Download Recognizing and communicating CAUTI

AHRQ Safety Program for Long-term Care: HAIs/CAUTI
Infection Prevention:
Recognizing and Communicating CAUTI
Onboarding #4 for All 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 by 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
3-10% of people develop bacteria in their urinary tract for
every day a catheter is in place
Collection Bag
Figure 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, C. 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 inflammatory cells, white blood cells
(WBC), 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 separate ASB from CAUTI
Nicolle LE Drugs Aging (2014) 31:1–10
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Diagnostic Tests – Urinalysis (UA)
Urinalysis considerations
• Abnormal findings on a urinalysis in a resident with an
indwelling urinary catheter are common and non-specific.
• A completely negative (normal) urinalysis is very helpful to
rule out a CAUTI.
– The negative test rules out CAUTI, but the positive test cannot
rule in 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
– New change in mental status for onset of confusion
• MDS confusion assessment tool
– New change in Activities of Daily Living (ADLs)
– 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 regular basis
• Keep a daily log of residents with an indwelling urinary catheter on each unit
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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 best-practices
• Tools can help to document and
verify if a process needs to be
reviewed and if staff need more
training and/or education
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Case Scenario: Mrs. Smith
Its 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 Project 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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