Reducing Catheter-Associated Urinary Tract Infections
By Lynette Smith, RN, BSN, CIC
During the past 10 months, LifeCare Hospitals of Pittsburgh, Inc. has compared data of catheter-associated urinary tract infections (CAUTIs) among its long-term acute care facilities. Analysis of historical data identified LifeCare of Pittsburgh consistently higher in CAUTI rates. The average rate of CAUTIs was 11.07 during the past 10 months while the average total rate for all LifeCare facilities was 7.69.
Because urinary tract infections associated with an indwelling catheter remain the most common site of nosocomial infection, accounting for more than 40% of the total number reported by healthcare facilities and affecting an estimated 600,000 patients per year, this issue became a focus for performance improvement project.1 Through literature review and product presentations it became evident by using specially treated indwelling urinary catheters and associated equipment, the incidence of CAUTIs could be significantly reduced. Two products were reviewed, comparing methods utilized in reducing CAUTIs, efficacy, and cost. A hydrophilic-coated catheter was chosen because studies have shown that neither gram-positive nor gram-negative bacteria adhered to a hydrophilic catheter surface.2 Additionally, the cost of this type of catheter was approximately $4 compared to a silver-coated catheter at approximately $14 per catheter.
The purpose of the Performance Improvement Project (PIP) was to determine the relationship of reducing nosocomial CAUTIs by utilizing a hydrophilic-coated catheter at LifeCare Hospitals of Pittsburgh, Inc. The goal of the PIP was to achieve the comparative rate of 8.0 or less. The patient population included all patients admitted with indwelling urinary catheters and who meet criteria to continue use of indwelling urinary catheters. Criteria of medical necessity for indwelling urinary catheters were approved by LifeCare Hospitals of Pittsburgh, Inc.
The PIP consisted of 30 patients. This number was chosen based on previous infection control CAUTI data for 3 months. The mean date of nosocomial acquired CAUTI in LifeCare Hospitals of Pittsburgh, Inc. based upon historical data was 30 days. Upon admission all patients with medically necessary indwelling urinary catheters had the existing catheter removed and replaced with a hydrophilic catheter. Urine specimens (urinalysis and culture/sensitivity) were collected upon insertion of the experimental catheter. No routine surveillance of bacteria was conducted throughout the PIP.
Urine collection (U/A, C/S) was obtained per physician order if clinical signs or symptoms warranted panculture. Efficacy of the PIP was evaluated based on clinical symptoms and signs of UTI based on Centers for the Disease Control and Prevention's (CDC) definition for UTI.
- Patients without an indwelling urinary catheter.
- Patients diagnosed with a CAUTI upon insertion of the hydrophilic-coated catheter and continue to have the same organism and clinical symptoms of UTI throughout the study.
UTI according to the CDC: A symptomatic urinary tract infection must meet at least one of the following criteria:
- Criterion 1: Patient has at least one of the following signs or symptoms with no other recognized cause: fever (>38oC), urgency, frequency, dysuria, or suprapubic tenderness and patient has a positive urine culture that is >105 microorganisms per cm3.
- Criterion 2: Patient has at least two of the following signs or symptoms with no other recognized cause: fever (>38oC), urgency, frequency, dysuria, or suprapubic tenderness and at least one of the following:
- Pyuria (urine specimen with >10 wbc/mm3)
- Organisms seen on gram stain of unspun urine
- Physician diagnosis of a UTI
- Physician institutes appropriate therapy for a UTI
Criteria for Indwelling Urinary Catheters
- Neurogenic bladder
- Strict intake/output
- Urinary tract obstructions
- Sacral/perineal decubitus
The hydrophilic-coated catheter performance improvement project began Feb 1, 2001 and ran through April 30, 2001. During this 3-month period, a total of 41 patients admitted to LifeCare met the criteria to participate in the project and utilize the experimental Foley catheter product. The mean age of participants was 75.2 years of age; 73% were female and 27% male.
In February, three UTIs associated with the hydrophilic-coated catheter were identified at a rate of 13.1 UTIs per 1,000 catheter days. In March, eight UTIs associated with the hydrophilic catheter identified at a rate of 25.4 UTIs, and in April, five UTIs associated with hydrophilic-coated catheter identified at a rate of 16.2 UTIs.
The organism most commonly identified with the experimental catheter was yeast, at 43.75% of identified symptomatic and treated urinary tract infections. The mean number of days from insertion of catheter to development and treatment of UTI was 14.6 days.
Comparing this data with the LifeCare control group without a "treated" Foley catheter for the three respective months, rates of UTIs associated with the untreated catheter were 16.6, 12.7, and 13.6 UTIs per 1,000 Foley catheter days respectively. The organism most commonly seen with the "untreated" Foley catheter was yeast at 44% of identified symptomatic and treated urinary tract infections. The mean number of days from insertion of catheter to development and treatment of UTI was 13.6 days.
Although the findings do not support the advent of antimicrobial-impregnated or coated catheters as an important addition to our armamentarium of preventive strategies to reduce nosocomial UTIs associated with indwelling Foley catheters, literature claims these devices can reduce the incidence of UTIs associated with indwelling Foley catheters. LifeCare's existing body of evidence suggest that attention to simple and practical interventions will lead to a reduction in potentially devastating UTIs associated with indwelling Foley catheters.
The primary focus at LifeCare will remain in the ongoing assessment of the medical necessity for the patient to have an indwelling Foley catheter and removal of the catheter as soon as possible. This strategy will remain paramount to the positive outcome of patients in the prevention of nosocomial UTIs associated with indwelling Foley catheters. Finally, sterile technique being an optimal condition during insertion of the indwelling Foley catheter and basic urinary catheter care and maintenance exceed any commercially available Foley catheter product.
Lynette Smith, RN, BSN, CIC, is the infection control coordinator for LifeCare Hospitals of Pittsburgh, PA.
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