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George Allen PhD, CIC, CNOR.  No Disclosures  Identify mandates, clinical & regulatory for monitoring and preventing CAUTI  Review the surveillance.

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Presentation on theme: "George Allen PhD, CIC, CNOR.  No Disclosures  Identify mandates, clinical & regulatory for monitoring and preventing CAUTI  Review the surveillance."— Presentation transcript:

1 George Allen PhD, CIC, CNOR

2  No Disclosures

3  Identify mandates, clinical & regulatory for monitoring and preventing CAUTI  Review the surveillance definitions and criteria for CAUTI  Discuss strategies institutions can utilize to reduce the risk for the development of CAUTI

4  Discomfort to the patient  Limit mobility  Prolonged hospital stay  Increased cost and mortality

5  Each year million Americans (5-10% of hospitalized patients) acquire at least one infection while hospitalized  thousand die of those infections  One third of these are believed preventable  Conservatively HAI cost $33 billion each year

6  Urinary tract – most common site of healthcare associated infections; most are associated with urinary catheterization  % of inpatients are catheterized  80% of hospital associated UTIs caused by a urinary catheter

7  CAUTI cost $500 – $ $2,800 if bacteremia  Most CAUTIs are asymptomatic bacteriuria, 1-5% lead to secondary bacteremia  5% of all deaths from HAI are urinary catheter associated.

8  CAUTI 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:

9  The 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 prevented Umscheid et al. Infec Control & Hospital Epidemiology 2011; Scott, 2009

10  Proper management and use of catheters could prevent infections  Study in Lansing, MI: Less than half of urinary catheters in teaching hospital were indicated. Am J Infect Control.Am J Infect Control Jun;32(4): Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital.Gokula RR, Hickner JA, Smith MA.Gokula RRHickner JASmith MA  Urinary catheters are uncomfortable, limit mobility

11  Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract  CAUTI can lead to complications

12  Cystitis  Pyelonephritis  Gram-negative bacteremia  Prostatitis  Epididymitis  Orchitis in males

13  Endocarditis  Vertebral osteomyelitis  Septic arthritis  Endophthalmitis  Meningitis

14  The Joint Commission NSPG  CMS Value Based Purchasing  CMS Inpatient Quality Reporting Program  Goals  To eliminate and sustain reductions in CAUTI

15  Mandatory Reporting through NHSN  Denial of CMS dollar reimbursement Core Measures  CAUTI must be included in monthly NHSN  NY Partnership for Patients ▪ To reduce unnecessary catheter utilization ▪ To eliminate preventable catheter-associated urinary tract infections

16  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.

17 Report by the following facility/institution:  Acute Care Hospitals: Adult and Pediatric ICUs ▪ January 2011  Long Term Care Hospitals: All inpatient location ▪ October 2012  Inpatient Rehabilitation Facilities: All inpatient locations ▪ October 2012

18  Report CAUTI indentified by surveillance  Indicate NO CAUTI detected for specific location  Report total device days for specific location  Report total patient days in specific location

19  NPSG Implement evidence based practices to prevent CAUTI (2012 = Planning year; by January 2013 = full implementation) _CAUTI-VAP_HAP_ pdf

20 EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following: Limiting use & duration to situation necessary for patient care Using aseptic techniques for site preparation, equipment & supplies EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following: Securing catheters for unobstructed urine flow & drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples

21 EPI 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 practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts

22 GUIDELINE 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

23 Category IAA strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms Category 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 evidence Category 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 harms No recommendation/ unresolved issue Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms

24  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)

25  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)

26  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)

27  1B.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)

28  1B.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)

29  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)

30  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)

31  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)

32  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)

33  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)

34  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)

35  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)

36  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)

37  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)

38  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)

39  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)

40  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)

41  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)

42  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)

43  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)

44  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) 

45  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)

46  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)

47  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)

48  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)

49  Urinary Tract Obstruction and Neurogenic Bladder  Urologic Study/Surgery  Urine monitoring in critically ill patients  Assistance in pressure ulcer management for incontinent patients  Exception – Patient request to improve comfort

50  Incontinence  Immobility  Patient/Staff Convenience  Obtaining Periodic Urine Specimens

51  Sterile gloves  Sterile drapes  Site cleaning supplies  Sterile lubricant  Sterile catheter attached to drainage bag (seal)  Hand Hygiene & Aseptic Technique

52  Avoid unnecessary urinary catheters; insert urinary catheters in the presence of an appropriate indication  Peri-operative use for selected surgical procedures  Urine output monitoring in critically ill patients  Managing acute urinary retention and urinary obstruction  Assisting with pressure ulcer healing for incontinent patients  As an exception, at patient request to improve comfort

53  Maintain urinary catheters based on recommended guidelines:  Tamper-evident seal is intact  Collection bag is not on the floor  Collection bag is secured to the leg  Every patient with a catheter has a labeled urine collection container at the bedside  Review urinary catheter necessity daily and remove promptly

54  Risk of CAUTI is 5% per day catheter is in situ  Increases to 25% after 1 week in situ  Increases to 100% after 1 month in situ

55

56 Point Prevalence = # of patients with urinary catheters # of patients at a point in time

57 Nursing Care UnitTotal Patients Foley Catheters Indwelling Foley Catheter Utilization Rate MICU`10550% L&D11100% NS721218% CTICU4250% CCU6117% PACU22100% NS % NS613426% NS % CPCU3813% TOTAL %

58 UNITCENSUS# WITH DEVICEPREVELANCE RATE ED ADULT1700 ED PED400 NS % NS NS % NS % NS % NS42900 NS43400 NS % NS % NS71/ % % NS % NS NS % TOTAL %

59 UnitObservation s % with Securement % Seal Intact % Below level of bladder % Not touching floor MSICU560%0%100% L &D1100%0%100% NS7210%100% CTICU250% 100% CCU1100%0%100% PACU2100%0%100% NS62475%50%100% NS612100% % Ns81367% 100% CPCU1100% Overall2273%41%100%

60 National Healthcare Safety Network (NHSN)

61 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 and  Was not present or incubating at the time of admission, unless the infection was related to a previous admission

62 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 catheter  Does not include (among others):  Straight in and out catheters  Suprapubic catheters  Nephrostomy tubes

63 A 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

64 Location 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).

65 Transfer Rule: Mr. Smith is transferred from SICU with a Foley and 36 hours after transfer has a fever of C. The next day a urine culture collected has >10 5 CFU/ml of E. coli. This CAUTI is attributed to the SICU

66 There are two criteria than can be applied for identifying a CAUTI ▪ Symptomatic 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.

67 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 (>38 0 C), suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urine culture of ≥ 10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms.

68 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 (>38 0 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urine culture of ≥10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms

69 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 (>38 0 C), suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings: a.Positive dipstick for leukocyte esterase and/or nitrite b.Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm 3 of unspun urine or ≥3 WBC/high power field of spun urine) c.Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ≥10 3 and <10 5 CFU/ml with no more than 2 species of microorganisms.

70 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 (>38 0 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings: a.Positive dipstick for leukocyte esterase and/or nitrite b.Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm 3 of unspun urine or ≥3 WBC/high power field of spun urine) c.Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ≥10 3 and <10 5 CFU/ml with no more than 2 species of microorganisms.

71 3. 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 (>38 0 C core), hypothermia (<36 0 C core), apnea, bradycardia, dysuria, lethargy, or vomiting and a positive urine culture of ≥ 10 5 CFU/ml with no more than 2 species of microorganisms.

72 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 (>38 0 C core), hypothermia (<36 0 C core), apnea, bradycardia, dysuria, lethargy, or vomiting and a positive urinalysis demonstrated by at least one of the following findings: a.Positive dipstick for leukocyte esterase and/or nitrite b.Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm 3 of unspun urine or ≥3 WBC/high power field of spun urine) c.Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ≥10 3 and <10 5 CFU/ml with no more than 2 species of microorganisms.

73 Patient with or without an indwelling urinary catheter with no signs or symptoms (i.e., for any age patient, no fever (>38 0 C ), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness, OR hypothermia ( 10 5 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

74 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

75  50 year old, end stage pancreatic cancer, liver & bone mets admitted with advance directive for comfort care & antibiotics only; foley catheter, peripheral IV & nasal cannula inserted  Day 4: patient is febrile to 38.0°C & has suprapubic tenderness; IV ampicillin started after urine obtained for culture  Day 5: difficulty breathing; CXR = infiltrate L lung base  Day 6: urine culture results = 105 CFU/ml E coli  Day 7: WBC/mm3 = 3400; patchy infiltrates in both lung bases; continued episodes of dyspnea; rales noted in LLL  Day 11: Patient expired

76

77 –(fever 38°C not high enough for criteria)

78  POD 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 pain  WBC 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

79

80

81  84 year old patient is hospitalized with GI bleed  Day 3: Patient has indwelling catheter in place and no signs or symptoms of infection  Day 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.

82

83 ABUTI:  –No signs or symptoms (fever not > 38°C)  –Positive blood culture with at least 1 uropathogen matching to the urine culture

84 For any questions or inquires about NHSN Criteria and Definitions: Website:


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