Catheter- Associated Urinary Tract Infections Kristy Gambill University of Wyoming

PICOT Question For hospitalized patients with an indwelling urinary catheter, does the use of a criteria based reminder system reduce the risk of catheter-associated urinary tract infections compared to the use of no reminder system?

Search Process Databases: PubMed, ProQuest Nursing and Allied Health Source Key Terms: catheter-associated urinary tract infection (CAUTI), indwelling urinary catheter, infection prevention, health care-associated infections, prevalence Articles limited to the past 10 years Articles all peer reviewed and chosen according to their credibility, significance, and applicability.

Background The most common hospital-acquired infection is a catheter-associated urinary tract infection (CAUTI). CAUTIs are formed by biofilms which are composed of clusters of microorganisms and extracellular matrix that form on the internal and external surfaces of urinary catheters shortly after insertion and then ascend the catheter to the bladder. CAUTIs can result in sepsis, prolonged hospitalization, additional hospital costs, and mortality. Annually, CAUTIs are associated with up to 13,000 deaths and around $450 million of direct health care costs in the US. Increased duration of catheterization is the greatest risk for development of a CAUTI as the estimated risk for infection is at least 5% per day of catheterization. 70% of CAUTIs may be preventable. Chenoweth et al., 2014; Mori, 2014; Elpern et al., 2009

Indwelling Urinary Catheter

Criteria Based Reminders Criteria based reminders are a daily check list that either the nurse or physician completes and based off its outcomes, the nurse or physician will know if its time to remove the indwelling catheter or not. Catheters are often maintained in the absence of any clear indication. Relying on physician orders alone may be inadequate for the management of catheters. In one study, 40% of physicians were unaware that their patient had a catheter. The goal of this reminder system is to decrease the amount of unnecessary catheter days to therefore reduce the risk of CAUTIs. Elpern et al., 2009; Mori, 2014; Chen et al., 2013

Indications for indwelling urinary catheters CDC and Prevention recommends the use of urinary catheters only when indicated and then prompt removal of catheter use when it is no longer appropriate. There are approximately 5 million catheters placed annually in the US, but 50% of the patients do not meet the appropriate indications. Elpern et al., 2009; Mori, 2014

Appropriate VS Inappropriate Indications Urinary Retention or bladder outlet obstruction As a substitute for nursing care of a patient with incontinence Patient to undergo prolonged (>4 hrs) procedure- should be removed in PACU As a means of obtaining urine for culture or other diagnostic tests when a patient can voluntarily void Urological surgery or other surgery on contiguous structure of the genitourinary tract For prolonged postoperative duration with appropriate indications Epidural catheter in place Diuresis Deep sedation/paralysis Frequent, but nonessential, determination of urinary output Stage III or IV skin ulcers Patients preference Aid in healing of open sacral or perineal wounds in incontinent patients Movement intolerance due to terminal illness or severe impairment Improvement in comfort for end of life care if needed Elpern et al., 2009; Chen et al., 2013

Elpern et al., 2009; Chenoweth et al., 2014 Prevention of CAUTIs Reducing the risk of developing a CAUTI requires avoiding urinary catheters when they are not indicated, and removing the catheters as soon as the indications for their use are no longer present. In 2005, a nationwide survey identified that 1/3 of hospitals did not conduct surveillance for UTIs, more than ½ did not monitor urinary catheters, and ¾ did not monitor the duration of catheterization. Elpern et al., 2009; Chenoweth et al., 2014

Prevention Strategies (if applicable) Avoid insertion and remove when indicated Alternatives: Intermittent urinary catheters Condom catheters for males Portable bladder ultrasound scanner Aseptic techniques for care of catheters: Sterile insertion Closed drainage system Maintain gravity drainage Avoid routine bladder irrigation Chenoweth et al., 2014

Research

Reducing Use of Indwelling Urinary Catheters and Associated Urinary Tract Infections Elpern et al. (2009) conducted a 6-month study in a MICU on patients that had an indwelling urinary catheter during their stay at the hospital. These patients were evaluated daily by using criteria for appropriate catheter continuance. Recommendations were made to discontinue indwelling urinary catheters in patients who did not meet the criteria. Results from the 6-month intervention period were compared to the preceding 11 months where no criteria was applied. Elpern et al., 2009

Urinary Catheter Device Days and Rates of CAUTIs Before and During the Intervention Period Variable Before Intervention During Intervention Mean # of device days per month 311.7 238.6 Mean # of infections per 1000 device days 4.7 Elpern et al., 2009

Elpern et al., 2009

Using a Criteria-Based Reminder System to Reduce Use of Indwelling Urinary Catheters and Decrease Urinary Tract Infections Chen et al. (2013) conducted an 8-month study in a respiratory ICU where all patients who had an indwelling urinary catheter for more than 2 days were randomly assigned to either the intervention group (use of a criteria-based reminder system) or the control group (no reminder). Chen et al., 2013

Chen et al., 2013

A- Voiding Catastrophe: Implementing a Nurse Driven Protocol Mori (2014) conducted a 6-month, all inpatient, study comparing the prevalence of catheter usage, dwell time, and CAUTIs before and after the implementation of the indwelling urinary catheter removal protocol intervention. Mori, 2014

Catheter Associated Urinary Tract Infections Number of CAUTIs Patients with Indwelling Catheters Occurrence of CAUTIs Pre-Intervention 3 389 0.77% 3 Months After Intervention 1 282 0.35% Mori, 2014

Indwelling Urinary Catheter Removal Protocol Mori, 2014

Conclusion Overall, the results of the studies suggests that the implementation of a criteria-based reminder system will not only decrease the duration of indwelling urinary catheters, but also decreases the incidents of CAUTIs. Utilizing a reminder approach can prevent CAUTIs and should be strongly considered to enhance the safety of patients.

West Park Hospital- Cody, WY After presenting this project to the staff at West Park Hospital, the Nursing Director was amazed at the rates of inappropriate indwelling catheter usage even at WPH. WPH is now talking about the possibility of implementing a criteria-based reminder system to reduce the inappropriate catheter days and risk of CAUTIs.

References Chen, Y., Chi, M., Chen, Y., Chan, Y., Chou, S., Wang, F. (2013). Using a Criteria Based Reminder to Reduce Use of Indwelling Urinary Catheters and Decrease Urinary Tract Infections. American Journal of Critical Care, 22(2), 105-114. Chenoweth, C.E., Gould, C.V., Saint, S. (2014). Diagnosis, Management, and Prevention of Catheter Associated Urinary Tract Infections. Infectious Disease Clinics of North America, 28(1), 105-119. Elpern, E.H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., Lateef, O. (2009). Reducing Use of Indwelling Urinary Catheters and Associated Urinary Tract Infections. American Journal of Critical Care, 18(6), 535-541. Mori, C. (2014). A-Voiding Catastrophe: Implementing a Nurse Driven Protocol. MedSurg Nursing, 23(1), 15-28.