Prevention of Catheter Associated Urinary Tract Infection (CAUTI) CAUTIs are the most commonly reported HAI in the US. Although morbidity and mortality from CAUTI is considered to be relatively low compared to other HAIs, the high prevalence of urinary catheter use leads to a large cumulative burden of infections with resulting infectious complications and deaths (“Prevention of CAUTI-Acute care settings,” 2011, p. 1).
In addition, bacteriuria frequently leads to unnecessary antimicrobial use, and urinary drainage systems may serve as reservoirs for MDR bacteria and a source of transmission to other patients (“Prevention of CAUTI-Acute care settings,” 2011, p. 4). Healthcare-associated infections exact a significant toll on human life. They are among the top ten leading causes of death in the United States, accounting for an estimated 1. 7 million infections and 99,000 associated deaths in 2002. In hospitals, they are a significant cause of morbidity and mortality.
Currently, urinary tract infections comprise the highest percentage (34%) of HAIs followed by surgical site infections (17%), bloodstream infections (14%), and pneumonia (13%). Some of the guidelines set forth for prevention of CAUTI are frequent catheter care, removal of the catheter as soon as possible, and using sterile technique on insertion (Center for Disease Control, n. d. ). Education of the staff, frequent RN assessment and patient education are also a very important factor in the prevention of complications associated with urinary catheterization.
Step 1: Assess the Need for Change in Practice Catheter-associated urinary tract infection (CAUTI), a frequent health care–associated infection (HAI), is a costly and common condition resulting in patient discomfort, activity restriction and hospital discharge delays (Saint, 2008, p. 243). Would the emphasis of RN assessment along with frequent catheter care and early removal of indwelling catheters decrease the incidence of CAUTI?
Currently Physicians are making the decision of when patients are catheterized, when to remove, and also the need to reinsert. The physician spends approximately 5-10 minutes at the bedside of the patients, and is making the critical decision as to when a patient should be catheterized. “Evidence based practice is the conscientious use of the current best evidence in making clinical decisions about patient care” (Saint, 2008). Implementation of evidence based practice is the perfect tool to help prevent CAUTI in the patients we serve daily.
By merely presenting evidenced based findings to medical staff is not enough to reduce the risk of CAUTI, but implementing the change into everyday medical practice supports a safe and healthy environment for our patients (Healthy People 2010, n. d. ). Evidence based practice offers integrated research expertise as a solution to improving health care in the communities we serve, and allows the facilities to provide cost effective care.
Step 2: Link the problem, Interventions, and Outcomes Catheter-associated urinary tract infection (CAUTI), a frequent health care–associated infection (HAI), is a costly and common condition resulting in patient discomfort, activity restriction, and hospital discharge delays (Saint, 2008, p. 243). The incidence of UTI in long-term catheterized patients is high, as a urethral catheter bypasses the normal host of defenses, allowing continuous access of organisms into the bladder (Center for Disease Control, n. d. p. 1). Bacteria can remain in the bladder because the bladder never completely empties itself.
CAUTI cost facilities as much as $6000 to treat at their own expense. By setting a plan into motion, which may include a number of different activities such as assigning specific duties to staff members, creating a timeline, identifying helpful resources, and testing the plan for effectiveness is a great start to prevention (“Prevention of CAUTI-Acute care settings,” 2011, p. 3). By preventing CAUTI in our patients this will not only promote patient satisfaction, earlier discharge, and prevent other complications from the infection caused from the catheterization, it reduces hospital cost associated with CAUTI. According to HICPAC, it’s recommended that long term care facilities not catheterize patients that suffer from incontinence, and in cooperative males use an outer source such as condom catheters, or adult diapers (http://www. cdc. gov/hicpac/). Techniques for insertion were also explored, and a critical point of insertion is merely strict hand washing before and after insertion to prevent infection. Another key point for staff is that they never clean the peri-urethral area with antiseptics to prevent CAUTI while the catheter is in place.
Moreover by simply cleaning the area with mild soap and water helps tremendously to prevent infection (Healthy People 2010, n. d. ). Step 3: Synthesize the Best Evidence “The Department of Health and Human Services” explored both male/female gender alternatives to catheterizing patients unnecessarily. These infections cause many other serious complications, affecting not only the bladder but the kidney as well. These complications put patients at risk for other complications, such as decubitus ulcers, thromboembolism, and health decline. The Agency for Healthcare Quality and Research,” seeks to establish ways of preventing the high incidence of CAUTI. The source also evaluated patients which were symptomatic vs. asymptomatic patients in the promptness of the treatment rendered. Also another serious complication of CAUTI is BSI (Blood stream infections) that can be fatal if not caught and treated promptly. “The Clinical Performance of Quality Health Care, along with Joint Commission” offers standards and objectives for facilities to assess measure and improve their standards at the lowest cost possible.
The database covers nursing care and education, along with guidelines on prevention. Moreover the JCAHO regulatory standards for catheterized patients are explained and the documentation that is expected when JCAHO inspections are rendered in a facility. The source “Stop orders to reduce inappropriate urinary catheterization in hospitalized patients” states that by following standard precautions with every patient these infections can be prevented. . Also the source explored whether catheters should be used at all in an effort to decrease the incidence of CAUTI’s.
Intermittent catheterizations along with supra-pubic were explored with a decreased incidence of bacteria being present in the bladder afterwards. The source “Strategies to prevent catheter-associated urinary tract infections in acute care hospitals” offered ways of cleansing and disinfecting the skin before insertion to reduce the risk of infection. Many CAUTI’s are linked to bacteria harboring in or around the site at insertion. By using not only aseptic technique but also cleansing the skin with chlorhexadine can decrease he incidence of infection (http://www. ealthcare. gov/law/resources/reports/nationalqualitystrategy). “The Health Protection Surveillance Centre” offers several methods on prevention and maintenance of patients with CAUTI. By offering education to both patient and staff the incidence of CAUTI can be decreased, and patient satisfaction rates can be increased. Step 4: Design Practice Change Provide Appropriate Infrastructure for Preventing CAUTI to all staff. Provide and implement written guidelines for catheter use, insertion, and maintenance.
Ensure that there are sufficient trained personnel and technology resources to support surveillance for catheter use and outcomes (http://www. cdc. gov/hicpac/). Include documentation in nursing flow sheet, nursing notes or physician orders. Documentation should be accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes. Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-volume areas (“Catheter Associated Urinary Tract Infection,” 2012).
Monitor compliance with evidence-based guidelines or best practices by evaluating the effectiveness of prevention efforts. Involve frontline staff in the initial process planning and implementation, encourage suggestions and ideas for needed change. Have a physician champion that is educated in urology, and aware of the most up to date data on the causes and prevention of CAUTI (“Catheter Associated Urinary Tract Infection,” 2012). Include charge nurses in the planning being that they will be the overseers, and resource people to the unit nurses.
Include staff development as well in the planning they can offer ways of insertion, and offer unit check-offs to make sure all staff are properly trained, and competent on catheter care and insertion (“Catheter Associated Urinary Tract Infection,” 2012). Step 5: Implement and Evaluate the Change in Practice A change in practice within my institution has been implemented, as the incidence of CAUTI’s and long- term use of indwelling catheters rises, due to the increasing number of long-term care patients admitted from long term are facilities my facility implemented a number of measures to help CAUTI’s and reduce the cost of the patient’s stay. By implementing the use of a catheter insertion note everyone on the medical team can be aware of when the catheter was inserted. Also by creating a catheter committee to check the dates of insertion, catheter care, and ensure that for our long-term care patients that they are being replaced after 72-hrs will decrease the incidence of CAUTI’s by over 50%.
By reinforcing the use of bladder training and offering the bedpan, and bathroom assistance Q-2hrs, and frequent RN assessment has also reduced the risk of infection. Consider interviewing patient with focused questions, focus on quality of information instead of quantity and feeding it back to staff. Track trends perform regular point prevalence surveys and compare to previous findings (“Catheter Associated Urinary Tract Infection,” 2012, p. 7). Monitor prevention outcomes and processes for CAUTI, based on the facilities risk assessment tool.
Incorporate a SWOT analysis tool to staff to evaluate where they are lacking skills, education, and the need for change. Finally develop strategies and SMART goals, while offering the needed support to maintain the change in practice (“Catheter Associated Urinary Tract Infection,” 2012). Step 6: Integrate and Maintain the Change in Practice In an effort to maintain the results of the change in practice several things should be done for the safety of the patient. Delete routine insertion of urinary catheters from preprinted order sets.
Develop a system that alerts care providers that patient has a urinary catheters and assessment of the need for continued catheterization is needed (“Catheter Associated Urinary Tract Infection,” 2012). Provide education and performance feedback regarding appropriate insertion and maintenance of catheters and alternatives for all staff members. Feedback regarding adverse outcomes including catheter obstruction, unintended removal, and catheter trauma are important in evaluating the effectiveness of the change.
Also, permitting nurses to use bladder scanners to assess urinary retention without a physician’s order is an important tool to decreasing the use of catheters unnecessarily (“Catheter Associated Urinary Tract Infection,” 2012). Scanning the bladder before placing urinary catheters and after a catheter is removed before reinsertion will also aide in the implementation of the change on the unit. Summary In conclusion, the evidence provided required a change to be initiated in the use and care of catheterized patients; evidence provided clearly supports the needed change in nursing practice.
By noting the reduction of CAUTI’s in long term care patients, hospital acquired costs have decreased largely reducing extended hospitalizations, and better patient outcomes. While catheter-associated urinary tract infection (CAUTI), are considered a frequent health care–associated infection (HAI), which is a costly and common condition resulting in patient discomfort, activity restriction, and hospital discharge delays (Saint, 2008, p. 243). The Rosswurm and Larrabee’s six-step model for change were explored to aide in the change in practice for the prevention of CAUTI.
The steps explored were assessing the need for change in practice, linking the problems, interventions, and outcomes, synthesizing the best evidence, designing practice change, implementing and evaluating a change in practice, and integrating and maintaining the change. While every aspect of these six steps are important to not only the patient, but the facilities staff members that render their care. Many facilities were basing the care of catheterized patients merely on the financial benefit of the facility and not taking the safety of the patient into account when educating, and evaluating nursing staff who provide care daily.