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Prevention of Catheter Associated Urinary Tract Infections

Prevention of Catheter Associated Urinary Tract Infections. Connie Garrett MSN, RN, CNOR & James A. Haley Veteran Hospital Operating Room Staff. Introduction. 600,000 patients develop hospital acquired urinary tract infections (UTIs) every year .

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Prevention of Catheter Associated Urinary Tract Infections

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  1. Prevention of Catheter Associated Urinary Tract Infections Connie Garrett MSN, RN, CNOR & James A. Haley Veteran Hospital Operating Room Staff

  2. Introduction • 600,000 patients develop hospital acquired urinary tract infections (UTIs) every year. • 80% of these infections are from a urinary catheter. • About half of the patients with a urinary catheter do not have a valid indication for placement. • Each day the urinary catheter remains in place the risk of urinary infection (CAUTI) increases 5% per day.

  3. Intro • Most common hospital-acquired infection: 40% of all HAIs • 1 million cases annually (hospitals & nursing homes) • 12-25% of all hospitalized patients receive a urinary catheter • Half of these found to not have valid indication

  4. Introduction • Increased length of stay 0.5 – 1 day • Estimated cost per case of CA-UTI ranges from $500-$3,000 • Cost to health care system up to $450 million annually according to CMS • CA-UTI not documented as present on admission can no longer code patient to higher reimbursement DRG for Medicare

  5. Background • Urinary catheters in the operating room have historically been a problem during assembly of the three part system. • Assembly during urinary catheter insertion is an unacceptable practice that results in catheter contamination and urine spills on the operating room bed. • Staff nurses in the operating room need a voice to make a standard of care change for current urinary foley catheters.

  6. Problem Statement • Current urinary foley catheter for hospital is not aligned with standard of care • Continuous “closed”urinary catheters are available which can prevent break in sterile technique during insertion and cross contamination of body fluids.

  7. Goals/Outcomes • Research one part continuous “closed”urinary foley catheter • Consider silver alloy gel coated catheter (community standard). • Research available catheter securing devices • Perform cost analysis • Implement “closed” system urinary foley catheter

  8. Plan • Collaborate with peers in community hospitals and assess current practice and standard of care for urinary foley catheter • Perform a literature review • Contact local vendor that supplies continuous “closed” catheter and 3-way temperature sensing foley catheter for cardiac surgery • Contact local vendor to discuss cost analysis of standard urinary catheter used in local community hospitals

  9. Plan • Collaborate with infection control practitioner to communicate concern of current urinary foley catheter system • Meet with chief of general surgery to present current community standard of care, current evidence, and cost analysis comparing current and future foley catheter system.

  10. Plan • Chief of general surgery performs independent literature review of evidence presented by OR and references provided from literature • Objective evidence is presented to Chief of Surgery • Evidence is presented to Infection Control Committee with request to pilot one piece continuous silver alloy urinary catheter • Chief of surgery requests quality management to perform OR cost analysis conversion for urinary foley system.

  11. Do • Use community standard and evidence supporting silver alloy catheter to perform pilot project in OR • Collaborate with vendor to stock necessary foley catheters including temperature sensing foley catheter for cardiac procedures and latex free catheters

  12. Do • Communicate pilot project with OR nurses • Educate OR staff on collection/data tool for urinary foley pilot • Provide prevention pack education to OR staff • Distribute education brochure for CAUTI prevention • Prompt surgeon for order to remove urinary catheter prior to transfer of patient from OR

  13. Do • Ensure education includes securing device is implemented for urinary catheter patients • Educate documentation must specify which foley catheter is inserted during pilot and “closed” system maintained • Educate documentation must include foley catheter securing device was used/not used and explanation when not used

  14. Study • Collect foley insertion and evaluation tool daily for 3 months on unit • Review evaluation tool daily and submit copy to infection control practitioner • OR nurses will peer review foley insertion by medical staff and document accordingly in the electronic health record • Infection control practitioner includes ICU in urinary foley pilot

  15. Act • Select evidence based model for change • Form interdisciplinary team and involve OR direct care nurses • Pilot one piece continuous catheter • Collect data tool • Review data tool and evaluations

  16. IOWA Model • Identification of problem • Topic is a priority for organization • Form team • MDs, RNs, • Unit educator/CNL-Project champion • Infection control practitioner-Process owner • Literature review and community standard critiqued for use in practice • Sufficient research base

  17. Pilot Change in Practice • Select Outcomes to be Achieved • Collect Baseline Data • Design Evidence-Based Practice (EBP) Guideline(s) • Implement EBP on Pilot Units • Evaluate Process & Outcomes • Modify the Practice Guideline

  18. Institute Change in Practice • Monitor and analyze structure, process, and outcome data • Environment • Staff • Cost • Patient and Family

  19. Disseminate Results • Insertion prep kit includes all necessary components pre-assembled • Securing device included in kit • Elimination of cross contamination during insertion • Elimination of urine spills on OR bed • Elimination of potential splash to health care provider

  20. Disseminate Results • Pilot initiated January 2008 with data collection for 6 months on unit • Data collected and analyzed for UTI rates in acute care July 2009 • UTI rates decreased from 3.0% to 1.7% after implementation of silver alloy catheter for Qtr 1, 2009 • Urinary catheter secured prior to transferring to receiving unit

  21. Foley UTI Results

  22. Literature Review Results • Support for one piece continuous enclosed system • Silver coating evidenced to reduce biofilm around catheter tip up to 7 days

  23. Favorable Data • AM J Infect Control 2002;30:221-5 • U Mass Med Center evaluated 5 months using silver-impregnated foley on all patients and compared to data from previous year using non-silver foleys. Rate of CAUTIs for noncoated catheters was 4.9/1000 patient-days compared to 2.7/1000 patient-days with silver-hydrogel catheters. A reduction of 45% (P=.1). The estimated cost savings rained from $12,563.52-$142,314.72.

  24. Favorable Data • American Journal of Medicine 105(3):236-41,1998 Sep. • Meta-analysis U of Washington. 8 trials with 2,355 patients. OR UTI was 0.59 (95% CI, 0.42-0.84) indicating a significant benefit to silver-coated catheters. Silver alloy catheters (OR=0.24; 95% CI, 0.11-0.52) were significantly more protective against bacteriuria than silver oxide catheters (OR=0.79;955 CI, 0.56-1.10).

  25. Favorable Data • Arch Intern Med.2000;160:2670-2675 • U Michigan cohort of 1000 patients (medical,surgical,ICU,etc.) with silver or standard foley. Silver-coated catheters led to 47% relative decrease in incidence of symptomatic UTI from 30-16 cases/1000 patients compared with standard catheters. Silver-coated catheters provided clinical benefits over standard catheters in all cases and cost savings in 84% of cases.

  26. Opposing Data • Infection Control & Hospital Epidemiology, 27(1):38-43,2006 Jan. • Johns Hopkins & Wake Forest prospective study of 3,036 patients with catheters, 1.165 (38%) of silver impregnated, and 1,871 (62%) not impregnated. The rate of UTIs/1000 foley days was 14.29 in silver catheter group, compared with 16.15 nonsilver catheter group (IR ratio, 0.88; 95% CI, 0.70-1.11; P=.29. In a multivariate survival analysis silver catheters were not statistically protective against UTI. • **Note- Study groups not identical-more men, and shorter duration of catheterization, & fewer urine cultures/1,000 catheter-days in the silver catheter group.

  27. Unit Pilot of Bard Prevention Pack • Bard foley catheter system evaluated and chosen for standard of care change • Silver alloy coated foley catheter selected for pilot • All in one prep kit consisting of a #16 Fr. foley catheter, bacteriostatic drainage bag, and stat-lock securing device • Use as small a catheter as possible that is consistent with proper drainage, to minimize urethral trauma. Therefore, #14 Fr. Foley catheter recommended in place of #16 during evaluation of size comparison

  28. Pearls of Wisdom for OR • Documentation received from Bard to exclude practice of balloon inflation prior to insertion • Maintain a sterile, continuously “closed” drainage system. • Keep catheter properly secured to prevent movement and urethral traction. • Keep collection bag below the level of the bladder at all times. • Maintain unobstructed urine flow.

  29. CAUTI Update • CAUTI prevention is now a VHA initiative • CDC updated guidelines 2009 are available • APIC -CAUTI guidelines updated • Evidence based guidelines in production by process owner

  30. EBP References • APIC CA-UTI Elimination Guide www.apic.org/CAUTIGuide • SHEA-IDSA Compendium http://www.shea-online.org/about/compendium.cfm • CDC Guideline http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html# N.b. An update to CDC guidelines is expected in early 2009. ***Note- Pilot research and project performed in 2008

  31. References • AM J Infect Control 2002;30:221-5 • American Journal of Medicine 105(3):236-41,1998 Sep. • Arch Intern Med.2000;160:2670-2675 • Infection Control & Hospital Epidemiology, 27(1):38-43,2006 Jan.

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