URINARY TRACT INFECTIONS (UTIs) are the most common type of healthcare-associated infection (HAI) in hospitals and long-term care facilities.1 In most cases, they result from the insertion and prolonged use of urinary drainage catheters. The longer the catheter is in the bladder, the higher the risk of a catheter-associated urinary tract infection (CAUTI). While UTIs account for over 30% of HAIs reported by acute care hospitals, approximately 75% of UTIs are related to the use of urinary catheters.2,3
This article discusses how nurses and other clinicians significantly decreased the CAUTI rate on a postoperative unit by initiating a two-person urinary catheter insertion protocol. This innovative strategy required an observer to be present during urinary catheter insertions to ensure that sterile procedure was maintained throughout the procedure.
Urgent mandate to reduce HAIs
On October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) made a change to its reimbursement policy for certain HAIs that included UTIs (see Implications for healthcare facilities). In 2012, The Joint Commission included reducing the risk of HAIs as Goal 7 of its National Patient Safety Goals.5 Responding to these pressures, administrators and clinicians examined existing protocols and explored new approaches to preventing HAIs, including CAUTIs.
One unit in a major teaching hospital had a UTI rate of one to three monthly or every other month since the second quarter of 2010 to the first quarter of 2012. The unit had been using the bladder scan protocol (see Applying the bladder scan protocol for more information) and faced the challenge of eliminating the UTIs. The patient population of the unit consisted mainly of postoperative patients, patients with relapsing-remitting multiple sclerosis in relapse, terminally ill patients, patients transferred from the ICU, and overflow patients from surgical specialties such as wound or diabetic limb salvage services.
In a daily census of 19 patients, typically 4 to 6 patients (21% to 32%) had indwelling urinary catheters (two to three new indwelling urinary catheters every day). This unit had one of the highest number of UTIs in the facility.
In 2010, the clinical educator conducted a back-to-basics course that included perineal care, urinary catheter insertion in men and women, urinary catheter care, and a review of interventions that were already in place. These included:
- using the bladder scan protocol
- using a urinary catheter securement device provided in the urinary catheter insertion kit
- maintaining a closed urinary catheter system
- placing the urinary drainage bag below the level of the patient's bladder whether the patient was in bed or on a stretcher and not allowing the drainage bag to touch the floor
- wiping off the drainage spigot with alcohol swabs after use and before covering the port
- using the sheeting clip to secure drainage tubing to the sheet and prevent catheter kinks.
The clinical manager required all staff, including RNs, clinical technicians, and unlicensed assistive personnel, to attend. The following year, the clinical manager and educator chose to validate the staff's competencies at the bedside in performing perineal and urinary catheter care as well as urinary catheter insertion with the hope of reducing the unit's CAUTI rate to zero.
In 2012, the unit staff competency validators decided to make urinary catheter and perineal care a competency for clinical technicians and unlicensed assistive personnel. In spite of the education and interventions, however, patients in the unit continued to experience a high number of CAUTIs.
Taking a fresh approach
While the unit faced this challenge, it was celebrating its success in having no central line-associated bloodstream infections (CLABSIs) for more than 2 years. The clinical educator reviewed the policies related to CLABSIs for clues to this success. What stood out was the presence of an independent observer who could stop the central venous catheter insertion procedure if any team member violated sterile technique. No one was doing this during the insertion of urinary catheters.
The clinical educator couldn't find any literature about urinary catheter insertion using two people, with one being an observer, nor heard of anyone who'd tried this procedure. She asked colleagues at other hospitals in the area if anyone practiced it as a formal procedure, but no one did. The clinical educator wanted to find out if, in addition to other measures already being implemented, the practice of a two-person urinary catheter insertion procedure would decrease the number of CAUTIs in the unit within 6 months.
Implementing the procedure
The clinical educator and clinical manager decided to implement a two-person urinary catheter insertion procedure for 6 months. This meant that every RN would ask a second RN to observe when he or she was inserting a urinary catheter. This protocol applied to both indwelling and straight in-and-out catheterization and both adult men and women patients. A urinary catheter kit containing a urinary catheter attached to a drainage bag with a urimeter (closed system), securement device, and cleaning items was used. Two RNs were present at the bedside during the procedure, which included these elements.
- Using sterile technique and sterile equipment and following the CDC Guidelines for Appropriate Indications for Indwelling Urethral Catheter Use,7 while Nurse 1 cleaned the patient's periurethral area and inserted the catheter, Nurse 2 observed to ensure that Nurse 1 followed sterile technique and performed the procedure correctly.
- Nurse 2 was empowered to stop the procedure if sterile technique was broken at any point during the insertion procedure.
- Nurse 2 could assist Nurse 1 in the cleaning and positioning of the patient when necessary. Because many patients on the unit had neurologic conditions causing unilateral weakness, mental status changes, and/or spasticity in addition to postoperative pain, maintaining asepsis during urinary catheter insertion can be challenging for a nurse working alone.
Six months before the two-person urinary catheter insertion procedure was implemented, five CAUTIs occurred per 746 device days. The CAUTI rate of the unit was 6.70 cases per 1,000 catheter days. Six months after implementation, the number of CAUTIs was three with 729 device days and a CAUTI rate of 4.11 cases per 1,000 catheter days. Two out of the three CAUTIs were related to the insertion of a urinary catheter. One was related to diarrhea. Six months after the project was completed, only one CAUTI occurred in 625 device days. The CAUTI rate was 1.6 cases per 1,000 catheter days.
No significant difference was seen between the number of device days before and after implementation, yet CAUTIs were reduced by 39% six months after initiation of the two-person urinary catheter insertion procedure (see CAUTI rates August 2012–January 2014).
The clinical manager and clinical educator received feedback from staff after the 6-month trial period. Staff said that inserting a urinary catheter became easier and quicker because the observer (Nurse 2) wasn't only observing the inserter (Nurse 1) to ensure asepsis, but was also helping to position and hold the patient.
Because maintaining asepsis during urinary catheter insertion can be challenging for a nurse working alone, the staff deemed the assistance by Nurse 2 as a clear advantage. Additionally, the staff exercised peer review by observing, critiquing, and correcting each other's practice. They used these opportunities to promote teaching and learning and to develop or maintain competency. They also felt empowered to teach other staff members floating from other areas who didn't follow the correct urinary catheter insertion procedure.
The awareness of the staff and their focus on CAUTIs helped them to better identify the cause of a CAUTI related to either insertion or maintenance of a urinary catheter. At the time this article was written, the practice of two-person insertion of urinary catheters had become part of the unit's culture. Every clinical nurse just expected to have a second person present during catheter insertion.
A positive option
These results show that having a two-person catheter insertion procedure can help lower CAUTI rates. More research should be done to see if this procedure would be a worthwhile pursuit and if healthcare providers should recognize it as a promising option for reducing CAUTIs.
Implications for healthcare facilities
Effective October 1, 2008, the CMS began refusing reimbursement for certain HAIs, including UTIs. This policy change was made in response to a 2002 report estimating that approximately 1.7 million HAIs occurred in hospitals across the United States and were associated with about 99,000 deaths, some of which were preventable.4 As a result, healthcare facilities began looking for preventive strategies and multimodal interventions and practices, including protocols to prevent or eliminate UTIs, improve the quality of patient care, make hospitals safer, and avoid unnecessary financial burdens. In addition, healthcare-related companies and businesses marketed new or improved products such as a urinary catheter insertion kit with a closed system that included the urinary catheter connected to a urinary catheter drainage bag and a cleaning device that is presoaked with a cleaning solution, while other kits included step-by-step instructions for urinary catheter insertion that helped hospitals reduce or manage CAUTIs and other HAIs.
Applying the bladder scan protocol6
Our facility was using the bladder scan protocol for its postoperative spine patients, specifically patients who had a laminectomy. Based on this protocol:
- The patient's indwelling urinary catheter was taken out the day after surgery at around 0600.
- If the patient voided within 4 hours, the nurse checked the patient's bladder volume using a bladder scanner within 15 to 30 minutes to check the postvoid residual urine volume.
- If the patient had more than 150 mL in the bladder, the nurse reinserted the urinary catheter.
- If the patient didn't void within 4 hours after the urinary catheter was discontinued and the bladder scan showed less than 300 mL bladder volume, the patient was rescanned in 2 hours.
- If the bladder volume was still less than 300 mL, the patient passed the voiding trial and the nurse reported it to the healthcare provider (HCP) for further evaluation, if needed.
- If the patient didn't void in 4 hours after the catheter was discontinued and the bladder volume was more than 300 mL, the patient failed the voiding trial and the nurse would reinsert a urinary catheter.
- Whenever the patient failed the voiding trial and an indwelling urinary catheter was inserted, it was taken out the next morning and the patient would go through a second voiding trial.
- If the patient failed the second voiding trial, the nurse would notify the HCP, who would usually decide to consult urology.
1. Magill SS, Hellinger W, Cohen J, et al. Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida. Infect Control Hosp Epidemiol. 2012;33(3):283–291.
Centers for Disease Control and Prevention. Catheter-associated Urinary Tract Infections (CAUTI). 2012. http://www.cdc.gov/HAI/ca_uti/uti.html.
Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee. 2010. http://www.cdc.gov/hicpac/CAUTI_fastFacts.html.
4. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160–166.
The Joint Commission. National Patient Safety Goals. 2013. http://www.jointcommission.org/standards_information/npsgs.aspx.
Belizario SM. Abstract: Integrating the bladder scan into standard nursing practice of bladder volume assessments to reduce the frequency of intermittent catheterizations in hospitalized patients. In: McLaughlin MMK, Bulla SA, eds. Real Stories of Nursing Research: The Quest for Magnet Recognition. Boston, MA: Jones and Bartlett Publishers; 2010:104–107.
Centers for Disease Control and Prevention. Guideline for prevention of catheter-associated urinary tract infections. 2009. http://www.cdc.gov/hicpac/cauti/02_cauti2009_abbrev.html.
The author would like to acknowledge the following UTI champions: Kristine Edson, RN; Kelly Harrington, RN; Sharon Smith, RN; and former clinical manager Susan Magbuhos, RN.