Indwelling Urinary Catheter

Management and CA-UTI

Prevention in NICHE Hospitals
Heidi Wald, MD, MSPH; Regina Fink, PhD, RN, AOCN,
FAAN; Heather Gilmartin, MSN, RN, CIC; Angela
Richard, MS, RN; Marie Boltz, PhD, RN, GNP-BC;
Elizabeth Capezuti, PhD, RN, FAAN

STOP
CAUT
I

Current Practice Survey

BACKGROUND

Catheter-associated Urinary
Tract Infection (CAUTI)
Single most common healthcareassociated infection (HAI), accounting for
34% of all HAIs.
Associated with significant morbidity and
excess healthcare costs.
Since 2008, CMS no longer reimburses
for additional costs required to treat
CAUTIs.

CDC Surveillance
Definition of CAUTI
A urinary tract
infection that
occurs while a
patient has an
indwelling urinary
catheter or within
48 hours of its
removal.

Source: Dennis G. Maki and Paul A. Tambyah. Engineering Out

the Risk of Infection with Urinary Catheters. Emerg Infect Dis,
Vol. 7, No. 2, March-April 2001.

Evidence-Based Guidelines
Since 2008, multiple evidence-based guidelines for
CAUTI prevention have been published
1980

CDC

1990

2000

2010

NHS
JBI
SHEA
NHS APIC
NHSN*
CDC IDSA

CDC= US Centers for Disease Control

JBI=Joanna Briggs Institute
NHS=UK National Health Service
SHEA=Society of Healthcare Epidemiologists of America
APIC=Association of Professionals of Infection Control
NHSN=CDCs National Healthcare Safety Network (*revised surveillance definition)
IDSA=Infectious Diseases Society of America

Evaluation of Practice is Key!

In light of these rapid
changes in the field,
the review of
practices, policies,
procedures, and
product use is
imperative for all
healthcare facilities.

Objectives
To understand the current state of
nursing practice in NICHE hospitals with
regard to bladder management,
indwelling urinary catheter care, and
surveillance

Current Practice Survey

METHODS

Survey Methodology
Sample: All NICHE Hospitals (n=250)
Mechanism: Email survey using Survey Monkey
sent to NICHE coordinators. Survey open for 1
month with two email reminders sent.
Stage 1: Dec, 2009: All potential STOP CAUTI
Workgroup sites
Stage 2: June, 2010: All remaining NICHE sites

Survey Topics based on

Review of Published Guidelines
Areas of interest:
1)Equipment
2)Insertion and maintenance techniques
3)Training, education, and policies
4) Documentation, surveillance, and reminders

Current Practice Survey

RESULTS

Characteristics of Hospitals
Responding to Survey
Characteristic
Bed Size (mean # beds, (range))

Response (N=75)
395 (23-1135)

Urban Setting (%)

84%

Teaching Hospital (%)

69%

Magnet Status (%)

31%

STOP CAUTI Participant (%)

27%

HAI Mandatory Reporting State (%)

61%

NICHE Hospitals Participating by State

Canada 4

3
4

MA - 3

1
1

CT - 1
NJ - 10

MD-1
VA - 3
3

1
1

N = 75

RI - 1

Current Practice Survey

RESULTS: Equipment

% of hospitals

In which populations does

your hospital use the following
indwelling catheter types?

(N=75)

What does the Evidence say

about Catheter Materials?
Antimicrobial catheter materials (versus
standard materials) for short-term
catheterization:
reduce catheter-associated bacteriuria
unproven for reduction of symptomatic CAUTI
do not substitute for a comprehensive CAUTI
prevention program.
No clear benefit among standard materials on CAUTI
rates including:
latex, hydrogel-coated latex, silicone-coated latex, or
all-silicone catheter

% of hospitals

How often are these alternatives or adjuncts

to indwelling catheters used at your hospital?

(N=75)

% of hospitals

How often does access to the following

equipment limit its use at your hospital?

N=75

*Access to female urinals limited usage

Do You Know the Evidence for

IUC Alternatives?
Condom catheters use reduces CAUTIs
and increases patient comfort
Straight catheter use reduces CAUTIs
because of reduced late infections
Bladder scanners use reduces IUC use
Securement reduces friction on urinary
tract structures

Current Practice Survey

RESULTS: Insertion and

Maintenance Techniques

% of hospitals

How often are each of the following used

when placing an indwelling catheter?

N=75

% of hospitals

How often are each of the following used

when placing an indwelling catheter?

N=75

Recommended: Aseptic
Technique During Insertion
1. Aseptic technique:
1. Donning sterile gloves
2. Use of sterile barrier
3. Perineal washing using an antiseptic
solution
4. No-touch insertion
2. Opening and using a sterile insertion kit

When an indwelling catheter is in place,

urethral meatus care is performed:
With what agents?

% of hospitals

How often?

Recommended: Meatal care should be performed with soap and

water daily and after bowel movement

Current Practice Survey

RESULTS Training,
Education, and Policies

Does your hospital have a

policy/procedure on indwelling urinary
catheter placement, management, and/or
prevention of CAUTI?
Among a subset of
policies reviewed:
40% were > 2 years
old
25% used Lippincott
or Delmars texts
Evidence-based
Ranged - 1994-2009
N=75

Policy and Procedure

Components
Appropriate catheter indication (50%)
CAUTI S&S assessment parameters (20%)
Bladder scanner parameters (20%)
Insertion technique parameters were discussed
but varied by hospital
Sterile closed system reinforced (70%)
Urine specimen procedure outlined (65%)
Lack of discussion
Emptying urinary bag (50%)
Meatal care frequency and agent used (50%)

Who is responsible for insertion

of indwelling urinary catheters?

N=75

Training and Validation

Initial Training of Staff

N=75
Annual validation
on aseptic
technique occurs
at ~47% of
hospitals

CDC Education
Recommendations
Ensure that only properly trained persons who know
the correct technique of aseptic catheter insertion and
maintenance are given this responsibility. (Category
IB)
Ensure that healthcare personnel who take care of
catheters are given periodic training regarding
techniques and procedures for insertion, maintenance
and removal. Includes: CAUTI, other complications of
catheters, alternatives. (Category 1B)

Provision of Patient/Family
Educational Materials
Type of material

N =75

Micromedex Notes
Discharge Instructions
Self-cath instruction
S&S infection
Care and maintenance

Current Practice Survey

RESULTS Documentation
and Surveillance

How is urinary output and catheter

care management documented on
your primary unit?

N=75

Which of the following aspects of urinary

output and catheter care management are
routinely documented on your primary unit?

N=75

CDC Documentation
Recommendations
Consider documenting the following:
indication, date and time of insertion,
who inserted, date and time of removal
(Category II)
Ensure that documentation is accessible
and in standard format. Searchable
electronic documentation is preferable.
(Category II)

Does your hospital have a system to remind

providers to remove indwelling catheters?
Nurse driven protocol to
discontinue (40%)
Paper reminders (36%)
Electronic reminders (37%)
Nurse led catheter rounds
(35%)
Other

N=75

Stickers on MD orders and

medical records
ICUs have prompt on daily
goal sheet
Electronic Stop Orders

Recommended strategies for

reducing catheter use and duration
(Category 1B)
System of alerts or reminders
Guidelines and protocols for nurse-directed
removal
Education and performance feedback
Guidelines for perioperative use
Protocols for management of postoperative
urinary retention

Do your infection practitioners perform

routine surveillance for CAUTIs?
Where is surveillance
conducted?
House-wide (64%)
ICU only (13%)
Did not answer or did not
know (13%)
NA (9%)

Catheter days are collected

All units (51%)
Selected units (35%)
Not done (14%)

N=75

CDC Surveillance
Recommendations
Consider surveillance for CAUTI when indicated by
facility-based risk assessment. (Category II)
Use standardized methodology for performing CAUTI
surveillance (includes measures of catheter-days)
(Category 1B)
Routine screening of catheterized patients for
asymptomatic bacteriuria is not recommended (Category
II)
Consider providing regular feedback of unit-specific
CAUTI rates to nursing staff. (Category II)

Summary
NICHE hospitals are implementing many
evidence-based CAUTI strategies
Evidence-based insertion and maintenance
CAUTI education
CAUTI QI projects

NICHE hospitals can improve upon

Use of stop orders and reminders
Use of alternatives to IUCs
Documentation and surveillance

Implications for CAUTI

Prevention in NICHE hospitals
Translate research into practice
Incorporate into policies and procedures
Regular educational updates
Implement system-wide standards for documentation
and surveillance
Examine products and availability in practice settings
Maximize catheter avoidance and early removals
When feasible, use multicomponent interventions

Current Practice Survey

ACKNOWLEDGEMENTS

Current Practice Survey

Participants
All 75 NICHE Coordinators responding
to the survey
The 20 dedicated STOP CAUTI
Workgroup NICHE Coordinators and
site Principal Investigators.

STOP CAUTI Funders

Primary funder: the Agency for Healthcare
Research and Quality (AHRQ), U.S.
Department of Health and Human Services (
http://www.ahrq.gov)
Dr. Walds time also funded by the National
Institute on Aging, U.S. National Institutes of
Health (http://www.nia.nih.gov)

The STOP CAUTI Project Team

University of Colorado Denver
- Heidi Wald, MD, MSPH, Principal Investigator
- Regina Fink, PhD, RN, AOCN, FAAN; Research
Scientist
- Angela Richard, MS, RN, Project Manager
- Brian Bandle, BS, Database manager
NICHE
- Elizabeth Capezuti, PhD, RN, FAAN, Co-Investigator
- Marie Boltz, PhD, RN, GNP-BC, Practice Director
- Nina Shabbat, BA, Benchmarking Assistant

What are the goals of the

STOP CAUTI study?
To understand care practices associated with
indwelling catheters at NICHE hospitals.
To disseminate an electronic method for tracking
CAUTIs and catheter duration.
To determine the effect of the feedback of these
data on processes of care (catheter duration)
and outcomes (CAUTIs).

For More Information:

http://www.ucdenver.edu/academics/colle
ges/medicalschool/departments/medicine/h
cpr/cauti/Pages/default.aspx

Current Practice Survey

THANK YOU!