Waging the War on CA-UTI’s

1. Waging the War on CA-UTI’s Evelyn White, RN,BAAS,IP Brenda Jones, RN,IP

2. NHSN Surveillance • The CDC defines an HAI as a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s). • There must be no evidence that the infection was present or incubating at the time of admission to the acute care setting. This is in reference to all HAIs.

3. Symptomatic UTI Patient has at least 1 of the following signs or symptoms with no other recognized cause: fever (>38C), urgency, frequency, dysuria, or suprapubic tenderness. and patient has a positive urine culture, that is, ≥100,000  microorganisms per cc of urine with no more than 2 species of microorganisms.

4. Patient has at least 2 of the following signs or symptoms with no other recognized cause: fever (>38C), urgency, frequency, dysuria, or suprapubic tenderness and at least 1 of the following:

5. Positive dipstick for leukocyte esterase and/ or nitrate • Pyuria (urine specimen with ≥10,000 WBC/mm or • ≥3 WBC/highpower field of unspun urine) • Organisms seen on Gram’s stain of unspun urine • At least 2 urine cultures with repeated isolation of the same uropathogen (gram-negative bacteria or Staphylococcus saprophyticus) with ≥1,000 colonies/mL in non-voided specimens      

6. ≤100,000 colonies/mL of a single uropathogen (gram-negative bacteria or S saprophyticus) in a patient being treated with an effective antimicrobial agent for a urinary tract infection. • Physician diagnosis of a urinary tract infection. • Physician institutes appropriate therapy for a urinary tract infection.

7. These are definitions for patients > 1 year of age. Definitions for infants are little different. There are a number of places where you can find the all the CDC/NHSN definitions for HAI and here is one website: http://www.azdhs.gov/infectioncontrol/pdfs/5haicasedefinitions2008.pdf

8. Asymptomatic UTI Patient has an indwelling urinary catheter within 7 days before the culture. and Patient has a positive urine culture, that is, ≥100,000 microorganisms per cc of urine with no more than 2 species of microorganisms. and Patient has no fever (>38C), urgency, frequency, dysuria, or suprapubic tenderness.

9. Patient hasn’t had an indwelling urinary catheter within 7 days before the first positive culture. and Patient has had at least 2 positive urine cultures, that is, ≥100,000 microorganisms per cc of urine with repeated isolation of the same microorganism and no more than 2 species of microorganisms. and Patient has no fever (>38C), urgency, frequency, dysuria, or suprapubic tenderness.

10. CMS-Centers for Medicare and Medicaid Services CDC-Centers for Disease Control NHSN-National Healthcare Safety Network APIC-Association for Professionals in Infection Control and Epidemiology IDSA-Infectious Diseases Society of America SHEA-Society for Healthcare Epidemiology of America

11. IHI-Institute for Healthcare Improvement

12. IHI Statistics • CA-UTI is the most common hospital associated infection: 40% of all HAIs • 1 million cases annually (hospitals & nursing homes) • 12-25% of all hospitalized patients receive a urinary catheter

13. Continued, • Increased length of stay 0.5 – 1 day • Estimated cost per case of CA-UTI range from $500-$3000. • Cost to healthcare 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.

14. For discharges occurring on or after October 1, 2008, IPPS hospitals (basically that means acute care hospitals) will not receive additional payment for cases when one of the selected conditions is acquired during hospitalization (i.e., was not present on admission). The case would be paid as though the secondary diagnosis were not present.

15. Foreign Object Retained After Surgery • Air Embolism • Blood Incompatibility • Pressure Ulcer Stages III & IV • Falls and Trauma: • Fracture• • Dislocation• • Intracranial Injury• • Crushing Injury• • Burn• • Electric Shock• • Catheter-Associated Urinary Tract Infection (UTI) • Vascular Catheter-Associated Infection • Manifestations of Poor Glycemic Control • Diabetic Ketoacidosis• • Nonketotic Hyperosmolar Coma• • Hypoglycemic Coma• • Secondary Diabetes with Ketoacidosis• • Secondary Diabetes with Hyperosmolarity• • Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG)

16. Risks of Acquiring UTI • Age, gender disease process hygiene practices • Methods of catheterization • Duration of catheter use • Quality of catheter care • Host susceptibility

17. Reasons for Increased Foley Catheter Use • Complex medical care • Increased acuity • Severity of illness • Decreased staffing levels

18. Foley Catheter Management Strategies • Good hand hygiene • Provide good personal patient hygiene • Maintain closed F/C system • Force fluids • Educate associate on correct catheter insertion and care • Ensure drainage and unobstructed urine flow

19. The Role of the IP in Reducing CA-UTIs • Assisting in policy and procedure writing • Introducing evidence based practices • Consultation on interventions • Facilitation of quality improvement projects

20. Advantages in using Bundles: • Decrease morbidity and mortality • Improve patient outcomes • Cost savings

21. UTI BUNDLE

22. ●Use alcohol gel hand hygiene before placing Foley catheter. ●Use silver/hydrogel coated Foley catheters. ●Use the smallest diameter size of the Foley catheter. ●Do not inflate the balloon prior to insertion.

23. ●Thoroughly wash peri area with soap and water before the sterile catheterization procedure. ●Insert Foley catheters with aseptic techniques. ●Secure Foley catheter to the thigh using Cath Secure from Pyxis. ●Maintain a closed system. ●Maintain the tubing above the gravity drainage bag.

24. ●Use luer lock with gravity to remove all the water from the balloon to facilitate pre-inflated shape of the balloon ●Identify patients who no longer need a Foley catheter and discontinue with a physician order ●Proper location of the gravity drain bag below level of the bladder at all time

25. ●Keep Foley catheter bag off the floor ●Daily peri care with soap and water ●Scrub hub on the Foley with alcohol before taking a specimen with luer lock syringe ● Keep the spigot on the Foley catheter gravity drain bag from touching the sides of the graduated container

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