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Interventions to Prevent CAUTI Focus on Avoiding Unnecessary Catheter Placement

National Content Call. Interventions to Prevent CAUTI Focus on Avoiding Unnecessary Catheter Placement. David Pegues, MD Professor of Medicine University of Pennsylvania School of Medicine Hospital of the University of Pennsylvania. Outline. Scope of the problem

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Interventions to Prevent CAUTI Focus on Avoiding Unnecessary Catheter Placement

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  1. National Content Call Interventions to Prevent CAUTIFocus on Avoiding Unnecessary Catheter Placement David Pegues, MD Professor of Medicine University of Pennsylvania School of Medicine Hospital of the University of Pennsylvania

  2. Outline • Scope of the problem • Lifecycle of the urinary catheter • Appropriate and inappropriate indications for catheter placement • Alternatives to indwelling urethral catheters • Proper insertion, maintenance, and removal of urinary catheters

  3. Epidemiology • UTI: • Most common healthcare-associated infection • 80% attributable to an indwelling urethral catheter1 • 15-25% of hospital inpatients will have a urinary catheter during admission2 • Most have urinary catheters 2-4 days • Daily risk of acquisition of bacteriuria: • 3% to 8% per day of urinary catheterization • ~100% at 30 days • Duration of catheterization = biggest risk factor 1 Saint S, Chenowith CE. Infect Dis Clinics North Amer 2003;17:411-32. 2 Weinstein JW, et al. Infect Control Hosp Epidemiol 1999;20:543-8..

  4. Scope of the Problem • Urinary catheters are often placed unnecessarily, in place without physician awareness and not removed promptly when no longer needed.1 • 17% to 69% of catheter-associated urinary tract infections (CAUTI) may be preventable with recommended infection prevention measures2: • Up to 380,000 infections and 2,225–9,031 deaths related to CAUTI per year could be prevented 1 Saint, S. et al. Am J Med 2000;109:476-80. 2 Umscheid CA, et al. Infect Control Hosp Epidemiol. 2011;32:101-14.

  5. Use of Urinary Catheters in Adult ICU Patients Burton DC, et al. Infect Control Hosp Epidemiol 2011;32:748-56.

  6. Asymptomatic Bacteriuria (ASB) • Up to 90% or more of hospitalized patients with catheter-associated bacteriuria (CA-ASB) are asymptomatic.1 • Bacteremia complicates CA-bacteruia in <1% to 4% of cases. • CA-ASB has no clear association with mortality risk. • CA-ASB should not be treated routinely in any care setting. • CA-ASB: • Reservoir of multidrug-resistant organisms • Driver of inappropriate antimicrobial utilization • 15/29 (52%) of patients with CA-ASB received treatment2 1 Hooton TM, et al. Clin Infect Dis 2010;50:625-63. 2 Dalen DM, et al. Can J Infet Dis Med Microbiol 2005;16:166-70.

  7. Surveillance Definition vs. Clinical Diagnosis of Catheter-Associated UTI NHSN Definition Clinical Diagnosis CA-bacteruia (>105cfu/ml) AND New fever or rigors with no other source New onset delirium, malaise, lethargy with no other source CVA tenderness, flank pain, pelvic discomfort Acute hematuria OR Usual UTI symptoms if the catheter has been removed in the past 48 hours Hooton TM, et al. Clin Infect Dis 2010;50:625-63.

  8. Clinical and Economic Impact * Adjusted (2009 dollars) Hooton TM, et al. Clin Infect Dis 2010;50:625-63. Umscheid C, et al. Infect Control Hosp Epidemiol 2011;32:101-14.

  9. Pathogenesis of CA-UTI

  10. Distribution of Pathogens Among CAUTIs Burton DC, et al. Infect Control Hosp Epidemiol 2011;32:748-56.

  11. Evidence-Based Guidelines to Reduce CAUTI Lo E, Nicolle L, et al. Infect Control Hosp Epidemiol 2008;29:S41-50. Greene L, et al. APIC. Washington, DC, 2008 Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26. Hooton TM, et al. Clin Infect Dis 2010;50:625-63.

  12. Appropriate Urinary Catheter Use Insert catheters only for appropriate indications, and leave in place only as long as needed. (Category IA) Do not use urinary catheters in patients and nursing home residents for management of incontinence. (Category IB) For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible post-operatively, preferably within 24 hours, unless there are continued appropriate indications. (Category IB) Aseptic Insertion of Urinary Catheters Ensure that only properly trained persons (e.g. hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Category IC) Insert catheters using aseptic technique and sterile equipment (except as stated where clean technique is appropriate for chronic intermittent catheterization). (Category IC) Proper Urinary Catheter Maintenance Maintain a sterile, continuously closed drainage system. (Category IB) Do not disconnect the catheter and urinary drainage system unless the catheter must be irrigated. (Category IB) HICPAC Priority Recommendations Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

  13. Do not screen for asymptomatic bacteriuria in catheterized patients Do not treat asymptomatic bacteriuria in catheterized patients except before invasive urologic procedures Avoid catheter irrigation Do not use systemic antimicrobials routinely as prophylaxis Do not change catheters routinely Approaches NOT to Use Routinely: CAUTI Lo E, Nicolle L, et al. Infect Control Hosp Epidemiol 2008;29:S41-50.

  14. “Lifecycle” of the Urinary Catheter Meddings J, Saint S. Disrupting the life cycle of the urinary catheter. Clin Infect Dis 2011;52:1291-3.

  15. “Lifecycle” of the Urinary Catheter Meddings J, Saint S. Clin Infect Dis 2011;52:1291-3.

  16. Avoid Unnecessary and Improper Placement Recommendations: • Insert urinary catheters only for appropriate indications • Avoid unnecessary and improper placement • Ensure only properly trained persons insert catheters • Insert using aseptic technique and sterile equipment Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26. Hooton T, et al. Clin Infect Dis 2010;50:625-63.

  17. Appropriate Indications for Indwelling Urinary Catheter Use Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

  18. Inappropriate Indications for Indwelling Urinary Catheter Use But what about the other well-intended reasons using urinary catheters? Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

  19. Other Reasons and Risk of Urinary Catheters • Other Reasons • Urine output monitoring outside the ICU • Incontinence without skin breakdown/decubitus • Prolonged post-operative use beyond 24 hours • Transfer from ICU to floor • Morbid obesity or immobility • Confusion or dementia • Patient request • Other Risks • Secondary bacteremia, sepsis, metastatic infection • “One-point restraint” = decreased mobility • DVT/PE, pressure ulcers • Fall risk by tripping over catheter • Deconditioning • Patient discomfort, need to retrain bladder Perceived Short term benefits • Real cumulative risks: • LOS • Cost • Mortality

  20. Inappropriate Catheter Placement • Initial indication for catheter placement1: • Inappropriate in 21%-54% of catheterizations • Varies by location of placement and site of care 1 Hooton TM, et al. Clin Infect Dis 2010;50:625-63. 2 Jain P, et al. Arch Intern Med 1995;155:1425-9.

  21. Avoid Unnecessary and Improper Placement Challenges • Urinary catheters are placed in multiple different locations • different systems of care • Emergency Department • Pre- and post-operative care areas and operating room • Inpatient Units: acute care, ICU, rehabilitation, long-term care • No single source for catheter distribution: • more difficult to regulate, monitor and provide feedback • Lack of consensus on appropriate indications for catheters. Saint S, et al. Infect Control Hosp Epidemiol 2008;29:333-41

  22. Limiting the Temptation • Ensure adequate resources to limit the use urinary catheters for inappropriate indications. • People • Lift teams • Care assistants • Physical therapy • Supplies • Alternatives to urethral catheters • Bedside commodes, urinals, hats, daily weights • Incontinence pads • Skin care and barrier creams • Communication • On transfer from ER floor or ICU floor

  23. Alternatives to Urinary Catheters

  24. Changing Catheter Use, by Environment

  25. Avoid Unnecessary Placement Tools • Require appropriate indications for catheter placement • Require physician order for placement • Bladder scanners to evaluate/confirm urinary retention Catheter Orders with Decision Support: • Embed reminders for appropriate indications • Embed reminders about alternatives to indwelling catheter use • Start clock (24-48 h) for catheter removal reminders or stop orders Saint S, et al. Infect Control Hosp Epidemiol 2008;29:333-41.

  26. Alternatives to Indwelling Urethral Catheters

  27. Avoid Unnecessary Placement

  28. Bladder Ultrasound • Primary use • Measuring post-void residual (PVR) in persons with incomplete bladder emptying • Target population • Urinary retention • Neurogenic bladder • Post surgical urinary retention with incontinence • Advantages • Noninvasive and more comfortable than catheterization • Less infection and trauma risk than catheterization • Compared to radiographic study—no risk of contrast dye or radiation exposure • Easy to use • Faster than in-and-out catheterization • Disadvantages: • Mild discomfort • Obese body habitus

  29. Bladder Ultrasound • Design: Single center, observational study; 2 years • Assess whether computerized feedback to physicians + a nurse-driven protocol and handheld bladder scanners would decrease the incidence of CAUTI. • Results: Topal J, et al. Am J Med Qual 2005;20:121-6.

  30. Bladder Ultrasound Ontario Health Technology Assessment Series 2006; Vol. 6, No. 11:1-51.

  31. Recommended Intervention Develop a protocol for management of postoperative urinary retention, including nurse-directed use of intermittent catheterization and use of bladder scanners Lo E, Nicolle L, et al. Infect Control Hosp Epidemiol 2008;29:S41-50.

  32. Intermittent Catheterization • Primary use • Standard method of determining PVR urine volumes • Target population • Urinary retention, primarily chronic • Neurogenic bladder • Vs. indwelling catheter • Reduced risk of SUTI and pyelonephritis • Increased risk of urinary retention • Disadvantages • Urethral trauma and stricture • Discomfort, especially with BPH (men) and atrophic urethritis (women) Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

  33. Condom Catheters Design: Prospective, randomized, unblinded, controlled trial of 75 VAMC patients condom catheter (34) vs. indwelling catheter (41). Methods: Outcome--cumulative risk of bacteriuria, symptomatic UTI, or death Patient satisfaction Saint S, et al. J Am Geriatr Soc 2006;54:1055-61.

  34. Condom Catheters • Target population • Typically used on elderly male patients with dementia • Advantages • Reduces risk of complications and better tolerated compared to indwelling catheter • Disadvantages • One size does not fit all • Leakage, skin necrosis, edema, allergy

  35. Cochrane review (2005): 14 studies comparing urethral vs. suprapubic catheterization Adults catheterized for up to 14 days Urethral catheterization associated with increased risk: Short-term Suprapubic Catheters • CDC/HICPAC (2009): Urethral vs. suprapubic catheters • Decreased duration of catheterization • Increased LOS and discomfort • SUTI: Unclear if suprapubic catheters reduce rate Niël-Weise BS et al. Cochrane Database Syst Rev 2005 Jul 20;(3):CD004203. Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

  36. Other Options: Toileting Programs • Target population • Primarily incontinent elderly residents in LTCFs • Require patient-specific assessment of incontinence + program of prompted voiding • Advantages: voiding vs. indwelling catheters • Reduced incontinence, medication use, PVR, and cost • Improved skin integrity • UTI rate (NS) in one trial • Disadvantages: • Limited population and setting • Labor intensive Roe B, et al. J Adv Nurs 2007;57:15-31.

  37. Limitations: Almost all studies use pre-2009 CDC NHSN urinary tract infection definition Includes both CA-UTI and CA-ASB No RCTs show benefit in CA-UTI, bacteremia, or mortality Silver alloy catheters: Significantly reduce CA-ASB in hospitalized adults catheterized for < 1 wk and > 1 wk Antibiotic impregnated catheters: Significantly reduce CA-ASB in hospitalized adults catheterized for < 1 wk but not > 1 wk CDC/HICPAC “Should be considered if CAUTI rates are not decreasing after implementing a comprehensive strategy” regarding use, insertion, maintenance care.” Other Options: Coated Catheters Cochrane Database Syst Rev 2008 Apr 16;(2):CD004013 Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26.

  38. Avoid Improper Placement • Ensure only properly trained persons insert catheters, and insert using “aseptic technique and sterile equipment.”1-2 • “Operator has been deemed competent for this procedure, or is being supervised by a competent operator.”2 • Hospital personnel who provide catheter care should be given periodic in-service training of correct technique. • If patient/family perform catheterization at home, “clean” technique by patient/family can continue, with evaluation by nursing to ensure/reinforce correct technique. 1 Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26. 2 Hooton TM et al. Clin Infect Dis. 2010;50:635-63. .

  39. Avoid Improper Placement • Ensure only properly trained persons insert catheters, and insert using “aseptic technique and sterile equipment.”1-2 • Supplies: • Sterile catheter (smallest bore) • Gloves, drape, sponges, antiseptic or sterile solution for periurethral cleaning • Single use lubricant jelly • Hand Hygiene immediately before and after insertion. • Secure catheter to leg to prevent movement, urethral trauma/irritation. • Position bag below bladder (“dependent”) with closed unobstructed tubing. 1 Gould C, et al. Infect Control Hosp Epidemiol 2010;31:319-26. 2 Hooton TM et al. Clin Infect Dis. 2010;50:635-63.

  40. “Lifecycle” of the Urinary Catheter Meddings J, Saint S. Clin Infect Dis 2011;52:1291-3.

  41. 2. Maintain Awareness of Catheters in Place • Options: • Daily care checklists • More obvious catheter documentation • Routine reminders of catheter presence to physicians/nurses Munasnghe RL, et al. Infect Control Hosp Epidemiol. 2001;22:647-9. Saint S, et al. Am J Med 2000;109:476-80.

  42. 2. Maintain Proper Care of Catheters in Place Appropriate Management Who impacts this? Properly secure catheters Maintain a sterile, continuously closed drainage system Do not disconnect the catheter and drainage tube Collect specimens aseptically Maintain unobstructed flow of urine Empty the collecting bag regularly Do not allow the spigot to touch the collecting container Keep the collecting bag below the level of the bladder at all times Nurses Patient care assistants Patient Family members Transporters

  43. “Lifecycle” of the Urinary Catheter Meddings J, Saint S. Clin Infect Dis 2011;52:1291-3.

  44. 3. Prompt Catheter Removal Traditional Steps to Catheter Removal Prompt Catheter Removal Physician recognizes catheter is present Physician recognizes catheter is no longer needed Physician writes order to remove catheter Nurse sees order and plans to remove the catheter Urinary catheter is removed Reminder: • Reminds that a urinary catheter is still in use; may also remind of appropriate indications to continue catheterization. Stop order: • Prompts removal of urinary catheter based upon specified time after placement (e.g., 24 hours), based upon clinical criteria.

  45. 3. Prompt Catheter Removal Pearls and Pitfalls Can be directed at physicians or nurses Can be written, verbal, or electronic (computer order entry) Nurse to nurse communication during transitions (ED, ICU): • “Does this patient have a catheter? Why?” • If not indicated, ask for catheter to be removed before transfer. Pearls Tailor to care setting Embed appropriate indications Include catheter alternatives Automate and time order Direct to primary care team Nurse-driven removal Pitfalls Reminders often ignored Sustainability over time Reminders and Stop Orders

  46. Systematic Review of Reminder Systems to Reduce CAUTI and Urinary Catheter Use • Methods: • Systematic review • Outcome measures: CAUTI risk, urinary catheter utilization, and catheter replacement • 14 studies evaluating reminders or stop orders met inclusion criteria • Conclusions: • Low cost / high impact strategies • Potential to change the default from “persistent use” to “timely removal” • Limitations: • Only 1 of 14 included studies was RCT • Only 1 in 10 US hospitals use reminders or stop orders1 Results Meddings J, et al. Clin Infect Dis 2010;51:550-60.

  47. “Lifecycle” of the Urinary Catheter Meddings J, Saint S. Clin Infect Dis 2011;52:1291-3.

  48. 4. Preventing Catheter Replacement • Do reminders or stop orders lead to increased need for re-catheterization? • No evidence higher rates of re-catheterization • Tools to prevent catheter replacement: • Urinary retention evaluation protocols • Use bladder scan and straight catheterization • Do not require physician order • Same tools as for preventing initial placement Meddings J, et al. Clin Infect Dis 2010;51:550-60.

  49. Summary • Appropriate indications for catheter placement • Derived from expert guidance with strong clinical rationale • Can be modified based on local consensus • Reducing inappropriate catheter use requires: • Focus on both placement and continued use • Understanding the clinical and economic impact of inappropriate catheter use • Adequate resources for alternative methods of voiding • Reminders and stop orders can disrupt the catheter “lifecycle” at all stages

  50. Acknowledgement and Contact • Jennifer Meddings, MD, MSc (U Michigan) • Slide / content development and review • meddings@med.umich.edu • David Pegues, MD • david.pegues@uphs.upenn.edu

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