CUSP-Stop CAUTI-Learning Session #2

Tina Adams, RN, Clinical Content Development Lead

August 22, 2012

The ICU Environment and Urinary Drainage Devices

1

Objectives:

1.Discuss incidence of urinary drainage device use and CAUTI in ICUs

2.State the HIPAC/CDC indications for urinary drainage device use

3.List 3 insertion best practices 4.List 3 maintenance best practices5.Describe systems to increase the earlier removal

of urinary catheters (UC) in ICU

2

CAUTI rate=outcome data

# of CA-SUTIs in a unit in a month x1000# of Catheter Days in a unit in a month

Signs and Symptoms of UTI:+ Urine culture with uro-pathogen Fever > 38 degrees CUrgencyFrequencyDysuria, pyuria (> 10 WBC unspun), +LE or NitrateSuprapubic tendernessCostovertebral angle pain or tenderness3

Rate of CAUTI in ICUs:

NHSN Report, Data Summary for 2010, Device-associated Module

ICU type: No. of location CA-UTI UC days Rate

Burn 23 115 24,324 4.7

MICU-teaching67 470 192,002 2.4

Medical-All other110 436 232,454 1.9

Neuro-ICU 12 84 27,681 3.0

Neuro-Surg ICU 45 446 110,797 4.0

SICU-teaching 59 471 157,384 3.0

SICU-All other 53 182 118,919 1.5

PICU-Medical/ Surgical78 127 57,420 2.2

Uro-pathogen microorganisms:

• Gram-negative bacilli• Staphylococcus spp.• yeasts• beta-hemolytic Streptococcus spp.• Enterococcus spp.• G. vaginalis,• Aerococcus urinae,• Corynebacterium (urease positive)

5

Device Utilization Ratio/DUR=process data

# of catheter days=catheter prevalence# of patient days

ICU’s catheter utilization ratio:

(50 catheter days ÷ 100 patient days)=0.550% of ICU’s patient days are days in which patients are at risk of CAUTI!

6

Rate of UC use in ICU:

NHSN Report, Data Summary for 2010, Device-associated Module

ICU type: No. of locations Mean UC utilization ratio:

Burn 23 0.51

MICU-teaching 67 0.73

Medical-All other 110 0.65

Neuro-ICU 12 0.82

Neuro-Surg ICU 45 0.74

SICU-teaching 59 0.76

SICU-All other 53 0.78

Peds-Med/ Surg. ICU 77 0.26

CAUTI Prevalence, Incidence

• Most common site of HAI, ~ 30-40%• Estimated >560,000 per year• 80% of HAI-UTI attributable to catheter• 15-20% patients in hospitals have urethral catheter• Most catheterized for 2-4 days, longer• Incidence of bacteriuria associated with indwelling

cath is 3-8% per day

CDC: http://cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf

8

What’s the problem?

• 15% of HAI of the bloodstream are attributable to UTI

• 13,000 attributable deaths per year• Increased length of stay by 2-4 days• Increased cost $0.4-0.5 billion annually in the US

CDC: http://cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf

9

CMS- payment rule changes:

• Hospital-Acquired Conditions (HAC)– HAI-CAUTI not reimbursed as of October 2008

• Present on Admission (POA):– Does your unit routinely order/obtain urine

cultures when UC’d patients admitted? – Do not obtain an admission urine culture UNLESS

the patient has signs and symptoms of UTI – Antibiotic stewardship

10

Complications related to UC:

• Infection:– Urinary tract infection (bladder)– Acute pyelonephritis (kidney)– Secondary bacteremia/sepsis(blood)– Late onset: osteomyelitis (bone) and meningitis

(brain)

11

Complications related to UC con’t:

• Adverse outcomes:– Increased mortality– Obstructions form to urine flow– Selection for multi-drug resistant organisms– Prostatitis and orchitis

12

Organisms that cause CAUTIs:

• Short-term urinary catheterization causing bacteriuria is usually from a single organism:– Bacteria: E. coli is most frequent

• GNR: Klebsiella spp, Serratia spp, Citrobacter spp, and Enterobacter spp, Pseudomonas aeruginosa, Proteus

• GPC: Enterococcus– Fungi: Candida is most frequent

13

Movement of organisms into urinary tract:

• Extraluminal-Outside of catheter• Intraluminal-Inside the catheter

14

15

Biofilm---what’s up with that?

• Free floating microorganisms attach themselves to a surface• Secrete extracellular polymers that provide a structural

matrix and facilitate adhesion• Biofilms protect the bacteria, they are often more resistant to

traditional antimicrobial treatment • A million cases of catheter-associated urinary tract infections

(CAUTI) reported each year, many of which can be attributed to biofilm-associated bacteria

Maki, D. and Tambyah, P. "Engineering Out the Risk for Infection with Urinary Catheters." Emerging Infectious Diseases 7.2 (2001)16

Normal flora of the Urethra:

• CoN Staph• Diphtheriods• Streptococci (various species)• Mycobacterium spp• Bacteroides and Fusobacterium spp• Peptostreptococcus spp

17

Normal Flora of the GI Tract:

• Small intestine:– Lactobacillus spp– Bacteroides spp– Clostridium spp– Mycobacterium spp– Enterococci– Enterobacteriaceae (e.g.,Klebsiella,

Enterobacter)

18

GI tract normal flora continued:

• Large Intestine:– E. coli– Klebsiella spp– Pseudomonas spp– Acinetobacter spp– Staph aureus

19

Normal Flora of the Skin:

• CoN Staph• Diphtheroids• Staph aureus• Streptococci (various species)• Bacillus spp• Malassezia furfur• Candida spp

20

Normal Flora of the Vagina:

• Lactobacillus spp• Peptostreptococcus spp• Diphtheroids• Streptococci (various)• Clostridium spp• Bacteriodes spp• Candida spp• Gardnerella vaginalis

21

Evidence-based Risk Factors:

Symptomatic UTI Bacteriuria

Prolonged catheterization* Disconnection of drainage system*

Female sex Lower professional training of inserter*

Impaired immunity Placement of catheter outside of OR

Older age Diabetes

Meatal colonization

Renal dysfunction

Orthopedic/neurology services

*Main modifiable risk factors 22

Lifecycle of the urinary catheter:

Meddings J , Saint S Clin Infect Dis. 2011;52:1291-129323

CDC’s INDICATIONS FOR UC:

1. Urinary retention/bladder obstruction2. Accurate measurement of urine output in

critically ill patients (usually in an ICU)3. To assist with healing open sacral/ perineal

wounds in the incontinent

CDC: http://cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf24

Indications continued:

4. Perioperative use-selected surgery:– Urological surgery (or on contiguous structures of

GU tract)– Patient anticipated to receive large volume

infusions or diuretics in OR– Need for intraoperative monitoring of urine

output (should be removed in PACU)– Prolonged duration of surgery

CDC: http://cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf

25

What can I do?

4 RULES to Prevent CAUTI:

1. Prevent indwelling catheter use when another urinary care system would work!

2. Optimize aseptic insertion technique3. Optimize aseptic maintenance care4. Remove the UC as soon as possible!

26

Alternative urinary care:

All Patients:

– Unconscious=Incontinence garment– Conscious=Scheduled toileting-Q 4 hours

The 3 B’s:•Bedpan•Bedside commode •Bathroom

27

Alternatives continued:

Male Patients:Urinal-Q 4 hours while awakeCondom catheter

• Size matters!-5 different sizes• Materials matter!-old latex, new silicone

28

Paradigm shift:

• Remember Rule #1! – Prevent urinary catheterization!

• All ICU patients do not require a UC because they are in ICU!

• All ICU patients admitted via OR/PACU do not automatically need a UC!

• All ICU patients admitted via ED do not automatically need a UC!

29

Admission to ICU:

• Report: ask about urinary needs– UC in place?– UC arrived with @ presentation to hospital?– UC placed in ED/OR-what indication?

• History: ask patient/family for indication and length of UC use?

• Assessment: consider removal to review for need

30

Asepsis during insertion:

1. Competency of inserter assessed?2. Assess patient’s anatomy! Look first, with

adequate assistance! Wash perineum with soap and water before procedure, chose smallest catheter

3. The Right Stuff? Use hand hygiene, sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion

31

Paradigm shift continued:

• Remember RULE #4:– Remove the catheters sooner!– All ICU patients that did have an indication for a

UC may not need it the entire ICU stay. Check daily!

– Goal: Remove as soon as possible and before transfer out of ICU!

– Information Tech – automatic notification to MD– Nurse-driven removal protocol?

32

Urinary Catheter Removal Protocol:

33

1. Meet indication today?2. If not, obtain catheter removal order3. Remove catheter4. Assessment for and encourage voiding

– Up and walking, using commode, privacy– If not spontaneously voiding-comfortable?– Bladder scan, if >400cc, contact MD for straight

catheterization order, continue intermittent x 24hr

34

Asepsis during maintenance care:

1. Hand hygiene, standard precautions to clean the perineum daily with soap and water during bath, contamination from feces/drainage, & emptying bag

2. Clean the catheter daily wiping crusting away from the urinary meatus and 4 inches down the catheter

3. Maintain clean securement of catheter to prevent movement and traction.– Tape vs. Stat-Loc®

35

Maintenance continued:

• Bag maintained below bladder:– never laid on the bed/stretcher (patient

transportation)– never on the floor (radiology, PT/OT)

• Bag emptying technique:– staff emptying many urinary drainage bags to

total I/O require hand hygiene and clean gloves before touching each patient’s urine bag

36

Not found to decreases CAUTI:

• Routine change of UC or bag• Washing the perineum with harsh antiseptics• Placing antiseptics into the collection bag• Routine bladder irrigations• Antiseptic or silver-impregnated catheter

37

Objective #1:

38

Can you review your unit’s data to discuss the

incidence of urinary drainage device use and CAUTI

in your ICU?

Objective #2:

Can you state the HIPAC/CDC indications for

urinary drainage device use?

39

Objective #3:

What 3 insertion best practices are you going to

validate (by observation) consistently take place in

your ICU?

40

Objective #4:

What 3 maintenance best practices are you going to

validate (by observation) consistently take place in

your ICU?

41

Objective #5:

Describe one system you can institute to increase the

earlier removal of urinary catheters (UC) in your ICU?

42

Questions or Comments?

• Thank you for your participation in today’s discussion!

43

Contact Information:

Tina Adams, RNAmerican Hospital AssociationHealth Research & Education Trusttadams2@aha.org

44