Infection Control Today - 04/2004: Mechanical Reduction

Mechanical Reduction of Catheter-Associated Urinary TractInfection Risk

By Maureen Carignan, RN

Urinary catheterization is a knownsource of bacterial infections, which in the worst-case scenario can lead todeath. Numerous antimicrobial technologies have been utilized to reduce theincidence of such infections, with varying rates of success. Somewhat overlooked is the contribution made by improvedmechanical securement of Foley catheters. In fact, preliminary evidence suggeststhat securement methods, not antimicrobials, may be the most effective solutionto urinary tract infection. In addition, clinicians and institutions should notethat proper securement has no downside, a claim that cannot always be made forantimicrobial catheter coatings. In sum, while more research is needed, superiorsecurement has shown such impressive potential for reducing catheter-associatedurinary tract infection (CAUTI) risk that institutions should make it central totheir strategy for addressing the issue.

Dimensions of the CAUTI Problem

Despite modest advances in controlling this problem, CAUTIsremain a frustratingly frequent consequence of urinary catheterization. Morethan 5 million patients every year will be catheterized in American acute-carehospitals and nursing homes.¹ Of those patients catheterized for more than sevendays, up to 25 percent will develop a CAUTI.1 Indeed, CAUTIs constitute the mostcommon nosocomial infection, comprising more than 40 percent of allhospital-acquired infections.¹

Beyond their ubiquity, CAUTIs are also dangerous and costly.The second most common cause of nosocomial bloodstream infection, they have beenshown to nearly triple the risk of death at an institution.² While theseinfections do not extend hospitalization in most cases, they add roughly $500 to$1,000 to direct, acute-care hospitalization costs.¹ This may seem like arelatively minor amount, but the large number of CAUTI cases multiplies theimpact tremendously.

Finally, patients with asymptomatic CAUTIs, who constitute themajority of infected patients, are commonly treated with antimicrobial drugs.While this strategy fights infection, it also selects for drug-resistantpathogens. These bacteria are in turn the source of most nosocomial CAUTIs.¹

Antimicrobial Prevention

Besides antimicrobial drugs, numerous antimicrobial practicesand technologies have been studied since the mid-1970s. The most effective ofthese appears to be a silverhydrogel catheter, the Bardex I.C. Foley (BardMedical, Covington, Ga.). In studies with small sample populations, the BardexI.C. reduced CAUTIs by 26 percent, without causing antimicrobial resistance.¹While an important development, this technology clearly cannot eliminate a largepercentage of CAUTIs.

In small studies, two other medicated catheters bothsignificantly reduced CAUTIs, but the benefit was undercut by the selection ofbacteria resistant to the medications used.¹

Research has been unable to establish benefit for severalother novel technologies, including a sealed junction between the catheter andthe collection tubing, and a catheter coated with silver oxide.1 Some otheranti-infective practices have also failed to prove their efficacy. Catheters have been soaked inanti-infective solutions and antimicrobial lubricants have been used duringinsertion. Anti-infective creams and ointments have been applied. Catheterizedpatients have had their bladders irrigated with antimicrobial solutions, or hadanti-infective solutions added to their collection cases. There is logic to eachof these ideas, but none of them have demonstrated value.¹

The Securement Solution

In contrast to the aforementioned approaches, theeffectiveness of one securement technology, StatLock Foley (VenetecInternational, San Diego, Calif.), may offer dramatic results, according topreliminary research and anecdotal reports. The device consists of a patented,releasable locking mechanism that swivels. The mechanism is affixed to anadhesive foam pad placed on the patients skin. Among the reports of itseffectiveness:

• A continuing care facility in Northern Californiaconducted a sixweek clinical trial of StatLock in an attempt to reduce its CAUTIrate. The facilitys CAUTI rate had averaged 3.46 percent in thefour months preceding the trial. Administration viewed this as an unacceptablyhigh level, considering that it occurred despite use of the above-mentionedBardex I.C. Foley catheter. For the six-week trial period, all patients withFoley catheters (23 males and females) had their catheters secured withStatLock. No CAUTIs occurred in the StatLock-secured patients. Following thetrial, the facility returned to its original practice of not securing Foleycatheters. The CAUTI problem reappeared; for the two-week period after thetrial, the rate was 4.93 percent.³

• At the Clark-Morrison Childrens Urological center atUCLA, Foley catheters were secured with tape prior to adoption of StatLock. Staff suspected tape securement was contributing to the centersCAUTI problem because the sticky surfaces of the tape tended to accumulatecontaminants that were difficult to remove, exposing patients to infection risk.In addition, tape-secured catheters almost inevitably dislodged, and made itdifficult for patients to ambulate after surgery without the catheters pullingon their bladders. StatLock dramatically improved each of these situations. Itmade it easy to clean catheters and eliminated the problem of tapecontamination. Catheter dislodgements ceased, and catheterized patients wereable to move more freely because the device was engineered to move with them.⁴

• These results must be viewed in proper context. Theevaluation at the Northern California facility was a preliminary study with asmall patient sample. The results at the Clark-Morrison center are anecdotal. While suggestive, these data are not definitive. They point tothe need for a prospective, randomized, multi-center trial that wouldconclusively determine whether a Foley-specific adhesive anchor device couldreduce CAUTI risk.

• Given the importance of cost control in todayscompetitive health marketplace, it would also be helpful to determine thefinancial benefit, if any, that adequate securement can provide institutions. Again, preliminary data suggests that the impact can besubstantial if CAUTIs can be completely or nearly eliminated. Compare the costof the StatLock device ($2.99) to the cost of treating CAUTIs (see Dimensionsof the CAUTI Problem above), and then consider the prevalence of infections.The potential for large savings is obvious.

Other Benefits of Proper Securement

When clinicians consider whether to alter protocols to includeFoley catheter securement devices, they should note the additional benefits thatthese devices can confer. For example, eliminating tape securement helps protecthealthcare workers. A study reported in The American Journal ofAnesthesiology has established that tearing tape creates microtears in latexgloves.⁵ Tears expose workers to infection risk.

The StatLock device has also been shown to help preventCarignans Syndrome, as described by the current author and Linda Nelson, RN,BSN. This dangerous syndrome occurs post-operatively when patientswith inadequately secured in-dwelling urinary catheters wake from anesthesia. Traction on the catheter causes the catheter to slip into thebladder neck during surgery, causing extreme pain and agitation, high bloodpressure, accelerated heart rate, occasional aberrant heart beats, andaggressive behavior. First identified at Royal Columbian Hospital (NewWestminster, British Columbia), the syndrome vanished when staff implementedStatLock in conjunction with hooking the urinary drainage bag to the OR table.⁶

Finally, the selection of an appropriate, effective devicelike StatLock avoids the complications caused by less effective or problematicsecurement methods. Some of the problems of tape securement have already beenmentioned. In addition, tape allows painful movements and traction because itdeteriorates over the course of just a few hours. Those same movements andtensions can also cause tissue trauma. Finally, tape can cause local skinreactions and is painful to remove. Elderly patients, who comprise by far thegreatest proportion of Foley-catheterized patients, are particularly vulnerableto tape-related pain and trauma because of their more fragile tissues.

Other securement devices have been developed, but none hasproven adequate and some may themselves be sources of complications. Forexample, circumferential leg straps and fasteners can essentially act astourniquets that can restrict venous and lymphatic flow. This means thatpatients who already suffer from impaired lower-extremity circulation or are atrisk of same will be put at further risk if a leg tourniquet is used on them.The literature accompanying the Dale strap acknowledges this, warning Not foruse on patients with phlebitis, poor circulation or advanced diabetes.⁷Possible complications of constrictive devices such as these include pulmonaryembolism and deep venous thrombosis (DVT).

Among other securement options, some devices employ Velcrofasteners in combination with a tape base. However, their superiority to simpleadhesive tape has not been proven, and in some areas for instance, adherenceand prevention of catheter movement they appear to offer no real benefitover tape.

A Reasonable Approach to Preventing CAUTIs

It is true that the literature has yet to point to a clearprotocol for preventing CAUTIs. But that is no reason for inaction. Theprevalence and potential dangers of CAUTIs demand that clinicians andinstitutions take certain appropriate steps now, based on current knowledge. Itshould be obvious, for example, that because of their complication potential,urinary catheters should only be used when no other alternative exists, andshould be removed as soon as they are no longer necessary.

Beyond this, urinary catheters should be secured with aFoley-specific device that has a documented record of successful use. Currently,the StatLock device fits this description, and others may eventually be proveneffective. Proper securement for infection control appears to be an issue in anysetting where a Foley catheter is used, except where the catheter is used forsimple bladder evacuation during surgery and removed immediately after surgery.It cannot responsibly be overlooked.

Using StatLock in combination with an anti-infective cathetersuch as Bardex I.C. also seems wise in the current environment. Cliniciansshould monitor the literature to see if future studies confirm the considerablepromise of these devices. But they should note that in the meantime, there is noknown downside to the above recommendations and tremendous upside if preliminaryresults are borne out.

Maureen Carignan RN, is senior marketing director, Canada, atVenetec International.