Prevention of Catheter- Associated Urinary Tract infections. Best Practices Guidelines

Prevention of Catheter- Associated Urinary Tract infections Best Practices Guidelines

The ACS NSQIP Best Practices Guidelines were designed to serve as complete yet concise resources for health care providers and quality improvement professionals. They create a framework that can be used to prioritize and direct efforts to address postsurgical complications. The Best Practices Guidelines contain information that is evidence based and has been assembled through reviews of the current literature and consultation with expert panels. ACS NSQIP Best Practices guidelines For more information and to learn how to access all of the Best Practices Guidelines, visit www.acsnsqip.org. 3

ACS NSQIP BEST PR ACTICES gu idelines ACS NSQIP Best Practices Guidelines have been developed for: Prevention of Catheter-Associated Urinary Tract Infections Prevention and Treatment of Venous Thromboembolism Prevention of Catheter-Related Bloodstream Infections Prevention of Surgical Site Infections 4 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

Prevention of Catheter- Associated Urinary Tract Infections Stanley K. Frencher, MD, MPH, and Nestor F. Esnaola, MD, MPH, MBA, FACS May 2009 Abstract Indwelling urinary catheters are a leading cause of nosocomial infection in medical and surgical patients in the United States. Risk assessment, adherence to key preventative strategies, and active surveillance can reduce rates of symptomatic catheter-associated urinary tract infections (CAUTIs). The purpose of this document is to review the current literature, consolidate recommendations from existing guidelines, and provide a concise, evidence-based, expert panelrated list of interventions to help reduce CAUTIs among surgical patients at your institution. Background More than five percent of Medicare patients in 2005 were diagnosed with postoperative urinary infections. 1 Urinary tract infections represent 32 to 40 percent of all nosocomial infections, which occur in up to 1.7 million patients annually. 2,3 As many as 80 percent of urinary tract infections are attributable to urinary catheterization. 1 In a recent study of over 36,000 patients undergoing major surgery, 86 percent of these patients had perioperative urinary catheters. 4 Of note, patients who had indwelling catheters for longer than two days postoperatively were twice as likely to develop a CAUTI. An episode of CAUTI results in direct and indirect costs of $676 and $2,386, respectively. 5 Due to the high frequency of catheter use in hospitalized patients, the cumulative economic impact of CAUTIs is significant. Patients who experience CAUTIs require an additional one to 3.8 hospital days. It is estimated that CAUTIs account for $340 to $450 million in additional health ACS NSQIP Best Practices guidelines 5

care costs every year. 6-8 In response, the Centers for Medicare and Medicaid Services no longer provides reimbursement to providers of covered beneficiaries for the treatment of CAUTIs. 9 In addition, the Surgical Care Improvement Project UTI measure (SCIP Inf-9) requires providers to submit data on the proportion of the sample of surgical patients captured for which a urinary catheter (if used) was removed on postoperative day one or two. 9 Risk Factors for CAUTIs Risk factors for developing CAUTIs have been identified (Table 1). While insertion of a urinary catheter is essential for developing a CAUTI, duration of catheterization is the most important risk factor (additional risk factors are shown in Table 1). As such, the best way to avoid CAUTIs is to avoid unnecessary catheterization and remove bladder catheters as soon as possible. 10 Ta b le 1: R i s k Fa c t ors for D eve loping A C AUTI Major Risk Factors Increasing duration of catheterization Female sex Diabetes mellitus Faulty aseptic management of indwelling catheter Bacterial colonization of drainage bag Additional Risk Factors Older age Azotemia Rapidly fatal underlying illness Periurethral colonization with uropathogens Catheter not connected to urine meter 6 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

Studies suggest that more than 50 percent of catheterizations in hospitalized patients may be unnecessary. 12-16 The indications for indwelling bladder catheterization are limited, based predominately on expert or consensus opinion, and commonly include: 9,17 Perioperative use for selected surgical procedures (with planned removal as soon as possible) 17-21 Patients undergoing urologic surgery (or other surgery on contiguous structures of the genitourinary tract) Anticipated prolonged duration of surgery (catheters inserted for this reason should ideally be removed in the postanesthesia care unit) Patients anticipated to receive large-volume infusions or diuretics during surgery Operative patients with urinary incontinence Need for intraoperative monitoring of urinary output Need for short-term, frequent monitoring of urine output in critically ill patients Management of acute urinary retention/obstruction Need to facilitate healing of advanced pressure ulcers in incontinent patients when other interventions (for example, condom catheters, wound dressings) are ineffective Use at patient request to improve comfort (for example, terminally ill patients) Indwelling catheters should NOT be used: As a substitute for nursing care of the patient or resident with incontinence As a means of obtaining urine for culture (or other diagnostic tests) when the patient can voluntarily void Routinely for patients receiving epidural anesthesia/analgesia ACS NSQIP Best Practices guidelines 7

Basic Strategies to Prevent CAUTIs Certain measures during the insertion and maintenance of a urinary catheter can help prevent against associated infection (Table 2). TA B LE 2 : BA S I C R E COMMENDATI O N S 17, 2 2-2 4 FO R PR E V E NTI O N O F C AUTI s Prior to Insertion of Urinary Catheter Use alternate bladder drainage methods (for example, condom catheters, in-and-out catheterization) when appropriate. 25-31 Educate staff regarding proper insertion and maintenance of urinary catheters. During Insertion of Urinary Catheter Ensure that only trained personnel insert urinary catheters. 11,32-34 Practice hand hygiene immediately prior to insertion of catheter. 35,36 Use standard precautions (including use of gown and gloves, as appropriate) prior to any manipulation of the catheter/drainage system. After Insertion of Urinary Catheter Properly secure to prevent movement/urethral traction. 37 Maintain sterile, closed drainage system. 34,38-41 Position drainage bag below bladder and off floor. 42 Perform routine, daily meatal care (use of antiseptics is NOT necessary). 43-45 Practice hand hygiene and wear clean gloves prior to any manipulation of the catheter/drainage system. 35,36 Obtain urine sample aseptically from sampling port. 23,34 Avoid routine catheter irrigation. If obstruction is anticipated, closed continuous irrigation may be used. To relieve obstruction due to mucus or clots, an intermittent method may be used. 46-48 Education of patients and caretakers via fact sheets (Appendix A) or nurse-directed education, competencybased training, or skills labs may help reinforce appropriate provider adherence and self-protective behaviors consistent with many of the recommendations cited above (for example, keeping the urinary drainage bag secure, unobstructed, and lower than the bladder). 49 8 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

Special Approaches to Prevent CAUTIs Additional, special strategies may be needed for use in locations/populations with unacceptably high rates of CAUTIs despite implementation of the basic strategies outlined above (Table 3). TA B LE 3: S PE C I A L A PPROAC H E S FO R 17, 2 2-2 4 PR E V E NTI O N O F C AUTI s Before Insertion of Urinary Catheter Develop procedure-specific guidelines or criteria to restrict perioperative catheter insertion. 50 Establish mechanism to ensure urinary retention medications resumed postoperatively (for example, alpha blockers). 51 Develop protocol for management of postoperative urinary retention (for example, nurse-directed use of bladder scanners, in-and-out catheterization, and so on). 52 During Insertion of Urinary Catheter Consider use of antimicrobial-coated catheters for selected, high-risk patients (for example, patients undergoing certain urologic procedures or requiring prolonged [>7 10 days] bladder catheterization). 53-58 After Insertion of Urinary Catheter Implement unit-/institution-wide protocol to identify and remove unnecessary bladder catheters. 10,15,59-63 ACS NSQIP Best Practices guidelines 9

Several of the basic and special approaches outlined in Tables 1, 2, and 3 can be implemented unit- or institution-wide as a bladder bundle that uses the mnemonic ABCDE: 64,65 Adherence to generally recommended infection control principles (for example, hand hygiene, aseptic insertion, proper maintenance). Bladder ultrasound may avoid indwelling catheterization. Condom and intermittent catheterization in appropriate patients. Do not use the indwelling catheter unless you must. Early removal of the catheter using reminders or stop orders. Identification and removal of unnecessary bladder catheters should be a priority. Unit- and institution-wide protocols to identify and remove unnecessary bladder catheters should be implemented, including: Procedure-specific guidelines for postoperative catheter removal. 50 Institutional policies requiring daily reassessment of need for continued catheterization. Daily, physician reminders (in chart, electronic, or nurse-generated form) to alert providers that an indwelling catheter is still in place and that its continued use should be reassessed (Appendix B). 10,36,59,63,66 Automatic stop orders requiring renewal of the indwelling bladder catheter. 67 Daily ward rounds by nurses/physicians to review patients with bladder catheters and determine continuing necessity. 15,61,68 10 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

Approaches that Should NOT Be Considered for the Prevention of CAUTIs TA B LE 4 : A PPROAC H E S N OT R E COMMENDED 17, 2 2-2 4 FO R PR E V E NTI O N O F C AUTI s During Insertion of Urinary Catheter Do not use silver-coated or antibiotic-impregnated catheters routinely. 17,54,56 After Insertion of Urinary Catheter Do not add antibiotics to drainage bag. 69,70 Do not use systemic antibiotic prophylaxis. 71 Do not change catheters or drainage bags routinely. 72-75 Do not screen for or treat asymptomatic bacteriuria in catheterized patients. 9,11,76 Surveillance Standardized criteria should be used to identify patients with asymptomatic bacteriuria versus symptomatic UTIs (Appendix C). 9,77 Use of uniform definitions by providers, infection control personnel, and data abstractors will ensure that the numerators used are reliable when discussing CAUTI rates. Patients at high risk for developing CAUTIs should be identified and followed closely. Adherence to the basic prevention guidelines cited above should be tracked, and CAUTI rates should be closely monitored using a program such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) or other hospital-based, internal data collection program. Documenting indications for use and cases where basic prevention recommendations are not used is encouraged to guide and focus ongoing quality improvement efforts. Because asymptomatic bacteriuria does not present an increased risk for CAUTIs unless other factors are present (and its treatment can lead to antibioticassociated disease and resistance), routine screening for and treatment of bacteriuria in catheterized patients is NOT recommended. 9,76,77 In lieu of participation in ACS NSQIP Best Practices guidelines 11

the ACS NSQIP, surveillance programs that monitor urine culture results through the microbiology lab can be used to identify patients with potential symptomatic urinary tract infections. Patients with positive urine cultures can then be assessed for the presence of an indwelling bladder catheter and possible CAUTI based on defined surveillance criteria. 23 The purpose of these surveillance programs should be to monitor rates of possible CAUTI in order to help guide, implement, and evaluate quality-improvement programs while providing critical performance feedback. Summary CAUTIs are a leading source of morbidity and increased length of stay and costs in hospitalized, postoperative patients. The best way to avoid CAUTIs is to avoid unnecessary catheterization and remove catheters as soon as possible. Adherence to generally accepted infection control principles, application of the basic and special recommendations contained in this document, and active surveillance can help guide quality improvement efforts and reduce CAUTI rates at your institution. 12 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

Appen dices Appendix A: Catheter-Associated Urinary Tract Infections Patient Education Sheet 49 ACS NSQIP Best Practices guidelines 13

Appendix B: Sample Urinary Catheter Provider Reminder 10 14 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

Appendix C: Clinical and Surveillance Definitions of Asymptomatic Bacteriuria and Urinary Tract Infections Clinical Definitions of Asymptomatic Bacteriuria 9 Isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen in a manner that minimizes contamination For women: two consecutive voided specimens with isolation of the same bacterial strain in quantitative counts 100,000 CFU/mL or a single catheterized urine specimen with one bacterial species isolated in a quantitative count >100 CFU/mL For men: a single, clean-catch voided urine specimen with one bacterial species isolated and quantitative count 100,000 CFU/mL or a single catheterized urine specimen with one bacterial species isolated and quantitative count >100 CFU/mL and the absence of signs and symptoms that may suggest urinary tract infection, such as: Fever Urgency Frequency Dysuria Suprapubic tenderness Costovertebral angle pain/tenderness Centers for Disease Control and Prevention National Healthcare Safety Network Surveillance Criteria for Symptomatic Urinary Tract Infections 77 Urinary tract infections (UTI) are defined using symptomatic urinary tract infection (SUTI) criteria or asymptomatic bacteremic UTI (ABUTI) criteria (Table 5). Report UTIs that are catheter-associated (for example, patient had an indwelling urinary catheter at the time of or within 48 hours before onset of the event). There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter associated. ACS NSQIP Best Practices guidelines 15

Appendix C (cont d) NOTE: SUTI 1b and 2b and other UTI (OUTI) cannot be catheter associated. EXAMPLE: A patient on an inpatient unit has a Foley catheter in place. It is discontinued, and four days later the patient meets the criteria for a UTI. This UTI is not reported as a CAUTI because the time since Foley discontinuation exceeds 48 hours. TA B LE 5: U r i n a ry Tr act I n f e cti o n C r ite r i a 16 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

TA B LE 5 (cont d ) ACS NSQIP Best Practices guidelines 17

Chair: Expert Panel Sanjay Saint, MD, MPH Hospitalist, Ann Arbor VA Medical Center Professor of Internal Medicine University of Michigan Medical School Ann Arbor, MI Committee Members: Sue Bradley, MD Professor, Department of Internal Medicine University of Michigan Medical School Ann Arbor, MI Thomas M. Hooton, MD Associate Dean and Professor, Department of Medicine University of Miami, Miller School of Medicine Miami, FL Jennifer Meddings, MD, MSc Assistant Professor, Department of Internal Medicine University of Michigan Medical School Ann Arbor, MI Lindsay E. Nicolle, MD Professor, Department of Internal Medicine University of Manitoba, Health Sciences Center Winnipeg, MB Russ Olmsted, MPH Epidemiologist, Infection Control Services Saint Joseph Mercy Health System Ann Arbor, MI Anthony J. Schaeffer, MD, FACS Professor and Chairman, Department of Urology Northwestern University, Feinberg School of Medicine Chicago, IL Heidi Wald, MD, MSPH Assistant Professor, Department of Medicine University of Colorado at Denver and Health Sciences Center Aurora, CO 18 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

REFERENCES 1. Centers for Medicare & Medicaid Services. Medicare Patient Safety Monitoring System. 2008. 2. Wong E, Hooton T. Guideline for prevention of catheter-associated urinary tract infections. Available at: http://www.cdc.gov/ncidod/dhqp/ gl_catheter_assoc.html. Accessed December 10, 2008. 3. Klevens RM, Edwards JR, Richards CL, Jr., et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. Mar-Apr 2007;122(2):160-166. 4. Wald HL, Ma A, Bratzler DW, et al. Indwelling urinary catheter use in the postoperative period: Analysis of the national surgical infection prevention project data. Arch Surg. Jun 2008;143(6):551-557. 5. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28(1):68-75. 6. Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. Am J Infect Control. Nov 2005;33(9):501-509. 7. Anderson DJ, Kirkland KB, Kaye KS, et al. Underresourced hospital infection control and prevention programs: Penny wise, pound foolish? Infect Control Hosp Epidemiol. Jul 2007;28(7):767-773. 8. Scott RD. The Direct Medical Costs of Healthcare- Associated Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta, GA: CDC; March 2009. 9. Saint S, Meddings JA, Calfee D, et al. Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med. Jun 16, 2009;150(12):877-884. 10. Saint S, Kaufman SR, Thompson M, et al. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf. Aug 2005;31(8):455-462. 11. Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med. April 26, 1999;159(8):800-808. ACS NSQIP Best Practices guidelines 19

12. Hazelett SE, Tsai M, Gareri M, et al. The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care. BMC Geriatr. 2006;6:15. 13. Munasinghe RL, Yazdani H, Siddique M, et al. Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service. Infect Control Hosp Epidemiol. Oct 2001;22(10):647-649. 14. Gokula RM, Smith MA, Hickner J. Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters. Am J Infect Control. Nov 2007;35(9):589-593. 15. Fakih MG, Dueweke C, Meisner S, et al. Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients. Infect Control Hosp Epidemiol. 2008;29(9):815-819. 16. Gokula RR, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control. Jun 2004;32(4):196-199. 17. Gould CV, Umscheid CA, Argawal R, et al. Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2008. Atlanta, GA: 2009. 18. Phipps S, Lim YN, McClinton S, et al. Short term urinary catheter policies following urogenital surgery in adults. Cochrane Database Syst Rev. 2006(2):CD004374. 19. Tang KK, Wong CK, Lo SF, et al. Is it necessary to catheterise the bladder routinely before gynaecological laparoscopic surgery? Aust N Z J Obstet Gynaecol. Oct 2005;45(5):380-383. 20. Iorio R, Healy WL, Patch DA, et al. The role of bladder catheterization in total knee arthroplasty. Clin Orthop Relat Res. Nov 2000(380):80-84. 21. Akhtar MS, Beere DM, Wright JT, et al. Is bladder catheterization really necessary before laparoscopy? Br J Obstet Gynaecol. Nov 1985;92(11):1176-1178. 22. Pratt RJ, Pellowe CM, Wilson JA, et al. epic2: National Evidence-Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England. Journal of Hospital Infection. 2007;65(suppl 1):S1-S59. 20 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

23. Lo E, Nicolle L, Classen D, et al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology. October 2008;29(suppl 1):S41-S50. 24. APIC. Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs): Developing and Applying Facility-Based Prevention Interventions in Acute and Long-Term Care Settings. 2008. 25. Baan AH, Vermeulen H, van der Meulen et al. The effect of suprapubic catheterization versus transurethral catheterization after abdominal surgery on urinary tract infection: A randomized controlled trial. Dig Surg. 2003;20(4):290-295. 26. Saint S, Kaufman SR, Rogers MA, et al. Condom versus indwelling urinary catheters: A randomized trial. J Am Geriatr Soc. Jul 2006;54(7):1055-1061. 27. Dobbs SP, Jackson SR, Wilson AM, et al. A prospective, randomized trial comparing continuous bladder drainage with catheterization at abdominal hysterectomy. Br J Urol. Oct 1997;80(4):554-556. 28. Lau H, Lam B. Management of postoperative urinary retention: A randomized trial of in-out versus overnight catheterization. ANZ J Surg. Aug 2004;74(8):658-661. 29. Sparks A, Boyer D, Gambrel A, et al. The clinical benefits of the bladder scanner: A research synthesis. J Nurs Care Qual. Jul-Sep 2004;19(3):188-192. 30. Saint S, Kaufman SR, Rogers MA, et al. Risk factors for nosocomial urinary tractrelated bacteremia: A case-control study. Am J Infect Control. Sep 2006;34(7):401-407. 31. Saint S, Lipsky BA, Baker PD, et al. Urinary catheters: What type do men and their nurses prefer? J Am Geriatr Soc. Dec 1999;47(12):1453-1457. 32. Garibaldi RA, Burke JP, Dickman ML, et al. Factors predisposing to bacteriuria during indwelling urethral catheterization. N Engl J Med. Aug 1, 1974;291(5):215-219. 33. Sanderson PJ. Preventing hospital acquired urinary and respiratory infection. BMJ. June 3, 1995;310(6992):1452-1453. ACS NSQIP Best Practices guidelines 21

34. Kunin CM, McCormack RC. Prevention of catheter-induced urinary-tract infections by sterile closed drainage. N Engl J Med. May 26, 1966;274(21):1155-1161. 35. Fendler EJ, Ali Y, Hammond BS, et al. The impact of alcohol hand sanitizer use on infection rates in an extended care facility. Am J Infect Control. Jun 2002;30(4):226-233. 36. Rosenthal VD, Guzman S, Safdar N. Effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in Argentina. Infect Control Hosp Epidemiol. Jan 2004;25(1):47-50. 37. Darouiche RO, Goetz L, Kaldis T, et al. Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: A prospective, randomized, multicenter clinical trial. Am J Infect Control. Nov 2006;34(9):555-560. 38. Thornton GF, Andriole VT. Bacteriuria during indwelling catheter drainage. II. Effect of a closed sterile drainage system. JAMA. Oct 12, 1970;214(2):339-342. 39. Huth TS, Burke JP, Larsen RA, et al. Clinical trial of junction seals for the prevention of urinary catheter-associated bacteriuria. Arch Intern Med. Apr 1992;152(4):807-812. 40. Klarskov P, Bischoff N, Bremmelgaard A, et al. Catheter-associated bacteriuria. A controlled trial with the Bardex Urinary Drainage System. Acta Obstet Gynecol Scand. 1986;65(4):295-299. 41. Lanara V, Plati C, Paniara O, et al. The prevalence of urinary tract infection in patients related to type of drainage bag. Scand J Caring Sci. 1988;2(4):163-170. 42. Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters. Emerg Infect Dis. Mar-Apr 2001;7(2):342-347. 43. Burke JP, Garibaldi RA, Britt MR, et al. Prevention of catheter-associated urinary tract infections. Efficacy of daily meatal care regimens. Am J Med. Mar 1981;70(3):655-658. 44. Burke JP, Jacobson JA, Garibaldi RA, et al. Evaluation of daily meatal care with poly-antibiotic ointment in prevention of urinary catheter-associated bacteriuria. J Urol. Feb 1983;129(2):331-334. 22 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

45. Classen DC, Larsen RA, Burke JP, et al. Daily meatal care for prevention of catheterassociated bacteriuria: Results using frequent applications of polyantibiotic cream. Infect Control Hosp Epidemiol. Mar 1991;12(3):157-162. 46. Schneeberger PM, Vreede RW, Bogdanowicz JF, et al. A randomized study on the effect of bladder irrigation with povidone-iodine before removal of an indwelling catheter. J Hosp Infect. Jul 1992;21(3):223-229. 47. Warren JW, Platt R, Thomas RJ, et al. Antibiotic irrigation and catheter-associated urinary-tract infections. N Engl J Med. Sep 14, 1978;299(11):570-573. 48. van den Broek PJ, Daha TJ, Mouton RP. Bladder irrigation with povidone-iodine in prevention of urinary-tract infections associated with intermittent urethral catheterisation. Lancet. Mar 9, 1985;1(8428):563-565. 49. SHEA (Society for Healthcare Epidemiology of America). Patient Guides on Healthcare-Associated Infections. Available at: http://www.shea-online. org/about/patientguides.cfm. Accessed June 2009. 50. Stephan F, Sax H, Wachsmuth M, et al. Reduction of urinary tract infection and antibiotic use after surgery: A controlled, prospective, before-after intervention study. Clin Infect Dis. Jun 1, 2006;42(11):1544-1551. 51. Klarskov P, Andersen JT, Asmussen CF, et al. Symptoms and signs predictive of the voiding pattern after acute urinary retention in men. Scand J Urol Nephrol. 1987;21(1):23-28. 52. Oishi CS, Williams VJ, Hanson PB, et al. Perioperative bladder management after primary total hip arthroplasty. J Arthroplasty. Dec 1995;10(6):732-736. 53. Johnson JR, Kuskowski MA, Wilt TJ. Systematic review: Antimicrobial urinary catheters to prevent catheterassociated urinary tract infection in hospitalized patients. Ann Intern Med. 2006;144(2):116-W122. 54. Liedberg H, Lundeberg T. Silver alloy coated catheters reduce catheter-associated bacteriuria. Br J Urol. Apr 1990;65(4):379-381. 55. Riley DK, Classen DC, Stevens LE, et al. A large randomized clinical trial of a silver-impregnated urinary catheter: Lack of efficacy and staphylococcal superinfection. Am J Med. 1995;98(4):349-356. ACS NSQIP Best Practices guidelines 23

56. Niël-Weise BS, Arend SM, van den Broek PJ. Is there evidence for recommending silver-coated urinary catheters in guidelines? J Hosp Infect. 2002;52(2):81-87. 57. Saint S, Elmore JG, Sullivan SD, et al. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: A metaanalysis. Am J Med. Sep 1998;105(3):236-241. 58. Srinivasan A, Karchmer T, Richards A, et al. A prospective trial of a novel, silicone-based, silver-coated foley catheter for the prevention of nosocomial urinary tract infections. Infect Control Hosp Epidemiol. Jan 2006;27(1):38-43. 59. Huang WC, Wann SR, Lin SL, et al. Catheterassociated urinary tract infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters. Infect Control Hosp Epidemiol. 2004;25(11):974-978. 60. Reilly L, Sullivan P, Ninni S, et al. Reducing Foley catheter device days in an intensive care unit: Using the evidence to change practice. SO - AACN Advanced Critical Care. July/Sept 2006;17(3):272-283. 61. Topal J, Conklin S, Camp K, et al. Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. Am J Med Qual. May 1, 2005;20(3):121-126. 62. Marklew A. Urinary catheter care in the intensive care unit. Nurs Crit Care. Jan-Feb 2004;9(1):21-27. 63. Cornia PB, Amory JK, Fraser S, et al. Computerbased order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Amer J Med. 2003;114(5):404-407. 64. Saint S. Bladder Bundle. Available at: http://www. mhakeystonecenter.org/. Accessed April 2009. 65. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: A national study. Clin Infect Dis. 2008;46(2):243-250. 66. Apisarnthanarak A, Thongphubeth K, Sirinvaravong S, et al. Effectiveness of multifaceted hospitalwide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand. Infect Control Hosp Epidemiol. Jul 2007;28(7):791-798. 24 A C S N S Q I P B e s t P r a c t i c e s g u i d e l i n e s

67. Loeb M, Hunt D, O Halloran K, et al. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: A randomized controlled trial. J Gen Intern Med. Jun 2008;23(6):816-820. 68. Goetz A, Kedzuf S, Wagener M, et al. Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections. Am J Infect Control. 1999;27(5):402-404. 69. Gillespie WA, Simpson RA, Jones JE, et al. Does the addition of disinfectant to urine drainage bags prevent infection in catheterised patients? Lancet. May 7 1983;1(8332):1037-1039. 70. Thompson RL, Haley CE, Searcy MA, et al. Catheter-associated bacteriuria. Failure to reduce attack rates using periodic instillations of a disinfectant into urinary drainage systems. JAMA. Feb 10, 1984;251(6):747-751. 71. Niel-Weise BS, van den Broek PJ. Antibiotic policies for short-term catheter bladder drainage in adults. Cochrane Database Syst Rev. 2005(3):CD005428. 72. Keerasuntonpong A, Thearawiboon W, Panthawanan A, et al. Incidence of urinary tract infections in patients with short-term indwelling urethral catheters: A comparison between a 3-day urinary drainage bag change and no change regimens. Am J Infect Control. Feb 2003;31(1):9-12. 73. Priefer BA, Duthie EH, Jr., Gambert SR. Frequency of urinary catheter change and clinical urinary tract infection. Study in hospital-based, skilled nursing home. Urology. Aug 1982;20(2):141-142. 74. Stelling JD, Hale AM. Protocol for changing condom catheters in males with spinal cord injury. SCI Nurs. Jun 1996;13(2):28-34. 75. Reid RI, Webster O, Pead PJ, et al. Comparison of urine bag-changing regimens in elderly catheterised patients. Lancet. Oct 2, 1982;2(8301):754-756. 76. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. Mar 1, 2005;40(5):643-654. 77. CDC National Healthcare Safety Network. The National Healthcare Safety Network (NHSN) Manual. March. Available at http:// www.cdc.gov/nhsn/pdfs/pscmanual/ pscmanual_current.pdf. Accessed June 2009. ACS NSQIP Best Practices guidelines 25

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For more information and to learn how to access all of the Best Practice Guidelines, visit www.acsnsqip.org. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Best Practices Guidelines have been developed for quality improvement purposes. The documents may be downloaded and printed for personal use by health care professionals at participating hospitals. The documents may also be used in conjunction with ACS NSQIP-related initiatives or programs. The documents may not be distributed for non-acs NSQIP related activities or for profit without the written consent of the American College of Surgeons. ACS NSQIP Best Practices guidelines The intent of the ACS NSQIP Best Practice Guidelines is to provide health care professionals with evidence-based recommendations regarding the prevention, diagnosis, or treatment of common postsurgical complications. The Best Practice Guidelines do not include all potential options for prevention, diagnosis, and treatment. The final decisions regarding patient care must be made by the responsible physician or health care provider and take into account the patient s individual clinical presentation. The ACS NSQIP Best Practice Guidelines may be modified without notice. 27

w w w. a c s n s q i p. o r g 633 N. Saint Clair St. Chicago, IL 60611-3211 Phone 312-202-5213 Fax 312-202-5011 E-mail acsnsqip@facs.org