Purpose
Improvement Tools/Methods
Limitations / Lessons Learned
Fishbone
•Catheter associated urinary tract infection (CAUTI) prevention
•To assist with the rollout of Bayfront Medical Center’s CatheterBundle
•To assist in decreasing the incidence of CAUTI
•Most common type of Healthcare Associated Infection (HAI)
•80% of urinary tract infections developed duringhospitalization occur from the use of indwelling urinarycatheters (560K annually) (CDC, 2013)
•As many as 25% of patients receive a catheter during theirhospital stay
•Prevention is key! Research shows the use of a prevention“bundle” significantly lowers the rate of CAUTI’s hospital wide.
•Excess length of stay
•Increased morbidity and mortality (~13,000 deaths annually)
•Increased cost (500 million per year nationally)
Clarke et al. (2013) studied the effectiveness of a bundle of 4 evidence-based interventions over a 9 monthperiod in a community hospital.
Bundle:
• Exclusive use of alloy/silicone catheters
• Use of securing devices to prevent movement of the catheter after insertion
• Repositioning the catheter if found to be touching the floor
• Requirement for documentation for most surgical patients for the catheter to remain in place on post opday 1 or 2 (patients who underwent perineal, gynecological and urological surgeries were exempt from this)
Results: Within 6 months of implementing the bundle, CAUTI rate was decreased by 71%, with an annualcost savings of $30,816-$120,696. The interventions of the bundle are relatively simple to implement andcost effective.
Barriers: exist in many hospitals! Research illustrates there are several barriers that contribute to the failureof using a bundle & reducing CAUTI rates. Krein et al. (2013) investigated the bundle in 12 hospitals inMichigan and identified common barriers to effectively using the bundle to decrease CAUTIs, and strategiesto address these barriers.
Results:
• Common barriers were as follows:
o Difficulty with nurse & physician engagement
o Patient & family request for indwelling catheter
o Catheter insertion techniques & customs in the emergency department
• Strategies to address barriers:
o Incorporating urinary management (planned toileting, etc.) as part of other patient safety programs,such as fall reduction
o Explicitly discussing risks of indwelling catheters with patients & families
o Engaging with ER nurses and physicians to implement a process that ensures the appropriateindications for catheter use
Findings: provide a model for implementing strategies to reduce CAUTI, and information to teach CAUTIprevention related activities in hospitals throughout the country
Katie Jackson, Katie Bitetto, Kellie Fowke, Beth Williamson—USF College of Nursing
•Have alternatives been considered?
•Obtain consent
•Aseptic insertion
o Right size and material (Do they have a latex allergy?)
o Put date and time of insertion
o Collect specimen if UTI suspected
•New foley if arrived to hospital with one (get urine sample)
•Secure to patient
•Bundle Check List—Maintain a closed drainage system
•Performed daily:
oHand hygiene
oClean technique for maintenance
oDrainage bag below the level of the bladder
oDaily meatal hygiene (qShift)
oMonitor for S&S of infection—sample taken from the port aseptically
oAssess for kinks, patency
oDocument output if required (minimal 30mL/hr)—empty when ½ full or q8h
oAssess need for continued use
oHanging on bed, not side rails, not on floor
•Empty prior to transfer
•Drain urine in tube
•Make sure spigot does not come into contact with nonsterile container
•Consider alternatives (condom cath, bladder scan, straight cath, incontinenceissue, antimicrobial-impregnated catheters such as silver-alloy coated catheters)
•After removal
oEncourage PO fluids
oBladder scan after 6h if pt hasn’t voided
•If 300-500cc present, straight cath
•If >500 new foley and notify physician
•Notify physician if cannot spontaneous void within 10h
References
Center for Disease Control and Prevention. (2010). Catheter associated urinary tract infections (CAUTI). Retrieved fromhttp://www.cdc.gov/HAI/ca_uti/uti.html
Clarke, K., Tong, D., Pan, Y., Easley, K., Norrick, B., Ko, C., … Stein, J. (2013). Reductions in catheter-associated urinary tractinfections by bundling interventions. International Journal for Quality in Health Care, 25(1), 43-49. doi:10.1093/intqhc/mzs077
Curran, E. & Murdoch, H. (2009). Aiming to reduce catheter associated urinary tract infections (CAUTI) by adopting a checklist andbundle to achieve sustained system improvements. Journal of Infection Prevention, 10(2), 57-61.
Gould, C., Umscheid, C., Agarwal, R., Kuntz, G., MSW, Pegues, D. (2009). Guideline for prevention of catheter associated urinarytract infections. Healthcare Infection Control Practices Advisory Committee.
Krein, S., Kowalski, C., Harrod, M., Forman, J., & Saint, S. (2013). Barriers to reducing urinary catheter use: A qualitative assessmentof a statewide initiative. JAMA International Medicine, 173(10), 881-886. doi: 10. 1001/jamainternmed.2013.105
Lewis, S. S., Knelson, L., Moehring, R. W., Chen, L. F., Sexton, D. J., & Anderson, D. J. (2013). Comparison of non-intensive careunit (ICU) versus ICU rates of catheter-associated urinary tract infection in community hospitals. Infection Control andHospital Epidemiology. 34(7). doi: 10.1086/671000
Background
Indications for Foley
•Output needs to be monitored
•Ineffective emptying of bladder
•Lack of bladder control and kidneys are notfunctioning optimally
•Open wound/sores that may be soiled with urine
•Severely ill or disabled (prolonged immobilization)
•Peri-operatively
•Comfort for end of life care
•NOT FOR INCONTINENCE
Lewis et al. (2013) performed a retrospective analysisof collected data from fifteen hospitals whichidentified hospital-acquired CAUTI in both ICU andnon-ICU settings.
• Historically, more effort has been given to surveyand prevent CAUTI in ICU patients
• Out of the total collection of CAUTI, 72% of CAUTIsoccurred in non-ICU patients while 28% occurred inICU
• The research group determined that non-ICUpatients are an important population for preventionefforts for CAUTI reduction
• The National Healthcare Safety Network (NHSN)observed rates of CAUTI were consistent with thisstudy’s findings
Team Members
All Healthcare Personnel that are involved in patientcare including but not limited to:
•Nurses
•Patient Care Technicians
•Physicians
•Nurse Practitioners
•Licensed Practical Nurse
•Transport personnel
•Physical Therapy
•Respiratory Therapy
Measures
Measures: comparing the past and current CAUTI rates to future rates
• Infection—cath bypasses the bodies natural defense mechanism of micturition when organisms are naturallyflushed from the lower urinary tract
oEnables organism to gain direct access
oBiofilm forms that can lead to infection or occlusion
oDue to insertion or maintenance
•Secondary infections: Bloodstream infection
•Complications of antibiotic treatment: C Diff
•Multi drug resistant organisms
• Use standardized methodology for performing CAUTI surveillance
o Number of CAUTI per 1000 catheter-days
o Number of bloodstream infections secondary to CAUTI per 1000 catheter-days
o Catheter utilization ratio: (urinary catheter days/patient days) x 100
• Internal Reporting: consider reporting both process and outcome measures to senior administrative, medical,and nursing leadership and clinicians who care for patients at risk for CAUTI
• Calculate percent of personnel who have proper training:
o Numerator: number of personnel who insert urinary catheters and who have proper training
o Denominator: number of personnel who insert urinary catheters
o Standardization factor: 100 (i.e., multiply by 100 so that measure is expressed as a percentage)
•Compliance with documentation of catheter insertion and removal dates: Conduct random audits of selectedunits and calculate compliance rate
o Numerator: number of patients on unit with catheters with proper documentation of insertion and removaldates
o Denominator: number of patients on the unit with a catheter in place at some point during admission
o Standardization factor: 100 (i.e., multiply by 100 so that measure is expressed as a percentage)
Process Improvement
ICU vs. non-ICU
CAUTI
Policy/Systems
Measurement
Knowledge/Skills
Not aseptically inserted
Tubingclamped
Use of catheterswhen not necessary
Drainage bagtouching floor orabove bladder
Not followingprotocol despiteknowledge
Leakage/holein tubing
Too large ofcatheter used
Not measuringI/Os regularly
Lack of education tostaff members
Lack of knowledge ofcatheter protocol
People
Device not securedproperly to patient
Lack of perinealcare
Lack ofauditing
Outdatedprotocol
Equipment
Methods/Procedure