Urinary tract infections (UTIs) are the most common type of healthcareassociated

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1 Overcoming Challenges to CAUTI Prevention By Linda Greene, RN, MS, CIC, Shannon Oriola, RN, CIC, COHN, James Marx, RN, MS, CIC Urinary tract infections (UTIs) are the most common type of healthcareassociated infection, accounting for more than 30% of infections reported by acute care hospitals.the majority of healthcare-associated UTIs are caused by instrumentation of the urinary tract. Catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost, and length of stay. The presence of bacteria in the urine commonly leads to unnecessary antibiotic use, and urinary drainage systems are often one of the greatest reservoirs for multidrug-resistant bacteria and can be a source of transmission of these resistant pathogens to other patients. An indwelling urinary catheter is a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system. A number of years ago, guidelines suggested that a closed collection system was one of the single most important factors in preventing CAUTI. Despite the fact that today virtually all systems are closed drainage systems, healthcare providers must be especially cautious in assuring that these systems do not become accidentally disconnected. Between 15% and 25% of hospitalized patients may receive short-term indwelling urinary catheters. In many cases, catheters are placed for inappropriate indications, and healthcare providers are often unaware that their patients have catheters, leading to prolonged, unnecessary catheter use. Patients who have indwelling urinary catheters will develop bacteria in their urine. It is estimated that the daily risk for bacteruria (the presence of bacteria in the urine) is 3% to 10%, and after 30 days, 100% of patients will develop bacteria in their urine. Bacteruria is not necessarily indicative of infection, especially in the absence of other signs and symptoms. This is called asymptomatic bacteruria. Indications for Urinary Catheters: 1. Hemodynamic monitoring in critically ill patients 2. Pressure ulcer healing in patients with decubitis 3. In select circumstances, endof-life care 4. Select surgical procedures 5. Urinary retention or obstruction Prevention Practices Should Include the Following: 1. Ensure that urinary catheters are used only when indicated. 2. Remove urinary catheters as soon as soon as possible when no longer indicated. 3. If a patient requires a urinary catheter, assuring that strict aseptic technique is followed during insertion. 4. Maintain urinary catheters to ensure that they are securely fastened, placed below the level of the bladder, and that they do not become accidentally disconnected. Removal of Urinary Catheters Catheters should be removed as soon as possible. Several studies have shown that catheters are often left in place for long periods of time because they are often forgotten by physicians. It is critically important that nurses and healthcare providers assess patients need for a urinary catheter on a

2 regular basis. Many organizations utilize a daily checklist. There is also recent evidence to suggest that electronic reminders or automatic stop orders have value in reducing the duration of catherization and, subsequently, the incidence of UTIs. Aseptic Technique Urinary catherization should generally be considered a sterile procedure. Because the bladder is sterile, it is important that bacteria from the genital tract not be introduced via the urinary catheter into the bladder. In select circumstances, such as in patients with chronic indwelling catheters or those who must self catheterize, a clean procedure may be used. Healthcare providers must wash hands before insertion, and a sterile, single packet of lubricant should be used. Care must be taken to not accidentally contaminate the catheter during insertion. Maintenance of Catheters It is important that catheters be maintained in a manner that prevents accidental disconnection and kept below the level of the bladder to prevent accidental backflow of urine. Catheters should be properly secured after insertion to prevent movement and urethral traction. Care must be taken to ensure that the catheter is not accidentally disconnected. Urine specimens should be collected aseptically and should be sent to the lab as soon as possible. The Clinical and Laboratory Standards Institute (CLSI) Guidelines recommend that the urine specimen be cultured within 2 hours of its collection. Overgrowth of bacteria can readily occur with mishandled specimens, which will cause a false positive or unreliable culture result. Catheters and drainage bags should be changed not on a routine basis but based only on clinical indications such as infection, obstruction, or when the closed system is compromised. Routine irrigation should be avoided unless obstruction is suspected It is vital that only trained personnel insert catheters and that all healthcare providers who care for patients with urinary catheters understand their role in the prevention of CAUTI. It is vital that only trained personnel insert catheters and that all healthcare providers who care for patients with urinary catheters understand their role in the prevention of CAUTI. Likewise, patients and families need to understand their role in prevention as well. Infection prevention is a team effort understanding your role in this important initiative is essential for infection prevention and safe patient care. Bringing Evidence to the Bedside: Interactive Scenarios As a care giver, you will be called upon to apply your knowledge to practical situations and which arise during the course of providing patient care. Taking evidence and applying it to your everyday practice can be challenging. The following scenarios represent real life situations and decisions which could ultimately affect whether or not a patient develops a CAUTI. Read the scenarios and decide which of the options is the best choice. Once you have made your selection, review the correct answer, rationale, and learning points associated with that section. Remember that bringing evidence to the bedside requires not only knowledge but the ability to apply that knowledge to your everyday practice. It will require the combination of knowledge, interpersonal and problem solving skills. 2

3 Scenario 1 Angela is a new graduate assigned to a surgical unit. Angela has been asked to insert a urinary catheter in a patient who will undergo major abdominal surgery this morning. She has assembled all of her equipment and supplies and is getting ready to insert the catheter. She uses sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion. Angela washes her hands before the procedure and very carefully sets up the sterile field. The patient accidently moves, causing Angela to contaminate the catheter. As Angela is about to ask someone for a new catheter, her charge nurse stops by to tell her that the surgery schedule has been moved ahead and that her patient will be going to surgery in the next few minutes. Angela is now scared and frightened and is faced with a dilemma. A few minutes later, a transporter arrives to take the patient to surgery. He appears very impatient. Angela s patient now has a urinary catheter in place. As the patient is moved over to the cart, Angela sees the transporter place the urinary catheter on the patient s bed. Everyone is in such a hurry that Angela questions whether she should stop the transporter or just remain silent. What is the best course of action for Angela to take regarding insertion of the catheter? 1. Stop and reinsert a new catheter. 2. Rationalize that it is only a small break in technique and will not affect the patient. 3. Continue the procedure in the interest of time. 4. Tell the charge nurse that she was unable to insert the catheter and ask her to do it for her. Correct answer: 1 Despite the pressure to move quickly, it is important to follow aseptic technique. Microoorganisms from the patient s skin could contaminate the catheter and have the potential to lead to a UTI. What should Angela do when she sees the transporter lay the urinary catheter bag on the patient s abdomen? 1. Nothing this is a brief transport and time is important. 2. Quickly move the bag to its correct position. 3. Offer to help the transporter secure the bag correctly below the level of the bladder, explaining what she is doing and why this is important. Aseptic technique is used when inserting a urinary catheter. Hand hygiene is performed immediately before and after a urinary catheter insertion. The source of microorganisms causing CAUTI can be endogenous, typically via meatal, rectal, or vaginal colonization; or exogenous, such as via contaminated hands of healthcare providers or equipment. An estimated 17% to 69% of CAUTI may be preventable with recommended infection control measures, which means that up to 380,000 infections and 9000 deaths related to CAUTI could be prevented per year. Contaminating the urinary catheter may lead to a UTI. Maintain unobstructed urine flow. Keep the catheter and collecting tube free from kinking. Keep the collecting bag below the level of the bladder at all times. Correct answer: 3 The urinary catheter should be kept below the level of the bladder to ensure unobstructed flow. Although Angela could do this herself without explanation, talking to the transporter is a learning opportunity that may prevent this from happening again in the future. 3

4 Scenario 2 Tom is working on a medical unit. His patient, Mrs. X, has a urinary catheter and is febrile. The doctor has ordered a urinalysis and urine culture. Tom collects the specimen and asks that it be transported to the lab. Later that night, Tom discovers that the specimen has been sitting for 4 hours. He is very busy and does not have the time to collect another specimen. For a moment, he wonders if he should just send the specimen. He rationalizes that it really could not make that much of a difference, and he does have several more pressing priorities. Later that night, he notices that the urine looks very cloudy, although it is draining well. He is concerned that he may have to replace the catheter. The nursing assistant reports that the catheter came apart earlier. Rather than replace the catheter, he contemplates whether irrigation might be necessary. When Tom finds out that the specimen has not been sent, he should: 1. send the specimen anyway. It does not really make a difference. 2. call the lab and explain so that they can adjust their procedure accordingly. 3. discard the specimen and obtain a new one. Correct answer: 3 The CLSI Guidelines recommend that a urine specimen be cultured within 2 hours of its collection. Overgrowth of bacteria can readily occur with mishandled specimens, and this will cause a false positive or an unreliable culture result. The CLSI Guidelines recommend that a urine specimen be cultured within 2 hours of its collection. Overgrowth of bacteria can readily occur with mishandled specimens, and this will cause a false positive or an unreliable culture result. Unless obstruction is anticipated (eg, as may occur with bleeding after prostatic or bladder surgery), bladder irrigation is not recommended. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Should Tom irrigate the urinary catheter when he finds that the urine is cloudy? 1. He should not irrigate but should change the catheter instead. 2. He should irrigate the catheter, and if it remains cloudy, he should change the catheter. 3. He should irrigate but not change the the catheter. Correct answer: 1. Routine irrigation is not recommended unless obstruction is anticipated. The urine is cloudy but freeflowing with no evidence of obstruction. Because a disconnection was reported and the cloudy urine may indicate a UTI, it is recommended that the urinary catheter be changed. 4

5 Scenario 3 Rachel is taking care of an elderly woman who has been transferred from the intensive care unit (ICU). She had been in congestive heart failure. During her stay in the ICU, the woman required close monitoring of her urinary output and had an indwelling urinary catheter in place. Upon transfer from the ICU, the catheter was removed. The family approaches Rachel and says they cannot understand why the catheter has been removed. They point out that their mother is sometimes incontinent of urine, and they are concerned about skin breakdown. Rachel quickly reviews the indications for a urinary catheter. As Rachel reviews the indications for catheter use, she is uncertain that her elderly patient meets the criteria for a catheter. Although the patient is incontinent on occasion, there is no skin breakdown. Which is the correct response from Rachel when she is questioned by the family? 1. Explain that the doctor feels their mother no longer needs a catheter. 2. Discuss with the family why the catheter was removed and how the presence of a catheter is a risk factor for a UTI. Assure the family that she will assist their mother to the bathroom on a regular basis. 3. Tell the family that if their mother continues to be incontinent, she will reinsert the catheter. Correct answer: 2 It is important to explain to the patient s family the risk factors for infection and why the presence of a urinary catheter could lead to infection. Assuring family members that you will attend to personal care is important. If Rachel s patient is incontinent, should she have a urinary catheter? 1. No, urinary incontinence without skin breakdown is not a criterion for a urinary catheter. 2. Yes, the fact that the patient is elderly and incontinent necessitates a urinary catheter. 3. Yes, the fact that the patient is elderly and could fall necessitates a catheter. Correct answer: 1 Urinary catheters are used for assistance in pressure ulcer healing in incontinent residents. Indications for a Urinary Catheter: Perioperative use for selected surgical procedures (eg, surgeries involving the genitourinary tract, anticipated prolonged surgery, operative patients with urinary incontinence, need for intraoperative hemodynamic monitoring, and patients anticipated to receive large-volume diuretics during surgery) Urine output monitoring in critically ill patients Management of acute urinary retention and urinary obstruction Assistance in pressure ulcer healing for incontinent residents As an exception, on patient request to improve comfort (eg, end-of-life care) Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract and are most frequently associated with the presence of an indwelling catheter. The 5

6 Scenario 4 Nurse Mark is concerned about skin breakdown in an 88-year-old male patient with dementia who is incontinent of urine. The patient was admitted with a urine catheter from the emergency department (ED). The patient does not have a condition that would require an indwelling catheter. Mark wants to ask the physician for an order to remove the catheter, but he expects the patient to be incontinent of urine. He includes the potential for skin breakdown in the nursing care plan. Which action is not correct? 1. Leaving the catheter in place because the physician ordered a urine catheter (it saves nursing time to monitor and change the bed when the patient is incontinent). 2. Considering the use of a condom catheter (if the patient is cooperative with keeping it on). 3. Considering a prompted voiding program, when the patient is stood at the bedside and assisted to use the bathroom or urinal on a planned schedule. 4. Considering checking bladder volume with the bladder ultrasound to assess retention every 6 hours. Correct answer: 1 The urine catheter should only be used when necessary. The list of appropriate uses does not include incontinence, nursing convenience, or because the physician wants a catheter. Consider the less invasive alternates to manage incontinence. The prevention of skin breakdown in the incontinence patient can be achieved using the following methods (check all that apply): 1. Using barrier cream to keep the skin dry. 2. Consider the use of an adult brief while the patient is out of bed (do not use them overnight). 3. Restricting fluid intake. 4. Keeping the patient on strict bed rest. Many indwelling urine catheters are inappropriate, especially in older, female patients. Inappropriate urinary catheter use in acute care hospitals ranges from 21% to 50%. It is estimated that 30% of all indwelling urine catheters are inserted in EDs. Indications for the use of indwelling urethral catheters are limited and include the following: The plan of care must be individualized for the patient with incontinence and should include the following components1: Assessment and management of incontinence etiology Perineal skin and risk assessment Gentle cleansing and moisturization Application of skin barriers Use of containment devices if indicated Correct answers: 1 and 2 Barrier cream and adult briefs will protect the skin if the patient is incontinent of urine. Restricting fluid intake and immobilization increase the risk of a urinary tract infection. 6

7 Scenario 5 A 65-year-old male patient with urinary retention has a urine catheter. The catheter is now clogged and not draining. The physician prescribes bladder intermittent irrigation. What additional actions should the nurse consider? (check all that apply) 1. Check the bladder volume to see how much urine is in the bladder using a bladder ultrasound device. 2. Consider replacing the catheter with a silicon catheter. 3. Consider increasing fluid intake, if the patient s condition permits. 4. Irrigate the catheter as a last resort, if replacement does not work. 5. All of the above Correct answer: 5 The catheter may not be clogged, so always check the volume of urine in the bladder before replacing it. Latex catheters may develop incrustations more easily than silicone, so think about this option. Low urine output may be related to edema or kidney failure, increasing fluid may help the urine flow through the catheter. Irrigation should be considered only after the urine catheter has been replaced. The risk of infection may be the only solution in rare circumstances. If intermittent irrigation is the only measure that keeps the catheter unclogged, what actions will decrease the risk of infection? (check all that apply) 1. The irrigant and syringe should be used once and discarded. Do not reuse the irrigation syringe or store unused irrigant. (Note: Label states to discard unused portion; past practice was to use until empty or within 24 hours.) 2. Disinfect the connection with an appropriate surface disinfectant before disconnecting; maintain aseptic technique when handling the tubing. 3. Use vinegar as the bladder irrigant. 4. Raise the drainage bag to allow the urine to flow back into the bladder prior to irrigation. Correct answers: 1 and 2 Irrigation supplies should only be used according to the label directions. The catheter-tubing connection may be a source of bacteria, so disinfect it prior to disconnection using aseptic technique to prevent the tubing from getting contaminated. Vinegar has not been found to be beneficial in preventing infection. Never allow the urine in the tubing to flow back into the bladder. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction. If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. Silicone may be preferable to other materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction. Further research is needed on the benefit of irrigating the catheter with acidifying solutions or use of oral urease inhibitors in long-term catheterized patients who have frequent catheter obstruction. Unless obstruction is anticipated (eg, as may occur with bleeding after prostatic or bladder surgery), bladder irrigation is not recommended. Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction. Use portable ultrasound in patients with low urine output to reduce unnecessary catheter insertions or irrigations (in catheterized patients). Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, catheters and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device. 7

8 Scenario 6 The patient with an indwelling urine catheter needs to be transported from his room to the radiology department by stretcher. Prior to moving the urine catheter, you would perform hand hygiene and observe standard precautions, including the use of gloves and gown as appropriate. What are the considerations before, during, and after transport? 1. Empty catheter bag prior to transfer; use a urinal labeled with the patient s name. 2. Ensure the catheter is secured to the leg or abdomen. 3. Keep the level of the catheter below the bladder at all times. 4. Have an appropriate place to hang the catheter bag during transport and while in the radiology department. 5. All of the above Correct answer: 5 All actions are appropriate to prevent urinary tract infection. 1. An empty urine collection bag reduces the risk of urine flowing back into the bladder. 2. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. 3. Maintain unobstructed urine flow. 4. Keep the catheter and collecting tube free from kinking. 5. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. 6. Empty the collecting bag regularly using a separate, clean collecting container for each patient, avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container. 7. 8

9 Scenario 7 Ginny, a nurse, has decided to reduce the usage of inappropriate indwelling urinary catheters as a quality improvement project on the medical unit where she works. She selects this project because of the new Centers for Medicare & Medicaid Services (CMS) rules related to nonreimbursement of CAUTI not present on admission. The surgical unit at her facility has reduced its catheter-associated UTI rate primarily because of the successful implementation of the recent Surgical Care Improvement Project (SCIP) measure, which states that a urinary catheter must be removed within 24 hours of surgery unless there are appropriate indications for continued use. Ginny s facility has adopted an electronic health record for nursing documentation, physician order sets, and radiologic and laboratory results. She has proposed that an automatic reminder be sent to the clinician ordering the urinary catheter, which includes the indications for indwelling urinary catheterization. As a follow-up request to the informatics team, she also requests an additional field in the nursing documentation section asking the clinician to indicate the reason for continued use of the catheter. Which reason would not be an indication to continue use of an indwelling urinary catheter for patients? 1. The patient has acute urinary retention or bladder outlet obstruction. 2. The patient requests the catheter because he/she does not want to ambulate to the bathroom after his/her recent surgery. 3. The patient has an open sacral wound and is incontinent of urine. Correct answer: 2 The patient requests the catheter because he/she does not want to ambulate to the bathroom after his/her recent surgery. By selecting criteria from an approved list of indications, the nurse can document why the urinary catheter is still medically necessary. If the patient does not meet the criteria, the nurse can then contact the physician for an order to discontinue the catheter. Some facilities have been successful in obtaining approval from the Medical Executive leadership team to allow nursing to utilize a protocol for discontinuing the catheter under a standardized protocol. This will allow the nurse to discontinue the catheter without contacting the physician. Ginny will need to measure the effectiveness of the education by evaluating the reduction in usage of urinary catheters on her unit. How can Ginny measure if the education was effective? 1. She can calculate a device utilization ratio (the number of indwelling urinary catheters to the number of patient days on her unit per month). 2. Ginny can conduct random audits to determine the compliance rate of proper documentation of appropriate indication for catheters on her unit (numerator: number of patients on her unit with proper documentation of indication; denominator: number of patients on her unit with a urinary catheter in place; multiply by 100). 3. Both A and B. Correct answer: 3 She can calculate a device utilization ratio or can determine the compliance rate of proper documentation. 1. The table below is available from the Centers for Disease Control (CDC) Guideline for the Prevention of Catheter-associated Urinary Tract Infections, 2009,2 and contains examples for appropriate and inappropriate indwelling urinary catheter use. 2. Ginny will need leadership support from her nurse manager and a physician leader to implement this intervention this could be the chief of staff for the hospital. After the informatics team has implemented the protocol in the electronic health record, she will need the assistance of nursing education or perhaps the clinical nurse specialist on her unit to assist with providing education to the nurses. 1. Evaluating the device utilization on her unit may be helpful to assess the usage on her unit. The rate is often calculated monthly and trends usage over time. If the education is effective, the device utilization should decline. 2. The nurses should also be documenting the reason for the urinary catheter if the indwelling urinary catheter remains after the initial assessment of the patient. 3. Evaluating CAUTI rates is another method to determine if the intervention was helpful. 4. The CAUTI rate can be obtained a variety of ways. The two most common are obtaining the rates from the Infection Prevention department or from the manager of the Health Information department (medical records). 9

10 Scenario 8 A nurse from the medical ICU has noticed that he has had to break the seal of the urinary catheter drainage system many times because the physician has ordered hourly urine output and the drainage system does not have a urimeter attached to the catheter when he receives the patient. Should the nurse should break the seal and switch out the regular drainage bag with a urimeter when this occurs again? 1. Yes 2. No Correct answer: 2 The CDC Guideline for the Prevention of Catheter-associated Urinary Tract Infections, 2009, states that if breaks in aseptic technique, disconnection, or leakage occur, the catheter and collecting system should be replaced using aseptic technique and sterile equipment. The strength of evidence is fairly strong. 1. The CDC Guideline states that following aseptic insertion of the urinary 2. catheter, a closed drainage system should be maintained. The strength of evidence is fairly strong. 3. This issue can be discussed with the director of the ED and director of supply chain services. They can be helpful by evaluating the possibility of stocking urinary catheter drainage systems with preattached urimeters rather than a drainage system with the traditional drainage bag in the ED. 4. If it is not feasible to switch out the entire department, switching out systems in key areas may be beneficial. 5. Key areas of the ED where the likelihood that a patient may be admitted to an ICU are trauma or critical decision unit (patients evaluated for possible myocardial infarction or stroke). 6. A decrease in the number of unnecessary disconnection or replacement of urinary catheter drainage systems can occur by targeting key areas for placement of appropriate urinary catheter drainage systems. 10

11 Scenario 9 Kathy was rounding for compliance with the new bladder bundle that was implemented on her unit. She noticed what she believed to be an inappropriate indication for indwelling urinary catheter usage on the log documented by the primary nurse caring for the patient. The reason listed was the physician s desire to continue the urinary catheter based on his belief that the patient was at risk for falling if she were to ambulate to the bathroom without asking for assistance. This particular reason for continuing the catheter was not on their hospital s list of indications approved by the Medical Executive Committee, nor is it recommended as a reason for urinary catheterization in the CDC Guideline for the Prevention of Catheter-Associated Urinary Tract Infections, What should Kathy do? 1. Note the documentation and continue with her rounds. 2. Speak to the nurse caring for the patient to determine if she has spoken to the physician regarding her documentation of the indication to continue the urinary catheter. Correct answer: 2 Often a urinary catheter may be used as a restraint or for nursing convenience. Just as it is important for the nurse to understand the need for urinary catheterization, it is equally important for the physician to understand indications for usage. The primary nurse caring for the patient or the charge nurse can speak with the physician during patient care rounds. The physician can then be notified that her rationale for continuing the urinary catheter is not approved by the medical leadership and that there are other alternatives to urinary catheterization that are safe for patient care. Many hospitals have decreased patient falls by implementing nursing rounds. The nurse rounds every 2 hours to assess his/her patient needs for pain control and the need to void, among other factors. By anticipating patient needs, patient safety and patient satisfaction can be achieved. 11

12 Scenario 10 Rebecca is scheduled to have surgery next week and is being assessed by a nurse to ensure that she has completed her preoperative requirements and is ready for surgery. Rebecca has recently read an article in her local newspaper on hospital-acquired infections and is concerned that her physician has explained to her that she will require indwelling urinary catheterization for the procedure. Rebecca asks the nurse what she can do to prevent a UTI from occurring. Which would be the correct response from the nurse to Rebecca s question? 1. Not to worry if the patient gets a UTI, the doctor can treat the infection with an antibiotic. 2. It is unlikely that the patient will develop a UTI. 3. It is important that the urinary catheter is removed as soon as it is no longer necessary, preferably within 24 hours after her surgery to prevent infection. Correct answer: 3 Rebecca would like to avoid complications from her surgery. The nurse can take this opportunity to teach Rebecca how she and the hospital can take steps to prevent a catheter-associate urinary tract infection from occurring. CAUTI is the most frequently occurring healthcare-acquired infection. Many healthcare facilities have created or adopted patient education tools on the prevention of certain types of healthcare-acquired infections. The Society for Healthcare Epidemiology of America, in partnership with other organizations, has created several documents or Frequently Asked Questions related to various types of healthcareacquired infections. Patient guides on healthcareassociated infections are available at 12

13 Conclusion CAUTI is the most frequently occurring healthcare-acquired infection and is associated with increased length of stay, morbidity, mortality, and overuse of antibiotics. Healthcare providers play an important role in preventing these infections. It is important to understand that in the course of everyday work, decisions about care of urinary catheters arise and we will be challenged to make the best decision consistent with evidence prevention practices. It is vital that nurses develop the required skills to allow them to assess patients thoroughly before inserting a urinary catheter and to ensure that all other options have been investigated. Nurses with expertise in urinary catheterization must share their knowledge with new nurses and nursing students and ensure that their practice is based on the best evidence available. Patients with catheters need to be taught catheter care to minimize the risk of UTI. The caregivers of dependent patients need to be taught the skills required for catheter care as well. Some risk reduction strategies that have been successful in many organizations include: Implementation of the Bladder Bundle Aseptic technique when inserting a catheter Bladder ultrasound may avoid unnecessary catheterization Condom or intermittent catheterization in select patients Do not catheterize unless you must! Early removal of the catheter using reminders or stop orders Nursing Interventions Developing nursing protocols that clearly define criteria for insertion and removal of a catheter Incorporating prevention practices into order sets or pathways Having a zero-tolerance policy for adverse events. Reviewing each case to identify opportunities for improvement. Creating a culture in which healthcare providers are comfortable reminding each other when any breach in infection prevention practices is identified and in which we hold each other accountable for good infection prevention practices. Infection prevention is everyone s responsibility. Understanding your role in preventing infections is an important first step in protecting our patients and ensuring that that we provide safe patient care. References 1. Nix D. Prevention and treatment of perineal skin breakdown due to incontinence. Ostomy Wound Manage. 2006;52(4): Guideline for Prevention of Catheter-associated Urinary Tract Infections, Society for Healthcare Epidemiology of America (SHEA). Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. Resources IHI Program to Prevent CAUTI. APIC CAUTI Elimination Guide. 13

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