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Catheter-Associated Urinary Tract Infections: A Nurse-Sensitive Indicator in an Inpatient Rehabilitation Program (CE)
Urinary tract infections account for 40% of all hospital-acquired infections; 80% of those infections are associated with indwelling urethral catheters. To meet the requirement for medical necessity, patients are being admitted to rehabilitation programs earlier in their hospital stays than in the past. As a result, there has been an increase in the use of urinary catheters, which prompted an evaluation of infection rates. A collaborative project between nursing and infection control was designed to collect baseline data on catheter-associated urinary tract infections (CAUTI) in a nonintensive care unit inpatient setting. Two inpatient rehabilitation units within our health system participated. The purpose of this article is to share the process used to determine a baseline CAUTI rate, the interventions implemented to reduce use of catheters, and the outcomes associated with this project. The results demonstrate an overall reduction in the use of catheters, as well as a reduction in CAUTI.
A staff nurse in our inpatient rehabilitation unit noticed the high incidence of urinary tract infections in our facility. Although projects to decrease the number of nosocomial urinary tract infections are not new, specific examples within the rehabilitation setting that report outcomes are not numerous in the literature. There are, however, some examples in academic settings (Doyle et al., 2001). The purpose of this project was to collect baseline data on catheter-associated urinary tract infections (CAUTI) in a hospital-based inpatient rehabilitation program and to benchmark the CAUTI rate against other inpatient rehabilitation programs in the National Healthcare Safety Network (NHSN), a division of the Centers for Disease Control and Prevention (CDC). Our facility has been a member of the CDC’s NNIS/NHSN (Formerly NNIS [National Nosocomial Infections Surveillance System], now NHSN [National Healthcare Safety Network]) program since 1999. Since that time, targeted device-associated-infection surveillance data have been collected routinely for the intensive care unit patient population but only intermittently for inpatient rehabilitation. Results of the data collection revealed several opportunities for improvement around the care of patients with indwelling urinary catheters.
CAUTIs that occur while a patient is hospitalized are considered “healthcare-acquired” or “nosocomial” infections. Healthcare-associated infections are the 11th-leading cause of death in the United States and cost more than $4.5 billion per year. CAUTI, surgical wound infections, lower respiratory wound infections, and blood stream infections are all examples of healthcare-associated infections. Urinary tract infections account for 40% of all hospital-acquired infections; 80% of these infections are associated with indwelling urethra catheters (Newman, 2007). Indwelling catheters irritate the urethra, which impairs the body’s natural defense mechanisms against bacteria. The most common pathogen associated with CAUTI is Escherichia coli (E. coli), which accounts for 80% of infections (Kalsi, Arya, Wilson, & Mundy, 2003).
All staff involved in the care of patients with indwelling catheters should be aware of the potential consequences of CAUTI. These consequences include pain and discomfort, physical damage to the urethra, pyelonephritis, kidney failure, spread of infection to surgical sites or bloodstream (bacteremia), increased use of antibiotics, increased hospital length of stay, and even patient death. Societal consequences include increased costs. It is estimated that CAUTI may increase length of stay by 1–3 days and add approximately $675 to overall patient costs. This amount increases an additional $3,800 if bacteremia occurs (Newman, 2007). The Centers for Medicare and Medicaid Services (CMS) has noted these numbers and described them as serious preventable events. Beginning in 2008, CMS stopped reimbursing for the care required for these preventable events (CMS, n.a.).
Appropriate use for indwelling catheters revolves around the needs of the patient, and should not be associated with making the caregiver’s job easier or because the patient wants one. The literature identifies some generally accepted uses for indwelling catheters. Uses include retention, obstruction, the presence of stage III or IV pressure ulcers, or the presence of irreversible medical conditions (Newman, 2007; Wong, 1981). CAUTI can be classified in two categories: symptomatic and asymptomatic (Table 1; Table 2).
Preparation for the project involved developing a paper data-collection tool (denominator data=collection sheet) and a computer-generated report of laboratory results and patient temperatures from electronic patient records. Two inpatient rehabilitation units were used for the initial data collection. The first unit (A) had 45 beds and the second unit (B) had 8 beds. Data collection was facilitated by the collaborative efforts of the health unit coordinators and the day-shift resource nurses. Each morning, the health unit coordinators generated the denominator data collection sheets by placing patient identification stickers on forms for each patient on the unit. The health unit coordinators gave the forms to the day-shift resource nurses, who talked with each nurse to identify patients with indwelling catheters. This information was then faxed to the infection control department. Concurrently, information services generated daily urinalysis reports containing the results of any urinalyses that were performed for patients on the unit. These reports contained data on bacteria present, urinalysis bacteria time, organisms found, nitrite, leukocyte esterase, white blood cells, and the most recent patient temperature recorded in the electronic record. Staff within the infection control department correlated the patients with indwelling urinary catheters to the urinalysis reports. Per NHSN criteria, CAUTI data analysis was done by the infection control department. The initial data collection occurred on the 45-bed unit for 4 months (January–April 2007) and on the 8-bed unit for 6 months (January–May 2007 ) to determine baseline CAUTI rates. This was followed by a 3-month period of education and product evaluation and another surveillance period from August–September 2007. Currently, surveillance is done once per quarter.
Baseline data for Unit A were compiled for January–April 2007. There were 634 device days/3,786 patient days, with an average utilization rate of 0.17. A total of 35 patients developed CAUTI during this time period. They included 21 females and 14 males, with an average age of 71 years. Nine pathogens were identified: E. coli (n = 13), Enterococcus sp (n = 6), coagulase-negative staphylococcus (n = 6), Klebsiella (n = 4), methicillin-resistant Staphylococcus aureus (n = 2), Enterobacter (n = 1), hafnia (n = 1), Enterococcus sp/S. epidermisis (n = 1), and Pseudomonas (n = 1). Of these infections, 17 were symptomatic and 18 were asymptomatic.
Ongoing surveillance data for Unit A were collected through April 2008. No CAUTI were reported in August and September 2007. In January 2008, there were 169 device days/1,208 patient days, with an average utilization rate of 0.14 (Figure 1). Six patients developed CAUTI; all were asymptomatic. In April 2008, there were 137 device days/1,028 patient days, with an average utilization rate of 0.13. Two patients developed CAUTI; both were asymptomatic (Figure 2).
Baseline data for Unit B were compiled for January–May 2007. There were 92 catheter days/647 patient days, with an average device utilization rate of 0.14. Three patients developed CAUTI. All three patients were female with an average age of 81 years. Three pathogens were identified: E. coli (n = 1), Proteus (n = 1), and Pseudomonas (n = 1). Of these infections, one was symptomatic and two were asymptomatic. Ongoing surveillance for Unit B occurred August–December 2007. There were 71 device days/393 patient days, with an average utilization rate of 0.15. A total of three patients developed CAUTI during this time period; two were symptomatic and one was asymptomatic. No additional data were collected in 2008 because the unit converted to an inpatient orthopaedic unit.
How It Was Done
Our positive outcomes can be attributed to the nurses’ ownership of their practice, education, and product evaluations. Ownership of nursing practices directly relates to the care nurses provide to patients, both individually and collectively. Nurses are responsible for directing and caring for their assigned patients, and sometimes patients’ needs can be overwhelming and prioritization must occur. Removing indwelling urinary catheters was a task relegated to the bottom of the priority list or was delegated to the next nurse. Unfortunately, the next nurse was often just as busy and would pass on the task yet again. Soon the catheter was forgotten altogether. It was relatively simple to bring the catheters back to the nurse’s individual attention by asking, “Why does this patient still have a catheter?” Anecdotal responses to this question included “I’m not sure why they still have the catheter,” “They are incontinent,” or “He’s not moving very well.” Connecting this lack of catheter-awareness with the brightly colored graphs highlighting the number of catheter-associated infections helped made nurses aware of how the lack of ownership for removing the catheters when they were no longer appropriate was contributing to high infection rates. This acknowledgment of partial responsibility for the infections helped reduce both the number of catheters used and the number of infections. Nurses began making catheter removal a priority. If a nurse could not accomplish the removal of the catheter, it was clearly communicated to the next nurse to follow up.
Education was the second component of our success. Two online learning modules were developed that highlighted evidence-based practice. Mercer Smith’s (2003) article about moving from habit-based care to evidence-based practice provided some guidance in the content development for our online learning modules. Content from the Society of Urologic Nurses and Associates Clinical Guidelines Task Force (2006) also influenced the educational content developed. The first module was directed at unlicensed personnel who care for patients with indwelling catheters. This module focused on the basics: what are hospital-acquired conditions, what happens when CAUTI occurs, what to report to the nurse, and the ABCs of care (always check the entire system; bag below the bladder; use clean technique when handling the catheter; secure the catheter). The second module was directed at caregivers who insert and monitor indwelling catheters. This module contained all the information in the first module and required reviewing a video on inserting a catheter and a demonstration of that skill. The requirement to demonstrate the skill is supported in literature by Leithauser (2005), who identified that 10%–20% of CAUTIs are caused by the introduction of microorganisms during the insertion of the catheter. All 86 nursing staff members (nurses and nursing assistants) completed the modules. In addition, the entire inpatient rehabilitation staff (licensed and unlicensed) and the hospital-patient transport staff completed the first online module. The learning modules have been added to the new-hire orientation requirements for all nursing staff.
The final contributing factor to our success focused on product evaluation. At the time the project began, we had only one option for securing catheters to reduce urethral trauma—a leg strap. Barriers to using the strap included the strap moving too easily on the leg and physicians who felt the straps could potentially be constricting. It was important to find a suitable alternative. We considered several products that adhered to the leg but did not impede circulation. We piloted our final choice and ultimately chose to implement the product (Darouiche et al., 2006). Staff communicated concerns about the adhesive product, and these concerns were shared with the manufacturer. It was rewarding for those involved in the pilot when the manufacturer made the suggested changes to improve the product. However, the leg strap is still available for use if appropriate.
In any project there is a period of reflection to evaluate what was done well and what could have been done better. One of the major contributing factors to the success of this project was the involvement of other disciplines. When there is a problem, it is not uncommon for nurses to be responsible to fix it. This project highlighted that the entire staff is a program, not individual disciplines working in silos. We all (nursing, physicians, therapy, transport) needed to look at how we contributed to the problem and how we could change and improve to be successful. In addition, it was essential to have the support of the infection control department. The staff in the infection control department made sure that data were collected according to standards to allow for benchmarking with others across the country. However, sustained success required work. We were able to achieve a 2-month period without any CAUTI; then our infection rate went up again. I believe we became too comfortable in our success and assumed everything was going smoothly. After celebrating our success, we reduced the frequency in which we asked “Why does this patient still have a catheter,” and decreased use of the CAUTI bundle tool. The absence of these two components allowed catheters to fall out of the spotlight, leading to an increase in infections. I would also recommend a concurrent evaluation of the policies associated with urinary catheterization. Although this was eventually done, it may have been beneficial to evaluate this earlier in the project. Finally, I suggest securing buy-in from physiatrists early in the project and keeping them informed of outcomes. Physiatrists have many things competing for their attention, and the presence of a urinary catheter may not be their main focus.
The purpose of this project was to collect baseline data on CAUTI in our hospital-based inpatient rehabilitation program and benchmark our CAUTI rate with other inpatient rehabilitation programs. The ability to benchmark has been hindered by the limited number of facilities submitting data to NHSN, but we successfully collected baseline data for our units. As a result of this project, we have been able to reduce CAUTI and sustain these reductions for more than a year. We have seen spikes intermittently in the number of CAUTI, but we attribute this to a period when we had an unusually high number of spinal-cord-injury patients with neurogenic bowel and bladder. There was also a period during which the CAUTI bundle tool was not routinely complete and the ABCs were not followed. We now routinely monitor compliance of the ABCs, and anticipate we will continue to reduce the number of CAUTI on our unit. The success of this project has been the impetus for revisions to our urinary catheterization policy and a system-wide effort to implement many of the strategies identified in this project. An additional benefit of this project has been meeting the management goals of acute care of the elderly to reduce the number of urinary catheters. Initial evaluation of outcomes has shown an overall reduction of CAUTI within our hospital system.
The author would like to acknowledge the staff members on the rehabilitation units who collected data; the staff on both inpatient rehabilitation units; Vera Lynn Pischke and Jan Freiheit in the infection control department; Mary Gavin in information services; the CAUTI bundle workgroup; Michael Maier in creative services; Marylou Schroeder for helping with product evaluation; Andy Cimbalnik, BARD sales representative; and Mary Hagle and Kathleen Bobay in nursing research.
About the Author
Lisa Salamon, MSN GCNS-BC WOCN, is a clinical nurse specialist at Aurora St. Luke’s Medical Center in Milwaukee, WI. Address correspondence to her at firstname.lastname@example.org.
Darouiche, R. O., Goetz, L., Kaldis, T., Cerra-Stewart, C., AlSharif, A., & Priebe, M. (2006). Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: A prospective, randomized, multicenter clinical trial. American Journal of Infection Control, 34, 555–560.
Doyle, B., Mawji, Z., Horgan, M., Stillman, P., Rinehart, A., Bailey, J., et al. (2001). Decreasing nosocomial urinary tract infection in a large academic community hospital. Lippincott’s Case Management: Managing the process of patient care, 6(3), 127–136.
Centers for Disease Control and Prevention. (2009). Cather-associated urinary tract infection (CAUTI) event. Retrieved September 2, 2009, from www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf.
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Society of Urologic Nurses and Associates Clinical Practice Guidelines Task Force. (2006). Care of the patient with an indwelling catheter. Urologic Nursing, 26(1), 80–81.
Wong, E. S. (1981). Guideline for prevention of catheter-associated urinary tract infections [Electronic version]. Retrieved July 31, 2009, from www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html. Washington, DC: Centers for Disease Control and Prevention.