Preventing CAUTI: A Patient-centered Approach
Preventing CAUTI:A patient-centeredapproachThe infection prevention community mustassure that ongoing CAUTI preventionprograms are inclusive and effective.By MaRiLyn HanCHett, Rn, Ma, CPHQ, CiCPhoto By francIs BlacK / istocKPhoto.com42 Autumn 2012 Prevention
Catheter-associated urinary tract infection (CAUTI) is widely recognizedin the United States as the most common healthcare-associatedinfection (HAI), representing an estimated 40 percent of all HAIs.1CAUTI has been shown to increase patient mortality and morbidity,increase length of stay, and add to the cost of care.2 Not only is CAUTI a challengein acute care, the prevalence of catheters in nursing homes expands the need foreffective clinical prevention programs across the health services continuum.Baseline valid measures forCAUTI are difficult to obtain.Utilization of indwellingcatheters in non-hospitalsettings is thought to be high,but estimates vary. Introductionof the updated NationalHealthcare Safety Network(NHSN) CAUTI definition bythe Centers for Disease Controland Prevention (CDC) in 200 has helped define criteria moreclearly. Earlier studies may havecombined cases of asymptomaticbacteruria with active infectionsand skewed the published rates.Despite the measurementchallenges, CAUTI is amongthose HAIs targeted for significant improvement, basedon evidence showing that morethan 50 percent of these infections are preventable.3National momentumfor changeOver the past three years, numerous initiatives have helpedescalate and sustain the nationaldemand for improved CAUTIoutcomes. For example, whenthe U.S. Department of Healthand Human Services (HHS)introduced the HAI ActionPlan in 200 , CAUTI wasamong the HAIs targeted fora 25 percent reduction over fiveyears. Also that year, the CDC’sHealthcare Infection ControlPractices Advisory Committeeupdated its CAUTI Guideline.The Joint Commission approveda new National Patient SafetyGoal specific to CAUTI, andother accrediting organizationshave focused on it as well.Not long after these changesoccurred, new federal fundingsupported extensive state-basedHAI prevention activities.Seven states launched collaboratives targeting CAUTI aspart of their specific preventionplans. Efforts by private organizations such as Leapfrog andthe Institute for HealthcareImprovement (IHI) also helpedreinforced the need to includeCAUTI among the nationalprevention priorities.More recently, the Centers forMedicare & Medicaid Servicesbegan requiring CAUTI re-porting via NHSN for adultand pediatric ICUs in acute carehospitals beginning in January2012, and for long-term acutecare hospitals and inpatient rehabilitation facilities beginningin October 2012. Additionally,the draft of the long-term care(LTC) chapter of the HAIAction Plan focused on targeting and measuring urinary tractinfections in LTC settings.The goal of these major projects is not the elimination of allcatheter use. Instead, the goalshave been the appropriate useof catheters and the safest possible management during theperiod when they are necessary.As in the previous national central line-associated bloodstreaminfection (CLABSI) reduction efforts started 10 years ago,prompt device removal is a keycomponent of this enhancedapproach. A lesson from theearly CAUTI projects was thattraditional approaches wereinsufficient in achieving the improvement targets identified atboth the federal and state levels.A new approach was needed.Prevention Autumn 2012 43
The shift fromproduct to patientThe migration of bacteria alongthe catheter surface has longbeen recognized as the causeof inevitable urethral andbladder colonization.4 Previousprevention efforts have targetedthe product components of theurinary draining system and/orrelated maintenance proceduresto mitigate the risk suchcolonization poses for infection.Many of these product-drivenapproaches have been shown tobe ineffective and are no longerrecommended practices. Theseinclude routine catheter replacement, catheter irrigation, flushingor rinsing the drainage bag, rou-tine replacement of the drainagebag, and use of antiseptics formeatal care. While antimicrobial coated catheters are stillused, current recommendationscaution against their use as a primary prevention strategy.Table 1Using the Four “E”s of implementation science* to develop a CAUTI prevention planFields have been completed using examples and are not intended as a comprehensive list.GeneralactivityEngageExplain why theinterventions areimportant.Essentials ofCAUTI prevention(evidence based)Rationale presented to allstakeholders.Case for prevention is clear,concise, compelling.Rationale is part of PatientSafety Program.Active, visible participationby senior leaders andinstitutional champions(all levels).EducateAdaptation ofinterventions for thisorganizationDetermine which groupsare already engaged andif others need greaterinvolvement.Verify that CAUTI preventionhas a high profile/prioritywithin the organization’ssafety program.Check to see that allstakeholders are involved.Groups often overlooked includethe lab, EVS, and patienttransport.Measures toaddress gapsNote: Full engagement isrequired for the remainingthree general activities(educate, execute, andevaluate) to be successful.Address any gaps with atargeted plan, includetime frames.Key resources forimplementationHHS HAI Action Plan(2009)See also CDC HAIincidence data, progressreports at www.cdc.govConsider novel, creative waysto showcase the involvementof senior leaders, includingmedical staff.Share CAUTI data, includingmorbidity, mortality andcost data.Teach and reinforce correctindications for catheter use,insertion and maintenance.Educate regarding use ofprevention techniques.Reinforce previous practicesthat should not be used.Describe need for thorough,accurate medical recorddocumentation.Teach and reinforceorganization standards fordocumentation.ExecuteImplement CAUTI bundle.Implement a CAUTI bundle.Design aninterventiontoolkit.Provide staff/patient/familyeducation.Consider use of a CAUTIchecklist.Conduct rigorous monitoringand offer frequent feedback.Determine need for alertsto physician and nurses re:potential catheter removal.Share evidencesupporting theinterventions.Identified gaps(knowledge, skills, behavior,resources, etc.)Compare new content to whatmay have been used in the past.Address discrepancies, includingpractices no longer used. Verifyaccurate baseline knowledgeamong staff before proceeding.Note: Do not assume thatcare staff familiar withcatheters know currentbest practices. Outdatedinformation can be difficultto eradicate; long standingcare routines are oftenresistant to change.HICPAC Guideline forthe Prevention of CAUTI(2009)Bundles and checklist areimportant but must be analyzedin terms of attitude and behavior.Determine of the structural,programmatic as well asbehavioral elements are alignedfor successful implementation.Note: Encourage care staffto suggest improvementsto the implementation plan.Small adjustments can offerlarge benefits in the overallsuccess of the program.APIC Implementation(formerly Elimination)Guide, CAUTI (2009)Evaluate both the programstatistics as well as proceduralcompliance. Include students ifthey handle catheters. Do notoverlook the opportunity forongoing understanding and useof correct aseptic technique.Note: Use statistics wisely;do not overwhelm staffwith data. Follow up on anycomplaints or adverse eventsin a non-punitive measure.Consider use of RCA.Compare organizationalresults to state, regionaland national data, asavailable.SHEA/IDSA Compendiumof Strategies to PreventHAIs in Acute CareHospitals (2008)Add catheter review todaily rounds.EvaluateRegularly assessperformancemeasures andunintendedconsequences.Identify measures of successand report progress perschedule.Describe both process andoutcome measures forCAUTI.Investigate errors and lapsesas opportunity to improve.Share progress towardsgoals at least once permonth.Include patients/families inevaluation process.Communicate, celebratesuccess.Compare progress to otherlocal, regional, and nationalmeasures.Consider use of CDCNHSN.Include CAUTI SIRreporting in results.Adapted from Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337:a1714*Implementation science: the use of scientifically valid methods to promote the integration of research findings and other best practices into the evolving standard of care. In this way, research not only movesfrom the laboratory to the beside, but also results in improved, safer and more cost effective healthcare.Additional reference: Saint S, Howell J Krein SL, Implementation Science: How To Jumpstart Infection Prevention Infect Control Hosp Epidemiol. 2010 November; 31(Suppl 1): S14–S1744 Autumn 2012 Prevention
These earlier efforts have beenimportant guideposts in theCAUTI prevention journey.Today, however, initiativesexpand upon product-relatedprocedures to offer a morecomprehensive, patient-centeredapproach. Technology, includingboth enhanced disposablesupplies and new equipmentsuch as portable ultrasound,remain integral to the overallplan. Instead of emphasizinginterventions after catheterplacement, current strategiesfocus on determining thenecessity for catheter insertionand insist on clinical justificationof its placement every day untilit can be removed.CUSP/Stop CAUTIOne example of the shift towarda more patient-focused approachis seen in the ComprehensiveUnit-based Safety Program(CUSP). CUSP was pioneeredin 2003 by Johns Hopkins andthe MHA Michigan Keystonegroup to reduce CLABSI rates.Based on the success achievedin 127 ICUs in Michigan, theAgency for Healthcare Researchand Quality then funded aproject in 2008 to replicate theCUSP model in 10 states withsimilar successful outcomes.The CUSP model focuses onassessment of the culture of safety,driving change at the unit level,empowering the interdisciplinaryteam to take immediateimprovement measures, andongoing involvement and supportfrom senior leadership. A widerange of tools and other resourcesare offered to help implementthese and other essential programcomponents.The On the CUSP: StopCAUTI initiative applies the ele-Table 2CAUTI Insertion BundleVerification of needprior to insertion.Insert urinary catheter usingaseptic technique.Maintain urinary catheter based onrecommended guidelines.Urinary retention/ObstructionHand hygieneSeverely ill/ImmobilityCatheter insertion kit with sterile gloves,Secure catheter to prevent irritationof the urethraLack bladder controldrape, cleaning supplies, sterile lubricant,sterile urinary catheter attachedto a drainage bag.Patient request/End of lifePerioperative – selected surgical proceduresAssisting with pressure ulcerhealing for incontinent patients.Maintain an unobstructed flow,maintain the drainage bag below thelevel of the bladder and off the floorPerform hand hygiene before andafter each patient contactProvide individual labeled collectioncontainer at the bedsideReview urinary catheter necessity daily,remove catheter promptly when not needed.CAUTI Maintenance BundleDATEBUNDLE CRITERIADAILYDOCUMENTEDASSESSMENTOF NEEDTAMPER EVIDENTSEAL IS INTACTCATHETERSECUREDSECUREMENTDEVICE IN PLACEHAND HYGIENEPERFORMEDFOR PATIENTCONTACTDAILY MEATALHYGIENEPERFORMEDWITH SOAP ANDWATERDRAINAGEBAG EMPTIEDUSING A VE ORCONTINUEYES NOYES NOYES NOYES NOYES NOYES NOYES NOREMOVECONTINUEYES NOYES NOYES NOYES NOYES NOYES NOYES NOREMOVECONTINUEYES NOYES NOYES NOYES NOYES NOYES NOYES NOREMOVECONTINUEYES NOYES NOYES NOYES NOYES NOYES NOYES NOREMOVECONTINUEYES NOYES NOYES NOYES NOYES NOYES NOYES NOREMOVECONTINUEYES NOYES NOYES NOYES NOYES NOYES NOYES NOREMOVECONTINUE46 Autumn 2012 Prevention
ments successfully demonstratedwith the national CLABSIinitiative to new type of deviceassociated infection. The CUSP/Stop CAUTI program aims toreduce mean rates of CAUTI inU.S. hospitals by 25 percent. TheHealth Research & EducationalTrust (HRET), through a contract with AHRQ, is managingthe project. HRET’s partnersinclude the Michigan Health &Hospital Association’s KeystoneCenter for Patient Safety &Access peer-reviewed articles on CAUTI in theAmerican Journal of Infection Control:Fakih MG, Greene MT, Kennedy EH, Meddings JA, Krein SL, Olmsted RN,Saint S. Introducing a population-based outcome measure to evaluate theeffect of interventions to reduce catheter-associated urinary tract infection.May 2012. Abstract URL: 2900834-0/abstractGokula M, Smolen D, Gaspar PM, Hensley SJ, Benninghoff MC, Smith M.Designing a protocol to reduce catheter-associated urinary tract infections amonghospitalized patients. March 2012. Abstract URL: %2901334-4/abstractEl-Kholy A, Saied T, Gaber M, Younan MA, Haleim MMA, El-Sayed H, et al.Device-associated nosocomial infection rates in intensive care units at CairoUniversity hospitals: First step toward initiating surveillance programs in aresource-limited country. March 2012. Abstract URL: %2901331-9/abstractFink R, Gilmartin H, Richard A, Capezuti E, Boltz M, Wald H. Indwellingurinary catheter management and catheter-associated urinary tract infectionprevention practices in Nurses Improving Care for Healthsystem Elders hospitals.February 2012. Abstract URL: 2901250-8/abstractConway LJ, Pogorzelska M, Larson E, Stone PW. Adoption of policies to preventcatheter-associated urinary tract infections in United States intensive care units.February 2012. Abstract URL: 2901256-9/abstractBurns AC, Petersen NJ, Garza A, Arya M, Patterson JE, Naik AD, et al. Accuracyof a urinary catheter surveillance protocol. February 2012. Abstract URL: %2900329-4/abstractTiwari MM, Charlton ME, Anderson JR, Hermsen ED, Rupp ME. Inappropriate useof urinary catheters: A prospective observational study. February 2012. AbstractURL: %2900325-7/abstractDudeck MA, Horan TC, Peterson KD, Allen-Bridson K, Morrell G, Pollock DA,et al. National Healthcare Safety Network (NHSN) Report, data summary for2010, device-associated module. December 2011. Abstract URL: %2901173-4/fulltext48 Autumn 2012 PreventionQuality, The University ofMichigan Health System, St.John Hospital and MedicalCenter, and the Johns HopkinsQuality and Safety ResearchGroup.APIC is participating in theextended faculty network forimplementation of CUSP/StopCAUTI. The APIC Boardof Directors is representedby Russ Olmsted and LindaGreene. Additional educationalsupport is being provided bythe Association of EmergencyNurses Association, Society forHealthcare Epidemiology ofAmerica, and Society of HospitalMedicine. For more informationon CUSP/Stop CAUTI visitwww.hret.org.Developing and usingthe catheter bundleThe concept of a “bundle” approach, the integrated and ideallysynergistic effect of a group ofstraightforward, evidence-basedpractices, was introduced by theIHI in 2001 and first applied forCLABSI prevention. Since thenthe approach has been extensivelyreplicated, by IHI and others, asan effective means of addressinga wide range of challenges.As the momentum to reduceCAUTI has increased, thebundle design has been appliedto urinary catheters. Currentexamples have varying titles(e.g., UTI, catheter, bladder and/or CAUTI bundle). Elementswell-described in the scientificliterature are included (e.g., appropriate clinical indicationfor use, aseptic insertion, handhygiene, use of sterile lubricant,prompt removal, adequate catheter securement) as well as other,less thoroughly researched interventions. Examples may includea maximum capacity for thedrainage bag prior to emptying,placement of the drainage systemduring transport, and avoidanceof lotions/powders in the groinarea. Whatever the number orexact types of interventions listed,the bundle approach requiresthat all must be used. The truebenefit of a bundle results fromthe integrated and consistent useof its elements; selective use compromises the intended outcome.5To further explain how aCAUTI bundle can improveinfection related outcomes,Brian Koll, MD, the projectleader, presented a case studyfrom Beth Israel MedicalCenter in NY at the recentAPIC Annual Conferencein San Antonio. Listen tothe APIC 2012 conferenceproceedings to hear the entiresession (www.apic.org/ac2012).This project is noteworthy inits use of assessment, planning,implementation, measurement,and final evaluation in making aclear, complete, and compellingcase for a bundle strategy.Additional resources offeredin this issue include one of themost overlooked CAUTI prevention measures. Lynn Roser,PhD candidate, MSN, RN, ofCentral Baptist Hospital inLexington, Kentucky describesher evidence-based work (page28) on demonstrating how anurse-led protocol for earlycatheter removal significantlydecreased CAUTI rates at herinstitution. APIC’s strategicfocus on using implementationscience is summarized in table1 (page 44) showing how thefour “E”s of implementation science (engage, educate, execute,evaluate) can be applied to aCAUTI prevention plan. In addition, George Allen, PhD, CIC,
Top seven things to rememberabout CAUTI NHSN reportingBy Connie Steed, MSN, RN, CICThe Centers for Medicare & Medicaid Services (CMS) requires acutecare hospitals to report catheter-associated urinary tract infections(CAUTI) through the Centers for Disease Control and Prevention’s NationalHealthcare Safety Network (NHSN). Beginning October 1, 2012, long-termacute care and rehabilitation hospitals are required to report CAUTI viaNHSN. Here are some key things to keep in mind:12345The NHSN CAUTI definition and reporting requirements must beadhered to. It may be helpful to keep the definition handy while youare conducting surveillance.Customize and standardize your chart review to maintain focus.Develop a collaborative relationship with someone in the informationservices department who knows the hospital databases. You mayneed their help to access needed data.Reporting includes symptomatic UTIs and asymptomatic bacteremicUTIs (ABUTIs). Don’t forget about the ABUTIs! Look for positiveblood cultures in patients with an asymptomatic UTI before youleave that patient record.Infection present on admission means that the patient had asymptomatic UTI or ABUTI upon admission. A patient with bacteriain the urine or otherwise positive urinalysis (U/A) and no othersymptoms does not count as a preexisting infection.Validate your denominator data (patient days and Foley days).This data should be collected at the same time each day.Whether this information is sent to you by nursing staff or by anautomated information system, it’s useless unless the data is accurate.Collect the information yourself, then check to see if your data matchthe data given to you.6Remember to update your monthly reporting plans to includeCAUTI in all locations where reporting is required. Data is to besubmitted by the end of the month following the month duringwhich the infection occurred so it has the greatest impact on infectionprevention activities. For data to be shared with CMS, each quarter’s datamust be entered into NHSN no later than 4 1/2 months after the end of thequarter. For example, quarter one (January–March) data must be enteredby August 15.7You must report in NHSN every month even if you don’t haveCAUTIs. Check the box on the summary denominator data formfor the month if there were no CAUTI events.Be sure to utilize all NHSN training opportunities available to you.Questions? Visit www.cdc.gov/nhsn/index.html or email nhsn@cdc.gov.Connie Steed, MSN, RN, CIC, is director of Infection Prevention forGreenville Hospital System University Medical Center in Greenville, SC.She is also on the APIC Board of Directors.50 Autumn 2012 PreventionCNOR, has provided CAUTIinsertion and maintenancebundles (table 2) as practicalexamples of how the bundle approach is used as a clinical tool.Measuring our progressAlthough much national attention and effort is being directedto CAUTI prevention andmeasurable progress has beenreported, the national reductiontarget of 25 percent remains achallenge. During the October2011 APIC National PolicySummit in Washington, DC, theCDC reported that, accordingto 2010 data, CAUTI was oneof four HAIs for which nationalimprovement had been verified:33 percent for CLABSI, 18 percent invasive MRSA, 10 percentfor surgical site infections, and 7percent for CAUTI.6 While thisis certainly good news for infection preventionists (IPs), it is clearthat more work is still needed.Why does CAUTI remainsuch a persistent challenge?Unlike central catheters,urinary catheters are virtuallyubiquitous in healthcaresettings. There is an undeniableif frequently unacknowledgedconvenience factor for providersand caregivers when thesedevices are in place. And whilemortality attributed to urosepsishas been reported, urinarycatheters are generally viewedas low risk devices for whichany potential complications canbe readily and easily managed.These factors diminish a senseof urgency in addressing theproblem, especially in healthcareenvironments confrontingmultiple, simultaneous patientsafety risks.Future challengeCurrent measures address thebest available U.S. hospitalstatistics. Yet in a rapidly agingsociety with a rising prevalenceof chronic diseases, there exists aneed for the infection preventioncommunity to better understandthe use of urinary catheters andtheir associated risks among allpatients – especially those inpost-acute settings, includingthe home. While IPs collectivelystrive to meet the HHS 25 percentnational reduction target, wemust also be vigilant about thosepatients who are not included inthat target, and assure that ourongoing CAUTI preventionprograms are inclusive as well aseffective.Marilyn Hanchett, RN, MA,CPHQ, CIC, is APIC senior director,Professional Practice.References1. Klevens RM, Edwards JR, Richards CL, et al. Estimating healthcare associated infections and death inUS Hospitals, 2002 Public Health report 2007; 122 (2): 160-166.2. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteruria. AJIC 2000;28 (1): 68-75.3. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportionof healthcare-associated infections that are reasonably preventable and the related mortality and costs.Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14.4. Lo E, Nicolle L, Classen D et al. Strategies to prevent catheter-associated urinary tract infections inacute care hospitals. ICHE 2008; 29: S41-S50.5. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHIInnovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012.(Available on www.IHI.org).6. CDC press release Oct 19, 2011. Health care-associated infections declined in 2010. Available at:http://www.cdc.gov/media/releases/2011/p1019 healthcare infections.html
in acute care, the prevalence of catheters in nursing homes expands the need for eff ective clinical prevention programs across the health services continuum. Baseline valid measures for CAUTI are diffi cult to obtain. Utilization of indwelling catheters in non-hospital settings is thought to be high, but estimates vary. Introduction
Preventing Catheter-Associated Urinary Tract Infection (CAUTI): Making It Happen Prof. Sanjay Saint, University of Michigan School of Medicine . A 1-page (10-item) trouble-shooting guide Help identify the key reasons why hospitals may not be successful in preventing CAUTI Once the barriers are identified, can then
The NPT has one primary goal and several secondary objectives for this project. The primary goal is to reduce the CAUTI rate in participating units upon completion of the 4-year initiative. This project also seeks to make decreased CAUTI rates sustainable through fostering a culture of safety in participating units.
Module 1: Overview . Slide 1 “Preventing CAUTI in the ICU Setting” is a four-module program designed for
Rationale: NHSN surveillance for infection is not aimed at a specific device. Instead surveillance is aimed at identifying risk to the patient that is the result of device use in general. Notes: In the examples above, Patient A is eligible for a CAUTI beginning on March 31,
Also called a Foley catheter Does not include (among others): Straight in and out catheters Suprapubic catheters Nephrostomy tubes Key Term: CAUTI A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset. *Note: There is no minimum period of time that the
3-303 Preventing Contamination from Ice Used as a Coolant 66 3-304 Preventing Contamination from Equipment, Utensils, and Linens 66 3-305 Preventing Contamination from the Premises 70 3-306 Preventing Contamination by Consumers 71 3-307 Preventing Contamination from Other Sources 72 3-4 DESTRUCTION OF ORGANISMS OF PUBLIC HEALTH
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