Catheter Associated

Urinary Tract Infections

(CAUTIs) & Urethral
Catheterizations

Outline

Introduction
Insertion
Maintenance/Sampling
Removal
Orders and Documentation

Catheter Associated
Urinary Tract
Infections (CAUTIs) &
Urethral
Catheterizations

Introduction

Catheter-Associated Urinary Tract Infection:

CAUTI

A urinary tract infection (UTI) will be defined as an infection involving any

part of the urinary system, including urethra, bladder, ureters, and kidney

Here are some important facts and statistics relating to UTIs

UTIs are the most common type of healthcare-associated infection

75% of hospital acquired UTIs are associated with a urinary catheter
12-16% of patients receive urinary catheters during their hospital stay
Prolonged use of a urinary catheter is the the most important risk factor
for developing a CAUTI

Catheters should only be used for appropriate indications and should be

removed as soon as they are no longer needed

Why all the fuss about the CAUTIs /foleys?

CAUTIs are reportable to CMS

CAUTIs are tied to reimbursement
Financial penalties are based upon:
High infection rates
Inaccurate documentation of Foley Device Days
(based off of RN documentation)

Public perception
Publicly reported
Commercial Insurers
Ex: Aetna/Anthem ask for this data

Patient safety

We want to avoid giving our Patients a HAI/HAC

(Hospital Acquired Infection/ Condition)

CAUTIs increase Length of Stay (LOS)

Estimated 0-2 additional days for a CAUTI
Costly
Average to treat a CAUTI is $896 / infection

It is a goal on HHCs balanced scorecard to decrease CAUTI rates in 2015

Hartford Healthcare: Current state at

Hartford Hospital
HH has been performing WORSE THAN EXPECTED for
CAUTIs.
HH reports ~15-20% higher Foley Device Days than like
units nationally.
CAUTI Rates at HH are well above those reported from like
units nationally.

Confidential and Proprietary Information

HHC CAUTI Analysis by Facility

Calendar Years 2013 - 2014

BARD Foley insertion gap analysis:

HH
Only 1 in 9 insertions were completed aseptically
Common areas noted for improvement:
Lack of Peri-Care prior to insertion
Not maintaining a sterile field
Gaps in drapes
Turning back to patient
Use of dirty glove to manipulate catheter prior to insertion
Trash being thrown in sterile field

Catheter Associated
Urinary Tract
Infections (CAUTIs) &
Urethral
Catheterizations

Insertion

Instructional video

Prior to continuing in this learning module, please

view the Bard Advance Foley Catheter Selection,
Insertion, Care, and Maintenance
in your online learning system (separate module).
The video will provide a detailed review of Foley
Catheter Insertion
Once video portion completed, please return here to
complete the remainder of this learning module

Indications for catheterization

In 2009, the CDC recommended a list of appropriate and
inappropriate indications for urinary catheter placement based on
critical review of literature.
Appropriate Indications
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Critically ill / unstable requiring strict I&Os

Urologic/gyn/perineal/ low rectal surgery
Kidney transplant
Lumbar/low thoracic epidural
Urinary retention / neurogenic bladder
Gross Hematuria
http://www.correntewire.com/a_foley_defined_x3
Chronic indwelling catheter
Comfort care / hospice
Orthopedic fracture prior to stabilization or planned return to OR
Incontinent patient with stage 3 or 4 perineal / sacral wound
Prolonged immobilization
Enrolled in clinical trial necessitating strict I&O monitoring

Inappropriate indications
Inappropriate Indications
1. Urine output monitoring outside the ICU for non-critical
patients
2. Incontinence without a sacral or perineal pressure sore
3. Prolonged post-operative use
4. Morbid obesity or immobility
5. Confusion or dementia
6. Patient request
7. Frequent urination

Contraindications
The only absolute contraindication to urethral catheterization is a confirmed or
suspected urethral injury

These are rare injuries

Most commonly associated with a pelvic
fracture
Blood at meatus or gross hematuria may be
warning signs of urethral injury

If any question of urethral injury,

do not place catheter!
Rectal exam by an MD and retrograde
urethrography should be considered

Indications for urology consultation:

The urethra cannot be entered due to severe
paraphimosis (the glans develops venous and
lymphatic congestion and then cannot be returned to
its normal position) or meatal stenosis (narrowing
or stenosis of the opening of the urethra).

The patient has an artificial urinary sphincter

The patient has had recent urethral, prostate,
or bladder surgery
The patient has documented history of difficult
anatomy requiring urology catheter placement
There is resistance during passage of the
catheter
The catheter kinks in the urethra and bloody
discharge is noted, urethral perforation may
have occurred. Withdraw catheter. No further
attempt should be made.

Alternatives to indwelling urinary catheters

Hourly rounding with pro-active toileting
External condom catheter or urinary pouch
Bladder scanner: confirm urinary retention before placing catheter
*should not be performed on a patient with ascites- scanner cannot differentiate the fluid types

Straight catheter for one-time, intermittent, or chronic voiding needs

Research has shown that having a constant direct route allowing bacteria to enter the urinary
tract, such as with a indwelling catheter, has a much higher risk for UTI than intermittent straight
catheterization.
Association for Professionals in Infection & Epidemiology (2008)

Bedside commode, urinal and disposable under-pads

Skin barrier spray/cream for protection

Catheter insertion best practices:

Cleaning peri-urethral area prior to start of procedure
Castile soap wipes are included in Bard Kits
As Supported by:
CDC- HICPAC CAUTI Guidelines, 2009
The Joint Commission Clinical Care Improvement Guideline for CAUTIs, 2011

Perform hand hygiene immediately before and after insertion

Insert urinary catheters using aseptic technique and sterile equipment

Choose the proper size and type of catheter

A 16 F catheter should be used
initially unless the provider order
indicates a larger size

Coud catheter
Consider using coud catheter

Male patients > 65yrs

History of BPH
Difficult catheterizations

For a coud, insert the catheter

with the tip facing up.

Male patient catheterization key points:

Retract foreskin, pull penis using light traction
Maintain taut and perpendicular during insertion
Lubricate catheter generously prior to insertion
MD order needed if using Lidocaine jelly
Hold catheter close to meatus
About an 1 inch from the tip
Inserting slowly, one inch at a time
Reduce foreskin (if applicable) to avoid paraphimosis

Lidocaine jelly

Proper position facilitates catheterization

S-shaped curve
By holding penis taut and perpendicular, the urethra
is straightened thus minimizing its S shape curve.

Key points to remember

Never inflate balloon unless there is a positive urine return
In males:
Insert catheter to the bifurcation
To ensure the balloon is securely within the bladder
In females:
Advance the catheter another 2 inches after urine is returned

If the patient complains of any pain during inflation of balloon,

STOP!!!
Deflate balloon completely and advance the catheter before reattempting to
inflate balloon.

Key points to remember

If on insertion, there is no urine return,
do not inflate balloon
The catheter may be obstructed by
lubricating jelly, attempt aspirating
through sample port or gently palpate
the bladder area

Free return of urine helps to confirm

that the catheter is properly positioned

Pretesting balloon inflation is not recommended

Research has shown that creases or

ridges remain after deflation when the
balloon was pre-inflated. This can cause
irritation to the urethra during insertion
and an increase chance of UTI.
HHC uses BARD MEDICAL catheters:

These should not be pre-inflated

Never force the catheter through the

urethra
If there is resistance during catheter insertion
Have the patient take slow, deep breaths to promote relaxation while
the catheter is inserted slowly
If resistance persists
The patient may have enlarged prostate or urinary abnormalities,
Consider a coud catheter.
If resistance persists, preventing catheter insertion:
Stop the insertion and notify the MD or LIP (licensed independent
practitioners).

Post insertion

5ml balloon inflated with 10ml of fluid

Inflation of Balloon:
Follow manufacturers instructions:
a 5 ml balloon requires 10 ml of fluid
for symmetrical inflation
Use sterile water only
Normal saline can lead to crystal
formation causing difficulty with
deflation
Documentation:
Please enter the color and amount of
urine drained upon initial insertion in the
patients MR

5ml balloon inflated with 5 ml of fluid

Catheter Associated
Urinary Tract
Infections (CAUTIs) &
Urethral
Catheterizations

Maintenance and Sampling

Maintenance of urinary catheters

Best practices include:
Minimize manipulation of system
Use a fixation device to secure the catheter
(Stat lock or leg strap) according to
manufacturers recommendation and
considering patients lower extremities ROM
(range of motion)
Please review a brief video on STAT lock application by
clicking on the link below and scrolling to video inservice:
http://www.bardmedical.com/products/urological-drainage/foley-stabili
zation/statlock%C2%AE-foley-stabilization-device/

Empty the drainage bag prior to any transport

http://www.bing.com/images/search?
q=foley+below+level+of+bladder&FORM

Maintenance of urinary catheters

Maintain unobstructed flow and dependent drainage
Keep bag below the level of bladder at all times
Focus during transport (do not place on bed)
Hang drainage bag at the foot of the bed

Keep a continuous Downhill flow of urine

Avoiding looping the tubing
Avoid resting bag on the dirty floor
Use green clip to position the tubing

Maintenance of urinary catheters

Maintain closed system of drainage
Use pre-connected catheters
Avoid using separately packaged items
Dont break the RED seal!
If breaks in aseptic technique, disconnection, or leakage occur, replace the
catheter and collecting system using aseptic technique and sterile equipment.
-Assn. for Professionals in Infection & Epidem. (2014)

Avoid irrigation!
If necessary, use aseptic technique

Avoid using
separate pieces

Maintenance of urinary catheters

Daily and PRN peri-care (including after a Bowel
movement)
Use patient pre-moistened bath wipes
Distinct & separate from the daily bath.
Wipe front to back beginning at the insertion site
moving down the catheter.
Prevent contamination of drainage spout
Drainage bag emptied at least once each shift
Use a container designated for that patient
only.

Aseptic specimen collection

Do not use hats/bed pans to collect specimens

Disinfect the sampling port with an alcohol wipe
scrub prior to collection or remove Curos cap
Collect with the approved collection device.
Place urine sample in the sterile and labeled
container Transport specimens to the lab ASAP!
Ensure specimen is received in the lab within one
hour of collection or sooner.

BARD MEDICAL
DIVISION

Coming soon!
New sampling kits are being ordered and will be
available through the storeroom
Luer lock (attaches to catheter collection port)
vacutainer collection device
Includes a yellow/red speckled top tube
(contains preservative) for UA with reflex to
culture
Grey top tube (contains a preservative) for
cultures
A specimen cup will also be available- it has a
vacutainer top that is sealed, once the seal is
removed it can be accessed aseptically to
minimize contamination for those patients who
can void into the cup. It is a needle in the top so
do not put your fingers in as it is a significant

Chronic Foley Catheters Considerations:

Do not change on a routine basis
Change only when indicated such as:
Suspected UTI
Mechanical problems (leaking or obstruction)
If concerned for possible UTI:
Change catheter prior to sending urine specimen
Send the specimen from the new catheter

Catheter Associated
Urinary Tract
Infections (CAUTIs) &
Urethral
Catheterizations

Removal

Prompt catheter removal

The best way to prevent complications is
to avoid catheterization whenever
possible

If catheterization is necessary,
Vigilant assessment for continued need
should be performed on a daily basis and
documented
Removal of catheter should be done as
early as clinically possible.

Catheter Associated
Urinary Tract
Infections (CAUTIs) &
Urethral
Catheterizations

Orders and Documentation

Foley removal
RN Driven Protocol

Providers need to identify patients appropriate for catheter removal protocol

Nurses will evaluate & document daily
If meets clinical criteria to maintain Foley catheter
For patients that no longer meet
clinical criteria, the nurse may
discontinue the Foley
Follow the post removal instructions as indicated in the orders
After Foley catheter removal:
If patient is unable to void: perform bladder scan within 6 hours

And lastly
proper documentation
MD order is required for the placement of routine or
specialty catheters (coud, 3-way, temp)
MD order required for use of Lidocaine jelly
Documentation recorded by RN should include:
Date/Time of insertion
Reason for insertion (appropriate indication)
Size and type of catheter
Characteristics of urine: Urine color/clarity and initial
volume when placed; odor if present
How patient tolerated the procedure
Any complications with insertion

Documentation drives data

For tracking CAUTIs

We need accurate Foley Device Days to
calculate our rates
Missing data
Can artificially inflate our infection rates
Electronic reports
Generated from RN documentation

Keeping our patients safe

We can:
Insert for appropriate indications
Insert aseptically
Never force in a catheter
Ensure daily care is performed
Keep the drainage bag below the bladder
Document a daily needs assessment
Use the Nurse Driven Protocol (if your facility has one)
Follow proper collection of urine specimens

Remove catheters as soon as clinically possible!

Whats next.
Completing the competency validation
This healthstream module and BARD video completion fulfills step
one of the pre-learning requirements- CONGRATULATIONS!!!
Please complete the following next steps:
Complete the short test attached to this program
Print out certificates of completion for both programs (Bard Insertion
Video and this program)
Complete the Hands-on Competency Validation session- dates to
begin in May 2015, stay tuned!