When the Bundle is Not Enough

October 5, 2012

By Charise Miltenberger, BSN, MBA, CIC, and Theresa Sampson RN, MSN, CNS

Ben Taub General Hospital (BTGH) is a 575-bed public teaching hospital serving  residents of Harris County, Texas.  It is one of only two designated Level 1 Trauma Centers in Houston, Texas. The Trauma Surgical Intensive Care Unit (TSICU) is a 30-bed unit consisting of 24 open ward beds and six isolation rooms. Catheter-associated urinary tract infections (CAUTIs) are the most common of the healthcare-associated infections (HAIs) in all hospitals across the United States costing $565 million dollars annually. The majority of these CAUTIs (50 percent to 75 percent) are preventable. 

The Trauma Surgical Intensive Care Unit

The Trauma Surgical Intensive Care Unit (TSICU) CAUTI rates for 2011 were consistently above the NHSN benchmark rates of 3.2 infections per 1,000 catheter days. While improvement measures were discussed and a CAUTI prevention bundle was implemented and showed hopeful gains, there was a lack of sustainability. With efforts showing little gain, the infection prevention coordinator (IPC) collaborated with the TSICU to develop a best practice model that went beyond the traditional CAUTI prevention bundle.

First, the infection preventionist led a root-cause interdisciplinary team to identify practice patterns that may be contributing factors.  Feedback was solicited from unit professional and ancillary staff. In addition, the IPC conducted concurrent case reviews on all possible infections which may have had other causes not identified earlier. The outcome of that team was identification of practices that may have contributed to the inability to maintain infection rate improvements. The most important issues were clinical bedside practice variation in both insertion and in catheter maintenance and communication between caregivers.

TSICU staff

The issue of catheter insertion was multi-factorial. The TSICU staff inserts few urinary catheters on the unit as most patients come straight to the unit from the OR, where their catheter has been inserted during surgery, catheter and aseptic technique competencies were not done at orientation or annually, and perineal hygiene was not done before the insertion prep.  A unit competency for Foley catheter insertion for all RNs was added, which will be done annually. Next, all insertion practices including soap and water perineal cleansing before site prep and aseptic technique were standardized.  An insertion checklist was used for every patient before insertion to remind the nurse of the standardized process. Lastly, another RN was used as an observer to ensure proper technique was used during insertion.

The catheter maintenance issues identified were use and availability of securement devices, tubing looping, overfilled Foleys, availability of hand hygiene gel, and improper placement of Foley bags during transport.  The par level was increased for securement devices to ensure availability.  Patients with Foleys were checked daily to make the sure that the securement device was in place. To prevent dependent looping of tubing, minimizing the possibility of backflow, clamps were used.  Frequent rounds were initiated to empty Foleys before overfilling and to determine continued need for the catheter. Hand hygiene product availability was identified at daily rounds, so that 100 percent of the dispensers were filled. Finally, the transport personnel were reeducated about placement of the Foley bag during transport and emptying of tubing to prevent backflow. 

Communication was identified as a major area for improvement. Several strategies were used to improve communication among all caregivers. Daily staff huddles are held to identify patients at high risk for a catheter associated UTI and identification of interventions to prevent an infection.  In addition, information about the CAUTIs that were identified was communicated to the unit staff. The staff was notified when there were no CAUTIs identified so that they could celebrate their success.

As a result of the interventions, the rate of 4.6 infections per 1,000 catheter days in 2011 dropped to 0.4 infections per 1,000 catheter days for year to date 2012, with no infections identified since January. We discovered a real sense of staff accountability concerning these infections. The team became engaged and committed to the decrease of infection rates. Staff also actively participated with the IPC to sustain the improvements. None of these improvements was high tech or costly, but the staff commitment was crucial. 

This best practice model has also been rolled out to medical/surgical units in the month of June 2012, as many of the same issues were identified.  In May the rate was 5.8 per 1,000 catheter days. In June the overall rate for the medical/surgical units was 1.1 infections per 1,000 catheter days and we hope to sustain these gains by following our best practice.

Charise Miltenberger, BSN, MBA, CIC, is infection prevention manager at Ben Taub General Hospital / Quentin Mease Community Hospital  in Houston, Texas. Theresa (Terry) Sampson RN, MSN, CNS, is director of nursing, TSICU and CWU for Ben Taub General Hospital.

On the CUSP:  Stop CAUTI Implementation Guide, Texas Medical Foundation, September 2011.

Guide to the Elimination of Catheter-Associated Urinary Tract Infections, APIC, 2008

Guideline for Prevention of Catheter-Associated Urinary Tract Infections, Healthcare Infection Control Practices Advisory Committee (HICPAC), CDC, 2009.

Translating Health Care-Associated Urinary Tract Infection Prevention Research into Practice via the Bladder Bundle, Olmstead, Russell, et. al. Joint Commission Journal on Quality & Patient Safety, September, 2009; 35(9): 449-455.