A Multi-Faceted Approach to Reduce Catheter Associated Urinary Tract InfectionsDeborah Pavlak, BSN, RN, CIC; Michelle Freitag, BSN, RN; Susan Carroll, MS, BA, RN, CNE

Rush Oak Park Hospital, Oak Park, IL

Introduction

References

Method

Nurse-Driven Algorithm Results Conclusion

In early 2007, while completing the 2006 annual

infection control report , an increased incidence of

resistant Pseudomonas was identified. On further

investigation the majority of these were cultures from

patients with urinary catheters.

For one month, house-wide surveillance was conducted

for all inpatients with catheter associated urinary tract

infections (CAUTI) to assess the scope and determine a

pattern. The ROPH 2007 CAUTI rate was significantly

higher than the national average for like hospitals.

Reduction of CAUTI needs to be a multi-faceted

approach, similar to bundles for prevention of ventilator

associated pneumonia and central line related

bacteremias.

The CAUTI “bundle” should include:

• Appropriate management/care of the urinary catheter

• Daily Assessment of the continued need for the

urinary catheter

“Reducing hospital acquired infections is the right thing

to do. Not only does it improve the quality of patient

care provided, it reduces the cost of hospitalization. In

an era of increasing transparency, and value based

purchasing, lowering infection rates is increasingly

important.”

Bruce Elegant

President and CEO

Rush Oak Park Hospital

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1

2

3

4

5

6

7

8

9

10

QTR 4 07 QTR 1 08 QTR 2 08 QTR 3 08 QTR 4 08 QTR 1 09 QTR 2 09 QTR 3 09 QTR 4 09 QTR 1 10 QTR 2 10

RO

PH

CA

UTI

Rat

e

ROPH Catheter Associated Urinary Tract Infection Rate

ROPH UTI Rate NHSN

NHSN: National Healthcare Safety Network (CDC Database)Data Includes all Inpatient Care Units

UTI Rate: (Number of CAUTI/ Number Catheter Days) X 1,000

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Catheter Anchored Catheter Bag Labeled with Insertion Date

Graduate Labled with Pt. ID

Catheter Bag Below Bladder

Daily Assessment of Cont. Need of Catheter

Pe

rce

nt

Co

mp

lian

t

ROPH Urinary Catheter Process Audit

Feb-08 Feb-09 Jun-09 Mar-10

Purpose

This project addressed a gap in both nurse and

physician clinical practice related to the use of indwelling

urinary catheters.

A literature review indicated that “attending physicians

are unaware of the indwelling urinary catheter in their

patients 40% of the time” (Topal et. al, 2005).

To reduce the risk of hospital acquired CAUTI a task-

force that consisted of front-line nurses, patient care

technicians, infection control, quality improvement

leaders (with support from physicians and

administrators) targeted several aspects of care to

reduce the incidence of CAUTI.

Baseline CAUTI Rate

Early 2007

• First CAUTI Task Force

• Urinary Catheter Anchor Device Upgrade

Mid 2007

Monthly surveillance of all CAUTI for

cluster identification

Late 2007

Robust Hospital-wide education & feedback to stakeholders

Late 2007/08

• Nurse-Driven Urinary Catheter Protocol

• EMR with daily assessment of cont. need

Dec. 2008

CAUTI Prevention

ROPH Strategic Goal

2009 -Present

0%

5%

10%

15%

20%

25%

30%

2007 2008 2009 YTD 2010

ROPH Urinary Catheter Utilization Rate

ROPH Rate

NHSN 2009

NHSN: National Healthcare Safety Network (CDC Database)Data Excludes ICUNumber of Urinary Catheter Days/Number of Patient DaysYTD 2010 = January - June

Daily assessment

Does the patient have any of the following?Urinary retention or obstruction?

Need for accurate I &O ?

Incontinent patient with possible harm to skin integrity?

(e.g. sacral decubitus, incision in perineal /gluteal area)

Selected gyne urinary lower abd surgery?

( e.g. TURP, Hysterectomy, cysto, prostate surgery)

Foley inserted or ordered by Urologist?

Discontinue indwelling

catheter

(MD order not required)

Patient has foley?

Perform bladder scan

Notify MD

and

Obtain order for straight

cath if indicated

Voids minimum of

250 ml of urine

without

discomfort

Symptoms:

incontinence ( or dribbling),

urgency, persistent

dysuria or bladder spasms,

fever, chills or

palpable

bladder distention

Rush Oak Park Hospital

Indwelling Catheter

Nurse protocol

Assess patient

every 6-8 hrs

Continue routine

genito-urinary

assessment

Yes

No

Yes

Yes No

Inserted prior to

admission; patient

with chronic foley

or history unknown

( NH Patient)

Inserted in ER or

during admission

Collect urine

for U/A and C/S.

Continue

foley.

Continue foleyYes

Cornia, P., Lipsky, B. (2008, September). Indwelling Urinary Catheters in Hospitalized Patients:

When in Doubt, Pull it Out. Infection Control and Hospital Epidemiology , pp. Vol 29, No.9.

Gould, C. V., Umscheid, C. A., et. al. (2009). Healthcare Infection Control Practices Advisory

Committee. Guideline for Prevention of Catheter-Associated Urinary Tract Infections .

DHHS/CDC.

IHI Getting Started Kit. Prevention Catheter -Associated Urinary Tract Infections. How-to Guide.

Perry, A. G. (2004). Care and Removal of the Indwelling Catheter. In A. G. Perry, & P. A. Potter,

Clinical Nursing Skills & Techniques (pp. 715-718). St. Louis: Mosby.

Saint, S., Kowalski, C., et. al. (2008). Preventing Hospital-Acquired Urinary Tract Infections in

the United States: A National Study. Clincial Infectious Diseases , pp. 243-250.

Schimke, L., Humphreys, S. (2006). Lippincott Manual of Nursing Practice. In S. Nettina,

Lippincott Manual of Nursing Practice (pp. 772-837). Philadelphia: Wolters Kluwer Lippincott

Williams & Wilkins.

Topal, J., Conklin, S., et.al. (2005). Prevention of Nosocomial Catheter-Associated Urinary Tract

Infections Through Computerized Feedback to Physicians and a Nurse-Directed Protocol.

American Journal of Medical Quality , 121-126.