1. Preventing Catheter-Associated Urinary Tract Infections June 12, 2013 Bonnie Norrick, MT(ASCP) cm, EdM, CIC

2. Objectives List risks for acquiring a catheter associated urinary tract infection (CAUTI) Identify interventions for prevention of CAUTI List at least 3 elements in a nurse driven protocol for removing a urinary catheter

3.  Licensed 276 acute care beds  Patient days 27,257 for FY 2012; Avg census 77  Observation days 1041  Average length of stay 3.4 days  LTC, Hospice, Heart Clinic, Women’s Center, Occupational Medicine, Sleep Center, Cancer Clinic

4. Impact of Healthcare Associated Infections (HAI) According to the Centers for Disease Control and Infection (CDC), each year – Approximately 1.7 million people develop HAIs – 100,000 people die due to complications of infections – Between 5 and 10 % of individuals who are admitted to an acute care hospital will develop at least one HAI – Costing $4.5-$5.7 billion – 15% of those are CAUTI

5. Definition of CAUTI Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place for >2 calendar days when all elements of the UTI infection criterion were first present together, with day of device placement being Day 1, and an indwelling urinary catheter was in place on the date of event,

6. Definition of CAUTI Definition of CAUTI 2 at least 1 of the following signs or symptoms: fever (>38°C); suprapubic tenderness*; costovertebral angle pain or tenderness* and a positive urine culture of ≥10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms. Elements of the criterion must occur within a timeframe that does not exceed a gap of 1 calendar day – *With no other recognized cause

7. Definition of CAUTI Definition of CAUTI 3 Patient had an indwelling urinary catheter in place for >2 calendar days and had it removed the day of or the day before all elements of this criterion were first present together and at least 1 of the following signs or symptoms: fever (>38°C); urgency*; frequency*; dysuria*; suprapubic tenderness*; costovertebral angle pain or tenderness* and a positive urine culture of ≥10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms. Elements of the criterion must occur within a timeframe that does not exceed a gap of 1 calendar day – *With no other recognized cause –

8. Risks for CAUTI Duration: Prolonged catheterization > 6 days Sex: Female gender Location of insertion: Catheter insertion outside the operating room – Urology Service Overall health – Other active sites of infection – Diabetes – Malnutrition – Elevated creatinine >2.0mg/dl Invasive interventions: Ureteral stent Maintenance of Foley

9. Our Story: In the Beginning Surveillance for CAUTI – Facility wide-medical, OB and ICU – Use Definitions – Calculate rates? ICU only, share data

10. Minimizing the Risks Use of silver coated Foley catheter’s in all areas Securement device Placement of tubing and bag in respect of bladder and floor Maintain a closed system Bags emptied appropriately – not overfilled

11. To Change Requires Measurement November 2008 survey 13 Foley’s reviewed Tubing kinked5 Bag on floor4 Seal Broken0 Bags overfilled0 Tubing not secure 11 April 2009 Survey-post education of nurses 22 Foley’s reviewed Tubing kinked0 Bag on floor5 Seal Broken0 Bags overfilled0 Tubing not secure 0

12. Interventions Jan-March 2009 Silver coated catheters Securement devices (one that stuck) Visualization of proper positioning of tubing and collection bag Method to obtain devices days UnitWGH RateNHSN Mean 6 South7.25.7 PCU5.44.7 5 th floor9.55.0 4 th floor3.45.7 ICU1.93.1

13. Education Aggressive education of staff – Computer based learning – On hire and annually – Skills day – Insertion of Foley and peri-care, urine collection One on one education – Observation of securement, tubing and bag position – Inquire-medical necessity?

14. Documentation in EMR

15. Slide 15

16. Other interventions An additional SCIP quality measure began in October 2009 requiring Foley catheter be discontinued on Post Operative Day 1 or Post Operative Day 2. If the Foley remains a reason for continuing urinary catheter must be documented by MD/APN/PA. Applied to all surgeries. Increase use of condom catheters for men.

17. Rates = infections/device days x 1000 Unit20102011NHSN Mean 6 South2.70.05.7 PCU0.07.24.7 5th1.20.05.0 4th0.01.55.7 ICU2.00.83.1

18. Nurse driven protocol - Foley Removal Criteria Patient is awake, alert, no problems voiding before the catheter was placed Catheter was not placed for urinary retention/obstruction and no recent urological surgery within 3 months Patient is able to resume their voiding position Patient able to cooperate with strict I&O monitoring No evidence of gross hematuria

19. Nurse driven protocol - Foley Removal Criteria Nurse driven protocol - Foley Removal Criteria 2 Epidural catheter is removed Patient is not intubated Patient not admitted with chronic indwelling Foley catheter Post-op patient surgery greater than or equal to 48 hours. Open wounds/excoriation absent or resolved. Catheter is not a suprapubic catheter Using the above guidelines, the indwelling (Foley ) catheter will be removed by the RN 48 hours after insertion of the foley unless a specific physician’s order indicates otherwise. Nurse will review reason why foley was initially inserted.

20. Bladder scan usage If one of the following is present RN will perform bladder scan. 1. Bladder discomfort 2. Distended bladder 3. Has not voided in 6 hours or at discretion of nurse 4. Post void residual (Not emptying bladder, voiding frequent small volumes) If urine volume is greater than 250 ml the nurse will call the physician for further instruction such as a straight catherization order. Volumes less that 250 document in nurses notes.

21. Rates 2012 2013 Risk assessment Decrease catheter associated UTI by 50% (1 catheter associated urinary tract infections) Devise days will be collected each month for ICU and ICU SD patients. Other units devise days will be collected on a rotating schedule. Unit2012NHSN Mean 6 South0.01.6 PCU0.00.5 5th0.01.5 4th0.71.6 ICU0.01.3 ICU SD1.71.8

22. On Going Initiatives Continue rounding on all nursing units Re-educate Foley removal policy during rounding Observe hand off communication between shifts discussing devices Identify root cause of each CAUTI

23. In Summary Risk assessment a must, prioritize strategy Measure Involve leadership Celebrate It’s a Team Effort!

24. References Guideline for Prevention of Catheter-Associated Urinary Tract Infection 2009, Healthcare Infection Control Practices Advisory Committee, Center for Disease Control Clarke, K.,Tong, D., Norrick, B., Reduction In catheter-associated urinary tract infection by bundling interventions, International Journal for Quality in Health Care Advance Access, 2012.

25. Thank you Any questions? I have the time. Questions later, email or call. Bonnie Norrick – Email norrickb@wghealth.orgnorrickb@wghealth.org – Phone 706-845-3180 West Georgia Health- So Healthy Together