Catheter Associated

Urinary Tract Infections

Ashley Campbell, Tanya Darkwah, Mack Flaherty, Sophie Griswold,
Natali Knight, Alma Lozano, Paige Martin, Jeremiah Palicka, Claritza Sanchez
University of Arizona
 What is a CAUTI?
A urinary tract infection (UTI) associated with an indwelling urinary catheter
that has been in place for more than two calendar days
CAUTI have been associated with increased:
Morbidity
Mortality
Hospital costs ($400-$500 million/year)
Length of stay (2-4 days)
Rates:
Most common healthcare-associated infections
UTIs are the leading cause of secondary healthcare-associated
bacteremia.
20% of hospital-acquired bacteremias arise from the urinary tract
Mortality is 10%

(Miller et al., 2016)

Why is this issue important?
In January of this year, the US Centers for Medicare and
Medicaid Services rated St. Joes, Banner, and TMC among
the 25% worst-performing hospitals in terms of nosocomial
infections
These hospitals were penalized with a 1% reduction in all
medicare payments through the fiscal year that ended
September 30th
Representatives from Banner predicted that this would cost
their hospital between $600,000 and $900,000
(Innes, 2016)
 St. Joes Statistics
In 2015:
There were 1.5 CAUTIs per 1000 patients in the medical
ICU
There were 0.7 CAUTIs per 1000 patients in the
neurological ICU
In 2016:
There have been 1.6 CAUTIS per 1000 patients in the
medical ICU
There have been 3.7 CAUTIS per 1000 patients in the
neurological ICU
(St. Joes representative, personal communication, October 26th, 2016)
 PICOT Question
Will the implementation of a nurse-driven protocol
to remove unnecessary indwelling urinary
catheters, compared to having no protocol in place,
reduce the incidence of CAUTIs in the Medical
Intensive Care Unit at Carondelet over a six month
period?
 PICOT Breakdown
Population: Nurses in the medical ICU at
Carondelet
Time: A six month period
Intervention:Demonstrating the removal of
unnecessary indwelling urinary catheters
Comparison: As compared to having no protocol
Outcome: To reduce the incidence of catheter
associated urinary tract infections
Summary of Current Practice
CAUTIs are currently the most common nosocomial infections
reported to the CDC
The CDCs National Healthcare Safety Network monitors
effectiveness of interventions
Arizona hospitals had a small reduction in the number of CAUTIs
from 2013-2014 (most recent data available)
St. Josephs performed worse than national benchmarks on CAUTI
prevention
Hospitals get punished financially for not meeting these benchmarks

(Centers for Disease Control and Prevention, 2015)

Summary of Current Practice
St. Josephs computer system does
have a reminder, but nurses report
that it is not obvious or readily
available.
 Synopsis of Current Literature
Collectively, as a group we analyzed
nine studies gathered from PubMed,
CINAHL, and Cochrane Database.
Our studies included several
randomized control trials, several
quasi-experimental trials, a descriptive
study, a cohort study, and a systematic
review.
 Synopsis of Current Literature
The populations of these studies included patients
admitted to:
Community hospitals and tertiary care facilities.
Neurological, respiratory, cardiovascular,
trauma, burn, and medical intensive care units.
Medical/surgical units and progressive care
units
 Synopsis of Current Literature
Some common themes of the current literature
included:
The prevalence of CAUTI, particularly among
intensive care units.
Education/specialized teams.
Changes in clinical practice/hospital protocol.
 Synopsis of Current Literature
The duration of catheterization

Evidence based reminders to remove

indwelling catheters.
 Synopsis of Current Literature
As a group, we found that all studies
that endorsed the implementation of an
evidence based reminder to remove
indwelling catheters reduced the
occurrence of catheter associated
urinary tract infections.
Specifics of the collected and analyzed
literature.
 Summary of Strengths and
Limitations
Strengths: Studies generally addressed similar interventions,
all evidence was level V or above (including multiple level II),
and ALL demonstrated reduced CAUTI incidences.
In the systematic review, only 9 appropriate studies were
found. Only one was a randomized control study, due to
computerized charting issues typically present. Also, there
was not a consistent definition of short-term catheterization.
Also, all settings had computerized systems, which could
affect the generalizability of results.
 Summary of Strengths and
Limitations
In the controlled randomized trial, the unit of insertion
was typically different, and UTIs were likely
overestimated
For the non randomized trials, common issues were:
retrospectiveness, gradual implementation of protocols,
inability to evaluate relative effectiveness of particular
interventions, interventions were typically unit-wide,
differences in urine testing protocols, and low numbers
of UTIs on individual units.
 The Common Goal

Catheter provides pathogen portal of

entry. For each catheter day, risk of
CAUTI ranges from 3-7%

Interventions aim to remove catheters

as soon as possible
Evidence-Based Nursing Recommendations that
Support Best Practice:

An EHR checklist linked to automatic

stop order that will remind nurses to
remove unnecessary catheters

(within the framework of the CUSP Program)

 Introduction to CUSP
Developed by CAUTI prevention experts and adopted with
great success

Goals:
1.CAUTI reduction by 25%
2. Culture of safety
 Methods
Adaptive
4 Es : Engage, Educate, Execute, and Evaluate
The Comprehensive Unit-based Safety Program (CUSP):
understanding safety and incorporating habits into unit
routines. A team effort
TECHNICAL
Appropriate Catheter Use Intervention
Proper Catheter Insertion and Maintenance Intervention
Prompt Catheter Removal Intervention
 Recommendations for Best Practice:
Addition of a mandatory-action checklist requiring RN review
Q shift of criteria for continued use:
Indications
Acute retention or bladder obstruction
Need for accurate measurements in critically ill
Selected surgeries: urologic, of genitourinary tract, prolonged,
high-fluid volume
In open sacral or perineal wounds with incontinence
Prolonged immobilization (back injuries, trauma)
Comfort in end of life care

If not, nurse-driven removal protocol linked to EHR

 Nurse-driven protocol
Reminder for MD; unless deselected w/
medical justification
no indications-->RN will discontinue
catheter per automatic stop order*
RN will document removal and reevaluate.
Alert to MD if no void in 8 hours.
Patient education: fluids, assistance with
toileting, activity, safety
Additional components: Education
Team lead training and monthly webinars (CUSP)
Assembling team
Training (1 hr) and monthly meetings for champions
Auditing, strategies and barriers
Appropriate indications, checklist, & protocol RN training
Continuing communication & CAUTI incidences
To RNs during report and huddles
To MDs via emails, rounds, MD champion
Regular staff newsletter
 Additional components: Content
of Education
Safety culture
Unit-specific prevalence and CAUTI rates
Risks
Costs
Indications and inappropriate use*
Managing resistance
Alternatives
Commodes, bed pans, urinals, super-absorbent
pads, bladder scanners, condom catheters,
intermittent
Additional components: Auditing
RN champion implements daily rounding on catheterized
patients
Questionable indication: encourage removal per
protocol or discuss case at rounds
Real-time education
Monitor RN awareness and compliance
CAUTI case reviews for improvement
Involved RN receives letter and invitation to participate
in root cause analysis, using following tool
 Additional components:
Sustainability
Long-term visual reminders
Appropriate indication posters
Days Since Last CAUTI posters
Incentives and Consequences
Staff celebration and CAUTI themed event
Staff feedback, roleplaying, recognition
Consequences for non-compliance
Probation etc.
Implementation: Timeline
 How Much Would It Cost to Implement?
Salary Breakdown:
ICU Nurse = ~$50.00/hour
Charge Nurse= ~$60.00/hour
IT = ~$45.00/hour
Technology
According to Adam Raeder (Epic IT Person)
IT Total Cost: ~$500.00
1.5 hours for a meeting with 2 nurses, a charge nurse, and
an IT person to obtain the requirements. = $307.50
1 hour for IT development. = $45.00
1 hour for IT deployment. = $45.00
1 hour for testing with IT and charge nurse. = $105.00
 How Much Would It Cost to Implement?
Training
According to Judy Cornwell (TMC Personnel)
Total for training nurses. = $3,000.00
Training Method: Advisement Memo = ~45 Minutes (0.75
Hours)
80 ICU Nurses
Webinar
Monthly 1 hour webinar training for the team leader for the
duration of implementation (6 months)= $120.00
Training charge nurses to become nurse champions= $180.00

Total cost of about $3,800.00 to implement the intervention and

about $500.00 annually for maintenance.
 What Did the Implementation Cost Other Hospitals?

Salem Hospital in Oregon implemented a similar intervention to ours.

Although cost of implementation was not acquirable.

Research showed hospital implementing similar interventions resulted in

savings of $700.00 per 100 patients with catheters.

In one of our articles, showed that the hospital that was involved in the
study had an overall return investment of $84,000 over one year after
implementation.

(Salem Health, 2014) (Quinn, 2015)

Implement Despite the Cost
CAUTIs are the most common healthcare-associated
infections.
Medicare and Medicaid are no longer reimbursing
hospitals for CAUTIs.
Annually in the United States there is an estimation of
25,000 cases of CAUTIs.
Annually it results in 259 million dollars in medical
costs.
(Kennedy, Greene, & Saint, 2013), (U.S Department of Health & Human Services, 2015)
 Risks of Implementation
Risk for skin breakdown
Risk for bladder overdistention
Risk for kidney infection and
trauma
 Benefits of Implementation
Studies have shown a reduction in CAUTI rates between 26 and
74% with the implementation of evidence-based practice and
nurse-driven protocols
The costs of implementation are outweighed by the savings
Medicare does not pay for CAUTI costs
Hospitals have to absorb all costs incurred through nosocomial
infections
Savings from not being penalized for not achieving benchmarks
(John et al., 2015), (Association for Professionals in Infection Control and Epidemiology, 2014), (American Nurses Association, 2016)
Evaluation - Expected Outcomes
By the end of the six month intervention
period, there will be 90% compliance
with our intervention among nurses in
the medical ICU at St. Joes.
 Expected Outcomes
The medical ICU at St. Joes hospital
will have a 25% reduction in CAUTIs
by the end of the six month
intervention period.
 Expected Outcomes
By the end of the six month
intervention period, the medical ICU at
St. Joes will have a 50% reduction in
catheter utilization as measured in
catheter days.
 Summary
P: Nurses in the Medical ICU at Carondelet T: over a six-month period I: does
demonstrating the removal of unnecessary indwelling urinary catheters C: as
compared to having no protocol O: reduce the incidence of catheter
associated urinary tract infections?
Studies and Best Practice
What we can do to fix it
Cost
Risks vs Benefits
 References
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Questions?