Preventing Catheter-Associated Urinary Tract Infections

1. Preventing Catheter-Associated Urinary Tract Infections Institute for Healthcare Improvement

2. Scientific Partners • APIC • Centers for Disease Control and Prevention • Infectious Diseases Society of America • Society for Healthcare Epidemiology of America

3. Goal • Reduce and ultimately prevent cases of symptomatic CA-UTI • What is “symptomatic CA-UTI”? • Infection-causing symptoms as defined by the CDC’s National Health Safety Network (NHSN) in the setting of an indwelling urinary catheter that is in place or has been removed within the past 48 hours

4. Why CA-UTI? • Most common hospital-acquired infection: 40% of all HAIs > 1 million cases annually (hospitals & nursing homes) • 12-25% of all hospitalized patients receive a urinary catheter • Half of these found to not have valid indication

5. Potential Impact • Increased length of stay 0.5 – 1 day • Estimated cost per case of CA-UTI ranges from $500-$3,000 • Cost to health care system up to $450 million annually according to CMS • CA-UTI not documented as present on admission can no longer code patient to higher reimbursement DRG for Medicare

6. Evidence-Based Guidelines • APIC CA-UTI Elimination Guide www.apic.org/CAUTIGuide • SHEA-IDSA Compendium http://www.shea-online.org/about/compendium.cfm • CDC Guideline http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html# N.b. An update to CDC guidelines is expected in early 2009.

7. Evidence of Success • Numerous published studies reporting reductions in CA-UTI rates of 48-81% • Use of reminders • Nurse-driven protocols • Reduction in duration of catheter days “The duration of catheterization is the most important risk factor for development of infection.” SHEA-IDSA Compendium, October 2008

8. Preventing CA-UTI • Avoid unnecessary urinary catheters • Insert using aseptic technique • Maintain catheters based on recommended guidelines (daily care) • Review catheter necessity daily and remove promptly

9. 1. Avoid unnecessary urinary catheters • Studies: • 21% of catheters not indicated at insertion • 41-58% in place found to be unnecessary • Catheters • Are uncomfortable for patients • Decrease mobility, which may impair recovery and contribute to other complications (e.g., pressure ulcers, deep vein thrombosis) Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med. 1999 Apr 26;159(8):800-808. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155:1425-1429.

10. Indications for Indwelling Urinary Catheters Based on expert guidelines and published literature: • Perioperative use for selected surgical procedures • Urine output monitoring in critically ill patients • Management of acute urinary retention and urinary obstruction • Assistance in pressure ulcer healing for incontinent patients • As an exception, at patient request to improve comfort (SHEA-IDSA) or for comfort during end-of-life care (CDC)

11. Avoidance Strategies • External condom catheters for appropriate male patients • Intermittent catheterization multiple times per day • Assessing urinary retention with bladder ultrasound

12. Changes to Avoid Unnecessary Catheters • Develop criteria for appropriate insertion and verify prior to every insertion • Empower nurses to contact physicians before insertion if criteria are not met • Use a checklist of criteria – include this with the insertion kits • Determine where most catheters are inserted (probably the ED) and start there

13. 2. Insert urinary catheters using aseptic technique • Utilize appropriate hand hygiene practice. • Insert catheters using aseptic technique and sterile equipment, specifically using: • gloves, a drape, and sponges; • sterile or antiseptic solution for cleaning the urethral meatus; and • single-use packet of sterile lubricant jelly for insertion. • Use as small a catheter as possible that is consistent with proper drainage, to minimize urethral trauma.

14. Changes to Ensure Consistency of Technique • Standard insertion kits with all necessary supplies • Include technique in checklist for insertion (along with criteria) • Design processes to ensure consistent stock of supplies in needed areas

15. 3. Maintain catheters based on recommended guidelines • Maintain a sterile, continuously closed drainage system. • Keep catheter properly secured to prevent movement and urethral traction. • Keep collection bag below the level of the bladder at all times. • Maintain unobstructed urine flow. • Empty collection bag regularly, using a separate collecting container for each patient, and avoid allowing the draining spigot to touch the collecting container. • Maintain meatal care with routine hygiene (bathing).

16. Practices to Avoid • Irrigating catheters, except in cases of catheter obstruction • Disconnecting the catheter from the drainage tubing • Replacing catheters routinely (in the absence of obstruction or infection); if the collection system must replaced, use aseptic technique These practices may actually increase the risk of infection and other complications.

17. Changes to Ensure Reliable Care • Include daily maintenance items in routine documentation - consider every shift. • Ensure all supplies are routinely available at the point of care. • Engage patients and families in ensuring consistency such as checking bag placement.

18. 4. Daily review of necessity with prompt removal “The duration of catheterization is the most important risk factor for development of infection.” SHEA-IDSA Compendium, October 2008 • 74% of hospitals surveyed did not monitor catheter duration. • 47% of patient days had no justification for continued catheterization. • 41% of the time, physicians were unaware of patients inappropriately catheterized. Saint S, Kowalski. 2008. Jain P, Parada JP.1995.

19. Daily Review of All Urinary Catheters • Determine need for continuation • Remove if not indicated • Possible strategies: • Nursing assessments at every shift, with requirement to contact physician if criteria are not met • Nursing protocols for removal of urinary catheters based on criteria • Automatic stop orders for 48 to 72 hours after insertion, continuation only when indication is documented in renewal order • Reminders in patient records requiring physicians to document indication for continuation of catheter

20. Measurement Outcome Measure: Urinary catheter-associated UTI rate # Symptomatic CA-UTI* # Urinary catheter days * Infection-causing symptoms as defined by the NHSN in the setting of an indwelling urinary catheter that is in place or has been removed within the past 48 hours X 1000

21. To Be Successful • Set an aim: “Reduce the incidence of CA-UTI by 50% by May 2009.” • Plan well: Adopt a change methodology that accelerates improvement such as The Model for Improvement.

22. Model for Improvement • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in an improvement? Plan Act Study Do

23. This is not work for one! • Form… a team • Include a diverse staff. • MDs, RNs, ICPs, nursing assistants / technicians • Identify… a project champion • Someone who maintains visibility on nursing unit • Identify… a process owner • For concerns now and in the future

24. Role of Leadership • Committed: Staff cannot improve without supportive leadership. • Set the standard: “This is how we will practice.” • Resources: Make time to work on testing. • Share data: To motivate staff for change

25. Small Tests of Change • Small tests... 1 nurse, 1 doctor, 1 patient • Move on to pilot test in one nursing unit: • - Refine the process. • - Test on all shifts. • - Test on all patients with catheters. • Measure your results to know if a change was an improvement.

26. Tips for Success • STOP the line • Empower nurses to stop catheter insertion if indications are not met • Leadership support & culture • Evidence • Standard equipment packs • Clinical appropriateness