Prevention Of Catheter-Associated Urinary Tract Infections

The urinary tract is meant to be sterile above the urethra, but when pathogenic microorganisms are introduced to the urinary tract it is termed a urinary tract infection (UTI) (Hinkle & Cheever, 2014). According to the Centers for Disease Control (CDC) to be considered a catheter-associated urinary tract infection (CAUTI) the indwelling urinary catheter (IUC) must be in place greater than two calendar days and the UTI must occur with the IUC still in place, on day of removal, or the day after removal (CDC 2018). If the patient is found to have a UTI and the patient has an IUC but the IUC has only been in one calendar it is not a CAUTI (CDC 2018).

An IUC is not a “condom or straight in-and-out catheters, nephrostomy tubes, ileoconduits, or suprapubic catheters” according to the CDC (CDC 2018). UTIs have become the fourth most common healthcare-associated infection, with 93,000 estimated UTIs in 2011 in acute care hospitals (CDC 2018). Of the 93,000 UTIs reported in 2011, 70-80% of these UTIs were exposed to a catheter and were determined to be the cause (MEDSURG Nursing 2017). Thus, making CAUTIs the most preventable health-care associated infection (MEDSURG Nursing 2017).

By taking into account the high number of IUC and that 70-80% of the 93,000 UTIs annually in the United States happen to be CAUTIs one can see that CAUTIs need to be improved using nursing judgement. The National Database of Nurse Quality in 2010 found catheter-associated urinary tract infections as a nursing sensitive indicator (Hinkle & Cheever, 2014). As well as the fact that CAUTIs are a national patient safety goal due to the fact that CAUTIs are preventable. IUCs are frequently used and more than 30 million are inserted annually in the United States (continuous quality improvement CAUTI prevention).

30 million IUC inserted annually seems like a lot but 90% of intensive care patients and 25% of inpatients have an indwelling urinary catheter at some point during hospitalizations (MEDSURG Nursing 2017). CAUTIs can be an easily avoidable problem with proper education and increased value of care. Therefore, due to how often IUC are used and how often they cause a problem for patients, nurses must evaluate if IUCs are essential to care and if they are how IUCs are being used and for how long they are being used for.

Background

Catheter associated urinary tract infections have growingly become a problem in healthcare. In 2008 the Centers for Medicare & Medicaid Services (CMS) identified eleven preventable adverse outcomes that hospitals would no longer receive reimbursement for to try and element these outcomes from occurring (CNE series 2016). Out of these eleven adverse outcomes four of them could be avoided with more skillful nursing care. These four include, severe pressure ulcers, falls and trauma, catheter-associated urinary tract infections, and vascular catheter-associated infections (CNE series 2016).

The outcomes that are nursing sensitive are noteworthy “because they increase patient pain and suffering, prolong hospital stays, and increase health care costs” (Do I cite the article or where the article got it from CNE 2016). CMS kicked off the reimbursement policy to try and improve facilities and their employees’ quality outcomes. At this time in research the policy has not been found to have resulted in fewer adverse outcomes for patients, but it is a step towards trying to decrease outcomes such as CAUTIs and other adverse results (CNE 2016).

The CMS reimbursement policy that was discussed earlier in the paper was seen to have a few stipulations that may have spoiled the proposal of trying to improve outcomes. These adverse outcomes from the policy include hospitals may not want to take the problematic patients to avoid the possibility of not being reimbursed. The study also found that when there was an increased census in hospitals there was an increased report of hospital acquired conditions included CAUTIs (CMS reimbursement). CAUTIs increase a patient’s hospital stay by 2-5 days and can increase the patient’s anxiety and pain while increasing cost and can even result in mortality (MEDSURG Nursing 2017). CAUTI-related deaths were found to be more than 13,000 annually (Urologic Nursing 2017).

Clinical Manifestations of CAUTIs

Catheter use is appropriate for many reasons such as Therefore, a list of signs and symptoms has to be universal to help avoid CAUTIs and help stop the infection from becoming graver (Blodgett et al., 2018). Blodgett et al. used the CAUTI Assessment Profile (CAP) to analyze whether the four clinical manifestations on the CAP were reliable in determining CAUTIs (Blodgett et al., 2018). The four clinical manifestations that were included on the CAP was delirium, fever, suprapubic tenderness, and flank tenderness (Blodgett et al., 2108). The CAP incorporated definitions as well as diagrams that helps measure whether fever, suprapubic tenderness, flank pain, and delirium are present or absent (Blodgett et al., 2018).

CAUTIs can be caused by an antibiotic resistant organism and therefore, harder to fight with medications and actions and this, it is important to use the CAP often (Murphey et al., 2018). Blodgett et al. found that three of the four clinical manifestations were reliable in assessing for CAUTIs (Blodgett et al., 2018). Flank tenderness was not reliable due to patients not wanting or not being able to turn onto their side for nurses to assess (Blodgett et al., 2018). A limitation of this study was not doing a urine sample to confirm or deny a positive CAUTI after using the CAP (Blodgett et al., 2018). The CAP isn’t a guaranteed yes or no answer if the patient has a CAUTI or not but it does assist clinicians by having a universal assessment tool (Blodgett et al., 2018).

Decreasing Inappropriate Catheter Use

Catheter use is the cause of CAUTIs. Therefore, if the amount of IUCs that are inserted annually decreased, which is more than 30 million in the United States, there would be a decrease of CAUTIs (Continuous quality improvement). Meddings et al. updated a prior systematic review that looked at avoiding inappropriate catheter use (Meddings et al. 2013). This integrative review showed that between 21% and 55.7% of IUCs inserted do not meet appropriate indications for insertion. A list from the CDC have examples of indications for insertion of urinary catheters but this list can be molded due to patient population.

Appropriate indications of IUC’s include:

1. patient has acute urinary retention or bladder outlet obstruction;
2. need for accurate measurements of urinary output in critically ill patients;
3. perioperative use for selected surgical procedures: patients undergoing urologic or other surgery on contiguous structures of genitourinary tract, anticipated prolonged surgery duration; catheters inserted for this reason should be removed in post-anesthesia care unit, patients anticipated to receive large-volume infusions or diuretics during surgery, need for intraoperative monitoring of urinary output;
4. to assist in healing of open sacral or perineal wounds in incontinent patients,
5. patient requires prolonged immobilization (eg, potentially unstable thoracic or lumber spine, multiple traumatic injuries such as pelvic fractures);
6. to improve comfort for end-of-life care if needed” (Meddings et al., 2013, p. 3).

Meddings et al. found that protocols may increase more appropriate insertion of urinary catheters rather than educational interventions (2013). Education is an important first step, but protocols are required by the organization and constant while educational interventions varies (Meddings et al. 2013). Studies found that there was a decrease in the amount of IUCs placed inappropriately when interventions are in place that list out appropriate catheter placement.

A urinary retention protocol was also found to have decreased the number of urinary catheters that were used inappropriately. A urinary retention protocol encompasses use of a bladder scanner that will help verify the amount of urine in the bladder that may result in intermittent straight catherization rather than an IUC (Meddings et al., 2013). This is beneficial due to retention typically being a temporary issue and not requiring an IUC generally (Meddings et al., 2013).

Decreasing Duration of Catheter Use

Each day an IUC is in place the chance of developing a CAUTI increases up to 7% (CDC 2018). Therefore, the amount of time a urinary catheter stays in place is a big component of CAUTIs. Janzen et al. conducted research of 149 patients that compared before and after the intervention was incorporated (2013). Research found that IUC were inserted appropriately 89.2% of the time (Janzen et al., 2013). Thus, they turned their research towards duration of time the catheters were used (Janzen et al., 2013). Janzen et al. found that when discussing the appropriateness of IUC’s each day resulted in zero CAUTIs in the post-intervention compared to the four CATUIs in the pre-intervention period (2013).

The cessation of CAUTIs during the post-intervention of assessing catheter appropriateness is due to the decrease in the amount of duration of the catheters from a median of 7 days in the pre-intervention to a median of 5 days in the post period (Janzen et al., 2013). When an IUC is inserted it could be appropriate but as time passes the IUC can become inappropriate and therefore, needs to be removed. Janzen et al. put posters in the breakrooms and physician offices to remind all personnel about the importance of swift removal as well as educating them (2013).

Reference:

1. Hinkle, J. L., & Cheever, K. H. (2014). Textbook of Medical-Surgical Nursing (13 ed). Pittsburgh, PA: Lippincott Williams & Wilkins.