Insertion or Maintenance?

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Disclosure• I am an employee of C.R. Bard, Inc., Bard

Medical Division. Any discussion regarding Bard products during my presentation is limited to information that is consistent with Bard labeling for those products.

• For all Bard products please consult product labels and inserts for any indications, contraindications, hazards, warnings, cautions, and directions for use.

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Foley Catheters: Risky Business

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Objectives

• Discuss indwelling urinary catheter (IUC) insertion and maintenance practices

• Identify strategies to help maintain aseptic technique during IUC insertion

• Discuss how variation in the insertion process can impact adherence to aseptic technique

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• A sterile closed system in which the path from the tip of the catheter inserted into the bladder, to the bag which catches urine.

• This is considered a closed system and should not be disconnected.

Indwelling Urinary Catheter

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Infection of the urinary tract caused as a result of bacteria moving through or migrating around the catheter and infecting the mucosa of the bladder and urethra

CAUTIs are among the most common healthcare-associated infections

April 2013 CDC/NHSN Protocol Corrections, Clarification, and Additions

Catheter-Associated Urinary Tract Infection (CAUTI)

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Scope of the CAUTI Issue• 100 million indwelling urethral catheters sold

worldwide annually1

• 24 million in the U.S.1

• 25% of hospitalized patients receive urinary catheters during their stay2

• UTI = up to 40% of all HAI2

• Vast majority of HA-UTI are urinary catheter related2

• Not without increased cost and morbidity2

1Saint S, Wiese J, Amory JK, Bernstein MI, Patel UD, Zemencutt JK et. al. Are physicians aware of which of their patients have catheters? Am. J. Med, 2000 Oct 15; 109 (6): 476-80

2Saint S, Kaufman S, Thompson M, Rogers M, Chenoweth C. A Reminder Reduces Urinary Catheterization in Hospitalized Patients. Journal on Quality and Patient Safety. 2005 August. (31)8; 455-62

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2012 The Joint Commission National Patient Safety Goal:

To implement evidence-based practices to prevent a CAUTIR3 Report: Requirement, Rationale, Reference (2011). Joint Commission

Strides in CAUTI Prevention

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Pathogenesis• Routes of entry of uropathogens:

1. Extraluminal: along the external surface1. Early: at insertion

2. Late: by capillary action

2. Intraluminal: through the catheter lumen1. Break in closed drainage

2. Contamination of collection bag urine

3. General infection

Maki, Dennis G., and Paul A. Tambyah. "Engineering out the risk for infection with urinary catheters." Emerging infectious diseases 7.2 (2001): 342.Newman, & Wein (2009). Managing and Treating Urinary Incontinence, 2nd Ed, Health Professions Press, Baltimore, Maryland:365-483.

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Consider Alternatives

• Bladder scanner to monitor bladder volume

• Intermittent catheter

• External catheter

• Bedside commode or urinal

Meddings J, Saint S. (2011) Disrupting the life cycle of the urinary catheter. Clin Infect Dis. Jun:52(11) :1291-3

Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. Available from: http://www.cdc.gov/hicpac/ cauti/001_cauti.html.

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Indications for Indwelling Catheter Use

Patient has acute urinary retention or bladder outlet obstruction

Need for accurate measurements of urinary output

Perioperative use for selected surgical procedures

To assist in healing of open sacral or perineal wounds

Patient requires prolonged immobilization

To improve comfort for end of life care if needed Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. Available from: http://www.cdc.gov/hicpac/ cauti/001_cauti.html.

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Foley Catheter Lifecycle

Adapted from: Meddings J, Krein SL, Fakih MG, et al. Reducing Unnecessary Urinary Catheter Use and Other Strategies To Prevent Catheter-Associated Urinary Tract Infections: Brief Update Review. In: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Mar. (Evidence Reports/Technology Assessments, No. 211.) Chapter 9.

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ABCDE Bladder Bundle • Adherence to general infection control principles (e.g.

hand hygiene, surveillance and feedback, aseptic insertion, proper maintenance, education)

• Bladder ultrasound may avoid indwelling catheterization

• Condom external catheters or other alternatives to an Foley catheter should be considered

• Do not use the Foley catheter unless you must

• Early removal of the catheter using a reminder or nurse initiated removal protocol

Saint, Olmsted, Fakih, Kowalski, Watson, Sales, & Krein, (2009). Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle. Jt Comm J Qual Patient Saf. 35(9), 449-55.

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Asepsis

• Asepsis: state of being free from microorganisms1

• Aseptic technique:– Method employed to maintain a state free from hospital

microorganisms and protect the patient from acquired infection by preventing introduction of bacteria1

Insert urinary catheters using aseptic technique (CDC Category IB Recommendation)2

1. Aziz AM. Variations in Aseptic Technique and Implications for Infection Control. British Journal of Nursing. 2009 (18)1: 26-31.2. Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory

Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. Available from: http://www.cdc.gov/hicpac/ cauti/001_cauti.html.

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• Know what is clean, sterile, or contaminated

• Keep clean, contaminated and sterile items separate

• Keep sterile sites sterile

• Resolve contamination immediately

• Recognize when aseptic technique has been broken

Mangnall & Watterson (2006). Principles of aseptic technique in urinary catheterisation. Nurs Stand. Oct;Suppl:15-7, 19-22, 24

Principles of Aseptic Technique

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Common Breaks in Sterile Technique

• Setting up and opening the sterile field

• Hand hygiene

• Gloving

• Prepping

• Draping

Hopper, William R., and Rose Moss. "Common breaks in sterile technique: clinical perspectives and perioperative implications." AORN journal 91.3 (2010): 350-367.

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Importance of a Standardized Process

Variables during insertion may lead to breaks in aseptic technique:

Scenario 1

Clinician fails to wash hands or use provided drapes

Scenario 2

Incorrectly donning sterile gloves

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Procedural Products

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Procedural Products

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Procedural Products

• Prepare patient with 3 foam swab sticks saturated in Povidone-Iodine

• Remove Foley catheter from wrap and lubricate catheter

• Use the non-dominant hand for the genitalia and dominant hand for the swabs

• Proceed with catheterization using the dominant hand

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A Look at Bacteria

Mixed biofilm of the yeast-like fungus Candida albicans and the Gram negative bacterium Serratia marcescens

Shown on a 100% All-Silicone Catheter

Weinstein RA. Nosocomial Infection Update. Emerging Infectious Diseases. 1998; 4(3): 416-420.

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Bacteria switch from a free-floating (planktonic) state where they function as individuals to a sessile state where they function as communities

Stages of Biofilm Formation

Image: Used by permission. Dirckx, Peg. Center for Biofilm Engineering, Montana State University, Bozeman, MT.

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• All 10 BARDEX samples tested were below the detectable limits of this test

• The BARDEX catheter has a significantly lower protein content than the off-the-shelf latex gloves and condoms

• The BARDEX catheter demonstrated statistically significant lower protein content than the Covidien and Medline latex catheters

• 10% of the Medline silicone elastomer catheters tested had detectable latex proteins versus 0% of the BARDEX catheters

RIGHT PRODUCT Latex vs. Silicone

‡ Data on file ‡ Data on file

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Catheter / Tubing Junction

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Outlet Tube

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Care and Maintenance• Maintain a closed drainage system

• Secure the catheter

• Keep the collecting bag off the floor and below the level of the bladder

• Remove catheter as soon as possible

Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. Available from: http://www.cdc.gov/hicpac/cauti/001_cauti.html.

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CAUTI Prevention

• All these guidelines/mandates, etc, point to the same direction

Care Process Strategies

Change in the culture of the organizationMedical StaffPatient Care StaffAdministrative/Management Staff

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JCAHO: NPSG.07.06.01• Elements of performance (insertion and use)

– Insert indwelling urinary catheters according to established evidence based guidelines that address the following:

• Limiting use and duration to situations necessary for patient care

• Using aseptic techniques for site prep, equipment and supplies

JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, 2011.

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JCAHO: NPSG.07.06.01• Elements of Performance (catheter management)

– Manage indwelling urinary catheters according to established evidence based guidelines

• Securing catheters

• Maintaining sterility of collection system

• Replacement when required

• Asepsis in urine sample collection

JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, 2011.

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JCAHO: NPSG.07.06.01• Measure and monitor the processes and outcomes

– Select measures based on evidence based guidelines or best practices

– Monitor compliance (ongoing audit or point prevalence)

– Evaluate effectiveness• UTI Surveillance• Decreased indwelling catheter days• Decreased inappropriate use• Improved nursing care practices

JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, May 9, 2011. 1408-24 30

Restate Process Measures• Make sure the catheter is indicated

• Adhere to general infection control principles (aseptic insertion, proper maintenance, hand hygiene, properly trained staff, feedback to care providers)

• Remove the catheter as soon as possible

• Consider alternatives to indwelling cathetersSaint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides] CatheterOut.org website, University of Michigan.

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Example: Nursing Process Monitoring Tool

Ref: Bard Medical Division: Foley Catheter Observation Survey. Compliance Document # 1007-02, 7-14-10Lo E, Nicolle L, Classen D, Arias K, Podgorny K, Anderson D, Burstin, H et. al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:S41-S50

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What can you do?

• Address the whole lifecycle of the Foley catheter

• Conduct a gap analysis:– Measure adherence to evidence-based guidelines – Focus on insertion and maintenance practices at your facility

• Become a champion

Meddings J, Saint S. (2011) Disrupting the life cycle of the urinary catheter. Clin Infect Dis. Jun:52(11) :1291-3

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