Preventing Catheter-Associated Urinary Tract Infections: Planning and Implementing the

Effort

Mohamad Fakih, MD, MPHAssociate Professor of Medicine

Wayne State University School of MedicineSt John Hospital and Medical Center, Detroit, MI

9/14/12

An 82-year-old woman was admitted for congestive heart failure…

• She had a urinary catheter (UC) placed and was started on diuretics. She appeared frail. Her physician and nurses felt that keeping the catheter in place would make her more comfortable.

• On the 5th day of admission, she started complaining of chills, had a fever of 102°F, and her BP dropped to 90 systolic. Blood cultures and urine cultures grew Escherichia coli. She was diagnosed with symptomatic CAUTI and had to be treated with intravenous antibiotics.

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A 78-year-old nursing home resident was admitted for a gastrostomy tube change…• The ED nurse noted that he was incontinent. The

male patient was confused because of long-standing dementia. Although a bladder scan did not show any urinary retention, the nurse spoke to the ED physician about placing a catheter. Several hours after the catheter was placed, the patient pulled it out, leading to a urethral injury and hematuria.

• This required a urology evaluation.

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Objectives

• Epidemiology of UC use and CAUTI• How to reduce the risk of CAUTI– Proper insertion/ maintenance– Prompt removal of no longer needed catheters– Limit use to indications

• Where to intervene• How to sustain improvements• Engaging nurses and physicians• Measuring improvements (process, outcome)

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Epidemiology

• Urinary catheters are frequently used in the hospital setting.

• The presence of the indwelling urinary catheter increases the risk of urinary tract infections.

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Urinary Catheter Utilization

• About 15 - 25% of patients will have a urinary catheter placed during their hospitalization.

• Many are placed either in the intensive care unit, emergency department or the operating room.

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Mean Use of UCs (NHSN): ICU > General Wards(Edwards, Am J Infect Control 2009; 37:783-805, Dudeck, Am J Infect Control. 2011;39(5):349-367;

Am J Infect Control 2011;39(10):798-816 )

Unit 2006-8 Urinary Catheter

Utilization Ratio

2009 Urinary Catheter

Utilization Ratio

2010 Urinary Catheter

Utilization RatioICU (med-surg, major teaching)

0.78 0.73 0.73

ICU (med-surg, >15 beds)

0.79 0.72 0.71

General Wards (med-surg)

0.22 0.19 0.19

Inappropriate Use• 40% - 50% of patients from non-intensive medical

and surgical units may not have a valid indication for urinary catheter placement.

• This can occur:

1. At the time of placement

2. With continued use

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Inappropriate Use in non-ICU: Michigan Experience 2007-10

(Fakih et al, Arch Intern Med 2012;172:255-260)

Baseline % of all patients with catheters (57.6%)

% of patients with catheters without appropriate indications*

Non-obstructive renal insufficiency

2.2 3.8

Transferred from intensive care

4.2 7.3

Patient request 1.5 2.6 Confusion 4.6 8.0 Incontinence 6.5 11.3 Other or no clear

reasons38.6 67.0

*Based on the 1983 CDC recommendations

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Very Elderly Women Are at High Risk for Unnecessary Utilization

(Fakih et al, Am J Infect Control 2010;38:683-8)

• Evaluated urinary catheter (UC) placement for all admissions from the emergency department (ED).

• 532 (11.8%) of 4521 patients had a UC placed. Of those, 69.7% were indicated, and 58.6% had a physician order documented.

• Inappropriate placement: older (mean age 71.3 vs. those with indication 60.0 years, p<0.0001, and patients with no UC placed 56.2, p<0.0001).

• Half of women ≥80 years with a UC placed did not have an indication.

• Independent factors: women were twice more likely than men, and very elderly (≥80 years) were 3 times more likely than those 50 or younger, to have UC placed without indication.

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Urinary Catheter

Harm

CAUTI

Increased Length of

Stay

Patient discomfort

Trauma

Immobility

Pressure ulcers

Falls?

Part of the HEN work

Venous thrombo-

embolism?

Isn’t this a patient safety issue, not just CAUTI?

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Catheter-Associated UTIs (CAUTIs)(Tambyah, Infect Control Hosp Epidemiol 2002;23:27-31; Saint S, Am J Infect Control 2000;28:68-75 ; Dudeck,

Am J Infect Control. 2011;39(5):349-367)

• Hospital-acquired bacteriuria and candiduria in 25% of those with urinary catheters placed for a week

• Risk of bacteriuria: about 5% per day• Symptomatic UTI: 16-32% of those bacteriuric

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Mean CAUTI Rates: Changes with New Definition(Edwards, Am J Infect Control 2009; 37:783-805, Dudeck, Am J Infect Control. 2011;39(5):349-367; Am J

Infect Control 2011;39(10):798-816 )

Unit 2006-8 NHSN CAUTI Rate* (per

1,000 catheter days)

2009 NHSN S-CAUTI Rate (per 1,000 catheter

days)

2010 NHSN S-CAUTI Rate (per 1,000 catheter

days)ICU (med-surg, major teaching)

4.7 2.3 2.2

ICU (med-surg, >15 beds)

3.1 1.2 1.3

General wards (med-surg)

5.9 1.6 1.5

*Prior to the new SUTI definition

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Limit catheter use to indications (Avoid placing

the catheter unless appropriately indicated)

Limit catheter use to indications (promptly remove those that are no longer necessary)

Appropriate Care of the Catheter

Proper Insertion Technique

Reducing Risk of CAUTI

Reduce urinary catheter days leading to a reduction in days at risk for CAUTI

Reduce risk of introducing organisms to the bladder leading to a reduction of risk of CAUTI when catheter in place

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Proper Insertion Technique

• Perform hand hygiene before and after placement.

• Maintain aseptic technique and use of sterile equipment.

• Use sterile gloves, drape, an antiseptic solution for periurethral cleaning, and a single packet of lubricant for insertion.

• Use the appropriate catheter size.

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Maintenance of Urinary Catheters

• Keep a closed system for the urinary drainage system.

• Make sure urinary flow is not obstructed:

1. No kinks in the catheter.2. Urinary bag should always

be lower than the bladder.

3. Regular emptying of urinary bag.

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Limit Use to Indications

Avoid use unless

appropriate indication

Promptly remove of catheter when no

longer indicated

Reduction in Inappropriate

Urinary Catheter Use

Clear Identification of what is considered an appropriate indication

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Removal of No-Longer Indicated Catheters

• Nurse-driven removal of no longer needed catheters– Pilot study: 45% reduction in unnecessary catheter

utilization (Fakih et al, Infect Control Hosp Epidemiol 2008; 29: 815-9)

• Identify appropriate indications based on HICPAC guidelines (Gould et al, Infect Control Hosp Epidemiol 2010; 31: 319-326).

2009 Prevention of CAUTI HICPAC Guidelines(Gould et al, Infect Control Hosp Epidemiol 2010; 31: 319-326)

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HICPAC Guidelines vs. Other Acceptable Institutional Indications

• 2009 CAUTI HICPAC guidelines: based on expert consensus, not randomized controlled or quasi-experimental trials.

• Institutions may opt to have additional limited number of reasons for placing the urinary catheter which they may consider acceptable.

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Nurse Driven UC Removal Program

• Education of nurses on:1. Appropriate indications. 2. Ways to avoid urinary catheter placement.

• Evaluation of urinary catheter use and compliance with appropriate indications.

• Sustainability: nurses own the process of evaluating for catheter appropriateness of use daily.

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Two Important Items

• Train nurses to drive the process of daily urinary catheter evaluation (regardless of whether data is collected or not).

• Provide periodic feedback to the units on their urinary catheter use and compliance with appropriate indications.

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Tools Used with Intervention

• Lecture for nurses• Pocket cards, posters

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Main Education is Performed During Nursing Rounds

• Does the patient have a urinary catheter?

• Reason for catheter use?• If no appropriate indication,

the patient nurse will contact the physician to discontinue the urinary catheter.

• This process will be continued after implementation with the patient’s nurse owning the process.

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Urinary Catheter Removal

• Prompt removal should not be interpreted as an increased workload for either the nurse or nurse aide.

• Promote alternatives to the urinary catheter.

• Highlight risks associated with having the urinary catheter.

Following Implementation

• Evaluation of catheter need is incorporated into the patient’s nurse daily assessment.

• A champion from the unit will promote appropriate urinary catheter utilization on the unit; this will be encouraged through daily nursing rounds.

• Units involved will receive feedback on the results of program implementation.

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Success with Implementation: Michigan Experience (Fakih et al, Arch Intern Med 2012;172:255-260)

• The implementation included 163 inpatient units in 71 participating Michigan hospitals.

• Urinary catheter use dropped from 18.1% at baseline to 13.8% at 2 years.

• Appropriate urinary catheter use (based on the 1983 CDC guidelines) improved from 44.3% at baseline to 57.6% at 2 years.

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25% relative decrease 30% relative increase

Success with Implementation: Michigan Experience (Fakih et al, Arch Intern Med 2012;172:255-260)

Partnering with Residents, PAs, NPs

• Resident physicians are responsible for a large number of patients in teaching hospitals and may have a significant effect on utilization if engaged.

• PAs and NPs are responsible for a substantial part of the care rendered in some hospitals.

• Residents, PAs, and NPs may help in 2 ways: 1. Evaluate the need for the catheter and discontinue if no

longer needed.2. Serve as an easier access to nurses to obtain order for

discontinuation of no longer needed catheters.

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Physicians• Physicians should evaluate the need for the catheter

daily.• High volume physicians (hospitalists) may be selected

to champion the effort.• Physicians who are considered leaders and whose

practice is followed by others (e.g., cardiology, nephrology) may also be instrumental in changing behaviors and monitoring of urine output in non-ICU.

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Avoiding Inappropriate Placement

• Avoiding inappropriate placement may have a substantial effect on utilization.

• Consider areas of high placement (e.g., emergency department) to focus your efforts.

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ED Compliance with Institutional Guidelines (Fakih

et al, Acad Emerg Med 2010; 17:337–340)

• Established institutional guidelines for UC placement in ED

• Compared the rate of placement before and after guidelines

• ED physician champion involved

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Physician Intervention in the ED (Fakih et al, Acad Emerg Med, 2010; 17:337–340)

• UC utilization dropped significantly after starting the physician intervention from 212 of 1421 (14.9%) pre-intervention to 110 of 1041 (10.6%) post-intervention (p = 0.002).

• Physicians ordered fewer UCs post-intervention (45 of 1041, 4.3%), compared to pre-intervention (106 of 1421, 7.5%), (p = 0.002).

• Only 151 of 322 (47.0%) of UCs initially placed in the ED had a physician order documented.

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Avoiding Urinary Catheter Placement: Emergency Department-Specific

• Addressing both nurses and physicians is important.• Consider agreed-upon institutional guidelines for

urinary catheter placement in the emergency department (ED).

• Identify nurse and physician champions for the ED.• Similar work has been recently implemented in

Michigan (through MHA) and Ascension Health hospitals with successful results

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How to Sustain Improvement• Make sure that the process is part of the daily

nursing assessment.• Provide feedback on urinary catheter use over time

to the units involved.• Evaluating compliance with appropriate urinary

catheter use may be helpful if no significant drop in utilization occurs.

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Does the Effect Persist?(Fakih, Am J Infect Control, in press)

Nurse-driven removal of

unnecessary catheters

Establishing institutional

guidelines for the ED and education

Incorporating the evaluation of

catheter need during nursing rounds, and

collecting urinary catheter prevalence twice weekly since

2007

Urinary Catheter

Prevalence (%)

SJHMC, Detroit, MI

2006 2007 2008 2009 2010 201110

11

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13

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16

17

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What Did We Do to Keep the Rates Down?

• Provided knowledge on appropriate indications.• Linked the target (appropriate utilization) to certain

stakeholders’ interests (case management), regarding LOS and complications.

• Intervened in the ED to reduce inappropriate placement from the 1st step reaching the hospital.

• Built a structure to evaluate the catheters at least twice weekly.

• Provided periodic feedback of rates.

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Alternatives to Indwelling Urinary Catheterization

• Bladder scanners may be used in cases where urinary retention is suspected, or when the patient did not have any witnessed urine output and the clinician needs to evaluate for obstruction. Consider having bladder scanners available.

• Condom catheters may be considered in men that require fluid monitoring. Their use reduces the risk of urethral trauma (compared to indwelling urinary catheter). Condom catheters are not used in cases of urinary retention.

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Alternatives to Indwelling Urinary Catheterization

• Intermittent catheterization may be considered in patients with non-obstructive urinary retention (e.g., patients with neurogenic bladder).

Engaging Physicians and Nurses

Physicians

• Play a significant role in shaping care in the hospital setting.

• Most are very autonomous and may not be employed by the hospital.

• Many are interested in treating illness, but not trained to focus on improving safety and preventing harm.

• Many are unaware of the efforts being implemented to promote safety in the hospital.

• Many may have a limited amount of time to volunteer for supporting the quality agenda.

Physicians as Partners

• Physicians are leaders of safety efforts.

• Make safety a “home-grown” product, not imposed on physicians, but owned by all of the stakeholders.

• Move physicians from reactive to proactive role (get involved in decision making related to safety, rather than reacting to a plan being implemented).

• Physicians responsible for safety: “could I have prevented a CAUTI with bacteremia if I removed the catheter a few days earlier?”

Physician Champions

• Identify motivated physicians who want to be engaged, want to help improve safety, excited to have the opportunity of making a change, and appreciate the recognition associated with their role.

• Physicians that have an interest in reducing the harm related to the catheter are more likely to be engaged in the effort to reduce unnecessary urinary catheter use.

• Physician champions should be engaged from the start and should be visible to both staff and other physicians.

Role of Physician Champions

1. Educate physicians on the guidelines for urinary catheter use and risks of the catheter (lectures, providing educational materials).

2. Encourage physicians to comply with the guidelines.

3. Support the work of the team to resolve any barriers to implementation.

4. Provide technical expertise for the team.

5. Provide feedback to other physicians about the progress of the project; share the results.

Physician Champions and Other Physicians

• Spread the word to physicians about the effort to reduce CAUTI and unnecessary utilization and the importance of physician support (may need to present the project to multiple disciplines in the hospital).

• Clarify with other physicians their concerns about any reasons for use that are not considered appropriate and work with physicians to gain their support (use EBM to help).

• Address physicians in training and midlevel providers to obtain their support.

Physician Champion and Indications

• The HICPAC guidelines identify the appropriate uses of the urinary catheter.

• Some hospitals may consider having a limited number of additional institutionally based acceptable indications for urinary catheter use.

• Physician champion to obtain consensus on the additional locally acceptable indications from key physician leaders; this will likely provide you with support during the implementation.

The Physician Champion…and Physician Supporters

CAUTI Physician Champion

Infectious Diseases

specialists/ Hospital

EpidemiologistUrologists

Hospitalists

Geriatricians

Rehabilitation Medicine specialists

Surgeons

Intensivists

Emergency Medicine Physicians

Physician Supporters: Reasons for Them to Support the Champion

Infectious Disease Specialists Urologists

• Reduce CAUTI.• Reduce antibiotic use.• Reduce potential of increased resistance

and Clostridium difficile disease.

• Reduce trauma (mechanical complications):

1. Meatal and urethral injury2. Hematuria

Hospitalists Geriatricians

• Infectious and mechanical complications.• Potential catheter complications

prolonging length of stay.• Hospitalists care for a large number of

patients. Their support may help significantly improve the appropriate use of the urinary catheter.

• Many elderly are frail.• Urinary catheters are placed more

commonly in elderly inappropriately. • Urinary catheters increase immobility

and deconditioning risk, in addition to infection and trauma.

Physician Supporters: Reasons for them to Support the Champion

Rehabilitation Specialists Surgeons

• The urinary catheter reduces mobility in patients: one point restraint.

• Rapid recovery (improvement in ambulation) may be hampered by the catheter (in addition to the other associated risks).

• Surgical Care Improvement Project: Remove catheters by postop day 1 or 2.

• Inappropriate urinary catheter use postoperatively will negatively affect the surgeon’s profile.

• Risk of infection and trauma related to the catheter.

Intensivists Emergency Medicine physicians

• A significant opportunity is present upon transfer from the ICU to discontinue no longer needed devices, including urinary catheters.

• Intensivists can support the evaluation of catheter need before transfer out of the unit and may significantly impact use.

• Up to half of the patients are admitted through the emergency department (ED).

• Inappropriate urinary catheter placement is common in the ED.

• Promoting appropriate placement of urinary catheters in the ED will reduce inappropriate use hospital-wide.

Physician Champions and the Team

• Meet with the other CAUTI team members regularly to discuss the progress of the work (keep meetings efficient and productive).

• Address the team’s concerns about any physician barriers to implementation and work as a facilitator between the team and the physicians.

• Relay physicians concerns to the CAUTI team to address any barriers to implementation.

Physician Champions and Their Leaders

• Physician leaders should identify physician champions with passion for improving safety and support them to promote a safer environment.

• Physician leaders should support the physician champion to achieve the goals of the project.

• The physician champions are at risk of having challenges in their efforts to reduce inappropriate catheter use.

• Physician champions need to be empowered to be able to succeed.

Nurse Champions

• Responsible for the education of other nurses, and the one who will trigger the process of assessment for the presence and indication for use of the catheter during implementation.

• May be a technical expert for peers. • May be the nurse manager, a unit nurse leader, or a

bedside nurse who is well respected by peers.

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Nurse Champion: Making the Case

• Adverse outcomes associated with the catheter

• Preventability• Urgency for the change (patient safety)• Not having the urinary catheter ≠ more work

(examples: bundling turning and skin care with addressing incontinence)

Transition of Bedside Nurse to Champion

• Initially, a nurse champion will support the effort

• The ultimate goal is to have the bedside nurse be the champion for every patient, assessing device need as part of the daily work

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The Bedside Nurse…and Supporters

Nurse (Bedside)Ch

ampion

Infection Preventionists

Case Managers

Nurse Manager

Physical Therapists

Intensive Care Nurses

Wound Care Nurses

Emergency Medicine

Nurses

Post-operative, Recovery

Nurses

Physician

Nurse Supporters: Reasons for Them to Support the Champion

Infection preventionists Case managers

• Reduce CAUTI.• Reduce antibiotic use.• Reduce potential of increased resistance

and Clostridium difficile disease.

• Less complications (mechanical or infectious)= lower cost

• Early removal of catheter may reduce length of stay

Nurse manager Physical therapists

• Leader and supporter to the bedside nurse (empowers the nurse)

• Makes the appropriate urinary catheter use a priority and a safety issue

• Addresses any barriers encountered by the bedside nurse

• The urinary catheter reduces mobility in patients: one point restraint.

• Rapid recovery (improvement in ambulation) may be hampered by the catheter (in addition to the other associated risks).

Nurse Supporters: Reasons for Them to Support the Champion

Intensive care unit (ICU) nurses Wound care nurses

• A significant opportunity is present upon transfer from the ICU to discontinue no longer needed urinary catheters.

• ICU nurse transferring the patient may evaluate catheter need before transfer out of the unit and discontinue unnecessary catheters.

• Urinary catheter use increases immobility, which in turn results in an increased risk of pressure ulcers.

• Wound care nurses may help in advising the bedside nurse on methods to reduce skin breakdown in patients with incontinence without using urinary catheters

Emergency medicine (ED) nurse Post-operative recovery nurses

• Up to half of the patients are admitted through the emergency department (ED).

• Inappropriate urinary catheter placement is common in the ED.

• Promoting appropriate placement of urinary catheters in the ED will reduce inappropriate use hospital-wide.

• Urinary catheters are commonly placed preoperatively for fluid management during the surgery.

• Post-operative recovery nurses evaluate the catheter for continued need and promptly remove no longer catheters.

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Metrics to Evaluate Improvement

• Process• Outcome

Process Measures

1. Urinary catheter utilization (number of urinary catheters/ number of patients)

2. Compliance with appropriateness of use (number of appropriately used catheters/ total number of catheters used)

– Utilization is easy to measure; reporting appropriateness is more challenging

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Outcome Measures

1. Number of CAUTIs (collected by infection preventionists)

2. NHSN CAUTI rate (requires accurate collection of catheter-days): important to measure risk with insertion and maintenance

3. Population CAUTI rate (uses patient-days in the denominator-easier to calculate): provides important assessment of improvement over time

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Summary

• Both nurses and physicians should evaluate the indications for urinary catheter utilization.

• Physicians should promptly discontinue catheters when no longer needed.

• Nurses evaluating catheters and finding no indication should contact the physician to promptly discontinue the catheter.

• Partner with different disciplines (e.g., case management, nursing, infection prevention) to successfully achieve your goals.

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Summary

• A continued reduction in urinary catheter utilization may be a marker of the program’s success.

• If no significant improvement is noted after implementation, you may need to reexamine the process for barriers or problems in implementation.