Success Story

Success Story
Reducing Catheter-Associated Urinary Tract Infections

By Lynette Smith, RN, BSN, CIC

During the past 10 months, LifeCare Hospitals of Pittsburgh, Inc. hascompared data of catheter-associated urinary tract infections (CAUTIs) among itslong-term acute care facilities. Analysis of historical data identified LifeCareof Pittsburgh consistently higher in CAUTI rates. The average rate of CAUTIs was11.07 during the past 10 months while the average total rate for all LifeCarefacilities was 7.69.

Because urinary tract infections associated with an indwelling catheterremain the most common site of nosocomial infection, accounting for more than40% of the total number reported by healthcare facilities and affecting anestimated 600,000 patients per year, this issue became a focus for performanceimprovement project.¹ Through literature review and productpresentations it became evident by using specially treated indwelling urinarycatheters and associated equipment, the incidence of CAUTIs could besignificantly reduced. Two products were reviewed, comparing methods utilized inreducing CAUTIs, efficacy, and cost. A hydrophilic-coated catheter was chosenbecause studies have shown that neither gram-positive nor gram-negative bacteriaadhered to a hydrophilic catheter surface.² Additionally, the cost ofthis type of catheter was approximately $4 compared to a silver-coated catheterat approximately $14 per catheter.

Purpose

The purpose of the Performance Improvement Project (PIP) was to determine therelationship of reducing nosocomial CAUTIs by utilizing a hydrophilic-coatedcatheter at LifeCare Hospitals of Pittsburgh, Inc. The goal of the PIP was toachieve the comparative rate of 8.0 or less. The patient population included allpatients admitted with indwelling urinary catheters and who meet criteria tocontinue use of indwelling urinary catheters. Criteria of medical necessity forindwelling urinary catheters were approved by LifeCare Hospitals of Pittsburgh,Inc.

Method

The PIP consisted of 30 patients. This number was chosen based on previousinfection control CAUTI data for 3 months. The mean date of nosocomial acquiredCAUTI in LifeCare Hospitals of Pittsburgh, Inc. based upon historical data was30 days. Upon admission all patients with medically necessary indwelling urinarycatheters had the existing catheter removed and replaced with a hydrophiliccatheter. Urine specimens (urinalysis and culture/sensitivity) were collectedupon insertion of the experimental catheter. No routine surveillance of bacteriawas conducted throughout the PIP.

Urine collection (U/A, C/S) was obtained per physician order if clinicalsigns or symptoms warranted panculture. Efficacy of the PIP was evaluated basedon clinical symptoms and signs of UTI based on Centers for the Disease Controland 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 atleast one of the following criteria:

• Criterion 1: Patient has at least one of the following signs or symptoms with no other recognized cause: fever (>38^oC), 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 (>38^oC), 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 41patients admitted to LifeCare met the criteria to participate in the project andutilize the experimental Foley catheter product. The mean age of participantswas 75.2 years of age; 73% were female and 27% male.

In February, three UTIs associated with the hydrophilic-coated catheter wereidentified at a rate of 13.1 UTIs per 1,000 catheter days. In March, eight UTIsassociated with the hydrophilic catheter identified at a rate of 25.4 UTIs, andin April, five UTIs associated with hydrophilic-coated catheter identified at arate of 16.2 UTIs.

The organism most commonly identified with the experimental catheter wasyeast, at 43.75% of identified symptomatic and treated urinary tract infections.The mean number of days from insertion of catheter to development and treatmentof UTI was 14.6 days.

Comparing this data with the LifeCare control group without a"treated" Foley catheter for the three respective months, rates ofUTIs associated with the untreated catheter were 16.6, 12.7, and 13.6 UTIs per1,000 Foley catheter days respectively. The organism most commonly seen with the"untreated" Foley catheter was yeast at 44% of identified symptomaticand treated urinary tract infections. The mean number of days from insertion ofcatheter to development and treatment of UTI was 13.6 days.

Conclusions

Althoughthe findings do not support the advent of antimicrobial-impregnated or coatedcatheters as an important addition to our armamentarium of preventive strategiesto reduce nosocomial UTIs associated with indwelling Foley catheters, literatureclaims these devices can reduce the incidence of UTIs associated with indwellingFoley catheters. LifeCare's existing body of evidence suggest that attention tosimple and practical interventions will lead to a reduction in potentiallydevastating UTIs associated with indwelling Foley catheters.

The primary focus at LifeCare will remain in the ongoing assessment of themedical necessity for the patient to have an indwelling Foley catheter andremoval of the catheter as soon as possible. This strategy will remain paramountto the positive outcome of patients in the prevention of nosocomial UTIsassociated with indwelling Foley catheters. Finally, sterile technique being anoptimal condition during insertion of the indwelling Foley catheter and basicurinary catheter care and maintenance exceed any commercially available Foleycatheter product.

Lynette Smith, RN, BSN, CIC, is the infection control coordinator forLifeCare Hospitals of Pittsburgh, PA.

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