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Home > RNJ > 2011 > September/October > Urinary Tract Infections in Patients Admitted to Rehabilitation from Acute Care Settings: A Descriptive Research Study

Urinary Tract Infections in Patients Admitted to Rehabilitation from Acute Care Settings: A Descriptive Research Study
Diane Romito, BSN RN CRRN • JoAnn M. Beaudoin, BSN RN• Patricia Stein, BSN RN MAOL CNOR

The use of an indwelling urinary catheter comes with associated risks. At a hospital in southern California, nurses on the acute rehabilitation unit suspected their patients were arriving from acute care with undiagnosed urinary tract infections (UTIs). This descriptive research study quantified the incidence of UTI on admission to a rehabilitation unit and correlations with catheter use. During the study period, 132 patients were admitted to acute rehabilitation from an acute care setting, and 123 met criteria to participate in the study. Among participants, 12% had a UTI upon admission. Questionnaires examined nursing attitudes toward appropriate urinary catheter use and proactive catheter removal. The data revealed that nurses want to be involved in decisions about urinary catheter use and that medical/surgical and rehabilitation nurses agree strongly about advocating for patients with indwelling urinary catheters.

Catheter use often results in catheter-associated urinary tract infections (CAUTIs). Approximately 80% of hospital-acquired infections (HAIs) are associated with urinary catheters and result in increased morbidity, mortality, hospital cost, and length of stay (Kleinpell, Munro, & Giuliano, 2008; Voss, 2009). Topol and colleagues (2005) established a correlation between the length of time an indwelling catheter is in the bladder and increased risk for CAUTIs. This particularly is important in acute rehabilitation units, in which patients are at high risk for device-related and antibiotic-resistive infections because of the severity of their injuries and shortened acute hospital stays (Mylotte, Graham, Kahler, Young, & Goodnough, 2000).

Cochran (2007), who stated that 25% of hospitalized patients have indwelling catheters, estimated that 34%–50% of these catheters may not be necessary. In a Robert Wood Johnson Foundation (2007) summary, nurses’ preferences and judgments heavily influence the decision to catheterize and maintain indwelling catheters. Furthermore, a study by Saint, Meddings, Calfee, Kowalski, and Krein (2009) noted that physicians often were not knowledgeable about their patients’ catheter status and did not know why their catheters had been inserted.

Nurses play an active role in decreasing the occurrence and risk of CAUTI (Gray, 2004). Use of strict aseptic technique during catheter insertion, maintaining rigorous adherence to hand hygiene, maintaining good hygiene around the urinary meatus, and maintaining hydration are practices nurses can implement without a physician order. In addition, nursing protocols can allow for indwelling urinary catheter removal without a physician order. These protocols guide nurses and physicians toward evidence-based appropriate and inappropriate use of indwelling catheters.

A descriptive research study was undertaken to examine patients newly admitted to the acute rehabilitation unit at a moderately sized hospital in southern California. The researchers suspected that these patients had arrived on the unit with an undiagnosed UTI. Some of these UTIs had been caused by indwelling urinary catheters that had been left in place for an extended period. The researchers also wanted to examine nursing attitudes toward and knowledge about early indwelling catheter removal.

Purpose

This study posed the following questions:

  1. What is the prevalence of UTIs in patients who are admitted to a rehabilitation unit from an acute care setting?
  2. Is there a correlation with indwelling urinary catheter use and the incidence of UTIs?
  3. What are nursing staff values related to advocating for indwelling urinary catheter removal?

Literature Review

The following key words were used to perform a literature review: UTI, CAUTI, urinary infections, Foley catheter, infections, acute rehabilitation, catheter removal protocol, nursing protocols, nurses’ attitudes regarding urinary catheters, and nursing actions related to urinary catheters. Although this search yielded an enormous quantity of articles primarily focusing on infections associated with catheter use, no study could be identified in acute rehabilitation that tracked patients with UTIs admitted from acute care settings. Only one study related specifically to HAIs occurring at least 72 hours after admission to an acute rehabilitation unit. Mylotte and colleagues (2000) pointed to a lack of studies conducted in the acute rehabilitation setting.

The history of catheterization dates back to 300 B.C.E. It is believed that a tubal structure constructed of palm or onion leaves and lubricated with oil, butter, or animal fat was inserted into the urethra to drain the bladder (Booth & Clarkson, 2007). One could suspect that complications associated with these techniques were frequent and problematic. It wasn’t until 1932 that Frederick Foley developed an indwelling, self-retaining balloon catheter made of vulcanized latex that could withstand deterioration. Before this time, intermittent catheterization was performed with a variety of metal tubes, including those made of silver, when bladder drainage was needed (Robinson, 2009).

Although the invention of the indwelling catheter seemed advantageous at the time, it has not been wholly positive for those requiring it. Each day of catheter use is associated with a 5% increase in bacteriuria (Saint et al., 2009). Its duration in the bladder is the primary risk factor for development of a CAUTI (Lo et al., 2008). Increased risk for CAUTI is associated with prolonged catheter exposure, female gender, dehydration, and positioning of the drainage tube above the level of the bladder (Voss, 2009).

Adverse consequences of CAUTI include local and systemic morbidity, secondary blood stream infections, increased costs, prolonged length of hospital stay, and mortality (Kleinpell et al., 2008). Literature supports the position that patients may be unnecessarily catheterized. A review of 285 charts of patients age 65 and older who were catheterized within 24 hours of admission to one Midwestern community hospital demonstrated that only 46% of patients had an appropriate indication for catheterization; the reason for catheterization was documented in only 13% of charts, and no order for catheterization was documented in 33% of charts (Gokula, Hickner, & Smith, 2004).

In many healthcare settings a urinary catheter is viewed as being so routine that neither its care nor purpose is worthy of mention in the patient’s chart (Nazarko, 2008). Saint and colleagues (2009) reported on a 2005 study of 600 U.S. hospitals in which 56% reported having no system for monitoring the length of time catheters had been in place, and “top orders” or catheter removal reminders were used only 9% of the time.

The Healthcare Infection Control Practices Advisory Committee proposed appropriate indications for indwelling urinary catheter placement based on expert concensus (Gould et al., 2009). The Committee identifies appropriate indications as the following:

  • obstruction (distal to the bladder)
  • close monitoring of urine output to dictate treatment
  • preoperative requirement for the surgical procedure
  • urinary incontinence that posed a risk to the patient (e.g., major skin breakdown).

Inappropriate reasons were identified as

  • having a catheter for nurses’ convenience to perform patient care, particularly if bed linens and patient gowns require frequent changes
  • keeping the catheter in for monitoring urine output beyond its usefulness to patient outcome, or unclear or lack of indication for catheter placement
  • using a catheter when the patient is incontinent without significant skin breakdown.

The use of nursing protocols specific to affecting early and appropriate indwelling urinary catheter removal has a positive influence on decreasing unnecessary catheter duration. Conklin (2004) reported a 42% reduction in calculated device days and a 47% reduction in calculated infection rates when nurses were allowed to discontinue urinary catheters on patients meeting pre-established criteria. Saint and colleagues (2009) reported on the use of a multidisciplinary team approach to prevent hospital-acquired CAUTIs. This approach included guidelines for appropriate catheter placement coupled with a protocol that enabled nurses to remove unnecessary catheters without a physician order. The interventions studied resulted in a 17%–45% decrease in CAUTIs. Stowkowski (2009) corroborated positive results of protocols demonstrating a 73% reduction in CAUTI following implementation of a nurse-led approach for proactive catheter removal in hospitalized patients.

Nursing knowledge about UTI rates also affects CAUTI incidence. Goetz, Kedzuf, Wagener, and Muder (1999) studied the effect of informing nursing staff about their patients’ infection rates. This information was presented both verbally and visually using graphs. Results from this study showed a 40% reduction in CAUTI rates over an 18-month period.

The Deficit Reduction Act of 2005 identified specific preventable hospital-acquired complications with high cost, high volume, or both. CAUTIs fit this description. Consequently, the Centers for Medicare & Medicaid Services (CMS) changed its compensation practices for these and other hospital-acquired infections (Saint et al., 2009). The cost of each episode of CAUTI is at least $600. Each episode of urinary tract bacteremia is at least $2,800. There is a financial incentive and ethical obligation to prevent CAUTI.

Methodology

The primary aim of this study was to ascertain the prevalence of CAUTIs/UTIs in an acute rehabilitation unit after transfer from an acute care setting. Following institutional review board approval for the study, urine samples were procured from all patients admitted to the acute rehabilitation unit from an acute care setting. Informed consent was not necessary for this study. Obtaining a urinalysis (UA) on admission is routine practice on this unit and no invasive interventions were performed for urine collection. A clean-catch or catheter specimen was obtained using aseptic technique for an initial UA. The specimen was sent to the laboratory marked “URC” to indicate it was part of the study. Specimens were cultured if the urine met hospital laboratory criteria for reflex to culture. Reflex to culture was based upon presence of leukocyte esterase, positive nitrite, greater than or equal to moderate bacteria, greater than five white blood cells per high-powered field, or greater than or equal to moderate yeast. A retrospective check also was performed to verify that no patient billing charges had been incurred.

Romito Table 1As shown in Table 1, UTIs were defined according to the Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) criteria to determine which patients qualified for our study (Horan, Andrus, & Dudeck, 2008). As per hospital protocol, all positive urine cultures were reported to the physician by the primary nurse. The decision to treat was left up to the physician.

A secondary aim of the study was to examine nursing attitudes and knowledge toward the early removal of indwelling urinary catheters. A two-page questionnaire using a Likert-type scale was distributed to staff nurses on the rehabilitation and medical/surgical units after the first 3 months of CAUTI/UTI data collection. The nurses were asked to complete the survey within 14 days and place it in an envelope in the nurses’ break room. If the questionnaire was completed, consent was inferred. These surveys were anonymous and completion was not mandatory. The directions for completing the survey allowed participants to opt out.

Sample and Setting

This study was conducted on a 30-bed acute rehabilitation unit that is part of a 148-bed community hospital in southern California. Based upon average admissions to rehabilitation per month, the researchers anticipated 50 admission UAs per month and believed a 3-month collection period would yield a sufficient sample size.

Data were collected between September 2009 and November 2009. Results were reviewed for completeness and to ensure that all patients admitted had a UA collected upon admission. The laboratory end-of-month tally report of the patient sample was compared to the list of admitted patients. A retrospective review of lab results within the electronic chart for the patient sample also was completed.

The rehabilitation unit received 132 patient admissions from the acute care setting during the 90-day collection period. Of these admissions, complete data were available for 123 patients to incorporate into the study. Patient gender was noted when data were collected.

After the 90-day interval a chart review of all admitted patients (from the acute care setting) who met criteria for urine culture was performed to calculate the total number of UTIs and CAUTIs. Strict inclusion criteria dictated who qualified for the study (Table 1).

After the patient data collection portion of our study, the staff nurses survey portion began. Beginning in December 2009 staff nurses on the rehabilitation and medical/surgical units were given the opportunity to complete a questionnaire regarding their attitudes about the placement, use, and removal of indwelling urinary catheters. Before its administration, the questionnaire was tested for content validity using a sample of 18 nurses from another hospital in our system.

Implicit in the instructions for completion of the nursing questionnaire was the disclaimer that completing the survey indicated consent. The nonmanager nurse researcher encouraged staff to complete the questionnaire; this person was not in a position to influence participants’ performance evaluations. Nurses’ performance evaluation was unaffected if they chose not to participate.

Results

During the study period, 132 patients were admitted to rehabilitation from an acute care setting. Of this group, 60% (n = 80) were known to have had an indwelling urinary catheter during their acute hospitalization, a number much higher than the 25% noted in the general hospital population according to Cochran’s 2007 study. Only 123 of the 132 patients who were admitted were included in the study. The biggest difficulty was determining if an indwelling urinary catheter had been used during the acute hospital stay and, if so, the duration of its use. Among patients with complete documentation regarding the presence of an indwelling catheter, duration ranged from 1–40 days, with a median of 3 days. A preponderance of CAUTIs occurred on Day 3 of urinary catheter use.

Of the 123 patients reviewed, 12% (n = 15) were determined to have UTIs using the CDC and NHSN’s definition. Of those with UTIs, 80% (n = 12) had indwelling urinary catheters. However, sample size was insufficient to prove causation. Three patients with UTIs did not have indwelling urinary catheters.

Although not a component of this study, there was clear evidence that UTIs were diagnosed and treated in the medical/surgical setting. Of significance, more women than men (n =13 of 15; 87%) developed CAUTIs (Fisher’s Exact, p < .001). CAUTIs affected 25% of women in the study.

Many of the institution’s surgical order sets called for removal of the indwelling urinary catheter on postoperative Day 2. However, there was no significant difference in UTI rates in this group of patients.

Romito Table 2The Statistical Package for the Social Sciences (SPSS, Version 12.0) was used for data analysis. Specifically, Fischer’s exact test and chi-square test of frequency were used to analyze the categorical data (Table 2).

The nursing questionnaire had the potential for 144 responders from the medical/surgical unit. Twenty-two nurses (15.3%) completed the survey. Of the 30 potential responders on the rehabilitation unit, 16 nurses (53.3%) completed the survey.

A comparison between acute care and rehabilitation nurses completing the nursing questionnaire (ordinal data) was analyzed using the Mann-Whitney U test. Two items from the survey were statistically significant. Half of medical/surgical nurses disagreed with the statement, “At this facility, it is easy to find out the date a Foley catheter was inserted in a patient I am caring for.” Three-fourths of the rehabilitation nurses disagreed with this statement (z = -2.202, p < .05)

In the section that asked nurses to identify conditions warranting Foley catheter use (categorical data; chi-square test of frequencies), 24-hour urine collection was selected by one-half of the rehabilitation nurses but only 3 of the 22 medical/surgical nurses (chi-square = 5.955, p < .06). No statistically significant differences were found in any of the other statements on the survey.

No nurse identified poor pain control as an appropriate reason for Foley catheter placement (Table 3 and Table 4).

 

Romito Table 3

Romito Table 4

Discussion

This study did not support the perception that a large number of patients coming to the rehabilitation unit had a UTI or CAUTI. When a UTI did meet criteria, it was not related to misuse or overuse of indwelling urinary catheters. Catheter use may reflect the relative complexity of patients admitted to the rehabilitation setting. Of concern, however, was the fact that 12% of the sample did meet criteria for a UTI/CAUTI. With an ethical obligation to prevent complications and the financial burden associated with HAIs, 12% is too high. The associated morbidity demands treatment and recovery.

Of significance is the preponderance of women meeting criteria for CAUTI/UTI. Given the proximity of the female urethra to the vagina and the influence of personal hygiene as a factor in catheter-associated infections, it is conceivable that contamination of the catheter upon insertion presents an increased risk for women. In men, unless they are uncircumcised, the chance for contamination is potentially lower (Wiswell, 2000).

This study’s nursing implications confirm that nurses want to be involved in decisions about indwelling urinary catheter placement and removal. Nurses also expressed an interest in a nursing protocol for early catheter removal. Medical/surgical and rehabilitation nurses agree strongly about advocating for their patients with indwelling urinary catheters. Physicians and nurses need to be familiar with the CDC criteria specifying appropriate and inappropriate catheter use. Nurses must recognize that women are at high risk for UTI/CAUTI.

Limitations

A priori, a 3-month period was deemed adequate for data collection. In actuality, our sample size was insufficient to conclude there were a significant number of UTIs/CAUTIs in patients coming to rehabilitation from the acute care setting. If sample size were dictated by a set number of patients rather than a fixed period, we may have been able to conclude more significant findings.

Patient demographics for this study did not include age. Thorough personal hygiene may be more difficult to achieve in older, infirm, or debilitated women than in younger, more active patients. With the higher incidence of women with UTI/CAUTI, age should be considered in future studies to detect correlations.

Interpretation of the data regarding nurses’ attitudes is limited because of the participation rate. The nursing survey’s response rate could have improved if the survey collection period had been extended. In addition, regular reminders sent via e-mail or initiated personally by study personnel during the collection period could have yielded more surveys.

Ideas for Future Research

Although the literature review revealed studies citing the effectiveness of nursing protocols for proactive catheter removal in the acute care setting, research specific to the rehabilitation setting would be valuable. A comparison of straight catheters and indwelling catheters would also be of interest to determine if the need for bladder decompression could be accomplished more simply and with less risk to patients. Surgical Care Improvement Project (SCIP) measures could lead us to review pre-SCIP and post-SCIP CAUTI rates. Such a review has the potential to uncover a relationship among outcomes, public reporting, and financial deterrents. If consistent and timely catheter removal is associated with a significant decrease in infection rates leading to a shorter length of stay, changes or mandates in professional practice could follow.

Another area of interest for future research is to pursue whether or not a disparity exists between recommendations for indwelling catheter removal and nurses’ practice. A questionnaire could assess nurses’ alignment with research-based appropriate and inappropriate catheter placement.

Conclusion

The use of indwelling urinary catheters in patients, particularly women, comes with associated risks. Despite their advantages, indwelling catheters placed without a clear removal strategy affect overall patient health.

Clear and established guidelines exist for the appropriate use of indwelling catheters, but removal guidelines in hospital settings may warrant a review. Nurses play a role in the length of indwelling catheter duration. This research indicates that nurses want more influence regarding proactive indwelling catheter removal.

Hospitals must bear the financial burden of preventable infections. Collaboration between physicians and nurses to reduce infection incidence and promote the early removal of indwelling catheters can positively affect patient outcomes. Knowledge about catheter-associated infections should be disseminated to nursing staff who routinely see catheters in use. Regular monitoring of infection rates, particularly CAUTIs, may focus attention on this problem and affect nurses’ attitudes and behaviors toward indwelling urinary catheter use.

About the Authors

Diane Romito, BSN RN CRRN, is the director of rehabilitation services at Scripps Memorial Hospital Rehabilitation Center in Encinitas, CA. Address correspondence to her at Romito.Diane@Scrippshealth.org.

JoAnn M. Beaudoin, BSN RN, is a manager of patient care medical services at Scripps Memorial Hospital in Encinitas, CA.

Patrician Stein, BSN RN MAOL CNOR, is a clinical documentation specialist at Scripps Green Hospital in La Jolla, CA.

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