Module 1: Overview

Preventing CAUTI in the ICU Setting Slide Presentation

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AHRQ Safety Program for Reducing CAUTI in Hospitals

Preventing CAUTI in the ICU Setting

Module 1: Overview

AHRQ Pub. No. 15-0073-4-EF
September 2015

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Learning Objectives

  • At the end of this educational event, the participant will be able to:
    • Describe the scope of catheter-associated urinary tract infections (CAUTI)
    • State the indications for an indwelling urinary catheter
    • Identify causes of CAUTI in the intensive care unit (ICU)
    • Describe methods to mitigate the risk of CAUTI

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Scope of the Problem

  • An estimated 560,000 patients develop  hospital-acquired UTIs per year1
    • 5% are urinary catheter-associated2
    • Almost 50% with a urinary catheter don’t have a valid indication for placement
    • Each day the urinary catheter remains, the risk of bacteriuria increases 3% to 7%3

1. Gould CD, Umscheid CA, Agarwal RK, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Centers for Disease Control and Prevention. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.
2. Centers for Disease Control and Prevention. Catheter-Associated Urinary Tract Infections. http://www.cdc.gov/HAI/ca_uti/uti.html. Accessed May 15, 2015.
3. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 May;35(5):464-79. PMID: 24709715.

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Scope of the Problem

  • CAUTIs:
    • One of the most common types of healthcare-associated Infection (HAI)3
    • Account for 23% of all HAIs in ICU4
    • Over 30% of all infections reported to Centers for Disease Control and Prevention’s National Healthcare Safety Network
    • Leading cause of secondary bloodstream infection3
    • Increase length of stay 2-4 days3
    • Result in additional antimicrobial use and antimicrobial resistance

4. Chenoweth C, Saint S. Preventing catheter-associated urinary tract infections in the intensive care unit. Crit Care Clin. 2013 Jan;29(1):19-32. PMID: 23182525.

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HICPAC* Indications for a Urinary Catheter1

  • Patient has acute urinary retention or obstruction
  • Critically ill patient needs precise, accurate measurement of urinary output
  • Assistance in healing incontinent patients with Stage III or IV open sacral or perineal wounds
  • Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine)
  • Improved comfort for end-of-life care if needed

* Healthcare Infection Control Practices Advisory Committee

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HICPAC Indications for a Urinary Catheter

  • Perioperative use for selected procedures:
    • Urologic surgery or other surgery on contiguous structures of genitourinary tract
    • Anticipated prolonged surgery duration (removed in post-anesthesia care unit)
    • Anticipated large-volume infusions or diuretics during surgery
    • Need for intraoperative monitoring of urinary output

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Challenges With Catheter Use in the ICU5

  • Potential catheter overuse
  • Definition of “critically ill patients”

5. Meddings J, Saint S, Fowler KE, et al. The Ann Arbor criteria for appropriate urinary catheter use in hospitalized medical patients: results obtained by using the RAND/UCLA appropriateness method. Ann Intern Med. 2015 May 5;162(9 Suppl):S1-34. PMID: 25938928.

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Recent Consensus Document5

Is HOURLY urine volume measurement being used to inform and provide treatment?

  • Hemodynamic instability
  • Acute respiratory failure
  • Management of life-threatening laboratory abnormalities

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Consensus

  • Is daily urine volume measurement being used to provide treatment AND volume status cannot be adequately or reliably assessed without a Foley catheter, such as by daily weight or urine collection by urinal, commode, bedpan, or external catheter?
    • Examples: Management of acute renal failure, IV fluids, or IV or oral bolus diuretics
    • Fluid management in acute respiratory failure requiring large volumes of oxygen (≥5 L/min or >50%)

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Stop and Think

  • What are you doing in your facility?
  • Are your practices well defined and current?
  • What are your barriers?

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Variables Impacting CAUTI in ICU Settings

  • Technical Issues
    • Evidence-based guidelines
  • Socio-adaptive (cultural issues)
    • Staff behavior and unit culture

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Technical Challenges

  • Can be solved with existing, “knowledge-based” science or technology
  • Ask yourself:
    • Have we summarized the evidence and disseminated to the frontline staff?
    • Is there a lack of knowledge of prevention and prevalence of CAUTI in ICU?
    • Do we evaluate and share info on CAUTI rates and device use ratios?

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Adaptive or Cultural Changes

  • Require a change of values, attitudes, or beliefs (i.e., “behavior based”)
  • Examples:
    • Are nurses reluctant to remove urinary catheters even when the patient no longer meets criteria for a catheter?
    • Are physicians engaged in CAUTI prevention?

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Etiology of CAUTI

  • Patient’s colonic or perineal flora
  • Bacteria on hands of patient and personnel
  • Microbes enter bladder via two routes:
    • Extraluminal: Around the external surface
    • Intraluminal: Inside the catheter
  • Daily risk of bacteriuria with catheterization
    • 3% to 7%
    • By day 30, 100%

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Patient Factors

  • ICU patients who are critically ill may be at high risk for infection for many reasons
    • Underlying comorbid conditions
    • Exposure to invasive devices
    • Antibiotic exposure putting them at risk for multiple drug-resistant organisms (MDROs)

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Behavioral or Cultural Factors

  • Pan culturing
    • ICUs may obtain cultures from multiple sites when a patient has a temperature spike
    • Not an automatic culture
  • Belief that all patients need a urinary catheter
  • Sending routine admission orders on patients admitted with a urinary catheter without signs and symptoms of infections

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Methods for Mitigating Risk

  • Optimize insertion practices
    • Prevent insertion of catheters when patient's case does not meet one of HICPAC's approved indications
    • Promote aseptic insertion by trained personnel with competency documented by direct observation

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Methods for Mitigating Risk

  • Optimize catheter maintenance
    • Periodic audit
    • Direct observation
    • Maintenance bundle
      • Maintain unobstructed urine flow
      • Maintain a continually closed system
      • Perform hand hygiene and use standard precautions
      • Empty urine drainage bag regularly and always before transport
      • Perform routine meatal care (minimum of daily)

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Methods for Mitigating Risk

  • Limit duration of catheter use
    • Device rounds
    • Daily assessment of indication
      • Continued need for hourly monitoring of fluid intake and output?
      • Needed to titrate meds?
    • Reminders/stop orders
    • Nurse-driven removal protocol

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Methods for Mitigating Risk

  • Follow evidence-based culturing practices
  • Perform clinical assessment for signs/symptoms of UTI
  • Increase use of alternatives to indwelling urinary catheters
    • `Condom catheters (evaluate multiple products)
    • Moisture-wicking incontinence pads
    • Bladder scanners
    • Intermittent catheterization

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Demonstrate Team-Based Practices

  • Mitigating risk of CAUTI requires a team approach
    • 1:1 Conversations
    • Drill down on CAUTI (Learning From Defects tool)
    • Nurse-physician cooperation!

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References

  1. Gould CD, Umscheid CA, Agarwal RK, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Centers for Disease Control and Prevention. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.
  2. Centers for Disease Control and Prevention. Catheter-Associated Urinary Tract Infections. http://www.cdc.gov/HAI/ca_uti/uti.html. Accessed May 15, 2015.
  3. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 May;35(5):464-79. PMID: 24709715.
  4. Chenoweth C, Saint S. Preventing catheter-associated urinary tract infections in the intensive care unit. Crit Care Clin. 2013 Jan;29(1):19-32. PMID: 23182525.
  5. Meddings J, Saint S, Fowler KE, et al. The Ann Arbor criteria for appropriate urinary catheter use in hospitalized medical patients: results obtained by using the RAND/UCLA appropriateness method. Ann Intern Med. 2015 May 5;162(9 Suppl):S1-34. PMID: 25938928.

Return to CAUTI Tools Resources Page

Page last reviewed December 2017
Page originally created November 2015
Internet Citation: Module 1: Overview. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/cauti-icu/facil-guide/mod1-slides.html