CATHETER-ASSOCIATED urinary tract infections (CAUTI) are one of the 10 hospital-acquired conditions (HACs) considered "never events" because they're preventable and should "never" happen. The Centers for Medicare and Medicaid Services (CMS) won't reimburse a facility for CAUTI and other never events unless the condition was documented as present on admission.1 Because many guidelines for preventing CAUTI are directly under nurses' control, CAUTI is considered a nurse-sensitive indicator.
Last spring, Nursing2010 conducted a survey in the journal and online to explore nurses' knowledge of CAUTI prevention and the level of support they get from their facilities. This article reviews the results of the survey, discusses best practices, and provides evidence-based rationales.
Challenges and opportunities
Many nurses' initial reaction to the CMS no-pay policy was dismay because of the extra burdens and pressure placed on them. But every cloud has a silver lining, and this one has two. First, the new policy puts a premium on quality care by focusing on best practices to deliver quality care. Our patients can only benefit from this.
Second, because many aspects of HAC prevention are within the scope of nursing, the policy presents a unique opportunity for nurses to shine. Successful outcomes depend on consistent bedside implementation of evidence-based best practices. This is an opportunity to demonstrate, in outcomes and dollars, the value of nurses to their organizations.
What survey results reveal
One hundred seventy-eight nurses from across the country responded to our survey. This convenience sample represented 58% RNs, 12% LPNs/LVNs, and 23% students. No licensing status was identified for 7% of the sample. For more details, see Respondent profile.
The mean score for participants was 64% correct. The scores reflect only correct answers; unanswered questions were considered incorrect. The scores were normally distributed, forming a bell curve with a slight negative skew (tail to the left). The minimum score was 23% and the maximum, 92%.
We found no differences in scores based on education, work setting, or licensing status. Likewise, we found no significant differences (statistical significance = p < 0.05) based on clinical specialty. However, nurses working in the ED (N = 10) and rehabilitation (N = 11) scored highest with means of 69%, standard deviation (SD) 8%, and 66%, SD 19%, respectively. Nurses working in intensive care (N = 10) scored lowest with a mean of 59%, SD 16%. This is an interesting observation, but these sample sizes are too small to make generalizations.
It should also be noted that when looking at the percent correct and the response choices made for each question, most nurses chose the correct response for the most important questions and at least a partially correct response for many others.
Responses to individual questions, correct answers, and rationales are presented in the following pages. Correct answers are highlighted in red. The percent of responses for each answer is found at the end of the row. Numbers have been rounded. Percentages don't always add up to 100% because not every participant answered every question.
1. Research indicates that on average, CAUTI increases a patient's length of stay by
The best answer is 2 days; however, this is just an average and the impact of CAUTI is extremely variable and dependent on many factors. Urinary tract infections are not benign: they're potentially fatal and have been estimated by the CMS to result in costs as high as $451 million annually.2–4
2. The most common type of healthcare-associated infection (HAI) is
As most nurses knew, CAUTI is indeed the most common HAI, representing up to 40% of all HAIs. The National Healthcare Safety Network reported that the average rate of CAUTI is between 3.1 and 7.5 per 1,000 patient days (calculated as number of CAUTI ÷ number of patient days 1,000).5
3. Which of the following is true?
As noted above, CAUTI represents 36% to 40% of HAIs and can lead to serious complications such as bloodstream infections. The risk of CAUTI increases 3% to 7% with each day of catheterization. When a catheter remains indwelling for a week, the risk of bacteriuria increases to 25%; at 1 month, the risk of bacteriuria is 100%. Although bacteriuria may not cause symptoms, it's the first step toward a CAUTI. From 10% to 24% of patients with bacteriuria will develop symptomatic CAUTI (fever, dysuria, urgency, frequency, suprapubic tenderness), and up to 3% will progress to bacteremia.2,6 Approximately 17% of hospital-acquired bacteremias have been found to have a urinary source and carry an associated mortality of 10%.5
4. Evidence shows that silver alloy-coated indwelling urinary catheters
Studies on silver alloy–coated urinary catheters demonstrate that they're effective in preventing CAUTI for the first 2 weeks of dwell time. Researchers have demonstrated that in hospital units, use of silver-coated urinary catheters reduced risk of CAUTI by 32%.7 This suggests that silver alloy–coated catheters may be of benefit in the acute care setting but have limited usefulness in long-term care. Antibiotic-impregnated catheters have been found to be effective in reducing incidence of CAUTI for only 7 days.8–10
5. Which of the following is true about biofilm?
Biofilm is a coating of polysaccharides and microorganisms that develops on every indwelling medical device. Within the biofilm, microorganisms are highly resistant to antimicrobial treatment and bind tenaciously to the surface. The microorganisms living in biofilm are virtually impossible to eradicate without removing the catheter.5
Biofilm may be composed of a single species or multiple species, depending on the device and its duration of use in the patient. Initially, urinary catheter biofilm may be composed of a single species, but longer exposures inevitably lead to multispecies biofilm.
The biofilm polysaccharides have been visualized by scanning electron microscopy and appear either as thin strands connecting the cells to the surface and one another, or as sheets of amorphous material on a surface. Most biofilm volume is actually composed of this extracellular polymeric substance rather than cells. Biofilm matrix may act as a filter, entrapping minerals or host-produced serum components.11
6. According to the CDC, CAUTI is diagnosed when
To create a reliable and valid database and benchmark for the incidence of CAUTI, everyone must use the same definition when identifying and diagnosing this infection. The CDC has issued specific criteria that must be met before the diagnosis of CAUTI can be made. These criteria include the following:12
* Patient had an indwelling urinary catheter at the time of or within 48 hours before specimen collection.
* Patient has at least one of the following signs or symptoms with no other recognized cause: fever (>38° C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness.
* A urine culture is positive: greater than or equal to 105 CFU/mL (CFU = colony forming unit) with no more than two species of microorganisms, which would suggest specimen contamination.
All patients with indwelling medical devices will have some degree of biofilm, and fever can occur for many reasons. Asymptomatic bacteriuria isn't classified as a CAUTI.
7. Which of the following reduces the incidence of CAUTI?
Only one intervention listed above decreases the incidence of CAUTI based on the evidence: reducing urinary catheter days.8 Catheter irrigation, instillation of antimicrobial solutions into the catheter or drainage bag, and antibiotic ointments applied to the urinary meatus have not been shown to decrease CAUTI. Some evidence indicates that routine meatal care with soap and water (good hygienic care) may reduce the incidence of CAUTI, especially in patients who are incontinent of stool.5,13
8. Signs and symptoms of CAUTI include
Signs and symptoms of CAUTI can develop early on, before the patient becomes seriously ill. Pediatric patients younger than 1 year may exhibit hypothermia (<36° C). CAUTI should be immediately suspected if a patient with any of these signs and symptoms has an indwelling urinary catheter or has had one removed in the last 48 hours.12
9. Components of the CAUTI prevention "bundle" (evidence-based practice guidelines) include
Key components of the CAUTI prevention bundle include education and monitoring patients for CAUTI. Assure that only properly prepared staff perform urinary catheterization. A system of regular surveillance and feedback on unit–specific CAUTI rates is recommended.
Change drainage bags and catheters based on clinical indications such as infection, obstruction, or compromise of the closed system. Changing drainage bags at routine or fixed intervals isn't recommended.14
10. All of the following are accepted indications for urethral catheterization except
According to the CDC, appropriate indications for indwelling urinary catheterization are:
* acute urinary retention or bladder outlet obstruction
* accurate measurement of urine output in critically ill patients
* selected perioperative situations; for example, for urologic surgery, when intra-operative monitoring of urine output is needed, and when large-volume infusions or diuretics during surgery are anticipated
* patient requires prolonged immobilization (unstable spine or pelvic fractures)
* to assist in healing of open sacral or perineal wounds in incontinent patients
* end-of-life care.
Patient comfort (except during end-of-life care) and convenience aren't appropriate uses for indwelling urinary catheters.5 Again, remember to remove the urinary catheter as soon as possible.
11. Evidence shows that using sterile insertion technique is the most effective measure for preventing CAUTI.
Sterile technique is required for insertion of an indwelling urinary catheter in the hospital setting, but clean technique can be used for intermittent catheterization in non-acute settings. By itself, sterile technique on insertion doesn't prevent CAUTI. Prevention of CAUTI depends on knowledge of causes, proper care techniques, and early catheter removal.14
The fact that 80% of participants chose the incorrect answer to this question is interesting but not surprising. Because healthcare professionals have so much trouble with hand hygiene, The Joint Commission has made Meeting Hand Hygiene Guidelines part of its National Patient Safety Goals.15
As nurses, we're taught the importance of strict sterile technique, but we seem to forget that there are many days of care and opportunity for infection after the initial insertion. Perhaps we've had sterile technique drummed into us in campus learning labs at the expense of some of the basics.
12. Evidence shows that use of smaller-diameter catheters and catheter stabilization devices improves patient comfort.
Using the smallest-bore catheter that will adequately drain the bladder is recommended to prevent bladder neck and urethral trauma. While this recommendation isn't based on strong evidence, such as a randomized controlled trial, it's supported by a weaker but valid type of evidence—"expert opinion." Indwelling urinary catheters should be secured after insertion to prevent urethral traction and movement that could damage the urethral lining.5
13. The strongest predictor of CAUTI is
The length of time a urinary catheter is in place is the strongest predictor that CAUTI is likely to develop. No evidence has shown that use of antiseptic solutions or catheter material has any effect on CAUTI.5
Analyzing current practices
The remaining questions on the survey dealt with identifying practices occurring in organizations across the country. We found that the policy for frequency of catheter care varies, but the most common frequency reported was routinely twice a day and after each bowel movement. Most institutions (74%) are following the CDC recommendation to clean the external catheter and perineal area with soap and water only (74%).5 According to the CDC's guidelines, "cleaning the meatal surface during daily bathing or showering is appropriate."5
Forty-eight percent of respondents reported that their institutions don't use antimicrobial-impregnated catheters. Only 15% responded that they do use antimicrobial-impregnated catheters, but many participants (36%) said they don't know.
Only 37% of respondents said their institution had a care bundle for urinary catheter insertion and care/CAUTI prevention. This improved slightly when analyzing results from those who work in a hospital: Among hospital-based respondents, 43% responded yes, they had a prevention bundle for CAUTI. But even in the hospital setting, 57% reported that either they didn't have a prevention bundle or they didn't know if they had one. This presents an opportunity to teach staff about proactive and evidence-based care. We'll discuss the CAUTI care bundle in detail below.
Other evidence-based best practices are use of a catheter removal reminder system and urinary catheter securement devices. In this survey, 45% of hospital-based respondents and 38% of others reported using catheter removal reminders. This is another opportunity for improvement, as prolonged urinary catheter dwell time is the number one predictor of CAUTI. Sixty-four percent of respondents reported using urinary catheter securement devices.
Blodgett (2009) identified 11 studies demonstrating benefits of using a reminder system to reduce duration of indwelling catheters. These systems can be physical reminders, such as stop orders, checklists, and discussion in rounds; virtual reminders using electronic medical record prompts; and combinations of both methods.16 Another recent meta-analysis concluded that "urinary catheter reminders and stop orders appear to reduce the rate of CAUTI and should be strongly considered to enhance the safety of hospitalized patients."17
Monitoring CAUTI rates
Nearly 58% of respondents overall and 66% of those working in hospitals reported that their organizations monitor CAUTI rates, and 10% reported they don't. It may be that many respondents just aren't aware of the monitoring. Most respondents (78% overall and 76% in hospitals) reported they don't know the CAUTI rate in their organization.
Institutional support is needed to provide the structure that allows nurses to participate in teams to prevent CAUTI. Providing information about CAUTI rates to all staff involved in caring for these patients is an essential strategy for preventing CAUTI. Engaging staff in improving CAUTI rates is extremely difficult if they don't know it's a problem and can't track progress. Graphs or run charts posted on the staff bulletin board are very helpful. A system of surveillance and a dedicated interdisciplinary team, including champions at the bedside, is highly recommended.2
Applying the CAUTI care bundle
A care bundle is a collection of guidelines and interventions that, when consistently followed, have been shown to improve outcomes. Research has shown that improved outcomes depend on all elements of the bundle being applied, not just some.18
The following bundle strategies are recommended by the CDC for prevention of CAUTI.14
* Insert catheters for appropriate indications only.
* Leave catheters in place only as long as needed.
* Ensure that only properly trained persons insert and maintain catheters.
* Insert catheters using sterile technique and sterile equipment (in acute care settings).
* Following sterile insertion, maintain a closed drainage system.
* Maintain unobstructed urine flow.
* Practice hand hygiene and standard precautions (in addition to other transmission-based precautions as appropriate) according to Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines.
Consider the quality of evidence
Like many other practices in medicine and nursing, the evidence for best practice in prevention of CAUTI is identified as Category IB or lower. Category IB is defined as a strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms, or an accepted practice supported by low to very low quality evidence. There are too few practices with a Category IA rating (meaning a strong recommendation supported by high-to-moderate quality evidence suggesting net clinical benefits or harms). Strong evidence for many nursing and medical practices is lacking due to multiple variables and ethical considerations.
The recommendation categories identified as the highest priorities by HICPAC are as follows:5
* appropriate urinary catheter use (including prompt removal when no longer needed)
* sterile insertion of urinary catheters
* proper urinary catheter maintenance.
These three recommendation categories are clearly within the scope of nursing. Nurses can implement many interventions to fulfill these recommendations. For example, to help ensure appropriate urinary catheter use, nurses in our facility keep the urinary drainage bag hanging on the side of the bed facing the door. This serves as a reminder system: Every day when the clinical team rounds, they see the drainage bag and are reminded that the patient still has an indwelling urinary catheter. The visual reminder prompts them to consider whether it can be removed.
Better evidence: You can help
Many recommendations require further research to establish better evidence for practice; for example:
* determining which catheter materials are optimal
* use of antiseptics and antimicrobials
* alternatives to indwelling urethral catheters and bag drainage
* use of portable ultrasound in patients with low urine output to reduce unnecessary catheterizations (see Lowering the risk of CAUTI with bladder scanning).
Each of these potential research topics is amenable to interdisciplinary research. Prevention of CAUTI is truly a nurse-sensitive indicator. Nurses should be leading as well as participating in ongoing efforts to attain zero CAUTI.
Approximately 20% of respondents had a BSN or higher degree. About 29% had an AD, 12% had an RN diploma, and 23% were students.
Twenty-eight percent of respondents were certified in their nursing specialty. The specialty area represented most frequently was medical-surgical nursing (34%) and the most common work setting was a hospital (61%).
Other work settings represented were long-term care (14%), home health (4%), office nurse (3%), and outpatient (2%). A few identified student clinical rotation, clinical research, and manufacturing as their work setting.
COMING TO TERMS WITH ACRONYMS
Here's a quick reference for abbreviations used in this article:
* CAUTI: catheter-associated urinary tract infection
* CMS: Centers for Medicare and Medicaid Services
* CDC: Centers for Disease Control and Prevention
* HAC: hospital-acquired condition
* HAI: healthcare-associated infection
Facts and Figures5
The National Healthcare Safety Network reported CAUTI rates to be from 3.1 to 7.5 per 1,000 catheter days in acute care hospitals in 2006. The highest rates were found to be in burn ICUs and the lowest rates in medical-surgical ICUs. The most common organisms associated with CAUTI are Escherichia coli (21.4%), Candida (21%), Enterococcus (14.9%), Pseudomonas aeruginosa (10%), Klebsiella pneumonia (7.7%), and Enterobacter (4.1%).
LOWERING THE RISK OF CAUTI WITH BLADDER SCANNING
The CDC guideline recommends various strategies to reduce the risk of CAUTI, including intermittent (rather than chronic indwelling) catheterization for patients with spinal cord injuries and those with bladder emptying dysfunction. The guideline recommends that clinicians consider using a portable ultrasound bladder scanner to assess urine volume in patients undergoing intermittent catheterization to reduce unnecessary catheter insertions. "If ultrasound bladder scanners are used, ensure that indications for use are clearly stated, nursing staff are trained in their use, and equipment is adequately cleaned and disinfected in between patients." Further research is recommended in the use of bladder scanners in patients with oliguria "to reduce unnecessary catheter insertions or irrigations (in catheterized patients)."5