Catheter-Associated Urinary Tract Infection (CAUTI) National Patient Safety Goal 07.06.01 Preventing Catheter-Associated Urinary Tract Infections (CAUTI) 9/7/2018

OBJECTIVES Describe appropriate screening for UTI Describe appropriate treatment of asymptomatic bacteriuria Describe the criteria for diagnosing a CAUTI List the appropriate versus inappropriate use of indwelling urinary catheters Identify the risk factors that contribute to CAUTI List the bundles involved in prevention of CAUTI 9/7/2018

The pathway of pathogens to the urinary tract 9/7/2018

Clinician Practice 9/7/2018

Clinician Practice Screening Urine The practice: “screening culture on admission”, “standing orders” or “reflex orders” for urine cultures based on urinalysis results: May increase utilization of unnecessary antibiotics, testing, consults May adversely affect patients exposing them to inappropriate testing and treatments. 9/7/2018

Clinician Practice 9/7/2018

Clinician Practice 9/7/2018

Clinician Practice 9/7/2018

Clinician Practice 9/7/2018

Clinician Practice 9/7/2018

Clinician Practice 9/7/2018

Urine Specimen If a urinary tract infection is suspected indwelling urinary catheter should be replaced before urine collection obtained. It is important to identify a true UTI. 9/7/2018

Catheter-Associated Urinary Tract Infection (CAUTI) UTI causes ~ 35% of hospital-acquired infections Most due to urinary catheters ~20% of inpatients are catheterized Leads to increased morbidity and healthcare costs CMS does not reimburse for the additional costs of hospital-acquired CAUTI Urinary tract infection causes over 40% of hospital-acquired infections, making it the most common nosocomial infection. Most of these infections are due to urinary catheters. 25% of inpatients are catheterized at some time during their hospital stay. Nosocomial UTI leads to increased morbidity and increased costs.

What is CAUTI (CDC defined) UTI: Patient has at least one of the following signs or symptoms: fever (>38.0°C), suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency, urinary frequency, dysuria Patient has a urine culture with no more than two species of organisms identified, at least one of which is a bacterium of ≥10˄5 CFU/ml Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place for >2 calendar days on the date of event, with day of device placement being Day 1, AND an indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for > 2 calendar days and then removed, the date of event for the UTI must be the day of discontinuation or the next day for the UTI to be catheter-associated. 9/7/2018

Clinician Practice Signs and symptoms “new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain, costovertebral angle tenderness; acute hematuria; pelvic discomfort” 9/7/2018

Clinician Practice 9/7/2018

Risk Factors for CAUTI Extended use of foley Microbial colonization of the drainage bag Female gender Diabetes Errors in catheter insertion 9/7/2018

Indwelling Urinary Catheters Studies have shown that initial catheterization was inappropriate 21% to 50% of the time, and that continued catheter use was inappropriate almost half of the days that patients are catheterized. A common reason for inappropriate continued catheter use is that physician is not aware that catheter is in place. Physicians should assess daily whether or not their catheterized patient still requires the catheter. References Am J Med 2000 Oct 15;109(6):476-80. Are physicians aware of which of their patients have indwelling urinary catheters? Saint S, Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, Lipsky BA, Hofer TP. http://catheterout.org/?q=physician-engagement%20 9/7/2018

Expert Consensus of Appropriate Versus Inappropriate Use of Urinary Catheters Annals of Internal Medicine, 2015, Website: http://annals.org/article.aspx?articleid=2280677 9/7/2018

Patients perspective Satisfaction survey of 100 catheterized VA patients: 42% found the indwelling catheter to be uncomfortable 48% stated that it was painful 61% noted that it restricted their ADLs 2 patients provided unsolicited comments that their catheter “hurt like hell” (Saint et al. JAGS 1999)

Latex and Urinary Catheters Most urinary catheters do contain latex This provides the pliable soft consistency. EIRMC does have latex free catheters if needed. 9/7/2018

Post Removal Orders Interventions should be employed to encourage spontaneous voiding: Early mobilization Toilet or bedside commode to allow for upright position Bladder scan for: Bladder discomfort Urge to void but is unable to do so Incontinent Lippincott Procedures for Bladder ultrasonography, and urinary incontinence care. 9/7/2018

Reduce the Risk of CAUTI 9/7/2018

Reduce the Risk of CAUTI 9/7/2018

Nurses Role/CAUTI Bundles Hand Washing Aseptic technique during insertion Daily peri-care/bathing Bag below the bladder Secure in place Closed system Avoid contamination when emptying 9/7/2018

No Dependent Loop. Go with the Flow Nurses Role/CAUTI Bundles No Dependent Loop. Go with the Flow 9/7/2018

How does CAUTI compare? Despite the small increase in the CAUTI rate, initial evidence from 2014 indicates this rate could be declining. Despite the marked decreases in most HAI categories, the U.S. did not meet 2013 goals. Source: CDC, "Healthcare-associated Infections (HAI) Progress Report,” January 13, 2015 9/7/2018

Clinician Practice 9/7/2018

Summary Avoid placing urinary catheter not indicated Order removal when not clinically indicated Consider alternatives: External catheters, frequent toileting, and briefs Avoid ordering urine cultures unless clinical signs of UTI present or other reasons prevail Don’t treat aseptic bacteriuria except for selected conditions If catheter is necessary, educate patient about risk of UTI 9/7/2018

Criteria for a Continuous Foley Catheter Summary Criteria for a Continuous Foley Catheter Acute urinary retention Perioperative use in selected surgeries Assist in skin healing for incontinent patient Palliative care Gross hematuria/irrigation Prolonged immobilization for trauma or surgery Hourly I/O in the setting of critically ill patient Why need that catheter? does your patient 9/7/2018

References Lippincott; care of patient with indwelling foley catheter Carolyn V. Gould, MD, MSCR ; Craig A. Umscheid, MD, MSCE ; Rajender K. Agarwal, MD, MPH; Gretchen Kuntz, MSW, MSLIS ; David A. Pegues, MD and the Healthcare Infection Control Practices Advisory Committee (HICPAC) The Joint Commission. (2014). Standard NPSG.07.06.01. Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: The Joint Commission. (Level VII) Healthcare Infection Control Practices Advisory Committee. (2010). "Guideline for prevention of catheter-associated urinary tract infections, 2009" [Online]. Accessed September 2014 via the Web at http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf (Level I) Institute for Healthcare Improvement. (2012). How-to guide: Prevent catheter-associated urinary tract infection. Cambridge, MA: Institute for Healthcare Improvement. (Level VII) Association of Professionals in Infection Control and Epidemiology (APIC). (2014). "APIC implementation guide: Guide to preventing catheter-associated urinary tract infections" [Online]. Accessed September 2014 via the Web at http://apic.org/Resource_/EliminationGuideForm/6473ab9b-e75c-457a-8d0f-d57d32bc242b/File/APIC_CAUTI_web_0603.pdf (Level IV) 9/7/2018