CAUTI: Reversing the Trend

1. CAUTI: Reversing the Trend

2. Why the focus? • CAUTI is the most common kind of HAI • Increases length of stay 2-4 days • Attributed to 13,000 deaths annually • $836 - $3213 additional cost per patient per CAUTI

3. Why now? • CAUTI rates are increasing nationally • Iowa remains a high performer • Reimbursement issues r/t HAC

4. Organisms enter the bladder by 3 ways: • At the time of catheter insertion • Through the catheter lumen (from a colonized drainage bag) • Along external surface of the catheter (migrate along the catheter-mucosal interface) Tambyah, Halvorson, Maki. Mayo Clinic Proc 1999

5. Urinary Catheters • 15-25% of hospitalized patients • Often placed for inappropriate indications • Physicians frequently unaware • In a recent survey of U.S. hospitals • >50% did not monitor which patients catheterized • 75% did not monitor duration and/or discontinuation

6. Current situation…. • Statewide Average NHSN data • CAUTI rate  1.1939 • Device use rate 0.2555 • CAHs • CAUTI rate per 1000 cath days 0.9671 • Device use  0.142 • PPS • CAUTI rate   1.2242 • Device use   0.2860

7. What is the goal? • Reduction of catheter utilization rate by 10% by July 2014 (< 0.22995)

8. Where do we start? • Reduction of insertion of indwelling catheters. • Empower nurses • Educate providers • Educate patients and families • Practice appropriate urinary catheter placement in the ED

9. Catheter Insertion in ED • More than half of hospital admissions come through the Emergency Department (ED) • Avoiding placement of unnecessary urinary catheters in the ED may significantly reduce catheter use among hospitalized patients. • Promote placement of urinary catheters based on appropriate indications and compliance with aseptic insertion technique. • Establish clear guidelines for urinary catheter use • Adoption of guidelines by the ED • Engage ED physicians and nurses • Educate staff on appropriate indications and aseptic insertion technique. • ED Champions– ideally, a nurse and physician

10. Examples of Appropriate Uses of Indwelling Catheters • Patient has acute urinary retention or bladder outlet obstruction • Need for accurate measurements of urinary output in critically ill patients • Perioperative use for selected surgical procedures: • Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract • Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU) • Patients anticipated to receive large-volume infusions or diuretics during surgery • Need for intraoperative monitoring of urinary output • To assist in healing of open sacral or perineal wounds in incontinent patients • Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures) • To improve comfort for end of life care if needed http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf; pg 11

11. Examples of Inappropriate Uses of Indwelling Catheters • As a substitute for nursing care of the patient or resident with incontinence • As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void • For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc.) http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf; pg 11

12. What else can we use? • Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction. (Category II) • Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients. (Category II) • Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. (Category II) • Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration.(Category II) • Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction. (No recommendation/unresolved issue) • Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization, particularly with respect to complications related to catheter insertion or the catheter site. (No recommendation/unresolved issue) http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf; pg12

13. Questions? • Nancy Wilde- IDPH • 515-242-3892 • nancy.wilde@idph.iowa.gov • Heather Matherly-IHC • 515-283-9393 • matherlyh@ihconline.org • Jennifer Brockman-IHC • 515-283-9371 • brockmanj@ihconline.org