Prevention of Catheter-Associated Urinary Tract Infections

Overview This self-study module has been developed to provide essential information about the prevention of catheter-associated urinary tract infections (CAUTI). All healthcare workers that participate in insertion and/or maintenance of urinary catheters should utilize this information. The underlined words noted throughout the module are defined in the glossary at the end. For additional information, please note the links located throughout and the references found at the end of the self-study module. Please read all of the information provided in the self-study module. Complete the post-test. A score of 80% is required on the post-test. If you do not achieve a score of 80%, please review the self-study module and retake the test. After completing this module, additional information may be obtained from your Unit Manager, Supervisor or your Infection Prevention Specialist. The information contained in these documents is not medical advice and should not be relied upon as such. This information is intended solely as general reference material and should not be relied upon solely in making any medical or clinical decisions. Clinicians should base their medical decisions on all data and information available to them, as well as their professional judgment. This information may contain errors or inaccuracies or, due to advances in medical and scientific knowledge, may be or become outdated or inaccurate. Table of Contents Overview... 1 Learning Objectives... 2 Introduction... 2 Epidemiology... 2 Symptoms of a Urinary Tract Infection... 3 Risk Factors for Developing a CAUTI... 3 Institute for Healthcare Improvement How-to Guide: Prevent CAUTI... 3 Appropriate Inwelling Urinary Catheter Use... 4 Appropriate Indications for Indwelling Urinary Catheters... 4 Inappropriate Indications for Indwelling Urinary Catheters... 4 Proper Techniques for Urinary Catheter Insertion... 5 Steps to Proper Bladder Catheter Insertion... 6 Proper Techniques for Urinary Catheter Maintenance... 7 Proper Catheter and Perineal Care... 7 Proper Urine Specimen Collection... 8 Removal of Urinary Catheter HOUDINI Nursing Protocol... 9 After the Urinary Catheter is Removed... 10 The Surgical Care Improvement Project (SCIP)... 11 Algorithm for SCIP and HOUDINI Protocols... 12 Patient Education Tool... 13 Home Care of an Indwelling Urinary Catheter... 14 References... 15 Glossary... 16 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 1

Learning Objectives Upon completion of this module, the participant will be able to: 1. list several risk factors for catheter-associated urinary tract infections 2. describe the proper technique for urinary catheter insertion and care 3. explain the proper procedure for collecting a catheterized urine specimen 4. list the elements of the Surgical Care Improvement Project (SCIP) postoperative catheter removal protocol 5. summarize the criteria for the discontinuation of a urinary catheter using the HOUDINI nursing protocol Introduction A urinary tract infection (UTI) is the most common type of healthcare-associated infection (HAI), accounting for more than 35% of infections reported by acute care hospitals. Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract. Catheter-associated urinary tract infections (CAUTIs) have been associated with increased morbidity, mortality, hospital cost, and length of stay. Bacteriuria in a catheterized patient is often asymptomatic and will resolve spontaneously with removal of the catheter. CAUTI has been identified by the Centers for Medicare and Medicaid Services (CMS) as a hospital acquired condition that can be prevented through the application of evidence-based guidelines, and therefore acute care hospitals will no longer be reimbursed for these infections. Epidemiology Between 15% and 25% of hospitalized patients may receive short-term indwelling urinary catheters 26% of patients with indwelling urinary catheters for 2 to 10 days will develop bacteriuria When a catheter is in place, the daily risk of developing a CAUTI ranges between 3% and 7% Approximately 25% of bacteriuria patients will develop a CAUTI 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 2

Approximately 3% of bacteriuria patients will develop bacteremia Acute care hospitals reporting to the National Healthcare Safety Network (NHSN) in 2010 reported a pooled mean of CAUTI rates ranging from 0.0 4.7 infections per 1000 catheter-days Symptoms of a Urinary Tract Infection Urinary tract infections commonly produce these symptoms: Burning or pain in the lower abdomen Fever Burning during urination or an increase in urination frequency after the urinary catheter is removed Risk Factors for Developing a CAUTI: Age Female gender Host susceptibility to infections (e.g., immunosuppressed) Anatomy and disease process Method of catheterization Duration of catheter use Quality of catheter care Urinary catheters provide a portal of entry for bacteria into urinary tract Biofilm of bacteria ascend on the internal and external surfaces of the catheter Reflux Opening of an otherwise closed-drainage system Institute for Healthcare Improvement (IHI) How-to Guide: Prevent Catheter-Associated Urinary Tract Infections The IHI s How-to Guides address specific healthcare interventions that healthcare systems can pursue to improve the quality of healthcare for their patients. The IHI developed the how-to guides for the 5 Million Lives campaign, a voluntary initiative to protect patients from medical harm. The IHI recommendations include: 1. Avoid unnecessary urinary catheters 2. Insert urinary catheters using aseptic technique 3. Maintain urinary catheters based on recommended guidelines 4. Review urinary catheter necessity daily and remove promptly 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 3

Appropriate Indwelling Urinary Catheter Use Insert indwelling urinary catheters only for appropriate indications and leave in place only as long as needed. Examples of Appropriate Indications for Indwelling Urinary Catheters Patient has acute urinary retention or bladder outlet obstruction Need for accurate measurements of urinary output in critically ill patients Perioperative use for selected surgical procedures: 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 be removed in the PACU) Patients anticipated to receive large-volume infusions or diuretics during surgery Need for intraoperative monitoring of urinary output To assist in healing of open sacral or perineal wounds in incontinent patients Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures, or intra-aortic balloon pump) To improve comfort for end of life care if needed Examples of Inappropriate Indications for Indwelling Urinary Catheters As a means of easing the nursing workload for incontinent patients As a means of obtaining urine for culture or other diagnostic tests when patient can voluntarily void For prolonged postoperative duration without appropriate indications such as those noted above Use urinary catheters in operative patients: only as necessary remove the catheter as soon as possible postoperatively within 24 hours unless there are appropriate indications for continued use such as structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate: 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 4

Use external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction Use alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction Use intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract infection Proper Techniques for Urinary Catheter Insertion Bladder catheterization and irrigation must be done using sterile technique and equipment. Personnel who care for catheters should be given periodic training of correct technique and explanation of potential complications. The following points are essential for proper insertion of a urinary catheter: Sterile gloves, drapes, sponges and appropriate antiseptic solution for periurethral cleaning and a single use packet of sterile lubricant must be used for insertion Hand hygiene should be completed immediately before and after insertion Foley trays come with catheter and drainage bag pre-connected and should be used routinely If the first attempt is unsuccessful, an entire new kit (tray) is used for second attempt Unless otherwise clinically indicated, use the smallest bore catheter possible, consistent with good drainage to minimize bladder neck and urethral trauma If resistance is felt, withdraw catheter and contact physician, DO NOT FORCE THROUGH URINARY MEATUS Specialty catheters do not have pre-connected drainage units. The drainage unit should be connected using sterile gloves after catheterization 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 5

Proper Bladder Catheter Insertion 1. Assemble necessary equipment and provide for patient privacy and proper positioning, as well as proper patient identification. 2. Perform hand hygiene and apply non-sterile gloves. 3. Wash perineal area with soap and water, then dry. 4. Remove and discard non-sterile gloves. 5. Perform hand hygiene. 6. Open catheter tray according to directions, maintaining sterility. 7. Apply sterile gloves and arrange tray contents for accessibility. 8. Open inner sterile package containing catheter. 9. Pour antiseptic solution into compartment containing sterile cotton balls. 10. Open sterile lubricant packet. 11. Remove specimen container and pre-filled syringe and set them aside on the sterile field. NOTE: Testing the balloon by injecting sterile water from the pre-filled syringe is no longer recommended. Testing the balloon may stretch the balloon and lead to damage, causing increased trauma on insertion. 12. Lubricate the catheter, 1-2 inches for females, 5-7 inches for men. 13. Apply the sterile drape just below the perineal area, between the thighs. 14. Place sterile tray and contents between thighs on sterile drape. 15. Cleanse urethral meatus with cotton balls soaked with antiseptic solution. 16. Insert catheter. When urine appears in the tubing, advance catheter 1-2 inches and then inflate balloon. 17. Secure catheter. Document reason for non-securement. 18. Hang drainage unit from bed frame or chair. Drainage unit should always be below bladder level. 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 6

19. Discard supplies and remove sterile gloves. 20. Perform hand hygiene. 21. Document catheter insertion, as applicable a) Type and size of catheter inserted b) Patency of drainage system c) Appearance of insertion site d) Bag below level of bladder e) Frequency and type of care f) Patient response g) Catheter secured to body h) Color of urine i) System remains closed (junction not compromised) Proper Techniques for Urinary Catheter Maintenance Follow standard precautions when handling the urinary catheter, drainage tubing or drainage bag Maintain a closed drainage system, do not disconnect the drainage system to irrigate the catheter o If the catheter tubing accidentally becomes disconnected from the drainage bag, replace the catheter and drainage bag using aseptic technique Allow for unobstructed urine flow Use a urinary catheter securement device unless patient complications outweigh the risks of catheter dislodgement o Patient complications include: Significant lower extremity edema Complications of the leg adhesive devices or straps, including blistering, skin ulcerations or tears Do not routinely change urinary catheter Use a clean, designated urine collection container for each patient 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 7

Catheter and perineal care should be done at least once daily, but may be done more often if needed Proper Catheter and Perineal Care 1. Provide routine perineal care with soap and water. 2. Assess urethral meatus and surrounding tissues for inflammation, swelling, and discharge; ask patient whether burning or discomfort is present. 3. Female: Gently retract labia to fully expose urethral meatus and catheter insertion site. Maintain position of hand throughout the procedure. 4. Male: Retract foreskin, if not circumcised, and hold penis at shaft just below glans, maintaining position throughout the procedure. 5. Cleanse catheter with soap and water. Proper Urine Specimen Collection 1. Coil the catheter tubing at the sample port until enough urine has been collected. 2. Cleanse the sample port with a hospital disinfectant, such as 70% alcohol. 3. Position the sterile syringe on the sample port, and twist gently. 4. Withdraw desired amount of urine. 5. Uncoil catheter tubing, transfer urine specimen into the specimen cup, and discard the syringe per hospital protocol. 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 8

Removal of Urinary Catheter HOUDINI Nursing Protocol The duration of catheterization is the one of the most important risk factors for developing CAUTIs. Limiting catheter use and, when a catheter is indicated, minimizing the duration of catheterization are front-line strategies to prevent CAUTIs. The continued need for a urinary catheter should be assessed daily. BJC developed the HOUDINI Nursing Protocol, which permits nurses to remove the catheter once the qualifying criteria for urinary catheterization are no longer met. If the patient does not meet the following criteria, then the urinary catheter should be removed and the patient assessed for voiding within six hours. Hematuria, gross? Obstruction, urinary? Urologic surgery/urology patient or gynecological or perineal surgery? Decubitus ulcer open sacral or perineal wound in incontinent patient? I & O for hourly management or hemodynamic instability? No code/comfort care/hospice care? Immobility due to physical constraints (i.e. unstable fractures, IABP)? NOTE: Physician order to maintain a urinary catheter supersedes the use of this protocol. 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 9

After the Urinary Catheter is Removed 1) Patient should be assessed for voiding within six hours. If the patient has not voided within six hours, please perform a bladder scan on the patient. a. If the bladder scanner shows < 150 ml: i. Contact the physician, provide a condition report, and obtain orders b. If the bladder scanner shows 150 ml, but < 300 ml and the patient is not uncomfortable: i. Reassess the patient within two hours c. If the bladder scanner shows 300 ml: i. Straight (in and out) catheterize the patient, and record the amount and catheter size Repeat this process in six hours; straight catheterize if necessary, and document. If no bladder scanner is available in the unit/hospital: Palpate the bladder for distention, assess patient s comfort level; straight catheterize the patient as determined by assessment 2) Find an alternative method for incontinence such as frequent toileting, condom catheter, diaper, etc. 3) Explain/teach the patient and family about alternatives, about CAUTI prevention and that removal is for their benefit 4) Document the lack of indication for the urinary catheter 5) Document the removal date in the patient chart 6) Complete the HOUDINI-SCIP algorithm form and place in the chart for the physician to see that the catheter was removed 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 10

The Surgical Care Improvement Project (SCIP) SCIP was implemented by CMS as a measure, effective October 1, 2009, to reduce urinary tract infections in post-operative patients. To meet the SCIP criteria, all surgical patients with a catheter in place postoperatively must have their catheter removed on post-operative day (POD) 1 or 2, unless: The surgeon has written an order indicating the reason for continued catheterization OR The patient belongs to one of several excluded populations: Patients less than 18 years of age Patients with a length of stay longer than 120 days Patients enrolled in clinical trials Patients with urological, gynecological, or perineal surgery, or a procedure performed Patients who ICD-9-CM principal procedures occurred prior to the date of admission Patients who expired peri-operatively Patients with a length of stay less than 2 days post-operatively Patients who did not have a catheter in place post-operatively Patients who had MD/APN/PA documentation of a reason for not removing the urinary catheter post-operatively Patients who had a urinary diversion or a urethral catheter or were being intermittently catheterized prior to hospital arrival Note: These exclusions do not require that the urinary catheter remain in place, simply that these groups are excluded from the SCIP measure. These patients may still be evaluated for catheter removal on a timely basis to reduce catheter-associated urinary tract infections (CAUTI). Any surgical patient is exempt from HOUDINI removal protocol until after POD 2. After POD 2, all patients should be evaluated daily using the HOUDINI protocol. 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 11

A Patient Education Tool Before inserting a urinary catheter, the patient and family should be educated on the proper insertion and care of their urinary catheter. Many indwelling catheter kits provide a suitable education sheet for this purpose. This is an example of an education sheet that can be downloaded for this purpose, if one is not provided: http://www.sheaonline.org/assets/files/patient%20guides/nnl_ca-uti.pdf 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 13

Home Care of an Indwelling Urinary Catheter Patients who are discharged with an indwelling catheter should be educated on the care of the catheter and bag. There are two types of drainage bags: Leg bags Wear during the day Attach to the leg with rubber, Velcro, or cloth strap May be worn under everyday clothing Bedside bags Longer tubing, allows bag to hang off side of bed Holds more urine, less frequent emptying required Guidelines for caring for your catheter and drainage bags Always keep the drainage bag lower than the catheter, so urine drains downhill Always wash hands with soap and water before handling the catheter tubing or drainage bags Frequently check the tubing for kinks Wash the skin around the catheter every day with soap and water; rinse the skin thoroughly and dry completely Clean the catheter daily with soap and water to remove any crusty material from the tubing Empty the drainage bag every 8 hours or when it becomes full Loosen the clamp or remove the cap on the end of the bag After draining the urine, clean the tip of the drain spout with a clean cloth and soap and water, or with an alcohol wipe It is important to clean your drainage bags thoroughly each day To clean drainage bags: Flush the bag with liquid soap and warm water to remove urine Rinse the soapy water from the bag with cool water Hang the bag upside down to dry If the drainage bag has an odor: flush the bag with ¼ cup vinegar or household bleach mixed with 1 cup or water allow the mixture to soak inside the bag for 30 minutes rinse the bag thoroughly with cool water and hang upside down to dry if odor persists, discard the bag 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 14

References APIC Elimination Guide: Guide to the elimination of catheter-associated urinary tract infections (CAUTIs). Washington, DC. APIC, 2008. APIC Text of Infection Control and Epidemiology (3 rd Edition), 2009. CDC. Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51 (No. RR-16). CDC. Guidelines for the prevention of catheter-associated urinary tract infections 2009. http://www.cdc.gov/hicpac/cauti/001_cauti.html CDC. National Healthcare Surveillance Network (NHSN) report, data summary from 2010, device associated module. Am J Infect Control 2011;39(10):798-816. Davis, FA. Taber's Cyclopedic Medical Dictionary. 19th Edition, 2001. Institute for Healthcare Improvement How-To Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge MA; 2011. (Available at www.ihi.org). Potter PA and Perry AG. Basic Nursing: Essentials for practice. St. Louis, MO. Mosby, Inc. 2003. SHEA/IDSA Practice Recommendation: Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S41-50. SHEA Patient Education Guides website: http://www.sheaonline.org/assets/files/patient%20guides/nnl_ca-uti.pdf (last accessed 02/12) 2012 BJC HealthCare. All rights reserved. Reproduction is strictly prohibited without written consent. 15

Glossary Aseptic technique Bacteremia Bacteriuria Catheter Catheterize Genitourinary Incontinence Indwelling urinary catheter Inflammation Intraoperative Lubricant Morbidity Mortality A method used in surgery to prevent contamination of the wound and operative site. The technique is adapted at the bedside (e.g., during procedures) and in emergency and treatment rooms. Bacteria in the blood. The presence of bacteria in the urine. A tube passed through the body for evacuating fluids or injecting them into the body cavities. To pass or introduce a catheter into a part. Pertaining to the genital and urinary organs. Loss of self-control, especially of the urine and feces. Drainage tube that remains inside the body for a prolonged time. An immunological defense against injury, infection, or allergy. Occurring during surgery. An agent, usually a liquid oil, that reduces friction between parts that brush against each other as they move. State of being diseased. The number of deaths in a population. Myelomeningocele Spina bifida with a portion of the spinal cord and membranes protruding. Patency Swelling Thoracic Urinary meatus Urinary Tract Infection The state of being freely open. An abnormal transient enlargement, especially one appearing on the surface of the body. Pertaining to the chest or thorax. External opening of the urethra. Infection of the kidneys, ureters, or bladder by microorganisms