Tell Me Again Why This Patient Needs a Catheter?

Back to Basics Tenth in a Series Patient Safety Tell Me Again Why This Patient Needs a Catheter? by Alecia Cooper, RN, BS, MBA, CNOR Insertion of an indwelling urinary catheter is a common procedure within perioperative services. In fact, as many as 86 percent of patients undergoing surgery have urinary catheters. 1 In addition, 50 percent of these catheters remain in place for more than two days. 1 Have you ever thought about or questioned if the catheter you were inserting was really necessary and clinically indicated for your surgical patient? It has become critically important that we evaluate the need for urinary catheterization and no longer insert catheters for convenience or because there is a preference card telling us to insert a catheter. What s more, did you know that requests from nurses to place a urinary catheter for nursing convenience are not uncommon? 2 New guidelines and recommendations tell us that we should determine if there is an approved medical indication for catheterization. This means that we evaluate and reconsider a common practice occurring pre-, intra-, or postoperatively insertion of an indwelling catheter prior to a certain surgical procedures. This evaluation may change how we have always done things. The Centers for Medicare & Medicaid Services (CMS), as a result of the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005, has identified catheter-associated urinary tract infection (CAUTI) as a healthcare-associated infection (HAI) that can reasonably be prevented through the application of evidence-based practice. CMS reported in the 2008 Federal Register that in 2007 there were 12,185 CAUTIs, Improving Quality of Care Based on CMS Guidelines 61

MAJOR BARRIERS TO CAUTI PREVENTION Too many indwelling urinary catheters are inserted It has been estimated at up to 50 percent of the indwelling urinary catheters are unnecessarily placed. 7 costing $44,043 per hospital stay. 2 CAUTI is one of 10 hospital-acquired conditions (HACs) for which CMS will no longer provide reimbursement if it occurs during hospitalization. 3 Brand-new CAUTI prevention guidelines CAUTI is the number one healthcare-associated infection (HAI), accounting for 40 percent of all hospital-acquired infections. 4 One in four patients receives an indwelling urinary catheter at some point during their hospital stay. 5 As a result of this data, leading industry experts, including the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology (SHEA), the Centers for Disease Control and Prevention (CDC), the Joint Commission and many others have joined together to outline strategies and guidelines to prevent catheter-associated urinary tract infections in acute care hospitals. 6 The CDC s Draft Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008 (released in June 2009) identifies new guidelines and recommendations to prevent CAUTI. Barriers to CAUTI prevention Three distinct barriers to the prevention of CAUTI become evident when analyzing the problem. In the perioperative environment it is hard to imagine that there are errors in aseptic technique because we are acutely aware of proper technique. But remember that most nurses outside of the perioperative environment do not routinely perform aseptic technique and may not be aware when contamination occurs. In fact, during most observations of nurses outside of the perioperative environment, we have seen inconsistent practice in setting up a sterile field and inserting indwelling catheters aseptically. It is perfectly clear that in perioperative services, two of the three barriers occur routinely too many catheters are inserted and catheters stay in too long. CAUTI incidence outside the perioperative environment To help you further realize the magnitude and role of perioperative services in preventing CAUTI, let s look at additional statistics from outside the perioperative environment. Did you know that the emergency department (ED) has the highest percentage of catheter placements? 7 In the ED, as well as in perioperative services, documentation of the reason for catheter placement is poor and a written physician order is frequently lacking. Without a physician order, physicians are unaware that the patient has a catheter. 5 When physicians do not know that a catheter has been inserted, it is no wonder that an order for timely removal is lacking, and catheters stay in longer than medically necessary. Common catheter practices in perioperative services Adding to the problem, inappropriately placed catheters are more often forgotten about. 5 In 56 percent of hospitals there is no system to keep track of which patients have catheters, and 74 percent of hospitals do not keep track of how long the catheter is in place. 8 Shocking as this may be, let s assess common practice in perioperative services and see if any of these common occurrences occur at your facility. 1. Do you have preference cards that tell you to insert an indwelling catheter for a specific procedures performed by a particular surgeon? 2. Do you assess patients to determine if the standing order to insert an indwelling catheter is medically indicated? 3. When a patient comes to the OR with an indwelling urinary catheter or when you insert one intraoperatively, do you evaluate the need to keep the catheter in place at the end of the surgical procedure before transporting the patient to the post anesthesia care unit (PACU)? 4. Do you date and time when the catheter was inserted? This critical step helps the clinicians on the patient care unit to remove the catheter within 48 hours or less following the surgical procedure. 62 Healthy Skin

Perioperative nurses are positioned to significantly impact the reduction and elimination of catheter-associated urinary tract infections by removing catheters when patients do not meet the approved indications. Take a peek at Table 1, which lists when indwelling urinary catheters should and should not be used. What is a nurse to do? If your patient has no alternatives, and you must insert a urinary catheter, is there anything you can do to help prevent catheter-associated urinary tract infections? Absolutely! CAUTI prevention methods a. Alternatives to urinary catheter use Do not allow routine urinary catheter placement in the OR. Remove as many urinary catheters as you can within 24 hours. Consider alternatives to indwelling urethral catheters, such as intermittent catheterization. Table 1. Appropriate Indications for Indwelling Urethral Catheter Use 10,11 Patient has acute urinary retention or 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 PACU) Patients anticipated to receive large-volume infusions or diuretics during surgery Operative patients with urinary incontinence 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) To improve comfort for end of life care if needed 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 For prolonged postoperative duration without appropriate indications Routinely for patients receiving epidural anesthesia/analgesia Note: These indications are based primarily on expert consensus. b. Appropriate urinary catheter use Use indwelling catheters only when medically necessary. c. Aseptic insertion of urinary catheters Use aseptic insertion technique with appropriate hand hygiene and gloves. Allow only trained healthcare providers to insert catheters. d. Proper urinary catheter maintenance - Properly secure catheters after insertion. - Maintain a sterile closed drainage system. - Maintain good hygiene at the catheter-urethral interface. - Maintain unobstructed urine flow. - Maintain drainage bag below level of bladder at all times. - Use portable ultrasound bladder scans to detect residual urine amounts. - Do not change indwelling catheters or urinary drainage bags at arbitrary fixed intervals. e. Timely removal - Remove catheters when no longer needed. - Document indication for urinary catheter on each day of use. - Use reminder systems to target opportunities to remove catheter. The above list was combined from recommendations in the CDC guidelines and 2008 APIC CAUTI Elimination Guidelines. Continued on Page 36 Improving Quality of Care Based on CMS Guidelines 63

MAJOR BARRIERS TO CAUTI PREVENTION Contamination occurs during insertion Most nurses are aware of the importance of aseptic technique but it can take extra time. Heavier nursing workloads contribute to poor compliance with aseptic technique. 7 Putting it all together to ERASE catheter-associated urinary tract infections Until recently, catheter-associated urinary tract infections have received little attention compared to many of the other types of HAIs. However, research and best practices for the prevention of CAUTI are readily available. Despite the link between urinary catheters and urinary tract infections in hospitals and other healthcare settings, a recent survey of U.S. hospital practices identified that no strategy is consistently or universally used in U.S. hospitals to prevent these infections. 11 Literature reports numerous organizations that have implemented successful strategies to reduce CAUTI. These organizations have utilized multidisciplinary teams to implement evidence-based changes in practice; have incorporated practice changes into the routine standard of care; and have performed ongoing or periodic review of progress to reinforce successful strategies. 11 Develop a CAUTI prevention program for your facility If your organization does not have a CAUTI elimination program, or you are not getting the results you had hoped for, start by assessing whether an effective organizational program exists. Work with your infection preventionist and other key multidisciplinary stakeholders to develop your campaign. Questions to consider to help you get started with your own CAUTI prevention program: Are there policies or guidelines that define criteria for insertion of a urinary catheter? Has the organization established criteria for when a catheter should be discontinued? Is there a process to identify inappropriate usage or duration of urinary catheters? Is there a program or guidelines to identify and remove catheters that are no longer necessary? (e.g., physician reminders, automatic stop orders or nurse-driven protocols) Are there policies or guidelines for use of a bladder scanner to detect urinary retention prior to insertion of a catheter? Are there mechanisms to educate care providers about use and care of urinary catheters? Overall Assessment: Is there an effective organizational program in place? 11 66 Healthy Skin

Start the race to erase CAUTI in the operative arena by educating your patients and staff about CAUTI. Ensure all staff practice aseptic technique and remove catheters in a timely manner. Join the RACE to ERASE CAUTI! Talk about prevention, raise awareness, then implement solutions in your organization. ON YOUR MARK... GET SET... References 1. Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data. Arch Surg. 2008;143:551-557 2. Ribby KJ. Decreasing urinary tract infections through staff development, outcomes, and nursing process. J Nurs Care Qual. 2006; 21:272-276. 3. CMS, Proposed Changes to the Hospital IPPS and FY2009 rates; Available at http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf. Accessed July 24, 2009 4. Catheter-related UTIs: a disconnect in preventive strategies. Physician s Weekly. 25(6), February 11, 2008. 5. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf. 2005; 31(8):455-462. 6. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiology. 2008; 29:S41 S50. 7. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at http://www.medscape.com/ viewarticle/587464_4. Accessed July 6, 2009. 8. Saint S, Kowalski CP, Kaufman SR, Hofer PH, Kauffman CA, Olmsted RN et al. Preventing hospital acquired urinary tract infection in the United States: a national study. Clinical Infectious Diseases. 2008; 46(2):243-250. 9. Magnall, J. Waterson, L. Principles of aseptic technique in urinary catheterization. Nursing Standards. 2006 November 1 7; 21(8) 49 56;quiz. Available at http://www.ncbi.nlm.nih.gov/pubmed/17111954. Accessed July 24, 2009 10. The CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008, Draft 11. An APIC Guide to the Elimination of Catheter-Associated Urinary Tract Infections 2008 GO! (CA-UTI) p. 22,35-41 The Association of Professionals in Infection Control and Epidemiology. Improving Quality of Care Based on CMS Guidelines 67