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Bladder Management and CAUTI Prevention: Results of the STOP CAUTI Workgroup Current Practice Survey in NICHE Hospitals

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Title: Bladder Management and CAUTI Prevention: Results of the STOP CAUTI Workgroup Current Practice Survey in NICHE Hospitals


1
Bladder 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

2
What is STOP CAUTI?
  • Surveillance to Prevent
  • Catheter-Associated Urinary
  • Tract Infection

3
Project 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

4
STOP 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)

5
What 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).

6
Participating 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

7
STOP 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

8
Intervention
  • 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.

9
the Baseline STOP CAUTI Current practice survey
  • December 2009

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

11
Survey 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)
13
Nursing 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
14
RESULTS - Products
15
Indwelling Catheter Types

16
CDC 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)

17
Silver 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

18
How 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
19
CDC 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)

20
CDC 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)

21
Does 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
22
RESULTS Insertion and Maintenance Techniques
23
How often are each of the following used when
placing an indwelling catheter?

24
How often are each of the following used when
placing an indwelling catheter?

All performed perineal washing with an antiseptic
cleanser and/or povidone iodine
25
Does 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

26
CDC 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)

27
When 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
28
When 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
29
Evidence for Routine Care
  • Do not clean periurethral area with antiseptics
    while the catheter is in place. Routine hygiene
    is appropriate. (Category 1B)

30
RESULTS Personnel, Training, and Education
31
Who 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)

32
Training 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

33
Effectiveness 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

34
CDC 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)

35
What 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

36
RESULTS Documentation, Removal, and Surveillance
37
Documentation 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?
38
CDC 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)

39
Does 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


40
QI 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

41
Surveillance 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)


42
CDC 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)

43
RESULTS Policy and Procedure Audit
44
Policies 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

45
Policy 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)

46
CDC 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)

47
Summary
  • 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

48
Implications
  • 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

49
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