1. CAUTI: Issues and Solutions
Deborah A. Lichtenberg, RN, BSN, CIC
Infection Preventionist
Bard Medical

2. Disclaimer
I am an employee of C. R. Bard, Inc., Bard Medical. Any discussion regarding Bard products during my presentation is limited to information that is consistent with Bard labeling for those products.

3. OBJECTIVES
Describe the impact of CAUTIs on patient outcomes and hospital costs.
Explain the pathogenesis of CAUTIs including the role of biofilm.
Identify 4 changes/updates impact CAUTI surveillance and prevention.
Review changes in practice identified above and the role of the hospital ICP.

4. Catheter-Associated Urinary Tract Infections
Urinary tract infections are the most common type of healthcare-associated infection, accounting for more than 30% of infections reported by acute care hospitals.
Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract.
Between 15% and 25% of hospitalized patients may receive short-term indwelling urinary catheters.
Reported rates of UTI among patients with urinary catheters vary substantially.
National data from NHSN acute care hospitals in showed a range of pooled mean CAUTI rates of infections per 1000 catheter-days.
The highest rates were in burn ICUs, followed by inpatient medical wards and neurosurgical ICUs
The lowest rates were in medical/surgical ICUs.

5. Cost of UTIs
Average cost of each uncomplicated UTI in was reported at $ Based on total of 84 patients
Average cost impact of each UTI reported in was $3, Based on 675 cases, 5,337 controls

6. Mechanisms of Infection
At time of insertion
Mechanical
during catheter insertion the catheter picks up organisms
urethral trauma during insertion
Blockage of periurethral glands

7. Mechanisms of Infection
Extraluminal
Biofilm
Encrustation
Organisms migration
Fecal incontinence
Intraluminal
Disconnection of catheter/drainage system
Contamination of outlet tube

8. Catheters and UTIs 3 “Ports of Entry” Catheter / Meatal Junction
Catheter / Tube Junction
Outlet Tube

9. Stages of biofilm formation
Bacteria switch from a free-floating (planktonic) state where they function as individuals to a sessile state where they function as communities

10. In a biofilm microorganisms are protected from antimicrobials

11. Preventing Biofilm on Foley Catheters
Catheter coatings are available to reduce bacterial adherence and prevent biofilm formation
Silver
Bardex® I.C. Anti-Infective Foley Catheter*
Dover™ Silver Foley Catheter
Silvertouch™ Foley Catheter
Nitrofurazone
Release-NF® Anti-Infective Foley Catheter

12. Silver and Hydrogel Foley Catheter
Pseudomonas aeruginosa
Reduced densities of 2hrs on a Silver and Hydrogel coated Foley catheter
Pseudomonas aeruginosa
Note extensive cell damage to organisms

13. Prevention is Primary!

14. How do you get people focused on CAUTIs?
It all begins with Awareness
What is the clinical impact of CAUTI ? 9
UTIs account for 40% of all HAIs and of these, 80% are associated with urinary catheterization.
What CAUTI lack in terms of severity they make up with in terms of volume
UTIs are the second most common cause of bloodstream infections and due to their frequency and subsequent treatment they are one of the largest breeding grounds for antibiotic resistant organisms
What is the financial impact of CAUTI ?9
UTIs cost U.S. hospitals more than $500 million per year to treat and can increase a patient’s length of stay by 3.8 days
Cost to Treat
Additional length of stay
Loss of CMS reimbursement

15. The Changing Face of Prevention
2008/2009
Changes
CMS Reimbursement Changes for HAIs
HICPAC /CDC CAUTI Guideline
Revised SCIP Guideline
APIC Guide to Elimination of CAUTIs

16. Centers for Medicare and Medicaid Services (CMS)
Changes in Reimbursement for Healthcare Acquired CAUTI

17. Hospital Acquired Conditions
Hospitals will not receive additional payment for cases where the condition was not present upon admission
Blood incompatibility
Air embolism
Object left after surgery
Mediastinitis after CABG surgery
Injuries from falls
Vascular catheter associated infection
Pressure ulcers
Catheter associated urinary tract infection (CAUTI)

18. Estimated Incidence of “Conditions”

19. Why are CAUTIs included?
High Volume: CDC reports there are 561,667 CAUTI every year
Most common healthcare-associated infection
High Cost: APIC HAI Cost Calculator estimates cost to treat urinary tract infection $1,006 plus 6.3 days excess length of stay
Assignment to Higher Paying DRG: Code
Reasonably Preventable: Prevention guidelines exist

20. CAUTIs and Medicare Patients
10% of Medicare discharges had a secondary diagnosis of UTI (2006 MedPAR)
Hospitals reimbursed $216M for these infections

21. Are there additional benefits besides saving money?
Medicare believes this will provide hospitals with additional incentive to engage in quality improvement efforts such as HAI reduction measures
Presently they are developing a Value-Based Purchasing Rule (VBP) based on criteria from the Patient Protection and Affordable Care Act (ACA) 2010

22. SO…What Was New in 2009? Change in NHSN/CDC Definition for CA-UTIs7
New HICPAC/CDC Guidelines for UTI Prevention9
Surgical Care Improvement Project (SCIP)10
APIC Guide to Elimination of Catheter- Associated Urinary Tract Infections (CAUTIs)11

23. NHSN Definition Change for 2009
UTI Definition for Patients with an Indwelling Foley Catheter7

24. Background: HHS Metrics and Prevention Targets
# of symptomatic UTI / 1,000 urinary catheter days as measured in NHSN
National 5-Year Prevention Target: 25% decrease from baseline
Appendix G in HHS plan discusses a new type of metric, the standardized infection ratio (SIR)
Several challenges and needs related to the measurement of CAUTIs were identified.
Participants suggested a comparison of NHSN symptomatic UTI (or available state data collecting similar variables) to administrative discharge data and a review of the UTI definition in non-acute care settings to validate data quality and ensure monitoring of the full burden of CAUTIs. Many experts pointed out current limitations of the UTI definition and proposed that the metric should focus only on bloodstream infections secondary to UTIs.
In addition, participants suggested that strategies to widely implement “best practices” in the prevention of CAUTIs in a range of settings be developed. Participants felt that these actions would help identify targets and play a vital role in the selection of future metrics.

25. Measurement: Recommended Outcome Measures
Examples of metrics:
Number of CAUTI per 1000 catheter-days
Number of BSI secondary to CAUTI per catheter-days
Catheter utilization ratio (urinary catheter- days/patient-days) x 100
Use CDC/NHSN definitions for numerator data (SUTI only):

26. CAUTI Definitions Symptomatic Infection
Do catheterized patients have symptoms?
Asymptomatic Bacteriuria
Is it or is it not just colonization?

27. 2009 CDC/NHSN Surveillance Definitions 7 8
NHSN SUTI 1-A NHSN SUTI 2-A CLINICAL CAUTI NHSN ABUTI
FOLEY
1a-1 Foley is currently in place
1a-2 Foley is out within last 48 hours
2a-1 Foley is currently in Place
2a-2 Foley is out within last 48 hours
Is in place or out within last 48 hours
COLONY COUNT
≥100,000
≥1,000 and <100,000
SIGNS, SYMPTOMS MARKERS
1 of the following
--Temp 38C or >
--CVA pain/tender
--S/P pain/tender
--Urgency
--Frequency
--Dysuria
PLUS
--Positive dipstick
--Positive pyuria
--Fails NHSN def
--MS changes
--Urine character
--PVR/retention
--CBC leukocytosis
--Physician treated
--No symptoms
--Matched BC
(at least 1 org)

28. Does a change in definition change the outcome?
What are clinically relevant infections?8
Clinical indicators
Physician diagnosis/treatment
8 McGeer A., et al.. Definitions of Infections for Surveillance in Long Term Care Facilities, Am J Infect Control 1991; 19(1); 1-7.

29. Examples
Examples of programs that have been demonstrated to be effective include:
A system of alerts or reminders to identify all patients with urinary catheters and assess the need for continued catheterization
Guidelines and protocols for nurse-directed removal of unnecessary urinary catheters
Education and performance feedback regarding appropriate use, hand hygiene, and catheter care
Guidelines and algorithms for appropriate peri-operative catheter management, such as:
Procedure-specific guidelines for catheter placement and postoperative catheter removal
Protocols for management of postoperative urinary retention, such as nurse-directed use of intermittent catheterization and use of ultrasound bladder scanners

30. Automatic Foley Catheter Stop Orders
Although there have been several articles related to decreasing catheter usage, not all of these studies measured CAUTI as an outcome
At urinary catheter removal, 51 participants (19%) in the stop-order group developed urinary tract infection compared with 51 (20%) in the usual care group, relative risk 0.94, (95% CI, 0.66 to 1.33), P=0.71
At 7 days post catheterization, 28 of those tested (21.1%) in the stop-order group compared to 19 (16.7%) in the usual care group had urinary tract infections, relative risk 1.26 (95% CI, 0.75 to 2.14), P=0.38.
Study demonstrated that Foley catheter stop orders safely reduced Foley catheter usage but failed to reduce CAUTI

31. What are the risks and benefits associated with antimicrobial Foley Catheters?
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)

32. HOW DO WE GET TO “ZERO” CAUTI ?
CAUTI Prevention Techniques
Appropriate Foley catheter Utilization
Proper Foley catheter Insertion, Maintenance, Removal
Monitoring Compliance
Continuing Education and Training
CAUTI Prevention Technology
Bladder Scanners
Antimicrobial Foley Catheters
Its not about what type of CAUTI prevention method works best; its about using every available method to try and prevent every CAUTI

33. 2009 APIC CAUTI Elimination Guide11
PURPOSE
To provide evidence-based practice guidance for the prevention of Catheter Associated Urinary Tract Infection (CAUTI) in acute and long term settings.

34. “Although infection control measures are the mainstay approach for preventing device-related infection, adherence to such measures is often inconsistent. That is why infection control measures need to be complemented with truly protective technology.”
- Rabih O. Darouiche, M.D.
Taken From Medical Devices Pose Big Infection Threat Copyright 2009 by Virgo Publishing. By: By Michelle Beaver Posted on: 08/28/2008

35. One more reason to follow the patient with a Foley ……
The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications. 10
The SCIP goal is to reduce the incidence of surgical complications nationally by 25 percent by the year 2010.

36. SCIP 2009-2010 ver. 3.0a10 SCIP-Inf-9 3 data elements added
Urinary catheter removed on Postoperative Day (POD) 1or 2.
3 data elements added
Urinary Catheter
Catheter removal
Reasons for continuing urinary catheterization

37. Overview of personnel roles in effort to reduce the incidence of CAUTIs
Policy and best practice expertise
Provision of surveillance data and risk assessment
Consultation on infection prevention interventions
Facilitation of CAUTI- related surveillance improvement projects.
Proper insertion of the Foley catheter
Proper care and maintenance of the
Foley catheter system
Must be held accountable for compliance with interventions.
For Infection Preventionist
Direct Patient Caregiver

38. Conducting a CAUTI Risk Assessment
Purpose
To develop a surveillance, prevention and control plan based on facility specific data and conditions

39. Steps for Conducting a Risk Assessment
Assess whether an effective organizational program exists.
Assess population at risk
Point Prevalence Survey
Assess baseline outcome data
Determine financial impact

40. The Difference Between Coding and Surveillance and Reimbursement11
Criteria for CAUTI
Coding
HAI Surveillance Data
Physician documentation of UTI, cystitis, urethritis or pyelonephritis
Used to establish UTI
Surveillance definition must be used
Documentation or clarification UTI associated with catheter
MD must document
Code assigned
Documentation by MD not used.
Presence of catheter is documented by direct observation or in chart
Antibiotic Treatment
Not sole criteria but coder may seek MD clarification
Not used. Must use surveillance definition
Lab Data
Not used to establish UTI
May be used to seek clarification by coder
Surveillance definition.
Combined with other criteria in some cases
Clinical Signs and Symptoms
No coder may query MD for clarification but may query for cause of S/S
Surveillance definition. Combined with other criteria.

41. Additional Prevention Practice Measures
Assess need for Foley on a daily basis
Implement early removal processes
Physician reminder systems
Nurse driven protocols
Automatic stop orders
Early Foley removal for the surgical patient
Consider routine use of bladder scanners
Consider technology as addition to the comprehensive prevention plan

42. The Bladder Bundle Concept
Aseptic insertion and maintenance
Bladder ultrasound may avoid indwelling catherization
Condom or intermittent catherization in appropriate patients
Do not use the indwelling catheter unless you must.
Early removal of the catheter using reminders or stop orders.

43. Summary – Connecting the Dots!
Are CAUTIs a Target for Improvement?
Change in CDC Definition/Reporting to NHSN
Changes in CMS Reimbursement
Guidelines
SHEA Compendium
HICPAC/CDC
SCIP
APIC Guide to Elimination of CAUTIs

44. Why Prevent CAUTIs CAUTIs Are Important
CAUTIs Have Serious Clinical and Economic Consequences
Actions Can be Taken to Reduce CAUTIs

45. Thank you!
QUESTIONS?

46. References
Weinstein RA. Nosocomial Infection Update. Emerging Infectious Diseases ; 4(3):
Salgado CD, Karchmer TB, and Farr BM. Prevention of Catheter-Associated Urinary Tract Infection. In Prevention and Control of Nosocomial Infections, 4thEd. Wenzel RP Ed. Philadelphia: Lippincott, Williams, and Wilkins, 2003.
Saint S and Chenoweth CE. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin N Am ; 17:
Public health focus: surveillance, prevention and control of nosocomial infections. MMWR Morb Mortal Wkly Rep ; 41:
Classen D. Assessing the effect of adverse hospital events on the cost of hospitalization and other patient outcomes. University of Utah, 1993.
SHEA Compendium, Strategies to Prevent Catheter Associated Urinary Tract Infections in Acute Care Hospitals. Infect Control Hospital Epidemiol 2008; 29: S41-S0.
National Healthcare Safety Network (NHSN) Manual, March 2009.
McGeer A., et al.. Definitions of Infections for Surveillance in Long Term Care Facilities, Am J Infect Control 1991; 19(1); 1-7.
HICPAC. Guideline for Prevention of Catheter-Associated Urinary Tract Infections; 2009.
Surgical Care Improvement Project., 2010; Version 3.0a.
APIC Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs), 2008.

47. WEB SITES for Guidelines/Compendiums

48. Measurement: Examples of Process Measures
Compliance with hand hygiene
Compliance with educational program
Compliance with documentation of catheter insertion and removal
Compliance with documentation of indications for catheter placement

49. Intermittent catheterization – consider for:
Supplemental Prevention Strategies: Alternatives to Indwelling Catheterization
Intermittent catheterization – consider for:
Patients requiring chronic urinary drainage for neurogenic bladder
Spinal cord injury
Children with myelomeningocele
Postoperative patients with urinary retention
May be used in combination with bladder ultrasound scanners
External (i.e., condom) catheters – consider for:
Cooperative male patients without obstruction or urinary retention

50. Supplemental Prevention Strategies: Examples
Consideration of alternatives to indwelling urinary catheterization (II)
Use of portable ultrasound devices for assessing urine volume to reduce unnecessary catheterizations (II)
Use of antimicrobial/antiseptic- impregnated catheters (IB, after first implementing core recommendations for use, insertion, and maintenance )
The following slides will provide further details on supplemental strategies…
httpwww.cdc.gov/hicpac/cauti/001_cauti.html ://

51. Core Prevention Strategies: Specific recommendations (IB)
Implement quality improvement programs to enhance appropriate use of indwelling catheters and reduce risk of CAUTI
Examples:
Alerts or reminders
Stop orders
Protocols for nurse-directed removal of unnecessary catheters
Guidelines/algorithms for appropriate perioperative catheter management

52. Core Prevention Strategies Specific recommendations (IB)
Maintain unobstructed urine flow
Keep catheter and collecting tube free from kinking
Keep collecting bag below level of bladder at all times (do not rest bag on floor)
Empty collecting bag regularly using a separate, clean container for each patient. Ensure drainage spigot does not contact nonsterile container.

53. Core Prevention Strategies Specific recommendations (IB)
Following aseptic insertion, maintain a closed drainage system
If breaks in aseptic technique, disconnection, or leakage occur, replace catheter and collecting system using aseptic technique and sterile equipment
Consider systems with preconnected, sealed catheter-tubing junctions (II)
Obtain urine samples aseptically

54. Core Prevention Strategies Specific recommendations (IB)
Insert catheters using aseptic technique and sterile equipment (acute care setting)
Perform hand hygiene before and after insertion
Use sterile gloves, drape, sponges, antiseptic or sterile solution for periurethral cleaning, single- use packet of lubricant jelly
Properly secure catheters

55. Core Prevention Strategies Specific recommendations (IB)
Insert catheters only for appropriate indications
Minimize use in all patients, particularly those at higher risk of CAUTI and mortality (women, elderly, impaired immunity)
Avoid use for management of incontinence
Use catheters in operative patients only as necessary

56. Core Prevention Strategies Specific recommendations (IB)
Insert catheters only for appropriate indications

57. Core Prevention Strategies (all Category IB)
Insert catheters only for appropriate indications
Leave catheters in place only as long as needed
Ensure that only properly trained persons insert and maintain catheters
Insert catheters using aseptic technique and sterile equipment (acute care setting)
Following aseptic insertion, maintain a closed drainage system
Maintain unobstructed urine flow
Hand hygiene and Standard (or appropriate isolation) Precautions

58. Prevention Strategies
Supplemental Strategies
Some scientific evidence
Variable levels of feasibility
Core Strategies
High levels of scientific evidence
Demonstrated feasibility
*The Collaborative should at a minimum include core prevention strategies. Supplemental prevention strategies also may be used. Most core and supplemental strategies are based on HICPAC guidelines. Strategies that are not included in HICPAC guidelines will be noted by an asterisk (*) after the strategy. HICPAC guidelines may be found at

59. Evidence-based Risk Factors for CAUTI
Symptomatic UTI
Bacteriuria
Prolonged catheterization*
Disconnection of drainage system*
Female sex†
Lower professional training of inserter*
Older age†
Placement of catheter outside of OR†
Impaired immunity†
Incontinence†
Diabetes
Meatal colonization
Renal dysfunction
Orthopaedic/neurology services
* Main modifiable risk factors † Also inform recommendations