Indwelling Urinary Catheter Management and CA-UTI Prevention in NICHE Hospitals Heidi Wald, MD, MSPH; Regina Fink, PhD, RN, AOCN, FAAN; Heather Gilmartin, MSN, RN, CIC; Angela Richard, MS, RN; Marie Boltz, PhD, RN, GNP-BC; Elizabeth Capezuti, PhD, RN, FAAN STOP CAUTI

BACKGROUND Current Practice Survey

Catheter-associated Urinary Tract Infection (CAUTI) Single most common healthcare- associated infection (HAI), accounting for 34% of all HAIs. Associated with significant morbidity and excess healthcare costs. Since 2008, CMS no longer reimburses for additional costs required to treat CAUTIs.

CDC Surveillance Definition of CAUTI A urinary tract infection that occurs while a patient has an indwelling urinary catheter or within 48 hours of its removal. Source: Dennis G. Maki and Paul A. Tambyah. Engineering Out the Risk of Infection with Urinary Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April 2001.

Evidence-Based Guidelines Since 2008, multiple evidence-based guidelines for CAUTI prevention have been published CDC JBI NHS SHEA APIC NHSN* CDC IDSA CDC= US Centers for Disease Control JBI=Joanna Briggs Institute NHS=UK National Health Service SHEA=Society of Healthcare Epidemiologists of America APIC=Association of Professionals of Infection Control NHSN=CDC’s National Healthcare Safety Network (*revised surveillance definition) IDSA=Infectious Diseases Society of America

Evaluation of Practice is Key! In light of these rapid changes in the field, the review of practices, policies, procedures, and product use is imperative for all healthcare facilities.

Objectives To understand the current state of nursing practice in NICHE hospitals with regard to bladder management, indwelling urinary catheter care, and surveillance

METHODS Current Practice Survey

Survey Methodology Sample: All NICHE Hospitals (n=250) Mechanism: survey using Survey Monkey sent to NICHE coordinators. Survey open for 1 month with two reminders sent. Stage 1: Dec, 2009: All potential STOP CAUTI Workgroup sites Stage 2: June, 2010: All remaining NICHE sites

Survey Topics based on Review of Published Guidelines Areas of interest: 1)Equipment 2)Insertion and maintenance techniques 3)Training, education, and policies 4) Documentation, surveillance, and reminders

RESULTS Current Practice Survey

Characteristics of Hospitals Responding to Survey CharacteristicResponse (N=75) Bed Size Urban Setting (%)84% Teaching Hospital (%)69% Magnet Status (%)31% STOP CAUTI Participant (%)27% HAI Mandatory Reporting State (%)61%

Canada – 4 CT NICHE Hospitals Participating – by State MA - 3 MD NJ RI VA N = 75

RESULTS: Equipment Current Practice Survey

In which populations does your hospital use the following indwelling catheter types? % of hospitals (N=75)

What does the Evidence say about Catheter Materials? Antimicrobial catheter materials (versus standard materials) for short-term catheterization: –reduce catheter-associated bacteriuria –unproven for reduction of symptomatic CAUTI –do not substitute for a comprehensive CAUTI prevention program. No clear benefit among standard materials on CAUTI rates including: –latex, hydrogel-coated latex, silicone-coated latex, or all-silicone catheter

How often are these alternatives or adjuncts to indwelling catheters used at your hospital? (N=75) % of hospitals

How often does access to the following equipment limit its use at your hospital? *Access to female urinals limited usage N=75 % of hospitals

Do You Know the Evidence for IUC Alternatives? Condom catheters use reduces CAUTIs and increases patient comfort Straight catheter use reduces CAUTIs because of reduced late infections Bladder scanners use reduces IUC use Securement reduces friction on urinary tract structures

RESULTS: Insertion and Maintenance Techniques Current Practice Survey

How often are each of the following used when placing an indwelling catheter? N=75 % of hospitals

How often are each of the following used when placing an indwelling catheter? % of hospitals N=75

Recommended: Aseptic Technique During Insertion 1.Aseptic technique: 1.Donning sterile gloves 2.Use of sterile barrier 3.Perineal washing using an antiseptic solution 4.No-touch insertion 2.Opening and using a sterile insertion kit

When an indwelling catheter is in place, urethral meatus care is performed: How often? With what agents? Recommended: Meatal care should be performed with soap and water daily and after bowel movement % of hospitals

RESULTS – Training, Education, and Policies Current Practice Survey

Does your hospital have a policy/procedure on indwelling urinary catheter placement, management, and/or prevention of CAUTI? Among a subset of policies reviewed: 40% were > 2 years old 25% used Lippincott or Delmar’s texts Evidence-based –Ranged N=75

Policy and Procedure Components Appropriate catheter indication (50%) CAUTI S&S assessment parameters (20%) Bladder scanner parameters (20%) Insertion technique parameters were discussed but varied by hospital Sterile closed system reinforced (70%) Urine specimen procedure outlined (65%) Lack of discussion –Emptying urinary bag (50%) –Meatal care frequency and agent used (50%)

Who is responsible for insertion of indwelling urinary catheters? N=75

Training and Validation Annual validation on aseptic technique occurs at ~47% of hospitals Initial Training of Staff N=75

CDC Education Recommendations Ensure that only properly trained persons who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Category IB) Ensure that healthcare personnel who take care of catheters are given periodic training regarding techniques and procedures for insertion, maintenance and removal. Includes: CAUTI, other complications of catheters, alternatives. (Category 1B)

Provision of Patient/Family Educational Materials Type of material Micromedex Notes Discharge Instructions Self-cath instruction S&S infection Care and maintenance N =75

RESULTS – Documentation and Surveillance Current Practice Survey

How is urinary output and catheter care management documented on your primary unit? N=75

Which of the following aspects of urinary output and catheter care management are routinely documented on your primary unit? % N=75

CDC Documentation Recommendations Consider documenting the following: indication, date and time of insertion, who inserted, date and time of removal (Category II) Ensure that documentation is accessible and in standard format. Searchable electronic documentation is preferable. (Category II)

Does your hospital have a system to remind providers to remove indwelling catheters? Nurse driven protocol to discontinue (40%) Paper reminders (36%) Electronic reminders (37%) Nurse led catheter rounds (35%) Other –Stickers on MD orders and medical records –ICUs have prompt on daily goal sheet –Electronic Stop Orders N=75

Recommended strategies for reducing catheter use and duration (Category 1B) System of alerts or reminders Guidelines and protocols for nurse-directed removal Education and performance feedback Guidelines for perioperative use Protocols for management of postoperative urinary retention

Do your infection practitioners perform routine surveillance for CAUTIs? Where is surveillance conducted? –House-wide (64%) –ICU only (13%) –Did not answer or did not know (13%) –NA (9%) Catheter days are collected –All units (51%) –Selected units (35%) –Not done (14%) N=75

CDC Surveillance Recommendations Consider surveillance for CAUTI when indicated by facility-based risk assessment. (Category II) Use standardized methodology for performing CAUTI surveillance (includes measures of catheter-days) (Category 1B) Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II) Consider providing regular feedback of unit- specific CAUTI rates to nursing staff. (Category II)

Summary NICHE hospitals are implementing many evidence-based CAUTI strategies –Evidence-based insertion and maintenance –CAUTI education –CAUTI QI projects NICHE hospitals can improve upon –Use of stop orders and reminders –Use of alternatives to IUCs –Documentation and surveillance

Implications for CAUTI Prevention in NICHE hospitals Translate research into practice Incorporate into policies and procedures Regular educational updates Implement system-wide standards for documentation and surveillance Examine products and availability in practice settings Maximize catheter avoidance and early removals When feasible, use multicomponent interventions

ACKNOWLEDGEMENTS Current Practice Survey

Current Practice Survey Participants All 75 NICHE Coordinators responding to the survey The 20 dedicated STOP CAUTI Workgroup NICHE Coordinators and site Principal Investigators.

STOP CAUTI Funders Primary funder: the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services ( Dr. Wald’s time also funded by the National Institute on Aging, U.S. National Institutes of Health (

The STOP CAUTI Project Team University of Colorado Denver - Heidi Wald, MD, MSPH, Principal Investigator -Regina Fink, PhD, RN, AOCN, FAAN; Research Scientist -Angela Richard, MS, RN, Project Manager -Brian Bandle, BS, Database manager NICHE - Elizabeth Capezuti, PhD, RN, FAAN, Co-Investigator - Marie Boltz, PhD, RN, GNP-BC, Practice Director - Nina Shabbat, BA, Benchmarking Assistant

What are the goals of the STOP CAUTI study? To understand care practices associated with indwelling catheters at NICHE hospitals. To disseminate an electronic method for tracking CAUTIs and catheter duration. To determine the effect of the feedback of these data on processes of care (catheter duration) and outcomes (CAUTIs).

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THANK YOU! Current Practice Survey