Title: Bladder Management and CAUTI Prevention: Results of the STOP CAUTI Workgroup Current Practice Survey in NICHE Hospitals
1Bladder Management and CAUTI Prevention Results
of the STOP CAUTI Workgroup Current Practice
Survey in NICHE Hospitals
- Heidi Wald, MD, MSPH
- Regina Fink, RN, PhD, AOCN, FAAN
- University of Colorado, Denver
2What is STOP CAUTI?
- Surveillance to Prevent
- Catheter-Associated Urinary
- Tract Infection
3Project Team
- University of Colorado Denver
- - Heidi Wald, MD, MSPH, Principal Investigator
- - Andy Kramer, MD, Co-Investigator
- - Regina Fink, PhD, RN, AOCN, FAAN Research
Scientist - - Angela Richard, MS, RN, Project Manager
- NICHE
- - Elizabeth Capezuti, PhD, RN, FAAN,
Co-Investigator Project Co-Director - - Marie Boltz, PhD, RN, GNP-BC, Content Expert
- - Nina Shabbat, PhD, Educational Support
4STOP CAUTI Funding
- Primary funder the Agency for Healthcare
Research and Quality (AHRQ), U.S. Department of
Health and Human Services (http//www.ahrq.gov) - Dr. Walds time also funded by the National
Institute on Aging, U.S. National Institutes of
Health (http//www.nia.nih.gov)
5What are the goals of the STOP CAUTI study?
- To understand care practices associated with
indwelling catheters at NICHE hospitals - To disseminate an electronic method for tracking
CAUTIs and catheter duration - To determine the effect of the feedback of these
data on processes of care (catheter duration) and
outcomes (CAUTIs).
6Participating NICHE Hospital Sites
- University of California, San Francisco
- Crouse Hospital
- Rochester General Hospital
- Cleveland Clinic
- Morton Plant Mease Countryside Hospital
- Covenant Healthcare Corporate/Ft. Sanders
Regional Hospital - Aspirus Wausau Hospital
- Inova Fairfax Hospital
- Roger Williams Medical Center
- University of Wisconsin Hospital and Clinics
- Robert Wood Johnson Hospital
- Addison Gilbert Hospital and Beverly Hospital
- Akron General Medical Center
- John Muir Medical Center, Walnut Creek Campus
- Mission Hospital
- Northwest Community Hospital
- Ocean Medical Center (formerly Brick Hospital)
- Sanford USD Medical Center
- University Case Medical Center
7STOP CAUTI Timeline
- Fall 2009 Assemble work group
- Winter/Spring 2010
- Survey and P P Evaluation
- Develop subcontracts, complete IRB approval
- Explore clinical IT issues
- Spring/Summer 2010 Preparation for data
collection pilot testing - Late Summer 2010 Data collection begins
- Fall/Winter 2010/11 1st intervention period
- Spring/Summer 2011 2nd intervention period
- Winter 2011 Study concludes
8Intervention
- Electronic audit and feedback reports to
hospitals on unit-specific, patient-level urinary
catheter duration and CAUTI rates. - Presented with educational session on CAUTI
prevention and evidence-based best practices for
urinary catheter management. - Sites will be randomly assigned to early or
delayed intervention.
9the Baseline STOP CAUTI Current practice survey
10 Goals and Methods
- To understand the current state of nursing
practice in participating NICHE hospitals with
regard to bladder management, urinary catheter
care, and surveillance - We conducted a zoomerang survey of all STOP CAUTI
Work Group sites about their practices - We reviewed all hospital policies and procedures
and patient education materials to determine if
they were based on best evidence
11Survey based on Review of Published Guidelines
- Areas of interest
- Product
- Insertion and Maintenance Technique
- Personnel, Training, and Education
- Documentation, Removal and Surveillance
- Audit of Policy and Procedures
- Areas not covered by survey
- Indications
- Specific practices and parameters
12(No Transcript)
13Nursing Interventions to ? CA-UTI
- Second article of a 2-part evidence-based report
card reviewing current evidence pertaining to
nursing actions preventing CA-UTI - Comparison CDC, ICI, Briggs Best Practice
- Searched for research articles using MEDLINE,
CINAHL, Cochrane library, Google scholar - Recommendations
- Strong, limited, mixed, no evidence
Updated to reflect most recent 2009
guideline International Consultation on
Incontinence
14RESULTS - Products
15Indwelling Catheter Types
16CDC on Catheter Materials
- If the CAUTI rate is not decreasing after
implementing a comprehensive strategy to reduce
rates of CAUTI, consider using antimicrobial/antis
eptic-impregnated catheters. (Category IB) - Further research needed on the effect of
antimicrobial/ antiseptic-impregnated catheters
in reducing the risk of symptomatic UTI. (No
recommendation/unresolved issue) - Hydrophilic catheters might be preferable for
patients requiring intermittent catheterization.
(Category II) - Silicone might be preferable to other catheter
materials to reduce the risk of encrustation in
long-term catheterized patients. (Category II)
17Silver Indwelling Urinary Catheters
- Evidence does not support use of silver
coated/alloy catheters to reduce CAUTI - As of March 2009 UCH is no longer using silver
coated foleys because this practice is not
supported by the evidence. - Cost savings 52,000/year
- Thus far, UCH hospital wide CAUTIs have not
increased with removal of silver products
18How often are these alternatives or adjuncts to
indwelling catheters used at your hospital? (
Respondents who said frequently always)
Access to female urinals limited usage 25
sometimes or never use a securement device
19CDC endorsed alternatives
- External catheters in cooperative male patients
(category II) - Intermittent catheters in spinal cord injury,
bladder emptying dysfunction (Category II) - Further research needed for suprapubic catheters
(No recommendation)
20CDC on Bladder Scanner Use
- If intermittent catheterization is used, perform
it at regular intervals to prevent bladder
overdistension. (Category IB) - Consider using a portable ultrasound device to
assess urine volume in patients undergoing
intermittent catheterization to assess urine
volume and reduce unnecessary catheter
insertions. (Category II) - If ultrasound bladder scanners are used, ensure
that indications for use are clearly stated,
nursing staff are trained in their use, and
equipment is adequately cleaned and disinfected
in between patients. (Category IB)
21Does Use of a Catheter Securement Device ? CAUTI
Incidence?
- Catheter securing is strongly recommended by CDC
but not mentioned by ICI and Briggs - Single RCT compared a securement device to other
devices or no device at all and found no
statistical difference in CAUTI although
prevalence was decreased in those with StatLock - Further research is needed with a larger number
of patients - In the meantime, securement is recommended based
on safety and prevention of urethral erosion (CDC
category 1B)
Darouiche et al., 2006
22RESULTS Insertion and Maintenance Techniques
23How often are each of the following used when
placing an indwelling catheter?
24How often are each of the following used when
placing an indwelling catheter?
All performed perineal washing with an antiseptic
cleanser and/or povidone iodine
25Does Aseptic/Sterile Technique During Insertion
? CAUTI Incidence?
- 3 clinical practice guidelines vary
- The use of sterile gloves, mask and gown,
sterile barriers, perineal washing using an
antiseptic cleaner, and no touch insertion may
not influence bacteriuria and CAUTI but is
moderately recommended
26CDC Insertion Recommendations
- Perform hand hygiene immediately before and after
insertion or any manipulation of the catheter
device or site. (Category IB) - In the acute care hospital setting, insert
urinary catheters using aseptic technique and
sterile equipment. (Category IB) - Use sterile gloves, drape, sponges, an
appropriate antiseptic or sterile solution for
periurethral cleaning, and a single-use packet of
lubricant jelly for insertion. (Category IB) - Routine use of antiseptic lubricants is not
necessary. (Category II)
27When an indwelling catheter is in place, what
routine care of the urethral meatus is used?
Meatal care using antiseptic cleaners is no
better than routine perineal and genital hygiene
using soap and water
28When an indwelling catheter is in place, how
often is urethral meatus care provided?
Meatal care should be performed daily and after
bowel movement with soap and water
29Evidence for Routine Care
- Do not clean periurethral area with antiseptics
while the catheter is in place. Routine hygiene
is appropriate. (Category 1B)
30RESULTS Personnel, Training, and Education
31Who is responsible for insertion of indwelling
urinary catheters?
- Various health care professionals
- 100 RNs
- Others include
- NPs (40)
- LPNs (50)
- MDs (30)
- Residents (35)
- Medical students (25)
- Nursing students (70)
- Patient care associates (25)
32Training and Validation
- Annual validation on aseptic technique is not
provided routinely - gt 50 of hospitals did provide an educational
offering on CAUTIs for nursing staff - 75 have completed a QI project in the last year
- New protocol developed
- Policy revision
- Guidelines were reviewed
- Web-based inservice
- Audit and feedback
Initial Training of Staff
33Effectiveness of Staff Education, Regular
Monitoring of CAUTI Prevalence, and Feedback in
reducing CAUTI Incidence
- Limited evidence
- Staff education, combined with monitoring CA-UTI
occurrences and staff feedback (quarterly), may
reduce CA-UTI incidence - Successful programs should incorporate staff
education about - Indwelling catheter insertion techniques
- Prompt removal
- Catheter care with principles of CAUTI prevention
34CDC Education Recommendations
- Ensure that only properly trained persons who
know the correct technique of aseptic catheter
insertion and maintenance are given this
responsibility. (Category IB) - Ensure that healthcare personnel who take care of
catheters are given periodic training regarding
techniques and procedures for insertion,
maintenance and removal. Includes CAUTI, other
complications of catheters, alternatives.
(Category 1B)
35What do you do about Patient Education?
- Micromedex Notes
- Discharge Instructions
- Self-cath instruction
- SS infection
- Care and maintenance
- Some materials need updates related to CAUTIs
36RESULTS Documentation, Removal, and Surveillance
37Documentation of Urine Output and Catheter Care
Management
- Date of insertion
- Description of urine
- Straight cath
- Bladder scan/volume
- Type and size of cath
- Cath removal
- S S infection
- Less frequently documented
- Place (unit) of insertion
- Insertion indication
Is catheter care documentation routinely done?
38CDC Documentation Recommendations
- Consider documenting the following indication,
date and time of insertion, who inserted, date
and time of removal (Category II) - Ensure that documentation is accessible and in
standard format. Searchable electronic
documentation is preferable. (Category II)
39Does your hospital have a system to remind
providers to remove indwelling catheters?
- Nurse driven protocol to discontinue (25)
- Paper reminders (20)
- Electronic reminders (20)
- Nurse led catheter rounds (5)
- Other
- Stickers on MD orders and medical records
- ICUs have prompt on daily goal sheet
40QI strategies for reducing catheter use and
duration (Category 1B)
- System of alerts or reminders
- Guidelines and protocols for nurse-directed
removal - Education and performance feedback
- Guidelines for perioperative use
- Protocols for management of postoperative urinary
retention
41Surveillance of CAUTIs
- Where is surveillance conducted?
- ICU only (45)
- House-wide (30)
- NA (10)
- Did not answer or did not know (15)
- Catheter days are collected
- Selected units (50)
- All units (20)
- Not done (30)
42CDC Surveillance Recommendations
- Consider surveillance for CAUTI when indicated by
facility-based risk assessment. (Category II) - Use standardized methodology for performing CAUTI
surveillance (includes measures of catheter-days)
(Category 1B) - Routine screening of catheterized patients for
asymptomatic bacteriuria is not recommended
(Category II) - Consider providing regular feedback of
unit-specific CAUTI rates to nursing staff.
(Category II)
43RESULTS Policy and Procedure Audit
44Policies and Procedures
- We received PP from 95 of hospitals
- 25 used Lippincott or Delmars texts
- 60 have revised PP within 2 years
- Evidence-based
- Ranged - 1994-2009
45Policy and Procedure Components
- Appropriate catheter indication (50)
- CAUTI SS assessment parameters (20)
- Bladder scanner parameters (20)
- Insertion technique parameters were discussed but
varied by hospital - Sterile closed system reinforced (70)
- Urine specimen procedure outlined (65)
- Lack of discussion
- Emptying urinary bag (50)
- Meatal care frequency and agent used (50)
46CDC Policy and Procedure Guidelines
- Provide and implement evidence-based guidelines
that address catheter use, insertion, and
maintenance.(Category 1B) - Consider monitoring adherence to facility-based
criteria for acceptable indications for catheter
use.(Category II)
47Summary
- The STOP-CAUTI workgroup is already very engaged
in CAUTI reduction - There is still room for improvement
- Policies and procedures
- Educational interventions
- Surveillance
- Best practices of hospitals can be shared so that
others can benefit
48Implications
- Hospitals need to constantly reassess the
evidence and incorporate into policies and
procedures regularly - Documentation needs to be streamlined
- Examine products and availability in practice
settings - Translating the research into practice is key
- Regular educational updates
- Audit and feedback
49Questions?