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CUSP-Stop CAUTI-Learning Session #2

CUSP-Stop CAUTI-Learning Session #2. The ICU Environment and Urinary Drainage Devices. Tina Adams, RN, Clinical Content Development Lead August 22, 2012. Objectives:. Discuss incidence of urinary drainage device use and CAUTI in ICUs

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CUSP-Stop CAUTI-Learning Session #2

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  1. CUSP-Stop CAUTI-Learning Session #2 The ICU Environment and Urinary Drainage Devices Tina Adams, RN, Clinical Content Development Lead August 22, 2012

  2. Objectives: • Discuss incidence of urinary drainage device use and CAUTI in ICUs • State the HIPAC/CDC indications for urinary drainage device use • List 3 insertion best practices • List 3 maintenance best practices • Describe systems to increase the earlier removal of urinary catheters (UC) in ICU

  3. 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 C Urgency Frequency Dysuria, pyuria (> 10 WBC unspun), +LE or Nitrate Suprapubic tenderness Costovertebral angle pain or tenderness

  4. Rate of CAUTI in ICUs:

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

  6. 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)=0.5 50% of ICU’s patient days are days in which patients are at risk of CAUTI!

  7. Rate of UC use in ICU:

  8. 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

  9. 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

  10. 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

  11. Complications related to UC: • Infection: • Urinary tract infection (bladder) • Acute pyelonephritis (kidney) • Secondary bacteremia/sepsis(blood) • Late onset: osteomyelitis (bone) and meningitis (brain)

  12. Complications related to UC con’t: • Adverse outcomes: • Increased mortality • Obstructions form to urine flow • Selection for multi-drug resistant organisms • Prostatitis and orchitis

  13. 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

  14. Movement of organisms into urinary tract: • Extraluminal-Outside of catheter • Intraluminal-Inside the catheter

  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: *Main modifiable risk factors

  22. Lifecycle of the urinary catheter: Meddings J , Saint S Clin Infect Dis. 2011;52:1291-1293

  23. CDC’s INDICATIONS FOR UC: • Urinary retention/bladder obstruction • Accurate measurement of urine output in critically ill patients (usually in an ICU) • To assist with healing open sacral/ perineal wounds in the incontinent CDC: http://cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf

  24. 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: • Prevent indwelling catheter use when another urinary care system would work! • Optimize aseptic insertion technique • Optimize aseptic maintenance care • 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 awake Condom 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: • Competency of inserter assessed? • Assess patient’s anatomy! Look first, with adequate assistance! Wash perineum with soap and water before procedure, chose smallest catheter • 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: • Meet indication today? • If not, obtain catheter removal order • Remove catheter • 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

  33. Asepsis during maintenance care: • Hand hygiene, standard precautions to clean the perineum dailywith soap and water during bath, contamination from feces/drainage, & emptying bag • Clean the catheter daily wiping crusting away from the urinary meatus and 4 inches down the catheter • Maintain clean securementof catheter to prevent movement and traction. • Tape vs. Stat-Loc®

  34. 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

  35. 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

  36. Objective #1: • Can you review your unit’s data to discuss the • incidence of urinary drainage device use and CAUTI • in your ICU?

  37. Objective #2: Can you state the HIPAC/CDC indications for urinary drainage device use?

  38. Objective #3: What 3 insertion best practices are you going to validate (by observation) consistently take place in your ICU?

  39. Objective #4: What 3 maintenance best practices are you going to validate (by observation) consistently take place in your ICU?

  40. Objective #5: Describe one system you can institute to increase the earlier removal of urinary catheters (UC) in your ICU?

  41. Questions or Comments? • Thank you for your participation in today’s discussion!

  42. Contact Information: Tina Adams, RN American Hospital Association Health Research & Education Trust tadams2@aha.org

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