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Overview

Health care- associated infections (HAIs) have received incresing scrutiny over the last decase and are now widely recognized as largely preventable adverse events related to medical care.  CAUTIs are the single most common HAI, accounting for 34% of all HAIs (Klevens et al., 2007) and associated with significant morbidity and excess health care costs (Saint, 2000). CAUTI is disproportionately reported amount older adults (Fakih et al, 2010). Although once largely overlooked as part of the price of doing business in hospitals, a significantly changed regulatory environment has emerged that will bring increased scrutiny to HAIs, in general and CAUTIs in particular.  Examples of this oversight include process and outcome measurement and reporting and financial incentives to improve these measures.  Since 2008, the Centers for Medicare and Medicaid Services (CMS) no longer reimburses for additional costs required to treat hospital- acquired urinary tract infections (UTIs; CMS, Department of Health and Human Services {DHHS}, 2007).  Long-term care facilities also follow CMS regulatory guidance and their federal regulations (F-315 Tag) mandate that IUC use must be medically justified and care rendered to reduce infection risk in all residents with or without an IUC (CNS, DHHS, 2005).  Enhanced public reporting  and financial incentives figure prominently in the Patient Protection and Affordable Care Act of 2010; HAIs are singled out for inclusion in both types of intiatives (Patient Proteition and Affordable Care Act, 2010).  Therefore, it is imperative that health care professional staff in various settings develop strategies and interventions to reduce IUC duration and prevent CAUTIs, thus benefitting both patient and financial outcomes. 

Nursing Standard of Practice Protocol: Prevention of Catheter-Associated Urinary Tract Infection Prevention 

Annemarie Dowling-Castronovo and Christine Bradway

The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:
I. GOALS: To ensure that nurses in acute care are able to:

A.   Define catheter-associated urinary tract infection (CAUTI)
B.    Understand the epidemiology of CAUTI
C.   Define indications for indwelling urinary catheters (IUC)
D.   Identify   evidence-based   strategies   and   interventions   for   the   prevention   of
CAUTI
E.    Understand  how  to  engage  an  interdisciplinary  team  in  the  management  of
CAUTIs in your setting

II. OVERVIEW

A.   CAUTIs   are   the   single   most   common   hospital-acquired   infection   (HAI),
accounting for 34% of all HAIs and associated with significant morbidity and
excess health care costs.
B.    Since 2008, the Centers for Medicare and Medicaid Services (CMS) no longer
reimburse for additional costs required to treat nosocomial urinary tract infec-
tions (UTIs).
C.   Between 2008 and 2010, at least six evidence-based practice strategies, recom-
mendations,  and/or  guidelines  for  preventing  CAUTI  in  hospitals  and  long-
term care have been published.
D.   In light of these rapid changes in the field, the review of policies, procedures,
practices, and products is imperative for all health care facilities.

III. BACKGROUND AND STATEMENT OF PROBLEM

A.   Introduction

1.   There  are  more  than  500,000  UTIs  in  the  United  States  annually.  At  a
mean  cost  of  $589  per  episode,  this  epidemic  results  in  $250  million  of
excess health care costs each year.
2.   Most UTIs are associated with the ubiquitous IUC, also known as a Foley
catheter.
3.   According to the Infectious Diseases Society of America, 21%–54% of all
IUCs are inappropriately placed and are not medically indicated.

B.    Definitions

1.   Symptomatic UTI. A patient has at least one of the following signs or symp-
toms with no other recognized cause: fever (higher than 38 °C), urgency,
frequency, dysuria, or suprapubic tenderness and positive urine culture (see
Table 19.1).
2.   Asymptomatic bacteriuria. A positive urine culture in a patient who does not
have symptoms referable to the urinary tract; may or may not be catheter-
associated.
3.   CAUTI.  A  symptomatic  UTI  that  occurs  while  a  patient  has  an  IUC  or
within 48 hours of its removal.

C.   Essential Elements

1.   The urinary tract is normally a sterile body site. In the presence of an IUC,
microorganisms can gain access to the urinary tract on either the extralu-
minal  surface  of  the  IUC  or  intraluminal  surface  through  breaks  in  the
catheter system.
2.   Once  bacteria  gain  access  to  the  urinary  tract,  microorganisms  can  thrive
in  a  “biofilm”  layer  on  either  the  extraluminal  or  intraluminal  surface  of
the IUC.
3.   Because  the  formation  of  a  biofilm  and  colonization  with  bacteria  takes
time,  most  CAUTI  occurs  after  48  hours  of  catheterization  and  increases
approximately 5% per day.
4.   The  mechanisms  described  previously  provide  the  rationale  for  evidence-
based care of IUCs. Four potential opportunities for intervention include
the following:

a.    Avoid the use of catheters
b.   Evidence-based care practices and product selection
c.    Timely removal
d.   Education and surveillance

IV. ASSESSMENT OF CAUTI

A.    The Centers for Disease Control and Prevention (CDC) has developed explicit
surveillance criteria for CAUTI. In brief, the patient must have the following:

1.   A  positive  urine  culture  (see  Table  19.1)  sent  more  than  48  hours  after
admission to the health care facility
2.   An IUC at the time of or within 48 hours prior to the culture
3.   One of the following: suprapubic tenderness, costovertebral angle pain or
tenderness, or a fever higher than 38 °C without another recognized cause;
or a positive blood culture with the same organism as in the urine

B.    Measures

1.   Outcomes

a.    CAUTIs/1,000 catheter days

2.   Processes

a.    Catheter days and hospital days
b.   Postoperative catheter days and patient days
c.    Proportion   of   catheterized   and   admitted   patients   from   emergency
department (ED) or operating room (OR)

C.   Indications for IUCs can be operationalized using algorithms or protocols.

V. NURSING CARE STRATEGIES
Twenty  percent  to  69%  of  CAUTIs  are  preventable  through  the  application  of  evi-
dence-based care strategies.

A.   Catheter Avoidance

1.   Established insertion guidelines for ED and OR
2.   Alternative strategies to manage urine output available:

a.    Bedside commodes
b.   Condom catheters
c.    Moisture-wicking incontinence pads
d.   Intermittent straight catheterization
e.    Bladder scanner for monitoring and assessment
f.    Bedpans and urinals that are functional

3.   Toileting schedules and frequent nursing rounds

B.    Product Selection and Routine Care

1.   Catheter material is controversial:

a.    Antimicrobial  catheter  materials  have  been  shown  to  reduce  catheter-
associated   bacteriuria   (colonization),   but   impact   on   prevention   of
symptomatic CAUTIs during short-term insertions is unproven.
b.   There is insufficient evidence to determine whether selection of a latex
catheter,  hydrogel-coated  latex  catheter,  silicone-coated  latex  catheter,
or all-silicone catheter influences CAUTI risk.

2.   Select the smallest size possible (less than 18 French).
3.   Use aseptic technique and sterile product during catheter insertion.
4.   Routine  urethral  meatus  cleansing  with  soap  and  water  during  bath  and
after bowel movement.
5.   Secure catheter to leg.
6.   Maintain a closed system at all times.
7.   Keep drainage bag below level of bladder.
8.   Empty the bag when two-third full and before transport.

C.   Timely Removal

1.   Systems  that  prompt  providers  to  review  the  need  for  the  catheter  and
encourage early removal. Examples include stop orders and reminder sys-
tems:  audit  and  feedback,  nurse-prompted  reminders,  and  nurse-driven
removal protocols.
2.   Measure  of  removal:  Surgical  Care  Improvement  Project  (SCIP),  SCIP-9
measure; catheter removal on postoperative Day 1 or 2.

D.   Surveillance and Education

1.   Measurement of processes and outcomes.
2.   Ongoing  system  evaluation,  nursing  reeducation,  practice  reminders,  and
public reporting of unit-based CAUTI rate data are strategies to inform the
health care team of current practice outcomes and effectiveness of CAUTI
prevention strategies.

VI. EVALUATION AND EXPECTED OUTCOMES

A.   Plan of Care

1.   Assessment that patient meets established insertion criteria
2.   Adherence to prompts for early catheter removal
3.   Standardized catheter care guidelines followed

B.    Documentation

1.   Dates of insertion and removal
2.   Type of catheter (new indwelling, chronic indwelling, reinsertion, change
of device)
3.   Reason for catheter insertion
4.   Justification that catheter is still necessary
5.   Post  residual  void  after  catheter  removal  if  patient  is  unable  to  void  in
6–8 hours; bladder volume; intervention.

C.   Catheter Utilization

1.   Monitor unit-specific CAUTI rates.
2.   Monitor average catheter duration (catheter days).
3.   Monitor SCIP postoperative catheter removal on catheterization Day 1 or 2.
4.   Trend unit-specific IUC usag

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