Preventing Catheter-Associated Urinary Tract Infections

1. Preventing Catheter-Associated Urinary Tract Infections Emergency Nursing Education

2. An 85 year old male with dementia… • Brought to the ED from his skilled nursing facility with a complaint of nonfunctioning PEG tube. • In the initial assessment, the nurse notes the patient was incontinent and placed a urinary catheter • The patient is admitted for a PEG change. Overnight the patient becomes more confused and pulls on his catheter leading to severe hematuria and requiring a urology evaluation. • Within 36 hours was febrile, with positive blood cultures, treated for CAUTI and requires a prolonged hospital stay.

3. Objectives • Describe urinary catheter use with focus on the emergency department (ED) • Identify current evidence on prevention of CAUTIs • Outline nursing assessment of the ED patient who may require urinary catheterization • List criteria for catheter placement • Review communication necessary between nurses and providers to facilitate appropriate clinical decision-making

4. Urinary Catheter Utilization • About 15 - 25% of patients will have a urinary catheter placed during their hospitalization. • Many are placed in • ED • ICU • OR

5. Reducing CAUTI • Determine appropriate indication • Avoid use if no indication • Seek alternatives when possible • Use sterile technique for placement • Remove as soon as possible

6. Why we think putting in a catheter is a good idea – but it’s not

7. Indications for catheterization • Patient is critically ill and will require accurate output measurement • Urinary retention/obstruction • Bladder scanner or bedside ultrasound first • Immobilization needed for trauma or surgery • Incontinent with open sacral/perineal wounds • End of life/hospice • Chronic or existing catheter use • Re-evaluate need and discuss with provider

8. “Not” indications for catheterization • Substitute for frequent toileting • To obtain a specimen if the patient can void freely • Patient preference • Dementia • Obesity

9. Patients at high risk for inappropriate catheterization • Elderly Women • Independent factors: women were twice more likely than men, and very elderly (≥80 years) were 3 times more likely than those 50 or younger, to have urinary catheter placed without indication. Fakih et al, Am J Infect Control 2010;38:683-8 • Incontinent • Obese • Immobile • Non-critically ill cardiac and renal patients • Monitor does not necessitate catheter

10. Reducing inappropriate placements reduces • Infection rates • Cost • Antibiotics use • Length of stay • Morbidity • Patient discomfort

11. Communication with providers • Clear understanding of indications • Commitment to nonmaleficence (doing no harm) • Patient focused care

12. So, how does this affect the care of this patient? • Brought to the ED from his SNF with a complaint of nonfunctioning PEG tube. In the initial assessment, the nurse noted the patient being incontinent and placed a urinary catheter • Incontinence is not an indication by itself for catheter placement

13. So, how does this affect the care of this patient? • The patient was admitted for a PEG change. Overnight the patient became more confused and pulled on his catheter leading to severe hematuria and requiring a urology evaluation. • The agitated patient (possibly due to dementia) is not a good candidate for catheter placement

14. So, how does this affect the care of this patient? • Within 36 hours was febrile, with positive blood cultures, treated for CAUTI and required a prolonged hospital stay. • This patient had no indications to place a catheter; the suggestion is that placement of the catheter in the ED was a potential cause of infection. Patient stay is prolonged, patient develops a clinical problem he did not present with initially. This infection is potentially preventable.

15. Another example… • A 76-year-old woman admitted for congestive heart failure… • Urinary catheter placed and started on diuretics • Condition improved; ready for discharge on 3rd day • No urinary output for 5 hours after catheter removal • Bladder scan showed 500 mL of urine • Straight catheterization • Observed overnight for symptom resolution CAUTI ED slides, Fakih, 2012

16. So, how does this affect the care of this patient? • Urinary catheter placed and started on diuretics • Accurate I & O measurement can be a valid indication for catheter placement for critically ill patients • Evaluate for need before placement

17. So, how does this affect the care of this patient? • Condition improved; ready for discharge on 3rd day • No urinary output for 5 hours after catheter removal • Bladder scan showed 500 mL of urine • Not all patients with congestive heart failure require catheterization • Early removal may have prompted evaluation of urinary retention • Additional day of hospitalization • Risk for urosepsis • Explore alternatives for measuring I & O • Removal after initial diuresis to shorten exposure • Frequent toileting • Communicate with inpatient staff indication for placement to assure timely removal

18. Another example… • A frail 82-year-old woman was admitted for congestive heart failure… • Urinary catheter placed and started on diuretics • Team felt the catheter would make her more comfortable • On day 5 • Chills; fever of 102°F • SBP dropped to 90 mmHg • Blood cultures and urine cultures grew Escherichia coli. • Diagnosed with symptomatic CAUTI and treated with intravenous antibiotics. CAUTI ED slides, Fakih, 2012

19. So, how does this affect the care of this patient? • Team felt the catheter would make her more comfortable • Comfort is a myth • It may be convenient for the staff and the patient, but does not promote comfort, nor is it a safe indication • Some patients may request a catheter to avoid the need to get up. It is still an inappropriate reason • Consequences • Prolonged, unexpected hospitalization from hospital-acquired CAUTI • Risk for urosepsis

20. The take home • Review indications for urinary catheter placement • Discuss placement with provider • Communicate indications for placement with inpatient staff for timely removal • Do no harm

21. Is the patient critically ill and will require accurate output measurement? No Yes • Other indications for urinary catheter: • Urinary retention/obstruction? • Use bladder scanner first • Immobilization needed for trauma or surgery? • Incontinent with open sacral/perineal wounds? • End of life/hospice? • Chronic or existing catheter use? • Re-evaluate need and discuss with provider • Insert catheter and treat signs of shock: • Hypotension • Decreased cardiac output/function • Decreased renal function • Hypovolemia • Hemorrhage • Re-assess after intervention No Yes Do NOT insert Explore alternatives Still critically ill, requiring accurate output measurement? Yes No Insert or maintain catheter Remove catheter prior to admission