Preventing Catheter-Associated Urinary Tract Infections

Laura A. Stokowski, RN, MS

Disclosures

February 03, 2009

Prevention of CAUTI

Preventing CAUTI used to be a relatively low priority in acute-care hospitals.[17] However, the CMS regulation that went into effect on October 1, 2008, ending reimbursement for CAUTI, has spurred hospitals into action. Many hospitals are now facing the challenge of implementing practices to prevent healthcare-acquired CAUTI. In a recent survey, Saint and colleagues[17] found that no single strategy was widely used across hospitals to prevent these infections. More than 50% of hospitals did not monitor which patients had urinary catheters, or the duration of catheter use. Providers often fail to document the indications for or placement of urinary catheters.[18]

Nurses are responsible for most management of indwelling urinary catheters.[11] Handwashing is the first and most important preventive measure. Although not all catheter-associated urinary tract infections can be prevented, it is believed that a large number could be avoided by properly managing indwelling catheters. The problem is that urinary catheters are quite common, and colonization is inevitable, leading some nurses to believe that nothing can be done to prevent CAUTI, a phenomenon known as "catheter apathy."[19]

The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) have developed joint guidelines for the prevention of CAUTI. These practical recommendations, designed to help acute-care hospitals prioritize and implement CAUTI prevention efforts, fall under the categories of infrastructure, surveillance, education and training, insertion technique, and accountability.[1] The guidelines also include practices that, on the basis of available evidence, should not be routine in the prevention of CAUTI. A selection of the prevention recommendations is described below; the interested reader can find the complete list of recommendations here.

Develop Organizational Guidelines for Urinary Catheters

Each facility should have written guidelines on the use, insertion, and maintenance of urinary catheters. These guidelines should specify the indications for urinary catheters and restrict their use to patients with appropriate indications.[18] Guidelines must also delineate who is qualified and trained to insert urinary catheters because only properly trained personnel should perform this procedure. A system for documentation of insertion and removal of urinary catheters should be implemented.

Guidelines should also specify how catheter duration is monitored, and how data are collected to determine rates of symptomatic CAUTI. Some hospitals have found it helpful to develop daily checklists to monitor the duration of and need for a catheter, and decision-making algorithms to evaluate continuing indications for catheter use.[20]

Follow Proper Insertion and Management Techniques

Urinary catheters should be inserted aseptically, using barrier precautions such as sterile gloves, drape, sponges, antiseptic solution, and single-use packets of sterile lubricant. A catheter as small and as soft as possible should be used to minimize urethral trauma, while still permitting proper drainage.[21]

Appropriate management begins with correctly securing the catheter to prevent movement of the catheter and traction forces on the catheter. "Securement should be a standard of care," argues Gray. There are few data on the benefit of catheter securement devices in reducing colonization and infection. One study, by Darouiche and colleagues,[22] compared the effect of a catheter securement device (StatLock®) with other methods of securement or no securement, on the occurrence of symptomatic CAUTI. Although no statistically significant differences were found, the investigators documented a clinically significant 45% reduction in the rate of symptomatic UTI in patients who received the securing device. Gray suggests that the best place to secure a urinary catheter is at the Y-port, because the catheter is more rigid at this point.

A closed drainage system should be used, and urine flow must be unobstructed (eg, make sure patient is not sitting or lying on the tubing). Maintaining a closed system requires that the catheter and drainage tube are not disconnected unless absolutely necessary. The catheter-tubing junction should be cleansed with antiseptic solution before it is disconnected to replace the collecting system.

The collection bag is positioned below the level of the patient's bladder, but not resting on the floor. The collection bag should be emptied regularly, protecting the spigot from contamination. The type of drainage system does not seem to influence the development of infection. A comparison of 2 drainage systems found no difference in the rate of bacteriuria between a complex closed drainage system and a 2-chamber drainage system in hospitalized patients.[23] However, in vitro testing of collection systems with a single or double nonreturn valve (NRV) revealed that the double NRV system prolonged the time to bladder colonization.[24] The NRV is a check valve that prevents or reduces the backflow of urine.

Reduce Unnecessary Catheter Use

Although precise numbers are not available, it is believed that as many as 1 in 4 hospitalized patients receive an indwelling urinary catheter.[25] Further, it has been estimated that up to 50% of these urinary catheters are unnecessarily placed.[26] An even higher rate of urinary catheter use has been documented in the perioperative period; as many as 86% of patients undergoing major surgery have urinary catheters, and half of these catheters remain in place for more than 2 days.[27] These patients are twice as likely to develop CAUTI, an event that can complicate the assessment of other postoperative infections.[27]

Limiting catheter use and, when a catheter is indicated, minimizing the duration the catheter remains in place are primary strategies for CAUTI prevention. The SHEA/IDSA guidelines recommend that other methods for urinary management, such as condom catheters or in-and-out catheterization, should be considered before indwelling catheters are used.[1] In males requiring a urine collection device, the condom catheter is an alternative to the indwelling catheter. Not only are condom catheters more comfortable, but their use is associated with lower rates of bacteriuria and symptomatic UTI in male patients without dementia.[28] Suprapubic catheters, percutaneously inserted, are also associated with a lower incidence of bacteriuria but are more invasive.[29]

Portable bladder ultrasound scanners accurately measure even relatively small urine volumes.[30] These devices may reduce the need for urinary catheterization to assess residual urine volume. Fewer catheterizations, even in-and-out catheterizations, mean fewer chances to introduce bacteria to the urinary tract. One hospital reduced its rate of CAUTI by 30% to 50% over a 12-month period by using portable bladder scanners.[31] Data reveal that about 30% of US hospitals use this technology.[17]

By a large margin, the highest percentage of urinary catheters are placed in the emergency department (ED).[32,33] Documentation of the reason for catheter placement in the ED is poor, and a physician's order is frequently lacking.[32] Gokula and colleagues[32] evaluated a urinary catheter indication intervention in the ED, consisting of an educational program for physicians and nurses and a urinary catheter indication sheet designed to guide appropriate use of urinary catheters. Physicians were required to select an indication from a list of 8 approved indications established by expert consensus. These interventions increased appropriate use of catheters, as well as physician orders for urinary catheters. The total number of catheters placed in the ED decreased after the intervention.[32]

Remove Urinary Catheters Promptly

An organization-wide program should identify catheters that are no longer necessary, and ensure their prompt removal. SHEA/IDSA recommends daily review of the necessity of continuing each urinary catheter. Cues to evaluate catheter necessity may take the form of automatic stop orders, standardized reminders in the patient record, or daily ward catheter rounds.

A measure as simple as daily reminders from nurses to physicians to remove urinary catheters that are no longer necessary can reduce the duration of catheter use and, therefore, the infection rate.[34] Huang and colleagues[35] tested the effectiveness of nurse-generated reminders to physicians to remove catheters 5 days after insertion, and they were able to reduce catheter duration from a mean of 7 to a mean of 4.6 days, lowering their CAUTI rate by about 25%. Others have taken advantage of electronic medical records and computerized physician order entry to automatically generate a computer reminder 3 days after catheter placement, reducing the duration of catheterization by a mean of 3 days.[36] Despite these promising results, fewer than 10% of US hospitals have applied the preventive strategy of urinary catheter reminders.

Fakih and colleagues,[37] used a nurse-led multidisciplinary approach to evaluate the continued need for urinary catheters and found that it significantly reduced unnecessary urinary catheter use. In this study, a specially trained nurse and member of a multidisciplinary team evaluated each hospitalized patient daily for the presence and appropriateness of indwelling urinary catheters. When a catheterized patient was determined to have no continuing indication for the catheter, the nurse requested the attending physician to order removal of the catheter. This intervention reduced by 45% the number of unneeded catheters. Topal and colleagues[38] combined technology using prompts in the computerized order entry system and handheld bladder scanners, with staff education and nurse empowerment to remove urinary catheters more promptly. This combination of interventions led to an 81% reduction in urinary catheter use and a 73% reduction in hospital-acquired CAUTI.

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