1. CAUTI: Reversing the Trend

2. Why the focus? CAUTI is the most common kind of HAI Increases length of stay 2-4 days Attributed to 13,000 deaths annually $836 - $3213 additional cost per patient per CAUTI

3. Why now? CAUTI rates are increasing nationally Iowa remains a high performer Reimbursement issues r/t HAC

4. Organisms enter the bladder by 3 ways: 1.At the time of catheter insertion 2.Through the catheter lumen (from a colonized drainage bag) 3.Along external surface of the catheter (migrate along the catheter-mucosal interface) Tambyah, Halvorson, Maki. Mayo Clinic Proc 1999

5. Urinary Catheters 15-25% of hospitalized patients Often placed for inappropriate indications Physicians frequently unaware In a recent survey of U.S. hospitals – >50% did not monitor which patients catheterized – 75% did not monitor duration and/or discontinuation

6. Current situation…. Statewide Average NHSN data – CAUTI rate 1.1939 – Device use rate 0.2555 CAHs – CAUTI rate per 1000 cath days 0.9671 – Device use 0.142 PPS – CAUTI rate 1.2242 – Device use 0.2860

7. What is the goal? Reduction of catheter utilization rate by 10% by July 2014 (< 0.22995)

8. Where do we start? Reduction of insertion of indwelling catheters. – Empower nurses – Educate providers – Educate patients and families – Practice appropriate urinary catheter placement in the ED

9. Catheter Insertion in ED More than half of hospital admissions come through the Emergency Department (ED) Avoiding placement of unnecessary urinary catheters in the ED may significantly reduce catheter use among hospitalized patients. Promote placement of urinary catheters based on appropriate indications and compliance with aseptic insertion technique. Establish clear guidelines for urinary catheter use – Adoption of guidelines by the ED – Engage ED physicians and nurses – Educate staff on appropriate indications and aseptic insertion technique. – ED Champions– ideally, a nurse and physician

10. Examples of Appropriate Uses of Indwelling Catheters Patient has acute urinary retention or bladder outlet obstruction Need for accurate measurements of urinary output in critically ill patients Perioperative use for selected surgical procedures: – Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract – Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU) – Patients anticipated to receive large-volume infusions or diuretics during surgery – Need for intraoperative monitoring of urinary output To assist in healing of open sacral or perineal wounds in incontinent patients Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures) To improve comfort for end of life care if needed http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf; pg 11

11. Examples of Inappropriate Uses of Indwelling Catheters As a substitute for nursing care of the patient or resident with incontinence As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc.) http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf; pg 11

12. What else can we use? Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction. (Category II) Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients. (Category II) Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. (Category II) Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration.(Category II) 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) 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) http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf; pg 12

13. Questions? Nancy Wilde- IDPH – 515-242-3892 – nancy.wilde@idph.iowa.gov Heather Matherly-IHC – 515-283-9393 – matherlyh@ihconline.org Jennifer Brockman-IHC – 515-283-9371 – brockmanj@ihconline.org