3ObjectivesIdentify mandates, clinical & regulatory for monitoring and preventing CAUTIReview the surveillance definitions and criteria for CAUTIDiscuss strategies institutions can utilize to reduce the risk for the development of CAUTI
4Issues Associated with Urinary Catheters – Clinical Mandate Discomfort to the patientLimit mobilityProlonged hospital stayIncreased cost and mortality
5The Burden of HAIEach year million Americans (5-10% of hospitalized patients) acquire at least one infection while hospitalizedthousand die of those infectionsOne third of these are believed preventableConservatively HAI cost $33 billion each year
6The Burden of CAUTIUrinary tract – most common site of healthcare associated infections; most are associated with urinary catheterization% of inpatients are catheterized80% of hospital associated UTIs caused by a urinary catheter
7The Burden of CAUTI CAUTI cost $500 – $1000 - $2,800 if bacteremia Most CAUTIs are asymptomatic bacteriuria, 1-5% lead to secondary bacteremia5% of all deaths from HAI are urinary catheter associated.
8The Burden of HAICAUTI are the most common HAI accounting for about 30%Each year more than 13,000 deaths are associated with UTI Klevens RM, Edwards JR, et al. Estimating health care-associated infections and deaths in U. S hospitals, Public Health Reports 2007: 122:
9The Burden of HAIThe good news is that many CAUTIs may be prevented with recommended infection control measures.Up to 380,000 infections and 9000 deaths related to CAUTI per year could be preventedUmscheid et al. Infec Control & Hospital Epidemiology 2011; Scott, 2009
10The Burden of CAUTIProper management and use of catheters could prevent infectionsStudy in Lansing, MI: Less than half of urinary catheters in teaching hospital were indicated.Am J Infect Control Jun;32(4): Inappropriate use of urinary catheters in elderlypatients at a midwestern community teaching hospital.Gokula RR, Hickner JA, Smith MA.Urinary catheters are uncomfortable, limit mobility
11The Burden of CAUTIVirtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tractCAUTI can lead to complications
12Complications of CAUTI CystitisPyelonephritisGram-negative bacteremiaProstatitisEpididymitisOrchitis in males
13Complications of CAUTI EndocarditisVertebral osteomyelitisSeptic arthritisEndophthalmitisMeningitis
14Regulatory Mandate The Joint Commission NSPG 07.06.01 CMS Value Based PurchasingCMS Inpatient Quality Reporting ProgramGoalsTo eliminate and sustain reductions in CAUTI
15Regulatory Mandate Mandatory Reporting through NHSN Denial of CMS dollar reimbursement Core MeasuresCAUTI must be included in monthly NHSNNY Partnership for PatientsTo reduce unnecessary catheter utilizationTo eliminate preventable catheter-associated urinary tract infections
16Centers for Medicare & Medicaid (CMS) As of Oct CMS will no longer reimburse hospitals for eight “reasonably preventable” conditions.Included are CAUTI and hospital acquired pressure ulcers.Reimbursement to the hospital for care of these patients will be decreased.
17CMS Requirement – Pay for Reporting CMS 2012 IPPS Final Rule Report by the following facility/institution:Acute Care Hospitals: Adult and Pediatric ICUsJanuary 2011Long Term Care Hospitals: All inpatient locationOctober 2012Inpatient Rehabilitation Facilities: All inpatient locations
18Monthly Reporting - NHSN Report CAUTI indentified by surveillanceIndicate NO CAUTI detected for specific locationReport total device days for specific locationReport total patient days in specific location
19The Joint CommissionNPSG Implement evidence based practices to prevent CAUTI (2012 = Planning year; by January 2013 = full implementation)
20The Joint CommissionEPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following:Limiting use & duration to situation necessary for patient careUsing aseptic techniques for site preparation, equipment & suppliesEPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following:Securing catheters for unobstructed urine flow & drainageMaintaining the sterility of the urine collection systemReplacing the urine collection system when requiredCollecting urine samples
21The Joint CommissionEPI 4 Measure & monitor catheter associated urinary tract infection prevention processes & outcomes in high-volume areas by doing the following:Selecting measures using evidence based guidelines or best practicesMonitoring compliance with evidence-based guidelines or best practicesEvaluating the effectiveness of prevention efforts
22GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 Carolyn V. Gould, MD, MSCR 1; Craig A. Umscheid, MD, MSCE 2; Rajender K. Agarwal, MD, MPH 2; Gretchen Kuntz, MSW, MSLIS 2; David A. Pegues, MD 3 and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
23Modified HICPAC Categorization Scheme for Recommendations Category IAA strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harmsCategory IBA strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (e.g., aseptic technique) supported by low to very low quality evidenceCategory ICA strong recommendation required by state or federal regulation.Category IIA weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harmsNo recommendation/unresolved issueUnresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
24Need for Urinary Catheterization 1A.1. Use urinary catheters in operative patients only as necessary, rather than routinely. (Category IB)1A.2. Avoid use of urinary catheters in patients and nursing home residents for management of incontinence. (Category IB)
25Need for Urinary Catheterization 1A.2.a. Further research is needed on periodic (e.g., nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown. (No recommendation/unresolved issue)1A.3. Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction. (No recommendation/unresolved issue)
26Need for Urinary Catheterization 1A.4. Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients. (Category II)1A.5. Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration. (Category II)
27Risk Factors for CAUTI1B.2. Insert catheters only for appropriate indications, and leave in place only as long as needed. (Category IB)1B.3. Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for CAUTI such as women, the elderly, and patients with impaired immunity. (Category IB)
28Risk Factors for CAUTI1B.4. Ensure that only properly trained persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Category IB)1B.5. Maintain unobstructed urine flow. (Category IB)
29Population at Highest Risk of Mortality 1C.1. Minimize urinary catheter use and duration in all patients, particularly those who may be at higher risk for mortality due to catheterization, such as the elderly and patients with severe illness. (Category IB)
30Risks & Benefits Different Approaches 2A.1. Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction. (Category II)2A.2. Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. (Category II)
31Risks & Benefits Different Approaches 2A.3. If intermittent catheterization is used, perform it at regular intervals to prevent bladder over-distension. (Category IB)2A.4. For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use. (Category IB)
32Risks & Benefits Different Approaches 2A.5. Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization, particularly with respect to complications related to catheter insertion or the catheter site.(No recommendation/unresolved issue)
33Risks & Benefits Different Approaches 2A.6. In the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization. (Category IA)
34Risk & Benefits Collecting Systems 2B.1. If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI, consider using antimicrobial/antiseptic-impregnated catheters. The comprehensive strategy should include, at a minimum, the high priority recommendations for urinary catheter use, aseptic insertion, and maintenance (Category IB)
35Risk & Benefits Collecting Systems 2B.1.a. Further research is needed on the effect of antimicrobial/antiseptic-impregnated catheters in reducing the risk of symptomatic UTI, their inclusion among the primary interventions, and the patient populations most likely to benefit from these catheters.(No recommendation/unresolved issue)
36Risk & Benefits Collecting Systems 2B.2. Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization. (Category II)2B.3. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. (Category IB)2B.4. Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use. (Category II)
37Risk & Benefits Collecting Systems 2B.5. Urinary catheter systems with pre-connected, sealed catheter-tubing junctions are suggested for use. (Category II)2B.6. Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications.(No recommendation/unresolved issue)
38Risk & Benefits Catheter Management 2C.1. Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery), do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization. (Category IB)2C.2.a. Further research is needed on the use of urinary antiseptics (e.g., methanamine) to prevent UTI in patients requiring short-term catheterization. (No recommendation/unresolved issue)
39Risk & Benefits Catheter Management 2C.2.b. Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction. (No recommendation/unresolved issue)2C.3.a. Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery), bladder irrigation is not recommended. (Category II)2C.3.b. Routine irrigation of the bladder with antimicrobials is not recommended. (Category II)
40Risk & Benefits Catheter Management 2C.4. Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended. (Category II)2C.5.a. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing)
41Risk & Benefits Catheter Management 2C.5.b. Further research is needed on the use of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to catheter insertion. (No recommendation/unresolved issue)2C.6. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, catheters and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II)
42Risk & Benefits Catheter Management 2C.7.a. Use a sterile, single-use packet of lubricant jelly for catheter insertion.(Category IB)2C.7.b. Routine use of antiseptic lubricants is not necessary. (Category II)2C.8. Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization.(No recommendation/unresolved issue)
43Risk & Benefits Catheter Management 2C.9. Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization. (No recommendation/unresolved issue)2C.10.a. Clamping indwelling catheters prior to removal is not necessary. (Category II)2C.10.b. Insert catheters only for appropriate indications, and leave in place only as long as needed. (Category IB)
44Risk & Benefits Catheter Management 2C.10.c. For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use. (Category IB)2C.11.a. Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions. (Category II)
45Risk & Benefits Catheter Management 2C.11.b. Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output.(No recommendation/unresolved issue)
46Risk & Benefits System Interventions 2D.1.a. Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion, maintenance, and removal. (Category IB)2D.1.b. Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment. (Category IB)
47Risk & Benefits System Interventions 2D.2. Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended. (Category II)2D.3. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device. (Category IB)
48Risk & Benefits System Interventions 2D.5. Maintain unobstructed urine flow. (Category IB)2D.6. Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems. (No recommendation/unresolved issue)2D.7. When performing surveillance for CAUTI, consider providing regular (e.g., quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff. (Category II)
49Indication for Urinary Catheter Urinary Tract Obstruction and Neurogenic BladderUrologic Study/SurgeryUrine monitoring in critically ill patientsAssistance in pressure ulcer management for incontinent patientsException – Patient request to improve comfort
50NOT Indications for Urinary Catheter IncontinenceImmobilityPatient/Staff ConvenienceObtaining Periodic Urine Specimens
51Urinary Catheter Insertion Kit Sterile glovesSterile drapesSite cleaning suppliesSterile lubricantSterile catheter attached to drainage bag (seal)Hand Hygiene & Aseptic Technique
52CAUTI Insertion Bundle Avoid unnecessary urinary catheters; insert urinary catheters in the presence of an appropriate indicationPeri-operative use for selected surgical proceduresUrine output monitoring in critically ill patientsManaging acute urinary retention and urinary obstructionAssisting with pressure ulcer healing for incontinent patientsAs an exception, at patient request to improve comfort
53CAUTI Maintenance Bundle Maintain urinary catheters based on recommended guidelines:Tamper-evident seal is intactCollection bag is not on the floorCollection bag is secured to the legEvery patient with a catheter has a labeled urine collection container at the bedsideReview urinary catheter necessity daily and remove promptly
54UTI Prevention Risk of CAUTI is 5% per day catheter is in situ Increases to 25% after 1 week in situIncreases to 100% after 1 month in situ
56Point Prevalence Study # of patients with urinary catheters# of patients at a point in timeX 100
57Point Prevalence Study 11/15/2011 Nursing Care UnitTotal PatientsFoley Catheters IndwellingFoley Catheter Utilization RateMICU`10550%L&D1100%NS72128%CTICU42CCU617%PACUNS623312%NS61346%NS8121314%CPCU383%TOTAL16122
58Point Prevalence Study 5/17/2012 UNITCENSUS# WITH DEVICEPREVELANCE RATEED ADULT17ED PED4NS3113215.4%NS3220NS24944.4%NS26633.3%NS331060%NS42NS43NS61287.1%NS623312.1%NS71/732114.8%70871525%NS7214NS74NS81414.9%TOTAL2502510%
59Point Prevalence Study 11/15/2011 UnitObservations% with Securement% Seal Intact% Below level of bladder% Not touching floorMSICU560%0%100%L &D1NS72CTICU250%CCUPACUNS62475%NS611005Ns81367%CPCUOverall2273%41%
61DEFINITION Healthcare – Associated Infection (HAI) A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that:Occur in a patient in a healthcare setting andWas not present or incubating at the time of admission, unless the infection was related to a previous admission
62DEFINITION Indwelling Catheter A drainage tube that is inserted into the urinary bladder through the urethra, is left connected to a closed collection system.Also called a Foley catheterDoes not include (among others):Straight in and out cathetersSuprapubic cathetersNephrostomy tubes
63CAUTI DefinitionA UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset.NOTE: There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
64DefinitionLocation CAUTIs are attributed to inpatient location at time of urine collection or symptom onset, whichever comes first. Exception: If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility, the infection is attributed to the transferring location (Transfer Rule).
65DEFINITION This CAUTI is attributed to the SICU Transfer Rule: Mr. Smith is transferred from SICU with aFoley and 36 hours after transfer has a fever of38.20C. The next day a urine culture collectedhas >105 CFU/ml of E. coli.This CAUTI is attributed to the SICU
66Definition There are two criteria than can be applied for identifying a CAUTISymptomatic UTI (SUTI)Asymptomatic Bacteremic UTI (ABUTI)NOTE: The specific site “Other Urinary Tract Infection” (OUTI) can also be used to identify an infection in the urinary tract, however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events.
67CRITERIA Symptomatic UTI - SUTI 1a 1a . Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause: fever (>380C), suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urine culture of ≥ 105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms.
68CRITERIA Symptomatic UTI - SUTI 1a OR Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause: fever (>380C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms
69CRITERIA Symptomatic UTI SUTI 2a 2a. Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause: fever (>380C), suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings:Positive dipstick for leukocyte esterase and/or nitritePyuria (urine specimen with ≥ 10 white blood [WBC]/mm3 of unspun urine or ≥3 WBC/high power field of spun urine)Microorganisms seen on Gram stain of unspun urine anda positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms.
70CRITERIA Symptomatic UTI SUTI 2a ORPatient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause: fever (>380C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings:Positive dipstick for leukocyte esterase and/or nitritePyuria (urine specimen with ≥ 10 white blood [WBC]/mm3 of unspun urine or ≥3 WBC/high power field of spun urine)Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms.
71Symptomatic UTI 3 & 4 (≤ 1 year old) Patient ≤ 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause: fever (>380C core), hypothermia (<360C core), apnea, bradycardia, dysuria, lethargy, or vomiting and a positive urine culture of ≥ 105 CFU/ml with no more than 2 species of microorganisms.
72Symptomatic UTI 3 & 4 (≤ 1 year old) 4. Patient ≤ 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause: fever (>380C core), hypothermia (<360C core), apnea, bradycardia, dysuria, lethargy, or vomiting and a positive urinalysis demonstrated by at least one of the following findings:Positive dipstick for leukocyte esterase and/or nitritePyuria (urine specimen with ≥ 10 white blood [WBC]/mm3 of unspun urine or ≥3 WBC/high power field of spun urine)Microorganisms seen on Gram stain of unspun urine anda positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms.
73Asymptomatic Bacteremic UTI (ABUTI) Patient with or without an indwelling urinary catheter with no signs or symptoms (i.e., for any age patient, no fever (>380C ), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness, OR hypothermia (<360C core), apnea, bradycardia, dysuria, lethargy, or vomiting) and a positive urine culture of > 105 CFU/ml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture, or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant.Note: All ABUTIs will have a secondary bloodstream infection
74Asymptomatic Bacteremic UTI (ABUTI) Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus spp., yeasts, beta hemolytic Streptococcus spp., Enterococcus spp., G. Vaginalis, Aerococcus urinae, and Corynebacterium (urease positive).Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C. urealyticum (CORUR) if so speciated.The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)Note: All ABUTIs will have a secondary bloodstream infection
75Case 150 year old, end stage pancreatic cancer, liver & bone mets admitted with advance directive for comfort care & antibiotics only; foley catheter, peripheral IV & nasal cannula insertedDay 4: patient is febrile to 38.0°C & has suprapubic tenderness; IV ampicillin started after urine obtained for cultureDay 5: difficulty breathing; CXR = infiltrate L lung baseDay 6: urine culture results = 105 CFU/ml E coliDay 7: WBC/mm3 = 3400; patchy infiltrates in both lung bases; continued episodes of dyspnea; rales noted in LLLDay 11: Patient expired
76Does this patient have a UTI? If, so what type? 1.Yes. SUTI Criterion 1a. √2.Yes, SUTI Criterion 2a.3.Yes, ABUTI.4.No UTI.
77Case 1 - Rationale–(fever 38°C not high enough for criteria)
78Case 2POD 3: 66 y.o. patient in the ICU with a Foley catheter s/p exploratory lap; patient noted to be febrile (38.9°) and complained of diffuse abdominal painWBC increased to 19,000. He had cloudy, foul-smelling urine and urinalysis showed 2+ protein, + nitrite, 2+ leukocyte esterase, WBC – TNTC, and 3+ bacteria. Culture was 10,000 CFU/ml E. coli. The abdominal pain seemed localized to surgical area
79Is this a UTI? If so, what type? No UTI.2.Yes, SUTI Criterion 1b.3.Yes, SUTI Criterion 2a. √4.Yes, ABUTI.
81Case 3 84 year old patient is hospitalized with GI bleed Day 3: Patient has indwelling catheter in place and no signs or symptoms of infectionDay 9: Patient becomes unresponsive, is intubated and CBC shows WBC of 15,000. Temp 38.0°C. Patient is pan-cultured. Blood culture and urine both grow Streptococcus pyogenes – urine >105 CFU/ml.
82Is this a UTI? If so, what type? No. Because the blood seeded the urine and therefore there is no UTI.2.Yes, ABUTI. √3.Yes, SUTI Criterion 1a with secondary BSI.
83Case 3 - Rationale ABUTI: –No signs or symptoms (fever not > 38°C) –Positive blood culture with at least 1 uropathogen matching to the urine culture
84Thank You !!! Questions?For any questions or inquires about NHSN Criteria and Definitions: Website: