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Prevention of Catheter Associated Urinary Tract Infections (CA-UTI)

Prevention of Catheter Associated Urinary Tract Infections (CA-UTI). Patti G. Grota PhD, RN, CNS-M-S, CIC Nurse Epidemiologist Assistant Professor, UTHSCSA SON Assistant Professor, Schreiner University. Objectives. Explore the epidemiology of CA-bacteriuria.

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Prevention of Catheter Associated Urinary Tract Infections (CA-UTI)

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  1. Prevention of Catheter Associated Urinary Tract Infections (CA-UTI) Patti G. Grota PhD, RN, CNS-M-S, CIC Nurse Epidemiologist Assistant Professor, UTHSCSA SON Assistant Professor, Schreiner University pgg/06-18-12

  2. Objectives • Explore the epidemiology of CA-bacteriuria. • Discuss national guidelines and recommendations that impact prevention of CA-UTI. • Describe the pathophysiology of CA bacteriuria. • List the differences in asymptomatic CA bacteruria and CA-UTI. • Describe how bundles prevent CA-UTI. • Explain appropriate documentation of indication insertion and maintenance of indwelling urinary catheters. pgg/02-22-12

  3. EpidemiologyProblems with Urinary Catheters • Urinary tract infection • Mechanical trauma to urethra and bladder • Immobility (restraining patient)* *Saint S, Ann Intern Med 2002; 137: 125-7 **Saint S, Am J Infect Control 2000;28:68-75 pgg/02-22-12

  4. EpidemiologyMore Problems • Discomfort and pain to patient • Add to direct costs of hospitalization: $500 to $1,000. If bacteremia present, cost up to $3,800.** • Increased length of stay *Saint S, Ann Intern Med 2002; 137: 125-7 **Saint S, Am J Infect Control 2000;28:68-75 pgg/02-22-12

  5. Epidemiology of CAUTI Most common type of healthcare-associated infection. 75% diagnosed in a hospital are associated with a urinary catheter *CDC, 2009 pgg/02-22-12

  6. EpidemiologyBurden of CA-UTI • The risk of CA-UTI increase 5% every day that an indwelling urinary catheter remains in place.(AACN, 2009) • More than 30 million Foley catheters are inserted annually in the United States, and probably contribute to 1 million CAUTIs . (APIC.org, 2008) • A complications of CA-UTI can increase a patient’s hospital length of stay from 0.4 days to 2 days. (APIC.org, 2008) • An additional average expense of $3,803 per episode, as reported in an ICU CAUTI study. (APIC.org, 2008) pgg/02-22-12

  7. Epidemiology • Indwelling urinary catheters may not always be appropriate • 288 physicians were unaware of the presence of indwelling catheters in 28% of their patients who had catheters. • Less than half of urinary catheters in teaching hospital were indicated. • Catheterization was 3.7 times more likely to be inappropriate if the physician was unaware a catheter was in place. • Approximately 74% US hospitals reported not monitoring how long a catheter had been in place. Saint et. Al Am J Med 2000 Tambyah, Infect Control Hosp Epidemiol 2002;23:27-31 pgg/02-22-12

  8. Pathophysiology Risk Factors for CA-UTI • Method of catheterization • Duration of catheter • Quality of catheter care • Host susceptibility pgg/02-22-12

  9. Pathophysiology: Key Point The risk of CA-UTI increases proportionally with the duration of the indwelling catheter. If you have to use an indwelling catheter, get it out as soon as possible! pgg/02-22-12

  10. Indwelling CatheterizationShort term vs Long term • Short-term catheterization Remains indwelling ≤ 2 weeks Commonly used in acute or critical care • Long-term catheterization Remains indwelling ≥ 2 weeks Gray M et al. Best practices in managing the indwelling catheter. Perspectives 2007 (Supp 1) pgg/02-22-12

  11. PathophysiologyCommon Pathogens • Endogenous intestinal flora • E. coli • Proteus • Enterobacter • Enterococci • Nonintestinal or environmental pathogens • Pseudomonas • Candida • Staph coag neg • MRSA • Acinetobacter pgg/02-22-12

  12. CAUTIFrequency of Common Pathogens pgg/02-22-12

  13. APIC elimination guide pgg/02-22-12

  14. PathophysiologyAscension of microbes . External (extraluminal) Bacterial Ascension ●Microorganisms colonize the external catheter surface, most often creating a biofilm. ●Bacteria tend to ascend early after catheter insertion suggesting a lack of asepsis during initial insertion. ●Bacteria can also ascend 1-3 days after catheterization, usually due to capillary action. Guide to the Elimination of CAUTIs. APIC, 2008. pgg/02-22-12

  15. PathophysiologyAscension of microbes Internal (intraluminal) Bacterial Ascension ●Bacteria tend to be introduced when opening the otherwise closed urinary drainage system. ●Microbes ascend from the urine collection bag into the bladder via reflux. ●Biofilm formation occurs, and damage to bladder mucosa facilitates biofilm on this surface. *APIC.2008. Guide to the Elimination of CAUTIs pgg/02-22-12

  16. CAUTI: Pathophysiology Intraluminal Extraluminal Detrusor spasm Shedding of cells Bacteremia Leakage Obstruction Fever (+) UA Hypotension Bladder infection with inflammation pgg/02-22-12

  17. National Guidelines • Who makes the national guidelines and recommendations? • CDC/NHSN • Infectious Disease Society of America • Joint Commission NPSG 7 • Association of Professionals in Infection Prevention and Control (APIC) • Medicare and Medicaid Regulations pgg/02-22-12

  18. National Guidelines ●Why national guidelines and recommendations? • Clinical indicator of quality of care • Contributes to increased morbidity, mortality, and costs • Increased length of hospital stay • Increased patient discomfort • Increased risk for hospital readmission *CDC, 2009 pgg/02-22-12

  19. Deficit Reduction Act P.L. 109-171 • Secretary of HHS must identify high cost, high volume preventable conditions that result in higher payment • October 1, 2008 CMS denied payments for 10 hospital acquired conditions (HACs), 3 of which were HAIs Selected surgical site infections Vascular catheter associated infections Catheter associated urinary tract infections pgg/02-22-12

  20. Joint Commission NPSG 07.07.01(adults only) • Implement evidence-based practices to prevent indwelling catheter associated UTI (CAUTI) pgg/02-22-12

  21. CAUTI BundleComponents Insertion Maintenance Surveillance pgg/02-22-12

  22. What is a bundle? • A collection of best practices identified by evidence-based science as necessary to provide optimum care for patients in certain circumstances involving particular risks to achieve the goal of improved outcome. • Keep It Smart but Simple Aseptic technique Secure the catheter Hand hygiene Closed drainage system Check daily for removal Appropriate indication pgg/02-22-12

  23. “Life Cycle” of the Indwelling Urinary Catheter pgg/06-18-12

  24. Disrupting the Life Cycle of the Indwelling Urinary Catheter pgg/06=18-12

  25. What does the evidence say?Category 1 Strongly Recommended* • Educate personnel in correct techniques • Catheterize only when necessary • Leave catheter in the least amount of time possible • Hand washing principles • Sterile technique • Secure catheter properly • Maintain closed sterile drainage • Obtain urine samples aseptically • Maintain unobstructed urine flow CDC, 2009 pgg/02-22-12

  26. Appropriate Indications for Insertion • Hospice Care • Neurogenic bladder • Obstruction/retention • Stage 3 or 4 pressure ulcer • Selected surgical procedures • Critically ill pt to monitor urine output • Prolonged immobilization ~Indications based on expert consensus pgg/02-22-12

  27. Inappropriate Indications • Nursing care of incontinent patients • A means of obtaining a urine specimen when the patient can voluntarily void • Prolonged postoperative duration without indications pgg/02-22-12

  28. Alternatives To Insertion External Urinary Catheter Devices Intermittent catheterization Bladder scanners pgg/02-22-12

  29. Advantages of Suprapubic Catheterization • Lower risk of CA-bacteriuria • Reduced risk of urethral trauma and stricture • Ability to attempt normal voiding without the the need for recatheterization • Less interference with sexual activity (Cochran Review of 14 trials that compared indwelling with suprapubic) pgg/02-22-12

  30. CAUTI BundlesMaintenance • Maintain sterility of closed urinary drainage • Maintain unobstructed urinary flow • Keep collection bag below the bladder and off the floor • Do not change indwelling catheters or collection bags routinely • Wash hands prior to handling the urinary drainage system and catheter pgg/02-22-12

  31. Maintain Proper Care • Hand hygiene immediately before and after insertion and before any manipulation of the catheter device • Use smallest bore catheter possible • Indwelling urinary catheter must be properly secured to prevent movement or urethral traction. • Date the Foley collection bag with permanent marker or label pgg/02-22-12

  32. CAUTI BundlesMaintenance • Check the skin condition around the securement device at least daily. Relocate if irritation of skin is noted. • Use port for urine collection-Do no break catheter system to collection specimen. • For long-term indwelling catheters, change the catheter prior to specimen collection. • Remove the catheter as soon as possible. pgg/02-22-12

  33. Strategies for Monitoring Catheter Use by Setting pgg/06-18-12

  34. Early Removal of Indwelling Catheters: Summary of the Evidence • 14 studies have evaluated urinary catheter reminders and stop-orders (written, computerized, nurse-initiated) • Significant reduction in catheter use • Significant reduction in infection • No evidence of harm (ie, re-insertion) (Meddings J et al. Clin Infect Dis 2010) pgg/02-22-12

  35. Removal of catheters: Additional principles • Remove as soon as possible after insertion • Use a portable ultrasound device to assess urine volume in patients before catheterizing to determine need. • Use a portable ultrasound device to assess for retention after removal of indwelling catheter and prior to reinsertion. pgg/02-22-12

  36. CAUTI BundleCaution C-Closed System, Catheter Selection, Consider Alternatives A-Aseptic Management U-Universal/Standard Precautions T-Tie/Secure Catheter to patient/Tubing to bed I-Indications for Use AND to Discontinue O-Obstruction Free, Specimens from Sampling Port N-No Dependent Loops *CDC, 2009 pgg/02-22-12

  37. Cochrane Review of Antimicrobial Catheters (2008) • 23 trials involving 5236 hospitalized adults in 22 parallel group trials met inclusion criteria • Conclusion #1: “…Silver alloy (antiseptic) coated or nitrofurazone impregnated (antibiotic) urinary catheters might reduce infections in hospitalized adults…..but the evidence is weak. • Conclustion #2: “Larger, more scientifically rigorous, trials are needed on whether catheters impregnated with antibiotics or antiseptics reduce infections. pgg/02-22-12

  38. Antimicrobial Catheter Recommendations (CID, 2010:50) • Short-term indwelling urethral catheters: May reduce onset of CA-bacteriuria but data is insufficient to support reduction of CA-UTI • No trial has compared antibiotic-coated versus silver alloy-coated catheters • No indication supported in long term indwelling urethral catheters. pgg/02-22-12

  39. CA-bacteruria or CA-UTIHow do you know? • CA-UTI will be accompanied by signs and symptoms with no other probable cause • Fever • Suprapubic tenderness • Acute hematuria • Altered mental status • Dysuria • Urgency pgg/02-22-12

  40. NHSN CA-UTI Surveillance DefinitionsCriterion 1a pgg/02-22-12

  41. NHSN CA-UTI Surveillance DefinitionsCriterion 2a pgg/02-22-12

  42. Pyuria alone is NOTindicative of a CA-UTI. pgg/02-22-12

  43. Foley Data Collection Tool Please print clearly. Indicate date of insertion with a “V”. Please mark each day of catheter with an “X” Please indicate “DC” on the date catheter is discontinued. pgg/02-22-12

  44. EP: CAUTI Rates • Metric #1: Number of foley catheters per unit per day (nursing) • Metric #2: Number of foley catheter days per unit per month (nursing) • Metric #3: Number of CA-UTI per unit (IC) pgg/02-22-12

  45. IPECData Entry Symptomatic CAUTI pgg/02-22-12

  46. IPEC Compliance Reporting pgg/02-22-12

  47. Documentation: Procedure Note • Note title: INSERTION OF INDWELLING URINARY CATHETER (Template note) • Bladder scan prior to insertion: Yes ____________ No____________________ • If yes, amount of urine return: (free text) • Type of procedure: Intermittent (In and Out)____ Indwelling________ • Type of insertion: Initial ________ Reinsertion_______ • Catheter description: Type (use drop down box) • Size (use drop down box) • Hand hygiene and aseptic technique were used by inserter. Yes No • Catheter was properly secured. Yes No • Collection bag placed below the level of the bladder. Yes No • Inserted without difficulty. Yes No If No, describe process • Amount of urine return: (free text) pgg/02-22-12

  48. DocumentationDaily Maintenance Note (new) • Note title: Urinary catheter Daily Care (Daily assessment note for units who do PIE notes) • Urinary drainage device Yes No • If yes, what type (drop down box): IUD_________ ICC__________ Suprapubic________ EUD_________ Dialysis________ • Other(free text)_________ • Sterile, continuously closed drainage system maintained (if appropriate) Yes No • If indwelling urinary catheter or EUD, catheter properly secured Yes No • Unobstructed urine flow maintained. Yes No • Drainage spigot not allowed to touch the collection container. Yes No • Meatal care provided with routine hygiene. Yes No pgg/02-22-12

  49. DocumentationNursing Admission Assessment • Bladder elimination: Denies problems Unable to assess. Urinary catheter device pgg/02-22-12

  50. Has urinary catheter device If checked, urinary catheter template opens up (see below) What type of device(drop down box): IUD_________ ICC__________ Suprapubic_______ EUD_________ Dialysis__________ Other(free text)_________ Catheter changed on admission using aseptic technique: Yes No Sterile, continuously closed drainage system maintained (if appropriate) Yes No If indwelling urinary catheter or EUD, catheter properly secured Yes No Description of urine: (drop down box) clear, turbid, hematuria Signs of CA-UTI: (drop down box). (Check all that are appropriate) oliguria, dysuria, hematuria, suprapubic pain, intervertebral coastal pain, fever , confusion pgg/02-22-12

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