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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
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:
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.