1. Preventing Catheter-Associated Urinary Tract Infections
Emergency Nursing Education

2. An 85 year old male with dementia…
Brought to the ED from his skilled nursing facility with a complaint of nonfunctioning PEG tube.
In the initial assessment, the nurse notes the patient was incontinent and placed a urinary catheter
The patient is admitted for a PEG change. Overnight the patient becomes more confused and pulls on his catheter leading to severe hematuria and requiring a urology evaluation.
Within 36 hours was febrile, with positive blood cultures, treated for CAUTI and requires a prolonged hospital stay.
Many people present to your emergency department with varied complaints and needs.
Decisions of care regarding the insertion of an indwelling urinary catheter demand a full assessment of the indications and risks of catheterization.
It is a decision that cannot be taken lightly.
Consider this case…
An 85 year old male with dementia is brought to the ED from his skilled nursing facility with a complaint of a nonfunctioning PEG tube.
In the initial assessment, the nurse notes the patient was incontinent of urine and placed a urinary catheter.
The patient is admitted for a PEG replacement. The procedure is uneventful and the plan is for him to return to the facility the following morning. Overnight, he becomes more confused and agitated, pulling the catheter, which leads to severe hematuria and necessitates a urology evaluation.
This extends his stay. Within 36 hours, he develops a fever, positive blood cultures and now requires antibiotic therapy for the catheter acquired urinary tract infection (CAUTI).
Are there clear indications for insertion with this case?
Are there contraindications for catheter use in this case?
Are there any urinary problems as part of his presentation or history?
Is incontinence a reason for placement of a catheter? (No, it is not.)
Are there points along the way where another decision could have prevented the CAUTI?
Consider these questions and we’ll revisit this case later.

3. Objectives
Describe urinary catheter use with focus on the emergency department (ED)
Identify current evidence on prevention of CAUTIs
Outline nursing assessment of the ED patient who may require urinary catheterization
List criteria for catheter placement
Review communication necessary between nurses and providers to facilitate appropriate clinical decision-making
At the end of this presentation, you will be able to:
Describe urinary catheter use with focus on the emergency department (ED)
Identify current evidence on prevention of CAUTIs
Outline nursing assessment of the ED patient who may require urinary catheterization
List criteria for catheter placement
Review communication necessary between nurses and providers to facilitate appropriate clinical decision-making

4. Urinary Catheter Utilization
About % of patients will have a urinary catheter placed during their hospitalization.
Many are placed in ED
ICU OR
Urinary catheterization is a common procedure with up to 25% of admitted patients undergoing placement.
The most common areas where patients have catheters placed are the emergency department, the intensive care unit, and the operating suite.
Because of this prevalence, the emergency nurse plays a significant role in the reduction of CAUTI.

5. Reducing CAUTI Determine appropriate indication
Avoid use if no indication
Seek alternatives when possible
Use sterile technique for placement
Remove as soon as possible
When looking at ways to reduce the incidence of CAUTI, there are 2 main decision points
First, is the decision to insert, be sure there is a strong indication for use and identify the reasons for placement as that will help at the second decision point.
Second, is to remove the catheter as soon as possible. If the indication is clear, the point at which it has served its purpose and is ready for removal will also be clear. This helps prevent the catheter remaining in place until discharge, because no one has considered why it is there, so there is no clear indication for removal.

6. Why we think putting in a catheter is a good idea – but it’s not
Perception
Facts
Facilitates I/O measurement
Alternatives are available with less risk (e.g., urinals, daily weights)
Prevents falls from getting up to urinate
Increases risk to fall, especially in the confused patient
Protects skin in the incontinent patient
Increases risk of skin breakdown from immobility, muscle loss, and catheter-related trauma
Saves time for the bedside nurse
Extended LOS, infection complications, and other risks, it does not
Traditional reasons for catheter placement may seem logical, but many are not, or at least not in every case.
A catheter facilitates intake and output measurement and in the critically ill patient, a urinary catheter may be indicated, but there are many patients who require accurate I & O measurement that can be accomplished with less invasive measurement devices, including urinals, daily weights, diapers or pads.
We traditionally thought that a catheter was helpful in preventing falls because patients didn’t have to get up to the bathroom. However, the catheter doesn’t eliminate the urge to urinate and the tubing can cause tripping and falling in the patient who may be confused and try to get up.
We thought that it would protect the skin in the incontinent patient, and a catheter may prove useful in advanced stage pressure ulcers, but it may promote the development of skin breakdown and pressure ulcers from immobility, muscle loss, and catheter-related trauma. To protect intact skin there are many other products that can create a barrier.
Finally, we thought it would save time, but clearly, with extended length of stay, infection complications, and other risks, it does not save time in the long run.

7. Indications for catheterization
Patient is critically ill and will require accurate output measurement
Urinary retention/obstruction
Bladder scanner or bedside ultrasound first
Immobilization needed for trauma or surgery
Incontinent with open sacral/perineal wounds
End of life/hospice
Chronic or existing catheter use
Re-evaluate need and discuss with provider
Current recommendations for identifying patients who would benefit from a urinary catheter include:
The patient who is critically ill and will require accurate output measurement
This does not mean every patient who is admitted to the ICU is critically ill.
Confirmation of lack of other options for measurement should be clear and documented.
Urinary retention/obstruction
Use a bladder scanner or bedside ultrasound first to identify retention and amount retained
Consider straight catheter use instead of an indwelling catheter to limit exposure
Immobilization needed for trauma or surgery
Inquire the length of the surgical procedure before placement or communicate with the OR staff to see if they would prefer to place the catheter and then remove it immediately after the surgical procedure.
Incontinent with open sacral/perineal wounds
Consult with wound care
End of life/hospice
Be sure it is what the patient wishes prior to inserting for hospice care
Chronic or existing catheter use
Some patients may present with a catheter in place and each one is evaluated for continued use upon arrival.
Re-evaluate need and discuss with provider

8. “Not” indications for catheterization
Substitute for frequent toileting
To obtain a specimen if the patient can void freely
Patient preference
Dementia
Obesity
A catheter should not be used for convenience and many of the contraindications are related to those convenient reasons.
It is not a substitute for frequent toileting. Toileting schedules promote continence and the use of a catheter instead can interfere with that continence training process.
There may be patients who will ask for a catheter, but that cannot be the only reason.
Dementia is a contraindication, because as we saw in the initial case study, catheter placement in the patient with dementia may increase the agitation as confusion worsens with nightfall or illness.
Obesity can limit movement and the obese patient may require additional staff to get up to toilet, but a catheter is not a solution for this.

9. Patients at high risk for inappropriate catheterization
Elderly Women
Independent factors: women were twice more likely than men, and very elderly (≥80 years) were 3 times more likely than those 50 or younger, to have urinary catheter placed without indication.
Fakih et al, Am J Infect Control 2010;38:683-8
Incontinent
Obese
Immobile
Non-critically ill cardiac and renal patients
Monitor does not necessitate catheter
Elderly women seem to be at the highest risk for catheterization with no documented indication for placement.
Others at risk for inappropriate placement include those who are incontinent, obese, immobile, and patients with cardiac or renal problems that require monitoring for urine output, but have other options.

10. Reducing inappropriate placements reduces
Infection rates
Cost
Antibiotics use
Length of stay
Morbidity
Patient discomfort
What are the benefits to reducing the inappropriate placement of a urinary catheter?
There are many;
Infection rates; CAUTI rates will drop with fewer catheters and eliminating those procedures that are unnecessary will eliminate the risk of infection for those patients. It seems simple, because it is. In many cases it is not just the UTI that is avoided, but risk of urosepsis is also avoided.
With decreased infection rates, costs for extended stays and additional treatment is also decreased.
The use of antibiotics is scrutinized more than ever and every time we can avoid the need to give antibiotics the better all of our patients are.
Finally, catheters are uncomfortable and the resulting urinary tract infection even more so.

11. Communication with providers
Clear understanding of indications
Commitment to nonmaleficence (doing no harm)
Patient focused care
In the emergency department, clear, concise, and frequent communication is necessary for efficient and safe care.
In prevention of CAUTI, this communication is vital. Discuss the indications. Identify and document the indication to promote early removal.
Think beyond the patient’s needs within the emergency department, but what will the needs and indications be upon admission. If the indication for the catheter was present, but conditions and status have changed prior to admission, and the need no longer exists, remove the catheter.
Make sure there is a written order to reflect that communication.

12. So, how does this affect the care of this patient?
Brought to the ED from his SNF with a complaint of nonfunctioning PEG tube. In the initial assessment, the nurse noted the patient being incontinent and placed a urinary catheter
Incontinence is not an indication by itself for catheter placement
Now, let’s return to the case study…

13. So, how does this affect the care of this patient?
The patient was admitted for a PEG change. Overnight the patient became more confused and pulled on his catheter leading to severe hematuria and requiring a urology evaluation.
The agitated patient (possibly due to dementia) is not a good candidate for catheter placement

14. So, how does this affect the care of this patient?
Within 36 hours was febrile, with positive blood cultures, treated for CAUTI and required a prolonged hospital stay.
This patient had no indications to place a catheter; the suggestion is that placement of the catheter in the ED was a potential cause of infection. Patient stay is prolonged, patient develops a clinical problem he did not present with initially. This infection is potentially preventable.

15. Another example…
A 76-year-old woman admitted for congestive heart failure…
Urinary catheter placed and started on diuretics
Condition improved; ready for discharge on 3rd day
No urinary output for 5 hours after catheter removal
Bladder scan showed 500 mL of urine
Straight catheterization
Observed overnight for symptom resolution
CAUTI ED slides, Fakih, 2012

16. So, how does this affect the care of this patient?
Urinary catheter placed and started on diuretics
Accurate I & O measurement can be a valid indication for catheter placement for critically ill patients
Evaluate for need before placement

17. So, how does this affect the care of this patient?
Condition improved; ready for discharge on 3rd day
No urinary output for 5 hours after catheter removal
Bladder scan showed 500 mL of urine
Not all patients with congestive heart failure require catheterization
Early removal may have prompted evaluation of urinary retention
Additional day of hospitalization
Risk for urosepsis
Explore alternatives for measuring I & O
Removal after initial diuresis to shorten exposure
Frequent toileting
Communicate with inpatient staff indication for placement to assure timely removal

18. Another example…
A frail 82-year-old woman was admitted for congestive heart failure…
Urinary catheter placed and started on diuretics
Team felt the catheter would make her more comfortable
On day 5
Chills; fever of 102°F
SBP dropped to 90 mmHg
Blood cultures and urine cultures grew Escherichia coli.
Diagnosed with symptomatic CAUTI and treated with intravenous antibiotics.
CAUTI ED slides, Fakih, 2012

19. So, how does this affect the care of this patient?
Team felt the catheter would make her more comfortable
Comfort is a myth
It may be convenient for the staff and the patient, but does not promote comfort, nor is it a safe indication
Some patients may request a catheter to avoid the need to get up. It is still an inappropriate reason
Consequences
Prolonged, unexpected hospitalization from hospital-acquired CAUTI
Risk for urosepsis

20. The take home Review indications for urinary catheter placement
Discuss placement with provider
Communicate indications for placement with inpatient staff for timely removal
Do no harm
So, what have we learned?
Every time you are considering a catheter placement, review the indications, discuss those indications with the provider, communicate with the inpatient staff, so that CAUTI can be prevented and no harm is done.

21. Other indications for urinary catheter:
Urinary retention/obstruction?
Use bladder scanner first
Immobilization needed for trauma or surgery?
Incontinent with open sacral/perineal wounds?
End of life/hospice?
Chronic or existing catheter use?
Re-evaluate need and discuss with provider
Insert catheter and treat signs of shock:
Hypotension
Decreased cardiac output/function
Decreased renal function
Hypovolemia
Hemorrhage
Re-assess after intervention No
Yes
Do NOT insert
Explore alternatives
Still critically ill, requiring accurate output measurement?
Insert or maintain catheter
Remove catheter prior to admission
Is the patient critically ill and will require accurate output measurement?