Catheter-Associated Urinary

Tract Infection (CAUTI)

Prevention Related to Annual
Renewed Nurse Training of Sterile
Foley Catheter Placement and Care
By: Sydney Reed, Rachel Naftulin, Sascha Spiegel, Duncan Shaw,
Kelly Conrad, Maddie Guziak, Shelby Case, Dulce Duarte, & Lauren
Real
 Introduction & Purpose
To explore if ICU patients with indwelling urinary
catheters will have reductions in CAUTIs, ensuring
quality patient safety and well-being, while reducing
financial burdens on health-care institutions by way of
continued, annual nurse reeducation/retraining on
sterile Foley catheter placement and care compared to
current nursing practice in ICU settings.
 PICOT Question
While caring for an ICU patient with an indwelling
Foley catheter, will continued nurse annual
reeducation/retraining on sterile catheter placement
and care reduce CAUTIs caused by Foley Catheters?
 Summary of Current Practices
Local: Banner
Approved 8/10/2015
Assess Indication:
Relieve a urinary tract obstruction
Permit urinary drainage (straight catheterization)
Aid in healing following urological surgery/injury
Treat gross hematuria with clot retention
Obtain accurate measurements of urinary output in ICU patients
Permit urinary drainage if pt. has a lumbar or low thoracic epidural & up to 6 hours
post epidural
Permit drainage of urine within 24-48 hours post surgery, or patient with
immobilization due to an unstable spine/pelvis
 Local: Banner
Urethral Catheter Insertion:

Utilize standardized catheter kits

Use two trained persons for insertion of female catheters
Hand hygiene & cleansing of the perineum is performed prior to procedure
Water-soluble 2% lidocaine jelly (up to 10mL) may be used to prevent
discomfort
Males have a longer urethra so its encouraged to use lidocaine
Placement is performed following protocol
Banner checklist for male or female
A chaperone is provided
The chaperone also serves as an assistant to the procedure and ensures that sterile
technique is maintained
 Local: Banner
Urethral Catheter Maintenance:
The bag is below the level of the bladder
The catheter tubing is to straight drainage
The catheter is secured using an approved securement device
Assess daily urethral catheter necessity. Must notify physician or LIP if the patient
does not meet listed indications to discuss discontinuation
The bag is kept less than full
Peri-care / urinary catheter care is performed twice daily
Assess for S/S of UTI (fever, chills, pyuria, suprapubic tenderness, flank pain, cloudy
urine, and mental status changes). If signs are present, change or discontinue
urethral catheter
 National: CDC
CDC Guidelines from 2009
The CDC split the recommendation into three key questions:
1. Who should receive urinary catheters?
2. For those who may require urinary catheters, what are the best practices?
Specifically, what are the risks and benefits associated with:
a. Different approaches to catheterization
b. Different catheters or collecting systems
c. Different catheter management techniques
d. Different systems interventions
3. What are the best practices for preventing CAUTI associated with
obstructed urinary catheters?
National: CDC
 National: CDC
Appropriate Urinary Catheter Use
Avoid use of urinary catheters in patients & nursing home residents
for management of incontinence (1B)
o Intermittent catheterization is preferable to indwelling urethral or
suprapubic catheters in patients with bladder emptying dysfunction (II)
Use urinary catheters in operative patients only as necessary, rather
as routinely (1B)
o For operative patients that have an indication for an indwelling catheter,
remove the catheter ASAP, preferably within 24 hours of operation (1B)
 National: CDC
Proper Technique for Urinary Catheter Insertion:
Perform hand hygiene immediately before and after insertion or any
manipulation of catheter device or site (1B)
Ensure that only properly trained persons who know the correct technique of
aseptic catheter insertion & maintenance are given this responsibility (1B)
In the acute care hospital setting, insert urinary catheters using sterile technique
(1B) and clean technique in non-acute care setting (1A)
Unless otherwise clinically indicated, consider using the smallest bore catheter
possible w/ good drainage to minimize bladder neck and urethral trauma (II)
If intermittent catheterization is used, perform it @ regular intervals to prevent
bladder over-distension (1B)
 National: CDC
Proper Techniques for Urinary Catheter Maintenance

Maintain unobstructed urine flow (1B)

Use standard precautions when manipulating the catheter or collecting
system (1B)
Recommended to only change catheters or drainage bags based on
clinical indications such as infection or obstruction (II)
Do not use systemic antimicrobials routinely to prevent CAUTI (1B)
Do not clean the peri-urethral area with antiseptics to prevent CAUTI
while the catheter is in place. Routine hygiene is appropriate (1B)
Routine instillation of antiseptic or antimicrobial solutions into urinary
drainage bags is not recommended (II)
 National: CDC
Education and Training
Ensure the healthcare personnel and others who take care of
catheters are given periodic in-service training regarding
techniques & procedures for urinary catheter insertion,
maintenance, and removal. Provide education about CAUTI, other
complications, and alternatives (1B)
When performing surveillance, ensure there are sufficient trained
personnel and technology resources to support surveillance for
urinary catheter use & outcomes (1B)
o Consider surveillance for CAUTI when indicated by facility-based risk
assessment (II)
 Synopsis of Current Research
Common themes amongst articles:

All research articles included some form of re-education or retraining

All studies pertained to/included patients undergoing urinary
catheterization in hospital settings
Most of the studies measured outcomes were in regards to rates of
CAUTIs
o Of these studies ALL showed a reduction in CAUTI rates post intervention
o Two focused on nurses perceptions/utilization of current preventative resources
All studies were published within the past 5 years, lie between levels
of evidence III-VI, and were published in credible journals
Many articles stressed the importance of nurses in
preventing CAUTIs
 Synopsis of Current Research
Forms of re-education/retraining:

Online learning
Competency validation sessions
Hands-on skill demonstration
General staff education sessions
Aseptic technique review sessions
Insertion competency testing
Post insertion management reviews
Education on alternative options to indwelling catheters
Peer-to-peer teaching
 Topics Included in Re-Education/Re-
Training
Indications for catheterization
Sterile technique for insertion
Proper management once inserted
Avoiding dependent loops
Placing Foley tubing and bag in a manner to avoid urine reflux
Checking Foley bag often to avoid overflow
Assessing perineal area thoroughly and often
Providing perineal care frequently
Indications for catheter removal
Alternative options to catheterization
 Synopsis of Current Research
Other components of intervention bundles
Protocol implementation
o Updating to evidence based recommendations
Implementation of a surveillance system
o Pre, during, and post insertion
Increasing availability of catheterization policy information/resources
Providing staff members with feedback on infection rates
o Increasing accountability
Improving inter-professional communication and teamwork
Empowering nurses
 Synopsis of Current Research
Findings of articles
CAUTI reduction rates
o 1.1%, 20.5%, 30%, 47%, 50%, 72%
Increased nurse confidence
Decreased cost associated with treating/managing CAUTIs
Decrease in catheterization rates
Clinical nurses play the most important role in reducing CAUTIs
Increased hand hygiene and correct placement technique compliance
Decreased catheter days for patients

*Conclusion: Education and training of clinical nurses as well as other staff

members are KEY in reducing the incidence of catheter associated urinary
tract infections.
 Strengths of the Articles
A majority of the articles were level IV or less
CAUTI rates were analyzed in various states, cities, and countries
Upwards of 1,000 patients were followed in select studies (one study even
neared 5,000 patients)
Specifically identified the nursing role in CAUTI prevention
Outlined the exact educational points in the education bundle
Directly measured the effect of re-education on CAUTI rates
Effectiveness of the educational programs was measured
The educational intervention was developed by professionals in infection
control departments and were based on best practice guidelines
Revealed statistics on the participation and adherence to CAUTI guidelines
and prevention practices prior to any type of intervention implementation
 Weaknesses of the Articles
Most of the articles had relatively small sample sizes
o Some just a couple hundred
Most articles utilized multidimensional interventions making it
impossible to narrow down the impact of just education
Many articles were conducted over a relatively short period of time
o Some just a couple months
Since many approaches were multidisciplinary, a compromised
degree of control may have been present
 Evidence-Based Recommendations
Our research supports that best practice includes
implementing an annual, peer-lead retraining program that
focuses primarily on sterile insertion technique for ICU nurses
and new hires in their practice. This education will also include
peer supervision, proper peri-care, and timely catheter removal
as a part of up-to-date CAUTI prevention bundle guidelines
regarding catheters.
Implementation
 Cost Analysis
Average cost per CAUTI incidence: $6834
The length of hospital stay increases 0.5-2.4 days for patients with
CAUTI
o The increased length of stay increases cost of caring for that patient by $1,005-
7,200
o The increased cost is due to need for lab work, antibiotics, and prolonged stay
Average cost of CAUTI for a hospital in the US annually: $115 million -
$1.82 billion
Since 2008, no additional payment has been provided to hospitals by
the Centers for Medicare & Medicaid (CMS) for CAUTI treatment related
costs
 Cost of Evidence Based Practice
Retraining program cost

Infection control trainer: $60/hr for 10 hours = $600/trainer

o Day and night trainers
o Total: $1200 for charge nurse education
4 nurse educators: receiving their normal salary
1 demonstration Foley catheter kit: $13/session
o Total: $1,248
1 male & 1 female perineal model: $400-500
1 Foley catheter kit/each training nurse for practice: $13/person
Peri-care supplies for demonstration and practice: washcloth, water, and
clean gloves: can use already purchased hospital supplies
Total: $2,961 + $13 x number of nurses being reeducated
 Does the Benefit Outweigh the Risk?
In terms of numbers, the savings are significant
oFrom instituting practices that are similar to our evidence based
protocol, a hospital projected an avoidance of $75, 174 for the
following annual year.
Medicare/Medicaid penalty
Prevention of CAUTIs is an issue beyond financial ramifications
As nurses our goal is to care, not harm
Hospitals ratings are affected by CAUTIs & CAUTI prevention
oExample: UMC/BUMC in Tucson
 Risk vs. Benefit: Institution
Risks
Staff (nurse) backlash
o Acceptance vs resentment
by nurses.
Cost
o Nurses paid during
training?
o Re-training cost effective?
Logistics
o Training on hospital time
or nurses personal time?
o At hospital or off-site
Benefits
Reduced CAUTIs
o Reduction rates near 50%!
Reduced hospital costs
of treating CAUTIs
(HAIs)
o Benefits far outweigh cost.
Catheter placement
standard
o All Foley catheter
placement determined by
hospital policy and
evidenced-based research.
 Risk vs. Benefit: Nursing
Risks
Cognitive dissonance
o Retraining resistance.
Constraints of time
o Retraining on personal
time
o Time away from patient
care
Financial
o Paid during training?
o Paying for re-education
certification out-of-
pocket?
Benefits
Evidence-based patient
care
o Best current practice
Stress reduction
o Lower CAUTI rates
o Patient care blame
reduction
CAUTI reduction
o Patient advocacy
 Risk vs. Benefit: Patient
Risks Benefits
Possible temporary Positive outcomes
reduced care o Lessen time in hospital
o Nursing responsibility o Concomitant condition
coverage during training reduction
seminars o Priority-focused care
Otherwise, minimal patient o Reduction of mental
and physiological
risk
burden
Quicker healing times
Patient satisfaction
 Evaluation
The review of CAUTI incidents in the ICU unit three months prior to
the sterile insertion training and three months after the training to
examine reduction rates.
Financial analysis detailing money lost to CAUTIs three months
prior to training, money spent on training, and money spent on
CAUTIs three months after training to formulate a cost-benefit of
evidence based practice.
The collection of total trainer and trainee nurse participants along
with a survey before and after the training evaluating their
knowledge and experience regarding the training.
 Conclusion
Nurses play the most important role in CAUTI prevention
Current research supports nurse re-training/re-education
Application to facility
Risks vs benefits
o Institution
o Nurse
o Patient
Cost analysis
o Hospital cost
o Hospital savings
 References
Alexaitis, I.,& Broome, B. (2014). Implementation of a nurse-driven protocol to prevent catheter-
associated urinary tract infections. Journal of Nursing Care Quality, 29, 245-252. Doi:
10.1097/NCQ.0000000000000041
Banner UMC policies & guidelines database
Blanck, A. W., Donahue, M., Brentlinger, L., Stinger, K. D., & Polito, C. (2014). A quasi-experimental study
to test a prevention bundle for catheter-associated urinary tract infections. Journal of Hospital
Administration, 3(4), 101-108. doi: 10.5340/jha.v3n4p101
Carter, E. J., Palin D. J., Mandel, L., Sinnette, C., & Schuur, J. D. (2016). A Qualitative Study of Factors
Facilitating Clinical Nurse Engagement in Emergency Department Catheter-Associated Urinary Tract
Infection Prevention. The Journal of Nursing Administration, 46, 495.
Doi: 10.1097/NNA.0000000000000392
Fink, R., Gilmartin, H., Richard, A., Capezuti, E., Boltz, M., & Wald, H. (2012). Indwelling urinary catheter
management and catheter-associated urinary tract infection prevention practices in Nurses Improving
Care for Healthsystem Elders hospitals. American Journal of Infection Control, 40, 715-720. Doi:
:10.1016/j.ajic.2011.09.017
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & HICPAC. (2009). Guideline for
prevention of catheter-associated urinary tract infections 2009. Retrieved from
https://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
 References
Leblebicioglu, H., Ersoz, G., Rosenthal, V. D., Nevzat-Yalcin, A., Akan, O. A., Sirmatel, F., Bacakoglu, F.
(2013). Impact of a multidimensional infection control approach on catheter-associated urinary tract
infection rates in adult intensive care units in 10 cities of Turkey: International Nosocomial Infection
Control Consortium findings (INICC). American Journal of Infection Control, 41, 885. Doi:
10.1016/j.ajic.2013.01.028
Marigilano, A., Barbadoro, P., Pennacchietti, L., Marcello, M. D., & Prospero, E. (2012). Active Training
and Surveillance: 2 Good Friends to Reduce Urinary Catheterization Rate. American Journal of Infection
Control, 40, 692-695. Doi: 10.1016/j.ajic.2012.01.021
Pashnik, B., Creta, A., & Alberti, L. (2017). Effectiveness of a nurse-led initiative, peer-to-peer teaching,
on organizational cauti rates and related costs. Journal of Nursing Care Quality, 00(00), 1-7.
doi:10.1097/NCQ.0000000000000249
Sutherland, T., Beloff, J., McGrath, C., Liu, X., Pimentel, M. T., Kachalia, A., Urman, R. D. (2015). A
Single-Center Multidisciplinary initiatice to Reduce Catheter Associated Urinary Tract Infection Rates:
Quality and Financial Implications. The Health Care Manager, 34, 218. Doi:
10.1097/HCM.0000000000000073
Umer, A., Shapiro, D. S., Hughes, C., Ross-Richardson, C., & Ellner, S. (2016). The Use of an Indwelling
Catheter Protocol to Reduce Rates of Postoperative Urinary Tract Infections. Connecticut Medicine, 80,
197-203.
QUESTIONS???
 WHATS WRONG WITH THE
PICTURE????
See if you can spot the improper
technique