1. Portneuf Medical Center CAUTI Prevention Plan
Evidence-Based Guidelines Utilizing a Nurse Driven Catheter Protocol

2. Background
Indwelling catheters are one of the main causes of hospital acquired conditions
CAUTIs increase morbidity & mortality
CAUTIs account for $ million in additional healthcare costs annually
CAUTIs are relatively preventable
CMS does not reimburse for CAUTIs
CDC

3. CAUTI & VBP
CAUTI are part of Value Based Purchasing in the Patient Safety Domain - up to 2% of Medicare payments are at risk

4. Efforts to Reduce CAUTI
Implementation of the Foley Bundle:
Insert using sterile technique
Hand hygiene before/after contact
Secure catheter to thigh at all times
Keep catheter below level of bladder
Avoid dependent loops
Maintain a sterile, continuously closed system
Peri care daily and after incontinent stool
Discontinue as soon as not required

5. Emphasis Has Been Care & Discontinuing as Early as Possible
Bacteria is a function of time with a Foley catheter:
Single event = risk for UTI < 1%
4 days = risk for UTI = 30%
30 days = risk for UTI = %

6. CAUTI Rates at PMC
Despite our efforts we have not decreased CAUTI to zero

7. Why The Need For Change?
Despite our efforts we have not deceased our CAUTI rate further
Evidence shows that a Nurse Driven Catheter Use Protocol can reduce catheter use and catheter days = reduced CAUTI risk/rates
Studies show that up to 50% of indwelling catheters are not medically necessary
Often physicians do not know their patients have catheters that were placed in the OR or ED

8. Recommendations by CDC & ANA
CDC – Centers for Disease Control; ANA – American Nurses Association
Medical necessity
Insertion guidelines
Catheter maintenance
Quality Improvement plan
Administrative infrastructure
Surveillance strategies
How will we meet these recommendations?

9. Medical Necessity
Acute urinary retention or bladder outlet obstruction
Need for accurate measurements of output in critically ill patients
Perioperative use for selected surgical patients
Assist in healing of open sacral or perineal wounds in incontinent patients
Patients that require prolonged immobilization
To improve comfort for end of life care

10. Selected Surgical Patients
Urologic surgery or other surgery on contiguous structures of the GU tract
Anticipated prolonged duration of surgery (remove in PACU)
Anticipated to receive large-volume infusions or diuretics during surgery
Need for intraoperative monitoring of urinary output

11. Alternatives
External catheters in male patients without urinary retention or bladder outlet obstruction
Intermittent catheterization with bladder scanning in patients with spinal cord injuries or neurogenic bladder

12. Insertion Guidelines
Implementation of BARD Foley Kits to assist with compliance of insertion – based on Lean process
Use smallest bore catheter possible unless ordered otherwise by physician
Hand hygiene before and after insertion
Aseptic technique with sterile supplies
National average compliance for hand hygiene in hospitals is 40-50%!

13. Catheter Maintenance Continue to utilize the Foley Bundle
Avoid irrigation unless obstruction is anticipated – requires a physician’s order
Use soap and water for routine pericare – avoid antiseptics in the periurethral area

14. Quality Improvement Plan
All patients that need or may need indwelling catheters will have Nurse Driven Catheter Protocol orders
CPOE order sets for Nurse Driven Catheter Protocol unless patient is excluded
Exclusions will require LIP documentation
CAUTI Prevention Team to assess compliance with protocol & Foley Bundle

15. Administrative Infrastructure
Nurses will demonstrate annual competencies for insertion and care/maintenance
CAUTI Prevention Team will monitor compliance and provide immediate education for variances in protocol and bundle
Catheters will be removed if medical necessity is not met, unless excluded by physician

16. Surveillance
All patients that receive indwelling catheterization will be monitored by the team
Urinary tract infections are defined using National Health Safety Network criteria
Date of event (DOE) is the date when the first element used to meet UTI criteria occurred
Location of attribution is the location where the patient was assigned on the date of the UTI event (see transfer rule)

17. Surveillance (continued)
CAUTI is defined as a UTI where an indwelling urinary catheter was in place for > 2 calendar days on the date of event (UTI), with day of device placement being Day 1 and an indwelling urinary catheter was in place on the date of event or the day before
i.e. if a patient is diagnosed with a UTI the day after catheter is placed, this is NOT a CAUTI

18. Surveillance (continued)
Transfer rule: if the date of event for the CAUTI is within 2 days of transfer or discharge, the infection is attributed to the transferring or discharging location
In instances where a patient has been transferred to more than one location on the date of a UTI, or the day before, attribute the UTI to the first location in which the patient was housed the day before the UTI’s date of event

19. CAUTI Criterion (Symptomatic)
OR (seen next slide)

20. CAUTI Criterion (Symptomatic)

21. CAUTI Criterion (Asymptomatic)

22. CDC/ANA Evidence-Based RN Tool

23. CDC/ANA Evidence-Based RN Tool

24. CDC/ANA Evidence-Based RN Tool
Bottom of Page 2:

25. CDC/ANA Evidence-Based RN Tool

26. Conclusion
A practice change needs to occur to further drive down our CAUTI risk/rate
Nurses spend an entire shift with patients, physicians see them for a short window each day – nurses can assess better the need for catheter placement and continuation unless patient is excluded by physician
It takes a team to reduce hospital acquired conditions