Catheter Associated Urinary Tract Infection Surveillance Dr Jodie McCoubrey

Overview ….. The extent of the problem of CAUTI SSHAIP CAUTI surveillance programme Data definitions of CAUTI Data collection process

HAI Background ……. 100, 000 patients affected per year 5,000 deaths per year

Cost of HAI to NHS …..

Current Climate …….. Public Concern Quality Issues Clinical Standards Clinical Governance Clinical Standards Accountability Reviews Performance Assessment Framework

Learning Outcomes To describe the epidemiology of CAUTI To overview the SSHAIP CAUTI surveillance programme To apply the data definitions for CAUTI correctly To evaluate the data collection processes available To maximise the potential for reduction of HAI through surveillance activities

Background to CAUTI surveillance What is the problem? Most common infection in acute hospitals and long-term care facilities 2.5% of hospital patients acquire a UTI  Length of hospitalisation (average 5-6 days) (Plowman et al, 1999) Cost to the patient Pain and discomfort Complicated upper urinary tract infection Bacteraemias

The extent of the problem……. HAI Proportion of all HAI (%) extra bed days(%) extra cost Proportion preventable? UTI 45 11 13 38 SSI 29 57 42 35 Pneumonia 19 24 39 Sur 27; Med13 Bloodstream 2 4 3 Other 6 N/A HAI Cost (£pp) Nat Burden*(£M) UTI 2955 123.89 in-patient only Source: Plowman et al. Socio-Economic Burden of HAI

Background to CAUTI surveillance Risk Factors Major predisposing factor indwelling urinary catheter average of 26% of hospitalised patients are catheterised (Glynn et al, 1997) risk of CAUTI is 1-2% per procedure Risk ↑ for each additional day of catheterisation Common in long-term catheterised patients

Associated Risk Factors A history of previous catheter use Duration the catheter is in situ Length of stay in hospital prior to catheter insertion Location of catheter insertion

SSHAIP CAUTI SURVEILLANCE PROGRAMME

(Centers for Disease Control and Prevention 1988) Surveillance ………. “Surveillance is the ongoing systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. The final link of the surveillance chain is the application of these data to prevention and control”. (Centers for Disease Control and Prevention 1988)

Why CAUTI surveillance? The HAI Task Force have prioritised urinary catheterisation Best Practice Statement Prepared by NHS Quality Improvement Scotland CAUTI Surveillance Carried out by SCIEH

Aims of CAUTI Surveillance Collect surveillance data and describe trends in catheter use and CAUTI Evaluate the impact of Best Practice in terms of: patient practice infection rates Assist hospitals in  of CAUTI

Essential elements of a successful HAI surveillance system Defining what outcomes to measure Ensuring everyone involved is aware of the outcomes Reliably collecting the data in a standardised/defined manner Analysing data for comparison Using the data locally in a timely manner to improve quality of care Gaynes and Solomon. J Quality Improvement (1996) 22:457-67

Patient Population 17 specialties have been chosen for CAUTI surveillance Each participating hospital will chose ONE of the listed specialties for surveillance Specialities represent: Medicine Surgery Gynaecology & Obstetrics Primary care Paediatrics are included

Who is included? Patients with a urinary catheter inserted in the chosen specialty emergency room theatre

Who is excluded? Patients are excluded if: The indwelling urethral catheter was inserted before the start of the UTI surveillance period Catheter is in situ on admission to the hospital (e.g. from the community or transferred from another hospital).

Exclusions cntd……… Patients are excluded if: The indwelling catheter is inserted in a specialty out with the chosen specialty (with the exception of the operating theatre and emergency department) They are nursed on wards not allocated to that specialty They are not from the chosen specialty but are nursed in a ward designated to the chosen specialty

Exclusions cntd…………… They have a single in-and-out catheter Patients are excluded if: They have a single in-and-out catheter The indwelling catheter has been in place for less than 6 hours The catheterisation is intermittent (i.e. insertion and removal of a catheter into the bladder every 3-6 hours for the drainage of urine) They have suprapubic catheterisation

Exclusions cntd…………… Patients are excluded if: They are undergoing treatment for a UTI when the catheter is inserted They are nursed on an ICU/HDU associated with the specialty, unless the patient population has been defined to include these wards when the surveillance started

Patient Pathways for CAUTI surveillance Catheter inserted in theatre or A&E Admission to chosen specialty Catheter Inserted Admission to chosen specialty Catheter removed UTI Catheter in-situ to day 30 Discharge Transfer Death 3-day follow-up End of Surveillance

Data collection methods Electronic data collection on Tablet PC or laptop An electronic data collection tool for CAUTI surveillance has been developed Paper data collection Paper forms sent to SCIEH for scanning and entry to database OR Data entered to database at local level

Data collection methods Data collection- Who? Designated data collector e.g. ICN; surveillance nurse; member of ICT or trained ward staff Data transferred by data collector or data manager/IT staff

Data collection- What? What data? Admission data Total no. of admissions to chosen specialty in the surveillance period Total number of patient days Catheter use Total number of catheter days Infection details onset date/symptoms and signs/causative organism and risk factors

Data collection- How? Admission data System of your choice Medical Records Ward Admission worksheet

Admission Data

Admission Data Worksheet

Data collection- How? Catheter use (identify patients eligible for surveillance) Daily Visit wards and identify catheterised patients from nursing records, medical records and ward staff CAUTI details Check urine microbiology reports for specialty under surveillance Review medical and nursing records temperature and treatment charts

CAUTI DATA DEFINITIONS

CAUTI Data Definitions A healthcare associated UTI considered to be catheter associated if: An indwelling catheter is in situ at time of onset of UTI (Criterion 1) OR An indwelling catheter was removed within 3 days prior to the onset of UTI (Criterion 2) 2nd point: This is to ensure detection of CAUTI’s which may have been incubating prior to the removal of the catheter.

AND The first positive urine specimen is taken or the physician makes a diagnosis more than 48 hours after the catheter was inserted

CAUTI Criterion 1 Definition CAUTI Data Definitions CAUTI Criterion 1 Definition For patient’s with an indwelling catheter in situ AND ≥104 micro-organisms per ml from a catheter specimen of urine

CAUTI Data Definitions CAUTI Criterion 1 cntd…. ONE or more of the following with no other recognised cause: Loin Pain Loin or suprapubic tenderness Fever (≥38oC skin temp) Pyuria (≥104WBC per ml)

CAUTI Data Definitions CAUTI Criterion 1 cntd…. OR….. The physician diagnoses UTI, institutes antibiotic therapy AND

CAUTI Data Definitions CAUTI Criterion 1 cntd…. The patient has TWO or more of the following with no other recognised cause: Loin Pain Loin or suprapubic tenderness Fever (≥380C skin temp) Pyuria (≥104WBC per ml)

CAUTI Criterion 2 Definition CAUTI Data Definitions CAUTI Criterion 2 Definition For patient’s who had catheter removal within 3 days before the onset of CAUTI AND ≥ 105 micro-organisms from a mid stream specimen

CAUTI Data Definitions CAUTI Criterion 2 cntd…. ONE or more of the following with no other recognised cause: Urgency Frequency Dysuria Loin Pain Loin or suprapubic tenderness Fever (≥ 38oC skin temp) Pyuria (≥ 104WBC per ml)

CAUTI Data Definitions CAUTI Criterion 2 cntd…. OR…….. The physician diagnoses UTI, institutes antibiotic therapy AND

CAUTI Data Definitions CAUTI Criterion 2 cntd…. The patient has TWO or more of the following with no other recognised cause: Urgency Frequency Dysuria Loin Pain Loin or suprapubic tenderness Fever (≥ 38oC skin temp) Pyuria (≥ 104WBC per ml)

CAUTI Definitions CAUTI must meet one of the criteria 1 or 2 as described Patients with asymptomatic bacteriuria/bacteria in their urine are NOT considered to have a CAUTI

Definitions state that quantitative bacterial counts should be recorded. “Light, Medium or Heavy Growth” may be recorded if these terms are defined to SSHAIP prior to starting surveillance.

In conclusion What am I looking for? Does the patient have an indwelling catheter? Does the patient have a CAUTI? Are there defined signs and symptoms? What is the infection onset date? Signs and symptoms should be recorded on form when first noticed

Summary Described the epidemiology of CAUTI Overviewed the SSHAIP CAUTI surveillance programme Overviewed the importance of data definitions for CAUTI Discussed the data collection processes

Any Questions?