This blog is part of an ongoing series focused on introducing the current quality initiatives. Thank you to the Quality Improvement Program team for sharing their important work with us, and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.
Learn more about the other initiatives by viewing the introduction to this series and previous topics.
Why do some people need a urinary catheter?
Urinary catheters are used for urinary drainage or as a means to collect urine for measurement. Indications for catheterization are as follows:
- Urinary retention
- Urine output measurement in ICU patients
- During surgery to evaluate fluid status
- During and following specific surgeries of the genitourinary tract
- Hematuria associated with clots
- Neurogenic bladder
Although urinary catheters provide many patient benefits, there are also associated risks. Due to these risks, urinary catheters should be removed as soon as the benefits no longer outweigh the risks.
According to the Centers for Disease Control and Prevention (CDC), between 15 to 25% of hospitalized patients receive urinary catheters during their hospital stay. Bacteriuria (positive bacteria in urine) in patients with indwelling catheters occurs at a rate of approximately 3 to 10% per day. Of those with bacteriuria, 10 to 25% develop symptoms of urinary tract infection (UTI). In the U.S., based on surveillance data reported to the CDC National Healthcare Safety Network (NHSN), the incidence of CAUTI in 2012 was 1.4 to 1.7 per 1,000 catheter days in inpatient adult and pediatric medical/surgical floors. This means if all the patients at UI Hospitals & Clinics had a urinary catheter today, between one and two of them will develop a CAUTI.
The duration of catheterization is an important risk factor for CAUTI and is a major target of prevention efforts. Other risk factors include female sex, older age, diabetes mellitus, bacterial colonization of the drainage bag, and improper catheter care.
Issues with CAUTI
Health care-associated infections cost U.S. hospitals an estimated $40 billion each year. CAUTIs are among the most common types of health care-associated infections. Research suggests CAUTIs are highly preventable and that perhaps as many as 50 to 70% of these episodes can be prevented. Complications associated with CAUTI result in increased length of stay, patient discomfort, excess health care costs, and contribute to increased mortality. The estimated total U.S. cost per year for CAUTI is $340–450 million. Since October 2008, the Centers for Medicare & Medicaid Services no longer reimburses costs associated with hospital acquired CAUTI.
How do we prevent CAUTI?
In general, the most important aspects of CAUTI prevention are avoidance of unnecessary catheterization, use of sterile technique when placing the catheter, proper catheter care, and removal of the catheter as soon as possible.
The need for a urinary catheter should be evaluated for every patient, every day by both physicians and nurses. It is important to insert catheters only for appropriate indications and leave them in place only if needed. The catheter should not be kept solely for the convenience of patient care. It is also important to consider using alternatives to indwelling urethral catheterization in selected patients when appropriate, such as external catheter or intermittent catheterization. If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension. We can use a bladder scanner to assess urine volume in patients undergoing intermittent catheterization and reduce unnecessary catheter insertions.
Proper technique during catheter insertion is critical. Health care personnel must perform hand hygiene immediately before and after insertion. We need to use aseptic technique and sterile equipment, and properly secure indwelling catheters after insertion to prevent movement and urethral traction.
Ideal catheter care is also instrumental to CAUTI prevention. Meatal care (cleaning around the catheter) once per shift and after every bowel movement is essential. In addition, daily bathing with chlorhexidine is necessary and is reported to reduce CAUTIs.
The way a urine culture is collected also has a significant impact on CAUTIs. For instance, urine cultures should never be obtained from a catheter that has been in place for more than 24 hours, because urine cultures collected from an existing catheter will almost always come back positive but may not be clinically significant. Once a CAUTI is suspected urinary catheters should be removed and urine specimens should be obtained from either a newly placed urinary catheter or via intermittent catheterization
CAUTI reduction initiative
In August 2022, a multidisciplinary CAUTI committee, led by Karen Brust, MD, hospital epidemiologist, was formed in an effort to reduce CAUTI across UI Hospitals & Clinics’ adult units. Members of the CAUTI committee provided feedback on contributing factors from the perspective of leaders and bedside nurses. Their feedback provided a foundation for potential future data collection and process improvement. The discussions and work of the CAUTI initiative led by Brust also aligned with another CAUTI committee led by the Department of Nursing Services and Patient Care. Since its initiation, the nursing-led committee reviewed and updated existing protocols and policies related to CAUTI. The group identified opportunities for additional guiding documents, specifically for bladder scanning and intermittent catheterization protocol, which is actively being developed. The team collaborated with clinicians to understand the current process of ordering urine cultures and how urine specimens are collected after an order is placed. The results of these conversations revealed variation in practice by the ordering provider and the nurse collecting the urine sample. This led to the ongoing development of an “ideal state” for both actions with recommendations brought to the clinical and nursing informatics teams.
-Karen Brust, MD, Clinical Associate Professor of Internal Medicine, Infectious Diseases, Hospital Epidemiologist
-Takaaki Kobayashi, MD, MPH, Clinical Assistant Professor or Internal Medicine, Infectious Diseases