At any given time, about 1 in 25 inpatients have an infection related to their hospital care. Healthcare-associated infections (HAI) can lead to the loss of tens of thousands of lives and billions in costs each year, according to the US Office of Disease Prevention and Health Promotion. Catheter-associated urinary tract infections (CAUTIs) are the most common type of HAI. A result of inappropriate or mismanaged use of indwelling urinary catheters, CAUTIs impact more than 560,000 patients each year and are responsible for significant morbidity and mortality, extended hospital stays, and additional healthcare costs associated with diagnostic and therapeutic interventions. These unfavorable outcomes have led the Centers for Medicare and Medicaid Services, the US Department of Health and Human Services, the CDC, and The Joint Commission to implement various clinical prevention initiatives and national safety prevention standard goals across the integrated healthcare system to prevent CAUTIs.
An indwelling catheter is a flexible plastic tube that's inserted into the urethra, providing continuous drainage from the bladder into a collection bag. A balloon is inflated to keep the catheter in place. For 95% of patients, indwelling catheters will have bacterial colonization at 4 weeks. CAUTIs may be caused by prolonged use of indwelling catheters, contamination of catheters upon insertion, backflow of urine from the catheter bag into the bladder, or the presence of bacteria from feces on the catheter.
Appropriate indications for indwelling catheter insertion include patients with:
- acute urinary retention or bladder outlet obstruction
- a need for accurate measurements of urinary output
- incontinence and open sacral or perineal wounds
- prolonged immobilization
- prolonged surgery or a urologic surgery
- a need for large volume infusions or diuretics during surgery
- a need for improved comfort during end-of-life care.
Proper hand hygiene practice and sterile technique during catheter insertion are the two most crucial components for reducing CAUTIs. Follow these steps before inserting an indwelling catheter:
- Verify the physician's order for catheter insertion and assess your patient for a latex allergy.
- Explain the procedure to your patient. Consider your patient's age, his or her educational level, and cultural and religious background. Remember to provide privacy.
- Perform proper hand hygiene.
- Assist your patient into the supine position, which is the easiest position to gain access for catheter insertion. For males, place the patient in the supine position with knees extended. For females, place the patient in the supine position with knees flexed and separated.
- Apply nonsterile gloves; inspect the perineal area for drainage, redness, odor, and abnormal anatomy; and clean the perineal area with soap and water.
- Remove gloves and perform proper hand hygiene.
- Gather supplies according to your hospital's policy, such as sterile gloves, catheterization kit, cleaning solution, lubricant, urine collection bag, catheter, and prefilled syringe for balloon inflation as per catheter size. Check for the size and type of catheter and use the smallest appropriate size to reduce the risk of urethral trauma.
Next, set up a sterile field, open the catheter kit, and take the following steps:
- Drape the patient with the sterile drape.
- Place the absorbent pad under the patient.
- Open the iodine solution and pour it over the cotton balls/swab sticks.
- Open the lubricant jelly and squirt it onto the tray.
- Open the catheter, taking care not to contaminate it.
- Lubricate the distal portion of the catheter.
- Attached the prefilled syringe to the Y pigtail port.
- Don't inflate the balloon.
Lastly, clean the urinary opening. For males, if the patient is uncircumcised, retract the foreskin before cleaning. Hold the penis with your nondominant hand, which shouldn't touch any of the sterile items. With your dominant hand, clean the area with the iodine-soaked cotton ball/swab stick, starting at the opening of the meatus and working outward in a circular motion. Use one cotton ball/swab stick for each circle. For females, separate the labia with your nondominant hand. With your dominant hand, use the iodine-soaked cotton ball/swab stick to clean with a downward stroke. Clean the right labia minora and discard the cotton ball/swab stick; repeat for the left labia minora. With the last cotton ball/swab stick, clean the middle area between the labia minora.
The prevention of cross-contamination must be taken into consideration in patients who are incontinent, who've had genitourinary surgery, or who may have decubitus ulcers or wounds near the catheter site by maintaining the sterile field during catheter insertion. To prevent infection, practice proper hand hygiene and wear clean gloves when performing catheter and perineal care. Clean the perineal area with a facility-approved cleansing agent or disposable wipes daily and after every bowel movement. Remember to use a clean cloth or wipe for each motion, cleaning from the front (urethra) to the back (anal) when performing perineal care. This cleaning method prevents bacteria from the anal area entering inside the urethra. Wipe around and down the catheter tubing daily and after each incontinence episode.
After cleaning the urinary opening, pick up the catheter with your dominant sterile-gloved hand and ensure that the catheter is only touching the sterile field. For females, insert the catheter approximately 2 to 3 inches into the urethral opening. For males, lift the penis into an upright position and insert the catheter approximately to the bifurcation from the tip of the catheter (see Picturing indwelling catheter placement). Stop advancement if resistance is met and notify the physician.
Next, insert the catheter until urine is returned. Inflate the balloon slowly using the prefilled syringe. Pull gently on the catheter until resistance is felt. Connect the urine collection bag to the catheter, secure the catheter tubing without tension to the patient's upper- to mid-thigh area, hang the collection bag below the bladder level and not touching the ground, ensure the patient's privacy, dispose of all material per your hospital's protocol, and remove your gloves.
After insertion, perform proper hand hygiene and document the catheter insertion procedure, the patient's tolerance to the procedure, urine output, and outcomes according to your hospital's protocol.
Prompt catheter removal is another important component in the prevention of CAUTIs. Education about the appropriate indications for catheters, developing a program for regular catheter assessment and removal, and establishing a catheter placement restriction protocol are some strategies that can facilitate prompt catheter removal. It's important to consider that a patient's risk of infection increases with each additional catheter day, therefore, awareness of catheter use in patients is an important nursing consideration.
Help prevent unnecessary catheter use by identifying inappropriate uses, such as:
- as a substitute for nursing care of a patient with incontinence
- to obtain urine for culture and other diagnostic tests in patients who can void
- for an extended post-op duration without appropriate indications for catheter use.
Advocating for improvement
As nurses, we're instrumental in advocating for quality improvement initiatives that can promote appropriate indications for the use of indwelling catheters and facilitate the reduction of CAUTIs in our hospitals. Nurses can conduct research to develop protocols for prompt catheter removal, such as alerts to assess the need for continued indwelling catheter use and stop orders to remove the catheter by default at a certain time or when clinical conditions are met such as the 24- or 48-hour post-op period ending.
Improvement initiatives shared by the CDC are focused on providing continuing education on the appropriate use of catheters, including the use of proper hand hygiene and catheter insertion techniques, establishing protocols for nurse-directed removal of unnecessary catheters, developing automatic stop orders, creating a system of alerts and reminders to assist in identifying all patients with indwelling catheters, and conducting daily multidisciplinary rounds to facilitate open communication between the healthcare team to establish ongoing optimal care for patients with indwelling catheters.
Appropriate indications, proper hand hygiene and sterile technique, proper maintenance, and prompt removal are crucial strategies for CAUTI prevention in patients with indwelling urinary catheters. In addition, education is instrumental to the establishment of successful quality of care initiatives. Hospitals can identify nurse champions to be change agents and lead the team to assess, implement, and evaluate strategies to prevent CAUTIs. A physician champion can also play a paramount role in CAUTI prevention by collaborating with the nurse champion and increasing buy-in from other physicians.
CAUTI signs and symptoms
- Fever and chills
- Urgency and frequency of urination
- Painful urination
- Cloudy urine or blood in the urine
- Pain in the lower back or stomach
- Purulent discharge at the catheter site
- Changes in mental status in older patients