Success Story

January 1, 2002

Success Story
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.

Purpose

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.

Method

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.

Exclusions

  • 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.

Definitions

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
  • Unresponsiveness
  • Urinary tract obstructions
  • Sacral/perineal decubitus

Findings

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.

Conclusions

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.

Editor's note: We welcome your success stories for publication. E-mail them
to kpyrek@vpico.com.