Preventing Catheter-Associated Urinary Tract Infections

Laura A. Stokowski, RN, MS

Disclosures

February 03, 2009

Adequate Nurse Staffing

Many preventable conditions, such as CAUTI, can be viewed as patient safety issues.[27,39] It is well known that inadequate nurse staffing levels jeopardize quality of care and compromise patient safety. The practices used to reduce the risk for CAUTI -- monitoring catheter use and duration, assessing patients for signs of infection, reminding physicians to remove urinary catheters, and applying strict asepsis in the management of urinary catheters -- all consume nursing time. Heavier workload contributes to poor compliance with aseptic technique.[40] Higher nurse staffing is associated with a > 30% reduction in the risk for healthcare-associated infection, and approximately 27% of all healthcare-associated infections could be eliminated if nurse-to-patient ratios were maintained at adequate levels.[41]

Nurse Education

Nurses are generally responsible not only for catheter insertion but also for ongoing catheter management and removal. It is critical, therefore, that nurses receive continuing education regarding the current evidence-based practices for preventing CAUTI.[42]

Although nurses do not make the decision to insert a urinary catheter, they may have some influence on catheter use. Requests from nurses to place a catheter for nursing convenience are not uncommon and represent a misuse of urinary catheters.[33] Therefore, education must include appropriate indications for catheter placement and the possible alternatives to indwelling catheters.

In their attempt to decrease CAUTI, and recognizing the primacy of the nurse's role in urinary catheter management, 1 hospital system completely revamped its policies and procedures related to the use of urinary catheters, making the following changes:

  • Deleting routine insertion of urinary catheters from preprinted order sets;

  • Permitting nurses to use bladder scanners to assess urinary retention without a physician's order;

  • Scanning the bladder before placing urinary catheters and after a catheter is removed before reinsertion;

  • Using daily prompts for physicians to order catheter removal and daily rounds by a clinical nurse specialist to encourage early discontinuation of urinary catheters; and

  • Instructing postanesthesia care unit nurses to attempt to remove operating room-inserted catheters before transporting the patient to the floor.[33]

A mandatory, organization-wide poster and video educational presentation prepared nurses for these changes to urinary catheters policies. This effort resulted in 548 fewer CAUTIs in the year after their intervention compared with the year preceding the intervention.[33]

All nurses caring for patients with urinary catheters require education about assessment of the need for urinary catheters, the use of bladder scanners,[43] proper insertion technique[21] (including principles of asepsis[40]), securement of urinary catheters,[44] and how to sample urine for culture.[45]

Evidence-Based Prevention Programs

At Yale-New Haven Hospital, a collaborative practice model has been in place for several years, with the aim of decreasing the overall use of urinary catheters and limiting the total number of catheter days. In the population of adults on general medical units, a physician-nurse protocol for urinary catheter management was instituted. Using a computerized order entry system, physicians could select to discontinue a catheter, maintain the catheter for 48 hours, or maintain the catheter as a long- term device. Nurses were able to independently remove urinary catheters for patients meeting established criteria. Data collected before and after the protocol was put in place revealed a 51% reduction in catheter use. Clinically significant reductions in catheter days and infection rate encouraged the hospital to continue the collaborative practice protocol.[46]

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