Catheters, both central venous and urinary, are medical devices that save lives, but they also can contribute to significant patient morbidity and mortality if the proper techniques for insertion, maintenance and removal are not followed. We review the basics of interventions related to infection prevention and control.
Catheter-Associated Urinary Tract Infections (CAUTIs)
More than 30 million urinary catheters are inserted annually in the United States, accounting for as many as 1 million CAUTIs. Saint (2000) reports that as much as one-quarter of patients are catheterized, and many are due to increased acuity of their illness, the complexity of care and decreased staffing levels. Klevens, et al. (2007) report that CAUTIs comprised more than one-third of the total number of healthcare-acquired infections (HAIs) which include bloodstream infections, surgical site infections and hospital-acquired pneumonia. It has also been documented that the presence of indwelling urinary catheters for two to 10 days can trigger bacteriuria (Saint, 2000).
Particularly germane to infection preventionists are the risk factors associated with the development of a CAUTI, including the duration of catheterization and breaches in catheter-care protocol. (Salgado et al., 2003), as well as the recognition of the complications and adverse outcomes associated with indwelling catheters, including urinary tract infection (UTI), secondary bacteremia/sepsis, the creation of a reservoir for multidrug-resistant organisms (MDROs), prolonged hospital stay and even mortality. An estimated 17 percent to 69 percent of CAUTIs may be preventable with recommended infection control measures, which means that up to 380,000 infections and 9000 deaths related to CAUTIs per year could be prevented. (Umscheid, 2008)
To help infection preventionists navigate CAUTI prevention and control, the Association for Professionals in Infection Control and Epidemiology (APIC) in 2008 issued its Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs), part of the organization’s ongoing series of HAI elimination guides. One of the CAUTI guide’s three co-authors, Linda Greene, RN, MS, CIC, director of infection prevention for Rochester General Health System in Rochester, N.Y., explains the impetus for the creation of the guide: “In keeping with APIC’s 30-plus year mission of delivering science to the bedside, the APIC CAUTI guideline was developed to serve as a definitive, comprehensive tool to questions raised by more than 13,000 infection preventionists worldwide. As such, APIC continues to update such vital documents in sync with guidelines released by HICPAC, thereby translating evidence into clinical practice and sharing strategies and tools for the successful implementation of evidence-based practices.”
Greene says that one of the real-life worries relating to CAUTIs that she brought to the guide-writing process is awareness of the problem itself. “Despite the fact that UTIs are the most common healthcare-acquired infections, they have traditionally not received the level of attention as have other HAIs.” She adds, “Because UTIs can compromise one of the largest reservoirs of multidrug-resistant bacteria in healthcare settings, it is essential that we find ways to minimize their occurrence. A recent study identified that no strategy is consistently or universally used in U.S. hospitals to prevent these infections. We hope that this guide can be used to highlight the importance of CAUTI prevention efforts and bridge the gap between evidence and implementation.”
Last year, the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) issued its Guideline for the Prevention of Catheter-Associated Urinary Tract Infections (Gould, et al. (2009), replacing its outdated 1981 guidance. The new guidance was necessitated, HICPAC said, due to new research and technological advancements for preventing CAUTI, the increasing need to address patients in non-acute care settings and patients requiring long-term urinary catheterization, and the greater emphasis on prevention initiatives as well as better defined goals and metrics for outcomes and process measures. The guideline provided recommendations on who should receive indwelling urinary catheters; recommendations for catheter insertion; recommendations for catheter maintenance; quality improvement programs to achieve appropriate placement, care and removal of catheters; administrative infrastructure required; and surveillance strategies.
Greene says that APIC’s CAUTI elimination guide is consistent with the HICPAC guideline, and emphasizes the take-home message for practitioners: “The strongest predictor of a urinary tract infection is duration of catheterization and the infection preventionist plays a key role in helping clinical staff standardize practices to assure that catheters are inserted only when necessary and are removed when no longer indicated,” she says. “The infection preventionist plays a pivotal role in sharing knowledge, providing real time data and helping to integrate infection prevention efforts across the institution and into everyone’s responsibility.”
According to APIC’s CAUTI guide, the following practices should be implemented in CAUTI prevention efforts:
Use indwelling catheters only when medically necessary
Use aseptic insertion technique with proper hand hygiene and glove use
Properly secure catheters after insertion to prevent movement and urethral traction
Remove catheters when no longer necessary
Consider alternatives to indwelling urethral catheters, such as intermittent catheterization
Catheter-Related Bloodstream Infections (CRBSIs)
There is no dearth of information related to CRBSIs in the medical literature, as it appears to be one of the most well documented and studied HAIs. It has been estimated by Raad, et al. (2007) that a mortality rate of 12 percent to 25 percent can be attributed to catheter-related bacteremia among critically ill patients. Crnich and Maki (2005) suggest that the most significant sources of CRBSI are device colonization or infusion of contaminated fluid, and that access to the device surface by pathogens can be accomplished through invasion of the percutaneous tract during catheter insertion or in subsequent days; contamination of the catheter hub during guidewire insertion or during other manipulation; and seeding from a remote source of localized infection.
CRBSIs are clearly preventable, as demonstrated by the Michigan Health and Hospital Association’s Keystone Center for Patient Safety and Quality Keystone ICU project (see related article on page 8). The 67 hospitals involved in the project implemented five evidence-based practices (hand hygiene, barrier precautions during insertion, skin cleansing with chlorhexidine gluconate, avoidance of the use of the femoral site, and removal of unnecessary catheters) were able to reduce their median CRBSI rate per 1,000 catheter days from 2.7 infections at baseline to zero at three months after implementation of the five-step intervention.
APIC’s 2009 Guide to the Elimination of Catheter-Related Bloodstream Infections (CRBSIs) outlines the progression of research relating to CRBSI prevention and control, noting that, “Emerging technologies, improvements in the evidence base, and promotion to facilities’ administration and infection prevention staff of ‘bundled’ prevention measures to be used during catheter insertion have revolutionized the strategies employed by clinicians to reduce CRBSIs.” Recent guidance has come from the Department of Health and Human Services (HHS) in its 2009 Action Plan to Prevent Healthcare-Associated Infections. In this document, the HHS gathered recommendations from the CDC’s Category 1A recommendations as follows:
Maintain aseptic technique during insertion and care of intravascular catheters
Use aseptic technique including the use of a cap, mask, sterile gown, sterile gloves, and a large sterile drape, for the insertion of central venous catheters (CVC),including for peripherally inserted central catheters (PICC) and guide wire exchange
Apply an appropriate antiseptic to the insertion site on the skin before catheter insertion and during dressing changes
Although a 2 percent chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor, or 70 percent alcohol can be used
Select the catheter, insertion technique and insertion site with the lowest risk for complications (infectious and noninfectious) for the anticipated type and duration of IV therapy
Use a subclavian site (rather than a jugular or a femoral site) in adult patients to minimize infection risk for non-tunneled CVC placement
Weigh the risk and benefits of placing a device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism and catheter misplacement)
Use either sterile gauze or sterile, transparent, semi-permeable dressing to cover the catheter site
Promptly remove any intravascular catheter that is no longer essential
Replace the catheter-site dressing when it becomes damp, loosened or soiled or when inspection of the site is necessary
Crnich CJ and Maki DG. The promise of novel technology for the prevention of intravascular device-related bloodstream infection. Ann Intern Med. 142(6):451-466. 2005.
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for the Prevention of Catheter-Associated Urinary Tract Infections, 2009.
Greene L, Marx J and Oriola S. Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs). APIC Elimination Guide. 2008.
Murphy C, et al. Guide to the Elimination of Catheter-Related Bloodstream Infections (CRBSIs). APIC Elimination Guide. 2009.
Raad I, Hanna H and Maki DG. Intravascular catheter-related infections: Advances in diagnosis, prevention and management. Lancet Infect Dis. 7(10):645:657. 2007.
Umscheid C, Mitchell M, Agarwal R, Williams K, Brennan P. Mortality from reasonably-preventable hospital-acquired infections. Included in written testimony by the Society of Healthcare Epidemiology of America for the Committee on Oversight and Government Reform Hearing on HAIs. April 16, 2008.