Download Catheter- Associated Urinary Tract Infections

CATHETERASSOCIATED 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
Appropriate Indications
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) procedureshould 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
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
0
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.