Download Recognizing and communicating CAUTI

AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Infection Prevention:
Recognizing and Communicating CAUTI
Onboarding #4 for Long-Term Care Staff
Learning Objectives
Upon completion of this session, long-term care staff will
demonstrate a working knowledge of:
• how an indwelling urinary catheter increases the risk of CAUTI;
• the limitations of urinary diagnostic tests used to diagnose CAUTI;
• what to communicate and document when a CAUTI is suspected; and
• how to document actions to prevent CAUTI.
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How Does an Indwelling Urinary Catheter
Increase Risk for a CAUTI?
• Bacteria can enter the urinary tract via the urinary
catheter
• Bacteria can stick to the catheter by forming a biofilm
• Once bacteria are included in a biofilm, they are
protected from antibiotics given to treat a UTI or CAUTI
• Presence of biofilm allows antibiotic-resistant bacteria
to develop
• When the catheter stops flowing, bacteria in the
bladder reflux back into the ureters and kidneys which
leads to signs/symptoms of infection
• Catheter flow can stop because of sludge/sediment;
kinks in the catheter or dislodging of the catheter
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Entry Points for Bacteria
Bacteria can gain access to and grow in the
bladder in several ways:
Bladder
• Contamination of the tube at the time of
placement
• Bacteria colonizing the perirectal area and
groin can creep up the catheter tube
• Contamination of the urine collection bag or
other breaks in the tubing
Collection Bag
3-10% of people develop bacteria in their
urinary tract every day a catheter is in place
Source: Dennis G. Maki and Paul A. Tambyah.
Engineering Out the Risk of Infection with Urinary
Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April
2001.
http://www.cdc.gov/ncidod/eid/vol7no2/makiG1.htm
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Understanding Asymptomatic Bacteriuria
Almost all residents with a catheter will have bacteria grow in a urine culture
Asymptomatic bacteriuria (ASB) = Presence of bacteria detected in the urine
culture when the resident doesn’t have any localizing signs/symptoms of a
CAUTI
•
Amount of bacteria growing in the culture does not help differentiate ASB
from CAUTI
•
The positive urine culture by itself is not enough to diagnose a CAUTI
Treating residents with antibiotics who have ASB does not improve their
clinical outcomes or prevent them from developing a symptomatic CAUTI
•
Antibiotic use for ASB can cause higher rates of antibiotic resistance,
Clostridium difficile infection and other adverse events
Nicolle LE Drugs Aging (2014) 31:1–10
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Interpreting Pyuria When a Catheter is Present
Pyuria is detection of white blood cells, by a urinalysis,
dip stick or urine microscopic exam.
The presence of the indwelling urinary catheter can
cause local irritation of the bladder wall, resulting in
WBCs in the urine.
Presence of pyuria cannot help you tell the difference
between ASB and CAUTI.
Nicolle LE Drugs Aging (2014) 31:1–10
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Diagnostic Tests – Urinalysis
Urinalysis considerations
• Abnormal findings on a urinalysis in a resident with
an indwelling urinary catheter are common and nonspecific
• A completely negative (normal) urinalysis is very
helpful to rule out a CAUTI
• The negative test rules out CAUTI, but the positive test
does not confirm CAUTI
Hooten et al. IDSA Guidelines, Clinical Infectious Diseases 2010; 50:625-663
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Diagnostic Tests – Urine Culture
Positive urine culture
• ≥ 100,000 colony forming units per ml of urine (105 CFU/ml)
when a catheter is present
• ≥ 100 colony forming units per ml (102 CFU/ml) from an in/out
catheter specimen
Common Pathogens
• Escherichia coli
• Proteus mirabilis
• Klebsiella pneumoniae
• Morganella morganii
• Pseudomonas aeruginosa
• Enterococci
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When Should a UA and Culture be Sent?
• Urine testing should only be performed when a resident has local
signs and/or symptoms of CAUTI (suprapubic or costovertebral angle
tenderness, fever, etc.).
• Odorous or cloudy urine are not indications for urine culture or
analysis. These non-specific changes in urine character are not
considered signs of CAUTI.
Hooten et al. IDSA Guidelines, Clinical Infectious Diseases 2010; 50:625-663
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Identifying CAUTI Signs and Symptoms
• Complete documentation of resident signs/symptoms is
important for accurate diagnosis and infection reporting
• You can help by reporting changes that you observe in
residents
Who should be communicating with whom?
Nurse
Nurseaide
Physician
Therapy
Other
Staff
All staff are key to early identification and notification of infections
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What to Assess When You Suspect a CAUTI
• Current and recent vital signs
• Recent change in mental status for onset of confusion
• MDS confusion assessment tool
• Recent change in Activities of Daily Living
• Physical exam findings
• Lower abdominal/suprapubic tenderness, flank/low back pain
• Fever
• Rigors (chills and sweats)
• Catheter findings:
• Purulent discharge at the insertion site
• Change in urine output, evidence of sediment which could be
obstructing flow
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Monitoring: Who is at Risk for CAUTI?
You can’t have a CAUTI if you don’t have a catheter
• Document date of insertion and indication for every resident
with an indwelling urinary catheter
• Review and document the urine output and quality of flow
for residents with indwelling catheters every day
• To ensure catheters are working properly and detect malfunctions
early
• Assess and document the ongoing need for the catheter on a
daily basis
• Keep a daily log of residents with an indwelling urinary
catheter
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Documenting Efforts to Prevent CAUTI
Proper care and handling of
the indwelling catheter can
reduce risk of CAUTI.
•
Use checklists to ensure
consistency and that
everyone follows bestpractices.
•
Tools can help to document
and verify if a process needs
to be reviewed and if staff
need more training and
education.
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Case Scenario: Mrs. Smith
It’s time to practice!
• Break into small groups of 2-3
• Each group should have the following materials:
• Case scenario and discussion guide
• CAUTI surveillance worksheet
• Indwelling urinary catheter insertion checklist
• Indwelling urinary catheter maintenance checklists
• Work together on Mrs. Smith’s case
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Stay Updated with Useful Resources
1.
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI website
Login information
Username: ltcsafety
Password: ltcsafety
2.
TeamSTEPPS® for Long-Term Care
3.
Long-term Care: Indwelling Urinary Catheter Insertion Checklist and
Instructions for Use
4.
Long-Term Care: Indwelling Urinary Maintenance Checklist and Instructions
for Use
5.
CAUTI Surveillance Worksheet
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