McCurdy - backup singers Extras: Di Patterson, RN Carrie Grabruck, RN Amir Haq, RN Laura Canright, RN Jacob Jordan, RN Marie Moses, RN Leslie Haas, RN Amanda Turton, RN Trudy Sanders, RN, Patient Safety Officer