1. ELIMINATING THE RISK FOR CATHETER-ASSOCIATED URINARY TRACT INFECTIONS
CAUTI CRUSHERS
ELIMINATING THE RISK FOR CATHETER-ASSOCIATED URINARY TRACT INFECTIONS

2. OBJECTIVES
Describe risk factors associated with urinary tract infections
Identify catheter-associated urinary tract infection (CAUTI) reduction strategies in order to implement into clinical practice.
Demonstrate setting up a sterile field for urinary catheterization.
Demonstrate the use of proper aseptic technique when inserting a urinary catheter.

3. Good morning. Welcome to a culture of Excellence
Good morning. Welcome to a culture of Excellence! We are honored to partner with you all – a team of highly motivated healthcare workers who have clear, achievable goals; who like to describe their workplace as “the best,” and who enjoy their jobs.

4. Founder of Modern Nursing Father of Infection Control
Florence Nightingale
Founder of Modern Nursing
In the history of the medical and nursing profession, one can look back and see vast changes that have occurred to bring about patient safety awareness.
Gone are the days of active resisters – those people who prefer doing things the way they have always done them.
Gone are ineffective leaders and underperformers who were not held accountable.
What brought about the change?
The “would haves,” the “could haves,” and the “should haves?” Undoubtedly!
It was the culmination of 25 years of “Ah-ha” moments that collectively brought about change.
Ignaz Semmelweis
Father of Infection Control

5. Evidence-Based, Best Practice
And yet, perhaps it was also the heart of champions who became patients’ advocates and catalysts of cultural change among the healthcare world.
A dramatic change that ushered in Evidence-Based, Best practice for all patients, every encounter, all the time!
And it is here to stay!
CAUTI is highly preventable, but continues to be a major Healthcare-associated infection, and occurs everywhere, including our UMC; therefore, it’s a Professional Practice Gap.
Please join us as we endeavor to bring about yet another positive change – one that will reduce catheter-associated urinary tract infections, or CAUTIs.
Evidence-Based, Best Practice

6. CAUTI CRUSHERS 101 Why is this important?
How will this benefit our patients?
Give me the facts!
Welcome to CAUTI Crushers 101!
We always want to know the rationale behind why a change in practice is important.
If it benefits the patient, it is the right thing to do!
Here are a few facts that will drive that response home.

7. What Are CAUTIs? A urinary tract infection (UTI):
Infection involving any part of the urinary system, including the urethra, bladder, ureters and kidneys.
Most common type of healthcare-associated infection (HAI) reported to the National Healthcare Safety Network (NHSN)

8. Urinary tract infections account for more than 30% of infections reported by acute care hospitals in the United States. What percentage of those are associated with a urinary catheter?
25%
50%
75%
90%

9. ANSWER
C. Approximately 75% are associated with a urinary catheter – tube inserted into the bladder through the urethra to drain urine

10. Clinical Manifestations
Vary Greatly
Asymptomatic bacteriuria → overwhelming sepsis
Symptomatic UTI:
Lower abdominal, suprapubic, or flank pain
Systemic symptoms:
Nausea
Vomiting
Fever

11. Burden of Illness Of patients who receive urethral catheters:
Bacteriuria rate is ≈ 5% per day
Among those with bacteriuria:
≈ 10% will develop symptoms of UTI
Up to 3% will develop bacteremia
Direct medical costs:
Symptomatic UTI: $600-$1,000
Catheter-associated bacteremia: ≈ $3,000 per episode

12. CAUTI Facts CAUTIs can result in increased: Morbidity Mortality
Hospital costs
Length of Stay

13. What percentage of patients who are hospitalized receive a urinary catheter?
b %
c %
d %

14. ANSWER
B % of hospitalized patients receive urinary catheters during their hospital stay

15. What is the most important risk factor for developing a catheter-associated UTI?
Insertion technique (sterile field, aseptic technique)
Peri-care; daily cleansing of perineal area surrounding the catheter
Prolonged use of the urinary catheter
Patient’s age, gender and mobility status

16. Answer
C. Prolonged use of the urinary catheter

17. CAUTI Stats 3% increase in CAUTIs nationally from 2009-2012
12% of Texas hospitals have a Standardized Infection Ratio (SIR) worse than the national SIR of 1.03 (2013)

18. Ruling by CMS
Hospital-acquired conditions (HACs): conditions that patients did not have when they were admitted to the hospital, but which developed during their hospital stay.
Centers for Medicare & Medicaid Services (CMS) now holds U. S. hospitals accountable for not preventing certain HACs.
CMS required to choose at least 2 conditions that:
Are high cost and/or high volume; and
Could reasonably have been prevented through the application of evidence-based guidelines.
CMS chose 10 conditions, and CAUTI was one of them.

19. Essential Hospitals Engaging Network (EHEN)
Formerly the National Association of Public Hospitals, EHEN initiated a program in 2012 for public hospitals
Goal: Reduce certain infections and conditions by 40% by the end of 2013 when compared to 2010 data
CAUTIs were selected as one of the target infections
UMC joined that initiative. Although we met goal for central line-associated bloodstream infections, we did not meet goal for CAUTIs.
We are committed to closing this Professional Practice Gap!

20. CAUTI RATES AT UMC

22. Challenge for 2014
Same challenge has been presented to UMC for 2014: reduce CAUTIs by 40% compared to our 2010 data
As part of their Nurse Residency program, 2 of UMC’s ICU nurses stepped up to the plate and offered to initiate a performance improvement project to reduce CAUTIs in our ICU.
I would like to introduce Cindy Hernandez, RN, and her co-worker Mariam Yazdi (photo), who cannot be with us today because she is in Thailand on her honeymoon!
Cindy and Mariam presented their CAUTI Elimination Plan to the Critical Care Committee in August, which was well received and endorsed by the Critical Care Physicians
We have asked them to present their PI Project to you.
Term CAUTI Crushers was their own inspired name – a name that we have whole heartedly adopted in our quest to eliminate CAUTIs.
In their presentation, Cindy and Mariam have incorporated the pathophysiology of a UTI and also components of the CAUTI Bundle –key elements that, when applied together on each adult patient with a urinary catheter, and for every day the catheter is in place, can have a significant impact on eliminating the risk for a CAUTI.
Please welcome Cindy at this time.

23. Mariam Yazdi, RN, BSN
Cindy Hernandez, RN, BSN

24. CINDY HERNANDEZ MARIAM YAZDI
CAUTI Crushers
CINDY HERNANDEZ
MARIAM YAZDI

25. CAUTI REDUCTION GOAL Reduce incidence of CAUTIs by 15% in 2014.

26. CAUTI ELIMINATION ACTION PLAN
Cultivate enthusiasm
Increase Awareness
Provide Ongoing Education
Institute PI Tool – Immediate Removal of foley
In-service Proper Catheter Maintenance
Ensure Intradepartmental Collaboration

27. Organisms enter the bladder by 3 ways:
At time of catheter insertion
Through the catheter lumen (from a colonized drainage bag)
Along external surface of the catheter (migrate along the catheter-mucosal interface)

28. all of the above; a & b only; c & d only
When is it appropriate to use an indwelling urinary catheter ? a. Need for strict, accurate output measurement as per MD orders b. For end of life issues regarding comfort when requested c. Strict prolonged immobilization (as in pelvic fracture) d. To help promote healing of Stage III and Stage IV sacral or coccyx pressure ulcers
all of the above;
a & b only;
c & d only

29. When Is a Catheter Appropriate?
A. All of the above
In addition, the following conditions may warrant using an indwelling urinary catheter:
Bladder Injury
Acute Urinary Retention
Acute bladder outlet obstruction
Select peri-operative needs

30. Catheter Insertion Components
Hand Hygiene prior to and after insertion
Proper sterile field set up
Aseptic Technique
Remember, inserting a foley is a component of evidence-based practice, no matter what the discipline. It requires careful attention and is not just a “task” to be completed

31. UTI
Bundle
Approach
Catheter
Maintenance

32. AWARENESS!
LABEL THE
FOLEY BAGS
In report, what Foley day is this?

33. KEEP URINE FLOWING FREELY
No kinks in tubing or
Securement Device

34. URINE FLOW  BAG
BLADDER
BAG

35. Securement Device

36. MORE HOUSEKEEPING KEEP FOLEY UNIT OFF FLOOR.
Empty Foley bag frequently; avoid allowing the spigot to touch the collection container
KEEP FOLEY UNIT OFF
FLOOR.

37. Tools FOLEY CARE Foley/Perineal Care frequency – EVERY 12 HOURS!
Step by step procedures with rationales.

38. Don’t Forget!
Bathe patients with product containing Chlorhexidine Gluconate (CHG), avoiding mucosal areas
Place CUROS cap on sampling port
Maintain a closed system
Collect urine sample from sampling port closest to insertion site.
DO NOT COLLECT URINE FROM DRAINAGE BAG.

39. Early Removal of Indwelling Catheters
14 studies have evaluated urinary catheter-reminders and stop-orders
Written, computerized, or nurse-initiated
Summary of the Evidence:
Significant reduction in catheter use (≈ 2.5 days)
Significant reduction in infection (≈ 50%)
No evidence of harm (i.e., re-insertion if necessary)

40. IMMEDIATE CATHETER REMOVAL
Review hospital policy and practice Foley removal
Catheter removed
MD Order
HUCs RN
Assistant

41. CAUTI ELIMINATION ACTION PLAN
Educate nurses and nursing support staff
Nurse Technicians
CNAs
Unit Council and Staff Meetings
Quarterly Education: for new hires; maintaining Unit competence

42. DATA COLLECTION PI Monitoring Tool
Covers all areas of foley management, including the UTI Bundle
Collaboration with Quality Management
Nurse residents round 2 times per week.
Quality Management rounds 1-2 times per week.
Rounding started on 8/18/14.

43. Alternatives to the Indwelling Catheter
Bladder Ultrasound
Intermittent Catheterization
Condom Catheter for males
Area for Research: female external catheters

44. References
Eliminating Catheter-Associated Urinary Tract Infections. Health Research & Educational Trust, Chicago: July Accessed at Educational Trust, Chicago: July Accessed at
Educational Tools | catheterout.org. (2014, January 1). Retrieved August 15, 2014.
Health and Research Educational Trust; CUSP, Eliminating CAUTI: A National Patient Safety Imperative. (2013). Interim Data Report on the National On the CUSP: Stop CAUTI Project. Retrieved from
Martinez-Resendez, MD, M., et al. (2014). Impact of daily chlorhexidine baths and hand hygiene compliance on nosocomial infection rates in critically ill patients. American Journal of Infection Control, 42,
Rebmann, T., & Greene, L. (2014). Preventing Catheter-associated Urinary Tract Infections: An Executive Summary Of The Association For Professionals In Infection Control And Epidemiology, Inc, Elimination Guide. American Journal of Infection Control,
Strategies to Prevent Catheter‐Associated Urinary Tract Infections in Acute Care Hospitals. (2008). Infection Control and Hospital Epidemiology, Vol. 29(S1). Retrieved August 1, 2014, from

45. WILL YOU BE A CAUTI CRUSHER?
PREVENTION TEAM
With every new endeavor, there comes a challenge to educate, initiate, monitor and sustain good results.
Getting positive results and sustaining those results is critical to a successful program.
WILL YOU BE A CAUTI CRUSHER?

46. And They All Came Tumbling Down
Today, we invite you to become champions where you are planted.
It doesn’t have to be only in the Critical Care areas.
CAUTIs are monitored in all nursing units.
Omitting one of the components of the UTI Bundle is like forgetting to lay a foundational block in a pyramid of bricks.
The pyramid will crumble. And so will our attempts to reduce CAUTIs.
And They All Came Tumbling Down

47. The Whole Bundle – Gotta Have It!
It takes teamwork, accountability and the mindset that, “If I were that person in the hospital, would I want all of the necessary steps taken to prevent me from getting a CAUTI?
The answer is obvious – of course you would.
If this were your best friend or child or parent, wouldn’t you want us to apply ALL elements of the Bundle, all of the time, so that a potential CAUTI will be crushed?
Sure you would!
The Bundle Approach is Evidenced-Based; Can we compare the healing power of chocolate to the healing virtue of the UTI Bundle? Probably not! But the response is still the same! Gotta have the whole bundle!

48. So we invite you now to participate in our Sim Lab
So we invite you now to participate in our Sim Lab. We will give you the opportunity to practice setting up a sterile field, inserting a foley catheter, and then going through different scenarios with a patient who has an indwelling catheter.