Purpose

Improvement Tools/Methods

Limitations / Lessons Learned

Fishbone• Catheter associated urinary tract infection (CAUTI)

prevention• To assist with the rollout of Bayfront Medical Center’s

Catheter Bundle• To assist in decreasing the incidence of CAUTI• Most common type of Healthcare Associated Infection (HAI)• 80% of urinary tract infections developed during

hospitalization occur from the use of indwelling urinary catheters (560K annually) (CDC, 2013)

• As many as 25% of patients receive a catheter during their hospital stay

• Prevention is key! Research shows the use of a prevention “bundle” significantly lowers the rate of CAUTI’s hospital wide.

• Excess length of stay • Increased morbidity and mortality (~13,000 deaths annually) • Increased cost (500 million per year nationally)

Clarke et al. (2013) studied the effectiveness of a bundle of 4 evidence-based interventions over a 9 month period in a community hospital. Bundle: • Exclusive use of alloy/silicone catheters• Use of securing devices to prevent movement of the catheter after insertion• Repositioning the catheter if found to be touching the floor• Requirement for documentation for most surgical patients for the catheter to remain in place on post

op day 1 or 2 (patients who underwent perineal, gynecological and urological surgeries were exempt from this)

Results: Within 6 months of implementing the bundle, CAUTI rate was decreased by 71%, with an annual cost savings of $30,816-$120,696. The interventions of the bundle are relatively simple to implement and cost effective.

Barriers: exist in many hospitals! Research illustrates there are several barriers that contribute to the failure of using a bundle & reducing CAUTI rates. Krein et al. (2013) investigated the bundle in 12 hospitals in Michigan and identified common barriers to effectively using the bundle to decrease CAUTIs, and strategies to address these barriers.Results: • Common barriers were as follows:o Difficulty with nurse & physician engagemento Patient & family request for indwelling cathetero Catheter insertion techniques & customs in the emergency department

• Strategies to address barriers:o Incorporating urinary management (planned toileting, etc.) as part of other patient safety

programs, such as fall reductiono Explicitly discussing risks of indwelling catheters with patients & familieso Engaging with ER nurses and physicians to implement a process that ensures the appropriate

indications for catheter useFindings: provide a model for implementing strategies to reduce CAUTI, and information to teach CAUTI prevention related activities in hospitals throughout the country

Katie Jackson, Katie Bitetto, Kellie Fowke, Beth Williamson—USF College of Nursing

• Have alternatives been considered? • Obtain consent• Aseptic insertion

o Right size and material (Do they have a latex allergy?)o Put date and time of insertiono Collect specimen if UTI suspected

• New foley if arrived to hospital with one (get urine sample)• Secure to patient • Bundle Check List—Maintain a closed drainage system• Performed daily:

o Hand hygieneo Clean technique for maintenance o Drainage bag below the level of the bladdero Daily meatal hygiene (qShift)o Monitor for S&S of infection—sample taken from the port asepticallyo Assess for kinks, patency o Document output if required (minimal 30mL/hr)—empty when ½ full or

q8ho Assess need for continued useo Hanging on bed, not side rails, not on floor

• Empty prior to transfer• Drain urine in tube• Make sure spigot does not come into contact with nonsterile container • Consider alternatives (condom cath, bladder scan, straight cath,

incontinence issue, antimicrobial-impregnated catheters such as silver-alloy coated catheters)

• After removalo Encourage PO fluidso Bladder scan after 6h if pt hasn’t voided• If 300-500cc present, straight cath• If >500 new foley and notify physician• Notify physician if cannot spontaneous void within 10h

ReferencesCenter for Disease Control and Prevention. (2010). Catheter associated urinary tract infections (CAUTI). Retrieved from http://www.cdc.gov/HAI/ca_uti/uti.html Clarke, K., Tong, D., Pan, Y., Easley, K., Norrick, B., Ko, C., … Stein, J. (2013). Reductions in catheter-associated urinary tract infections by bundling interventions. International Journal for Quality in Health Care, 25(1), 43-49. doi: 10.1093/intqhc/mzs077Curran, E. & Murdoch, H. (2009). Aiming to reduce catheter associated urinary tract infections (CAUTI) by adopting a checklist and bundle to achieve sustained system improvements. Journal of Infection Prevention, 10(2), 57-61.Gould, C., Umscheid, C., Agarwal, R., Kuntz, G., MSW, Pegues, D. (2009). Guideline for prevention of catheter associated urinary tract infections. Healthcare Infection Control Practices Advisory Committee. Krein, S., Kowalski, C., Harrod, M., Forman, J., & Saint, S. (2013). Barriers to reducing urinary catheter use: A qualitative assessment of a statewide initiative. JAMA International Medicine, 173(10), 881-886. doi: 10. 1001/jamainternmed.2013.105Lewis, S. S., Knelson, L., Moehring, R. W., Chen, L. F., Sexton, D. J., & Anderson, D. J. (2013). Comparison of non-intensive care

unit (ICU) versus ICU rates of catheter-associated urinary tract infection in community hospitals. Infection Control and Hospital Epidemiology. 34(7). doi: 10.1086/671000

Background

Indications for Foley• Output needs to be monitored • Ineffective emptying of bladder• Lack of bladder control and kidneys are not

functioning optimally• Open wound/sores that may be soiled with urine• Severely ill or disabled (prolonged

immobilization) • Peri-operatively • Comfort for end of life care• NOT FOR INCONTINENCE

Lewis et al. (2013) performed a retrospective analysis of collected data from fifteen hospitals which identified hospital-acquired CAUTI in both ICU and non-ICU settings.• Historically, more effort has been given to

survey and prevent CAUTI in ICU patients • Out of the total collection of CAUTI, 72% of

CAUTIs occurred in non-ICU patients while 28% occurred in ICU

• The research group determined that non-ICU patients are an important population for prevention efforts for CAUTI reduction

• The National Healthcare Safety Network (NHSN) observed rates of CAUTI were consistent with this study’s findingsTeam Members

All Healthcare Personnel that are involved in patient care including but not limited to: • Nurses• Patient Care Technicians • Physicians • Nurse Practitioners • Licensed Practical Nurse• Transport personnel • Physical Therapy • Respiratory Therapy

MeasuresMeasures: comparing the past and current CAUTI rates to future rates• Infection—cath bypasses the bodies natural defense mechanism of micturition when organisms are

naturally flushed from the lower urinary tracto Enables organism to gain direct accesso Biofilm forms that can lead to infection or occlusiono Due to insertion or maintenance

• Secondary infections: Bloodstream infection• Complications of antibiotic treatment: C Diff• Multi drug resistant organisms • Use standardized methodology for performing CAUTI surveillanceo Number of CAUTI per 1000 catheter-days o Number of bloodstream infections secondary to CAUTI per 1000 catheter-days o Catheter utilization ratio: (urinary catheter days/patient days) x 100 • Internal Reporting: consider reporting both process and outcome measures to senior administrative,

medical, and nursing leadership and clinicians who care for patients at risk for CAUTI• Calculate percent of personnel who have proper training:

o Numerator: number of personnel who insert urinary catheters and who have proper training o Denominator: number of personnel who insert urinary catheterso Standardization factor: 100 (i.e., multiply by 100 so that measure is expressed as a percentage)

• Compliance with documentation of catheter insertion and removal dates: Conduct random audits of selected units and calculate compliance rate

o Numerator: number of patients on unit with catheters with proper documentation of insertion and removal dates

o Denominator: number of patients on the unit with a catheter in place at some point during admissiono Standardization factor: 100 (i.e., multiply by 100 so that measure is expressed as a percentage)

Process Improvement

ICU vs. non-ICU

CAUTI

Policy/Systems

Measurement

Knowledge/Skills

Not aseptically inserted

Tubing clamped

Use of catheters when not necessary

Drainage bag touching floor or above bladder

Not following protocol despite

knowledge

Leakage/hole in tubing

Too large of catheter used

Not measuring I/Os regularly

Lack of education to staff members

Lack of knowledge of catheter protocol

People

Device not secured properly to patient

Lack of perineal care

Lack of auditing

Outdated protocol

Equipment

Methods/Procedure