Success in Fighting Catheter-Related Urinary Tract Infections

In this era of antibiotic resistance, a catheter-associated urinary tract infection, (CAUTI) can have a significant effect on patients and on hospital systems. Urinary catheters are used in 15 percent to 25 percent of all hospital patients, to monitor urine output or to provide bladder drainage. They are passed via the urethra into the bladder, and because they bypass the normal defense mechanisms of the body, there are risks associated with their use. Urinary tract infections (UTIs) are the most common problem associated with the use of indwelling catheters. Other potential complications include urethritis, urethral strictures, hematuria, bladder perforation, and encrustation of the catheter leading to blockage of the urine flow.

UTIs are one of the most common nosocomial infections, accounting for approximately 20 percent to 40 percent of all hospital-acquired infections and 80 percent of these are associated with the use of indwelling urinary catheters. Most studies advise that between 10 percent and 30 percent of patients with short-term catheters will develop bacteriuria. Multi-center studies of intensive care units found the prevalence of UTIs to range from 2.4 percent to 17.6 percent. CAUTIs have been shown to prolong the mean length of hospital stay by 2.4 days to 4.5 days and are associated with an increased in hospital mortality. The results of two studies indicated that there is a lower rate of bacturia in surgical patients who have a catheter for only one day vs. three days, however when the catheter was removed after one day the retention and recatheterization rate was higher. Possible complications need to be considered when deciding on the length of time of catheterization. As patients with positive pre-operative urine cultures were included in the studies, it was difficult to establish the rate of bacteruria that occurred as a result of catheterization. A retrospective review of 100 renal transplant patients who had their catheters removed within 48 hours of surgery revealed a significantly lower rate of UTIs than in patients with catheters left in for longer periods supporting previous study findings. A case-matched and controlled study showed a significant increase in the post-operative stay for patients with catheter-related urinary tract infection that accounted for substantial hospitalization cost per patient.

In our 150-bed urban hospital, infection control performed a snapshot of the number of patients who had indwelling catheters. We found that 35 percent had been in place for more than 48 hours, 20 percent had no orders, and 81 percent had no mention of the catheter in progress notes, although 80 percent did have an order for catheter insertion. We felt this to be rather dismal!

One of our energetic nursing students took this on as a leadership project, implementing a chart flagging mechanism to remind physicians and nurses to assess the need to continue or discontinue a patient's indwelling urinary catheter.

After aggressive education and train-the-trainer sessions, the computer-driven awareness trigger for urinary catheters in place for more than 48 hours was implemented. Four months later, infection control performed a second snapshot and found that 46 percent of the patients had urinary catheters in place, without orders, therefore the computer driven trigger never fired. Out of those with the trigger in place, 77 percent were not addressed at 48 hours. This was hardly an improvement!

At this point, infection control decided to put a forcing function in place on all physician standing orders. This statement reads, If patient has an indwelling urinary drainage catheter, please remove 24 hours after surgery, unless otherwise directed by physician.

The other option for physicians to place in their standing orders was Indwelling urinary catheter to bedside drainage. Discontinue by 0600 post op day No. 1 or when epidural is removed. If patient is unable to void, bladder scan every 4-6 hours, straight cath as needed to maintain bladder volumes greater than 400 mL. Begin intermittent self-cath teaching.

A third snapshot after education and implementation showed that 100 percent of the patients with urinary catheters had orders, no one had a urinary catheter in longer than 24 hours without physician documentation, and there have been no complaints from physicians or nursing. In 2005, only 2 percent of our patients with urinary catheters acquired catheter-associated urinary tract infections, none of which led to bacteremia. That is down from 5 percent in 2004 and 7 percent in 2003.

This method proved successful for us. With the continued nursing shortage, it is important to reduce workload wherever possible. The continual addition of just one more task onto nursing personnel adds to job frustration and burnout. Building the solution into the system has been a win-win for the patient, physician, and nurse in our healthcare facility. 

Bibliography

Dunn S, Pretty L, Reid H, and Evans D. Management of short term indwelling Urethral catheters to prevent urinary tract infections, 2000, No. 6, The Joanna Briggs Institute, Adelaide. Saint S and Lipsky BA. Preventing catheter-related bacteriuria; should we? can we? how?, Archives of Internal Medicine, 1999, 159; 8, 800-8. 10. Platt R, Polk BF, Murdock B, Rosner B. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1983;1:893-7. Huth TS, Burke JP, Larsen RA, Classen DC, Stevens LE. Clinical trial of junction seals for the prevention of urinary catheter-associated bacteriuria. Archives of Internal Medicine 1992;152:807-12. Dobbs SP, Jackson SR, Wilson AM, Maplethorpe RP, Hammond RH. A prospective, randomized trial comparing continuous bladder drainage with catheterization at abdominal hysterectomy. British Journal of Urology 1997;80(4):554-6.