1. CUSP-Stop CAUTI-Learning Session #2
The ICU Environment
and Urinary Drainage Devices
Good ________________! I want to thank Laura and the group here in SC for the invitation to be with you today for Learning Session #2. I have been asked to talk with you today about CAUTI prevention in the ICU environment. So, let me start off by asking how many ICU staff we have in the room-raise your hand if you work in ICU at this time.
How many of you in the room are Infection Preventionists? Of those that are Ips, how many of you have worked in ICU in your past life?
I have worked in an Adult Medical ICU in a large teaching hospital. I have served as a transport nurse on a Pediatric Flight Team, moving critically ill children to the PICU at University of North Carolina Health Care.
Tina Adams, RN,
Clinical Content Development Lead
August 22, 2012

2. Objectives:
Discuss incidence of urinary drainage device use and CAUTI in ICUs
State the HIPAC/CDC indications for urinary drainage device use
List 3 insertion best practices
List 3 maintenance best practices
Describe systems to increase the earlier removal of urinary catheters (UC) in ICU
These are the expectations for my talk today. We’ll discuss Incidence, indications, insertion, maintenance, and removal in relation to the ICU environment.

3. CAUTI rate=outcome data
# of CA-SUTIs in a unit in a month x1000
# of Catheter Days in a unit in a month
Signs and Symptoms of UTI:
+ Urine culture with uro-pathogen
Fever > 38 degrees C
Urgency
Frequency
Dysuria, pyuria (> 10 WBC unspun), +LE or Nitrate
Suprapubic tenderness
Costovertebral angle pain or tenderness
Let’s set a few ground rules to begin. We are going to compare apples to apples because all of our units will use the same definition for CAUTI. First off, how is a CAUTI defined? What is the CAUTI rate of your unit…who determines if a patient has a CAUTI ? What are the approved signs and symptoms of UTI according to the NHSN (National Healthcare Safety Network) CDC? Does your electronic medical record have the ideal spot for you to document such findings?
The CAUTI rate is the number of CAUTI per the CDC definition (requires symptoms) divided by the number of catheter days in a unit per month times 1000.
CAUTI by definition requires symptoms, I’ve listed them here as a reminder to staff about symptoms that should be communicated to MD and documented in the MR.

4. Rate of CAUTI in ICUs: ICU type: No. of location CA-UTI UC days Rate
Burn 23
115
24,324
4.7
MICU-teaching 67
470
192,002
2.4
Medical-All other
110
436
232,454
1.9
Neuro-ICU 12 84
27,681
3.0
Neuro-Surg ICU 45
446
110,797
4.0
SICU-teaching 59
471
157,384
SICU-All other 53
182
118,919
1.5
PICU-Medical/ Surgical 78
127
57,420
2.2

5. Uro-pathogen microorganisms:
Gram-negative bacilli
Staphylococcus spp.
yeasts
beta-hemolytic Streptococcus spp.
Enterococcus spp.
G. vaginalis,
Aerococcus urinae,
Corynebacterium (urease positive)
This is a list of the approved uro-pathogens. These are the organisms that cause infection of the Urinary Tract.

6. Device Utilization Ratio/DUR=process data
# of catheter days=catheter prevalence # of patient days ICU’s catheter utilization ratio: (50 catheter days ÷ 100 patient days)=0.5 50% of ICU’s patient days are days in which patients are at risk of CAUTI!
Data elements required to calculate this number are 1.) Catheter days and 2.) Patient days
Divide the number of urinary catheter days by the number of patient days and this gives you the DUR-device utilization ratio, we call it the catheter prevalence.
Why is this an important number to know and pay attention to? How can the number of days that the patients in your unit are at risk for CAUTI be lowered?
WAIT……………….
Less catheters=less catheter days=less risk for infection

7. Rate of UC use in ICU: ICU type: No. of locations
Mean UC utilization ratio:
Burn 23
0.51
MICU-teaching 67
0.73
Medical-All other
110
0.65
Neuro-ICU 12
0.82
Neuro-Surg ICU 45
0.74
SICU-teaching 59
0.76
SICU-All other 53
0.78
Peds-Med/ Surg. ICU 77
0.26

8. CAUTI Prevalence, Incidence
Most common site of HAI, ~ 30-40%
Estimated >560,000 per year
80% of HAI-UTI attributable to catheter
15-20% patients in hospitals have urethral catheter
Most catheterized for 2-4 days, longer
Incidence of bacteriuria associated with indwelling cath is 3-8% per day
These facts you have heard before, remember UC disturbs the host defense mechanisms and provides easier access of uro-pathogens to the bladder and kidneys. Because the kidneys are blood filtering organs…it is not far for the organisms to travel to get into the bloodstream once they get to the kidney.
Remember bateriuria associated with indwelling urinary catheter will cause death in ____________% of our patients. This information covers all patients in the hospital, not just ICUs.
CDC:

9. What’s the problem?
15% of HAI of the bloodstream are attributable to UTI
13,000 attributable deaths per year
Increased length of stay by 2-4 days
Increased cost $ billion annually in the US
We have all thought that the UC was a given in the ICU! Just like we believed the central line was required for all ICU patients! We have been lulled into thinking UCs pose very little risk if any. But look at the fallout from those innocuous catheters!
CDC:

10. CMS- payment rule changes:
Hospital-Acquired Conditions (HAC)
HAI-CAUTI not reimbursed as of October 2008
Present on Admission (POA):
Does your unit routinely order/obtain urine cultures when UC’d patients admitted?
Do not obtain an admission urine culture UNLESS the patient has signs and symptoms of UTI
Antibiotic stewardship
Because CAUTI is so common and therefore costly, the payors have stopped paying hospitals for the care patients receive related to this hospital-acquired infection. As some attempt to document that patients have urinary tract infection Present on Admission, they have gone to sending urine cultures on admission. The NPT does not recommend this practice as it results in the treatment of bacteria in the urine which may not be an infection per se.
Present on Admission- Does your unit routinely perform urine culture at admission or immediately when a UC is placed?
National Project Team does not support this action as it is related to increased antibiotic usage-due to bacteriuria is treated more often. MORE CULTURES=More antibiotics

11. Complications related to UC:
Infection:
Urinary tract infection (bladder)
Acute pyelonephritis (kidney)
Secondary bacteremia/sepsis(blood)
Late onset: osteomyelitis (bone) and meningitis (brain)
Infection may spread from the bladder to the kidneys, from there to the blood and bones and finally to the brain. Once the infection reaches the blood, sepsis and shock may ensue.

12. Complications related to UC con’t:
Adverse outcomes:
Increased mortality
Obstructions form to urine flow
Selection for multi-drug resistant organisms
Prostatitis and orchitis

13. Organisms that cause CAUTIs:
Short-term urinary catheterization causing bacteriuria is usually from a single organism:
Bacteria: E. coli is most frequent
GNR: Klebsiella spp, Serratia spp, Citrobacter spp, and Enterobacter spp, Pseudomonas aeruginosa, Proteus
GPC: Enterococcus
Fungi: Candida is most frequent
Short term UC is about a week long and the bacteriuria caused is usually from a single organism whereas long term catheterization results in multiple organisms at one time.
Where does the E. coli and Candida come from? Let’s examine the nearby flora.

14. Movement of organisms into urinary tract:
Extraluminal-Outside of catheter
Intraluminal-Inside the catheter

15. This photo is a Staph aureus biofilm on an indwelling catheter.

16. Biofilm---what’s up with that?
Free floating microorganisms attach themselves to a surface
Secrete extracellular polymers that provide a structural matrix and facilitate adhesion
Biofilms protect the bacteria, they are often more resistant to traditional antimicrobial treatment
A million cases of catheter-associated urinary tract infections (CAUTI) reported each year, many of which can be attributed to biofilm-associated bacteria
Maki, D. and Tambyah, P. "Engineering Out the Risk for Infection with Urinary Catheters." Emerging Infectious Diseases 7.2 (2001)

17. Normal flora of the Urethra:
CoN Staph
Diphtheriods
Streptococci (various species)
Mycobacterium spp
Bacteroides and Fusobacterium spp
Peptostreptococcus spp
Where do they come from?
Not from the urethra!

18. Normal Flora of the GI Tract:
Small intestine:
Lactobacillus spp
Bacteroides spp
Clostridium spp
Mycobacterium spp
Enterococci
Enterobacteriaceae (e.g.,Klebsiella, Enterobacter)
Small intestine content? Maybe…does you patient have a ileostomy that leaks?

19. GI tract normal flora continued:
Large Intestine:
E. coli
Klebsiella spp
Pseudomonas spp
Acinetobacter spp
Staph aureus
Did our patient with CAUTI have a recent bout of diarrhea? Do you routinely give ICU patients stool softeners? Bowel programs? Fecal drainage systems?

20. Normal Flora of the Skin:
CoN Staph
Diphtheroids
Staph aureus
Streptococci (various species)
Bacillus spp
Malassezia furfur
Candida spp
Where do the organisms that cause CATUI come from?

21. Normal Flora of the Vagina:
Lactobacillus spp
Peptostreptococcus spp
Diphtheroids
Streptococci (various)
Clostridium spp
Bacteriodes spp
Candida spp
Gardnerella vaginalis
Remember that when we give patients antibiotics, the normal bacterial flora will be killed off and the Candida will be therfore selected and overgrow!

22. Evidence-based Risk Factors:
Symptomatic UTI
Bacteriuria
Prolonged catheterization*
Disconnection of drainage system*
Female sex
Lower professional training of inserter*
Impaired immunity
Placement of catheter outside of OR
Older age
Diabetes
Meatal colonization
Renal dysfunction
Orthopedic/neurology services
Some of these risk factors are modifiable and some are not. Let’s talk about the ones that we can work on.
Who is the person at your hospital that places the UC?
Do your patients come with a UC from OR, ED, LTCF?
Ask you peers in your ED what level training staff are allowed to insert ?
Ask your peers in the OR what level training staff are allowed to insert?
How many of your patients with UC are receiving antibiotics?
What do antibiotics do to the UG and perineal flora?
How many of your patients are colonized with an MDRO
If a patient is colonized with VRE, what percentage of this patient group will acquired a CAUTI with VRE?
*Main modifiable risk factors

23. Lifecycle of the urinary catheter:
This is Dr. Meddings slide. Lifecycle of the urinary catheter. This conceptual model illustrates 4 stages of the urinary catheter lifecycle as targets for intervention to decrease catheter use and subsequent catheter-associated urinary tract infection.
Meddings J , Saint S Clin Infect Dis. 2011;52:

24. CDC’s INDICATIONS FOR UC:
Urinary retention/bladder obstruction
Accurate measurement of urine output in critically ill patients (usually in an ICU)
To assist with healing open sacral/ perineal wounds in the incontinent
You noticed that these indications include a critically ill patient usually housed in the ICU. On any given day…how many patients get transferred out? Are those patient “critically ill” at that point? Do they meet any of the other indications to have a UC? Take it out!
CDC:

25. Indications continued:
4. Perioperative use-selected surgery:
Urological surgery (or on contiguous structures of GU tract)
Patient anticipated to receive large volume infusions or diuretics in OR
Need for intraoperative monitoring of urine output (should be removed in PACU)
Prolonged duration of surgery
Does every surgery patient in your unit automatically have a UC placed?
Do they ALL meet one of these 4 indications during surgical inpatient admissions?
CDC:

26. 4 RULES to Prevent CAUTI:
What can I do?
4 RULES to Prevent CAUTI:
Prevent indwelling catheter use when another urinary care system would work!
Optimize aseptic insertion technique
Optimize aseptic maintenance care
Remove the UC as soon as possible!
You can begin the change process in your ICU by becoming a patient advocate and take an active role in the prevention of UC use whenever another urinary care system would work.
Ok, we are going to talk about RULE #1 AND RULE#4 first and then come back to discuss RULE #2 and #3.

27. Alternative urinary care:
All Patients:
Unconscious=Incontinence garment
Conscious=Scheduled toileting-Q 4 hours
The 3 B’s:
Bedpan
Bedside commode
Bathroom
Rule #1: What other options are available to provide urinary care for the ICU patient? Well, it depends on their level of consciousness-right?
Obviously the higher the LOC the more actively involved the patient can be. If your pt is unconscious, there are fewer options-Depends. Once they are awake and able to communicate-it’s time for the 3B’s. Bedpan, Bedside Commode and the Bathroom! Do any of you have a scheduled toileting program in your unit?
I am aware that for some of your patients this is a difficult proposition! Getting ICU patients up to the BR is a major event! But, by using a combination of these three assisted toileting processes, we are helping the patient avoid HAI and getting closer to graduation from ICU!

28. Alternatives continued:
Male Patients:
Urinal-Q 4 hours while awake
Condom catheter
Size matters!-5 different sizes
Materials matter!-old latex, new silicone
If you believe that a condom catheter won’t stay on or that they leak, you haven’t used on recently! There are new manufacturers, new sizing and made from newer substances!

29. Paradigm shift: Remember Rule #1! Prevent urinary catheterization!
All ICU patients do not require a UC because they are in ICU!
All ICU patients admitted via OR/PACU do not automatically need a UC!
All ICU patients admitted via ED do not automatically need a UC!
Ok, what do we know is the best way to prevent CAUTI?
No Catheter!
How are we going to begin to move our units in that direction?
It’s going to require a new way of thinking, a new belief, a new rule!

30. Admission to ICU: Report: ask about urinary needs UC in place?
UC arrived presentation to hospital?
UC placed in ED/OR-what indication?
History: ask patient/family for indication and length of UC use?
Assessment: consider removal to review for need

31. Asepsis during insertion:
Competency of inserter assessed?
Assess patient’s anatomy! Look first, with adequate assistance! Wash perineum with soap and water before procedure, chose smallest catheter
The Right Stuff? Use hand hygiene, sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion
(ICU, ED, OR?)
What does aseptic technique mean? In the acute care hospital setting, aseptic technique and sterile equipment is used for this procedure.
Use the smallest bore UC possible, consistent with good drainage, to minimize bladder neck and urethral trauma
Have all HCWs doing this sterile procedure been competency tested? How
are those who do this procedure in ED, OR?
Can Med. Students, Interns, Residents, Fellows do this without check off?
Can Nursing Students, Nursing Assistants , Care technicians, Surgical Techs, etc…

32. Paradigm shift continued:
Remember RULE #4:
Remove the catheters sooner!
All ICU patients that did have an indication for a UC may not need it the entire ICU stay. Check daily!
Goal: Remove as soon as possible and before transfer out of ICU!
Information Tech – automatic notification to MD
Nurse-driven removal protocol?
ICU Goals Sheet use contains device use check-in. What can be removed today?
Fluid status stabilized?
Urine output WNL?
Inotropes D/C’d?
Diuretics D/C’d?
If patient is stable enough to be transferred-meaning no longer critically ill, then no longer meets that indication.

33. Urinary Catheter Removal Protocol:
Meet indication today?
If not, obtain catheter removal order
Remove catheter
Assessment for and encourage voiding
Up and walking, using commode, privacy
If not spontaneously voiding-comfortable?
Bladder scan, if >400cc, contact MD for straight catheterization order, continue intermittent x 24hr
Website has an example nurse driven catheter removal protocol.

35. Asepsis during maintenance care:
Hand hygiene, standard precautions to clean the perineum daily with soap and water during bath, contamination from feces/drainage, & emptying bag
Clean the catheter daily wiping crusting away from the urinary meatus and 4 inches down the catheter
Maintain clean securement of catheter to prevent movement and traction.
Tape vs. Stat-Loc®
Once the UC is in place we must be vigilent to protect the patient’s urinary tract from microbes!

36. Maintenance continued:
Bag maintained below bladder:
never laid on the bed/stretcher (patient transportation)
never on the floor (radiology, PT/OT)
Bag emptying technique:
staff emptying many urinary drainage bags to total I/O require hand hygiene and clean gloves before touching each patient’s urine bag
I know all of you know these steps for prevention of contamination of the drainage system. This is what to do, can you be sure you have the system to do this every time?
Illinois hospital obtain hooks for IV poles to make this more consistently practiced.
The end of shift I/O practices of some units have been observed to be so bad that they had to never assign the nursing staff to more than one patient with a UC/drainage bag.

37. Not found to decreases CAUTI:
Routine change of UC or bag
Washing the perineum with harsh antiseptics
Placing antiseptics into the collection bag
Routine bladder irrigations
Antiseptic or silver-impregnated catheter

38. Objective #1: Can you review your unit’s data to discuss the
incidence of urinary drainage device use and CAUTI
in your ICU?

39. Objective #2: Can you state the HIPAC/CDC indications for
urinary drainage device use?

40. Objective #3: What 3 insertion best practices are you going to
validate (by observation) consistently take place in
your ICU?

41. Objective #4: What 3 maintenance best practices are you going to
validate (by observation) consistently take place in
your ICU?

42. Objective #5: Describe one system you can institute to increase the
earlier removal of urinary catheters (UC) in your ICU?

43. Thank you for your participation in today’s discussion!
Questions or Comments?
Thank you for your participation in today’s discussion!

44. Contact Information:
Tina Adams, RN
American Hospital Association
Health Research & Education Trust