Decreasing Catheter Associated Urinary Tract Infections
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Urinary Tract Infections are one of the most common hospital-acquired infection and many are associated with an indwelling catheter. For each day a catheter is in place the risk of developing a CAUTI increases 3%-7% (Kahnen, Flanders, & Magalong, 2011 ). Although indwelling urinary catheters are widely used in hospitalized patients and can provide an appropriate means of therapeutic management, they are often used without clear indications putting the patient at a risk for complications during their hospitalization. Complications related to a urinary catheter include physical and psychological discomfort to the patient, bladder calculi, renal inflammation and most frequently CAUTI (Bernard, Hunter, & Moore, 2012, 32(1)). Not only does the urinary catheter cause complications to the patient and put them at a higher risk for morbidity and mortality they also increase the hospital costs. Therefore CAUTIs are considered by the Medicare and Medicaid Services to represent a reasonably preventable complication of hospitalization and as such will not provide any additional payment to hospitals for CAUTI treatment (American Association of Critical Care Nurses, 2012).
A great amount of attention has been placed on improving quality of care and minimizing preventable harms that are occurring in the healthcare setting. With the passage of the Deficit Reduction Act of 2005 and the implementation of the Final Rule in October 2008 the CMS, Centers for Medicare and Medicaid Services, will no longer pay hospitals for the additional cost of care resulting from hospital-acquired conditions such as CAUTI (Palmer, Lee, & Wroe, 2013, 33(1)). Urinary tract infections can lead to bacteremia which can produce fever, chills, confusion, hypotension and leukocytosis, but more seriously can lead to the patient becoming septic (Palmer, Lee, & Wroe, 2013, 33(1)). More than 13,000 deaths occurred in 2002 associated with UTI and increased the costs of hospital visits by an additional $600 per CAUTI episode by increasing the length of the hospital stay, tests needed and antibiotics administered (Meddings, Reichert, & Rogers, 2012). Guidelines have been established and CAUTI prevention bundles have been implemented throughout hospitals to aid in the reduction of CAUTI. These bundles outline a group of evidence based interventions aimed at reducing overall usage of indwelling urinary catheters, encourage timely removal of catheters no longer clinically indicated, and delineates infection prevention strategies to follow when catheters are in place (Kahnen, Flanders, & Magalong, 2011 ).
Indications for use of an indwelling catheter for a short term period, meaning less than 30 days, include urinary retention, obstruction of the urinary tract, close monitoring of the urine output of critically ill patients, urinary incontinence that poses a great risk to the patient because of stage 3 or greater ulcer to the sacral area, and for comfort care of the terminally ill patient (Bernard, Hunter, & Moore, 2012, 32(1)). Even though there are guidelines to follow urinary catheters are often placed for inappropriate or poorly documented reasons with totals close to 50% not being needed (Bernard, Hunter, & Moore, 2012, 32(1)). The majority of unnecessary urinary catheters are placed in the emergency department without a doctor order or if there is an order there is no documentation of the need for the catheter. This lack of documented rationale has proved to be an ongoing problem. Other factors relating to catheters are that the assessment of the continued need for the catheter is often overlooked and the catheters remain intact without proper indications. Urinary catheters are often used for personal preference of the nursing staff and even with the best nursing care, each day a catheter is present the risk for infection goes up 3%-10% (Burnett, Erikson, & Hunt, 2010).
Evidence based strategies are used to decrease the use of indwelling urinary catheters. Some of these strategies are nurse driven and include the charge nurse or staff nurse assessing the need for the catheter after a period of time and discussing with the doctor the finding or following a standing order for the catheter. Data was collected on this process for a 6 month time frame and showed that the active intervention of daily consultation and review of the need for a catheter significantly reduced the number of indwelling urinary catheter days per month as well as the number of CAUTIs (Bernard, Hunter, & Moore, 2012, 32(1)). Another study according to Fakih et al. (2008) used quasi-experimental design that made use of nurse led multidisciplinary rounds. The nurses were given education guidelines on the indications for urinary catheters based on recommendations by the CDC, Centers for Disease Control and Prevention (Fakih, 2008). During the daily rounds of the nurse if there were no indications for the continued use of the catheter the nurse would contact the physician for an order to discontinue. This process drastically reduced the number of days the catheter was used and also the percentage of catheters in use (Fakih, 2008).
According to the American Association of Critical Care nurses the expected practice of a nurse to reduce CAUTIs is that prior to the placement of the catheter assess the patient for any accepted indications and alternatives, adhere to aseptic technique for placement and maintenance of the catheter, document all instances of the catheter including the insertion date, indication and removal date. Nurses should also promptly discontinue the urinary catheter as soon as the indications expire. In order to follow the best practice there should be written guidelines for the catheter including indications and that only patients meeting these requirements have urinary catheters placed (American Association of Critical Care Nurses, 2012). Have available in the department devices, supplies, and techniques that allow alternative routes (American Association of Critical Care Nurses, 2012). Several other actions are recommended such as reviewing on a daily basis the need for the catheter, develop systems to ensure prompt removal of the catheters, implement infection surveillance programs to measure the days and rates of CAUTI, and develop an action plan to address needed improvements (American Association of Critical Care Nurses, 2012).
Surveillance data suggests that 4.5 out of 100 hospitalized patients get hospital acquired infections with 32% of them having a urinary tract source associated with a catheter (Meddings, Reichert, & Rogers, 2012). One assessment made in the research was that hospitals with higher CAUTI rates may not have a higher incidence of CAUTI than another reporting hospital they may do a better job documenting the results of indwelling catheter use. By 2015, rates of hospital-acquired events will be used to report hospitals performances and compare them nationwide causing a reduction in the payments made by Medicaid.
American Association of Critical Care Nurses. (2012). Cathter-Associated Urinary Tract Infections. AACN Bold Voices, 13. Bernard, M., Hunter, K., & Moore, K. (2012, 32(1)). Review of strategies to decrease the duration of indwelling urethral catheters and reduce the incidence of catheter associated UTI. Urologic Nursing, 29-37. Burnett, K., Erikson, D., & Hunt, A. (2010). Strategies to prevent Urinary Tract Infection from Urinary Catheter Insertion in the Emergency Department . Journal of Emergency Medicine, 546-550. Fakih, M. D. (2008). Effects of nurse led multidisciplinary rounds on reducing the unnecessary use of urinary catherizations inhospitalized patients. Infection control and hospital epidemiology, 815-819. Kahnen, D., Flanders, S., & Magalong, T. (2011 ). CAUTI: Making them Matter. Academy of Medical Surgical Nurses, 4-7. Meddings, J., Reichert, H., & Rogers, M. (2012). Effects of nonpayment for hospital acquired CAUTI. American College of Physicians, 305-312. Palmer, J., Lee, G., & Wroe, P. (2013, 33(1)). Including Catheter-Associated Urinary Tract Infections in the 2008 CMS Payment Policy: A Qualitative Analysis. Urologic Nursing, 15-24.