Deborah A. Lichtenberg, RN, BSN, CIC Infection Preventionist Bard Medical 1

Deborah A. Lichtenberg, RN, BSN, CIC

Infection PreventionistBard Medical

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I am an employee of C. R. Bard, Inc., Bard Medical.Any discussion regarding Bard products during my

presentation is limited to information that is consistent with Bard labeling for those products.

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Describe the impact of CAUTIs on patient outcomes and hospital costs.

Explain the pathogenesis of CAUTIs including the role of biofilm.

Identify 4 changes/updates impact CAUTI surveillance and prevention.

Review changes in practice identified above and the role of the hospital ICP.

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Urinary tract infections are the most common type of healthcare-associated infection, accounting for more than 30% of infections reported by acute care hospitals.

◦ Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract.

Between 15% and 25% of hospitalized patients may receive short-term indwelling urinary catheters.

Reported rates of UTI among patients with urinary catheters vary substantially. ◦ National data from NHSN acute care hospitals in 2006

showed a range of pooled mean CAUTI rates of 3.1-7.5 infections per 1000 catheter-days.

The highest rates were in burn ICUs, followed by inpatient medical wards and neurosurgical ICUs

The lowest rates were in medical/surgical ICUs.

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Average cost of each uncomplicated UTI in 1992 was reported at $6804

- Based on total of 84 patients Average cost impact of each UTI reported in

1996 was $3,8035

- Based on 675 cases, 5,337 controls

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At time of insertion◦Mechanical during catheter insertion the catheter picks up organisms

urethral trauma during insertion◦Blockage of periurethral glands

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• Extraluminal– Biofilm– Encrustation– Organisms migration– Fecal incontinence

• Intraluminal– Disconnection of catheter/drainage system– Contamination of outlet tube– Encrustation– Biofilm

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3 “Ports of Entry”◦Catheter / Meatal Junction

◦Catheter / Tube Junction

◦Outlet Tube

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Bacteria switch from a free-floating (planktonic) state where they function as individuals to a sessile state where they

function as communities9

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• Catheter coatings are available to reduce bacterial adherence and prevent biofilm formation

• Silver– Bardex® I.C. Anti-Infective Foley Catheter*– Dover™ Silver Foley Catheter– Silvertouch™ Foley Catheter

• Nitrofurazone– Release-NF® Anti-Infective Foley Catheter

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Pseudomonas aeruginosa

Reduced densities of bacteria @ 2hrs on a Silver and Hydrogel

coated Foley catheter

Pseudomonas aeruginosa

Note extensive cell damage to organisms

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It all begins with Awareness– What is the clinical impact of CAUTI ? 9

• UTIs account for 40% of all HAIs and of these, 80% are associated with urinary catheterization.– What CAUTI lack in terms of severity they make up with in terms of

volume• UTIs are the second most common cause of bloodstream

infections and due to their frequency and subsequent treatment they are one of the largest breeding grounds for antibiotic resistant organisms

– What is the financial impact of CAUTI ?9

• UTIs cost U.S. hospitals more than $500 million per year to treat and can increase a patient’s length of stay by 3.8 days – Cost to Treat– Additional length of stay– Loss of CMS reimbursement

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Changes in Reimbursement for Healthcare Acquired CAUTI

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◦ Hospitals will not receive additional payment for cases where the condition was not present upon admission

Blood incompatibility Air embolism Object left after surgery Mediastinitis after CABG surgery Injuries from falls Vascular catheter associated infection Pressure ulcers Catheter associated urinary tract infection

(CAUTI)

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33 45 108 764

175,000

248,678

322,946

561,667

0

100000

200000

300000

400000

500000

600000

WrongBlood

Air Embolism Mediastinitis Objects Leftin PostSurgery

Injuries fromFalls

VascularCatheter

Infections

PressureUlcers

CA-UTI

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• High Volume: CDC reports there are 561,667 CAUTI every year– Most common healthcare-associated infection

• High Cost: APIC HAI Cost Calculator estimates cost to treat urinary tract infection $1,006 plus 6.3 days excess length of stay

• Assignment to Higher Paying DRG: Code 996.64

• Reasonably Preventable: Prevention guidelines exist

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◦ 10% of Medicare discharges had a secondary diagnosis of UTI (2006 MedPAR)

◦ Hospitals reimbursed $216M for these infections

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Medicare believes this will provide hospitals with additional incentive to engage in quality improvement efforts such as HAI reduction measures

Presently they are developing a Value-Based Purchasing Rule (VBP) based on criteria from the Patient Protection and Affordable Care Act (ACA) 2010

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Change in NHSN/CDC Definition for CA-UTIs7

New HICPAC/CDC Guidelines for UTI Prevention9

Surgical Care Improvement Project (SCIP)10

APIC Guide to Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs)11

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UTI Definition for Patients with an Indwelling Foley Catheter7

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# of symptomatic UTI / 1,000 urinary catheter days as measured in NHSN◦ National 5-Year Prevention Target: 25%

decrease from baseline Appendix G in HHS plan discusses a new

type of metric, the standardized infection ratio (SIR)

http://www.hhs.gov/ophs/initiatives/hai/prevtargets.htmlhttp://www.hhs.gov/ophs/initiatives/hai/appendices.html

Examples of metrics:◦ Number of CAUTI per 1000 catheter-days◦ Number of BSI secondary to CAUTI per 1000

catheter-days◦ Catheter utilization ratio (urinary catheter-

days/patient-days) x 100 Use CDC/NHSN definitions for numerator

data (SUTI only): http://www.cdc.gov/nhsn/library.html

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Symptomatic Infection Do catheterized patients have symptoms? Asymptomatic Bacteriuria Is it or is it not just colonization?

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NHSN SUTI 1-A NHSN SUTI 2-A CLINICAL CAUTI 8 NHSN ABUTI

FOLEY 1a-1 Foley is currently in place

1a-2 Foley is out within last 48 hours

2a-1 Foley is currently in Place

2a-2 Foley is out within last 48 hours

Is in place or out within last 48 hours

Is in place or out within last 48 hours

COLONY COUNT

≥100,000 ≥100,000 ≥1,000 and <100,000 ≥1,000 and <100,000 ≥100,000 ≥100,000

SIGNS, SYMPTOMS MARKERS

1 of the following--Temp 38C or >--CVA pain/tender--S/P pain/tender

1 of the following--Temp 38C or >--CVA pain/tender--S/P pain/tender--Urgency--Frequency--Dysuria

1 of the following--Temp 38C or >--CVA pain/tender--S/P pain/tender

PLUS1 of the following--Positive dipstick--Positive pyuria

1 of the following--Temp 38C or >--CVA pain/tender--S/P pain/tender--Urgency--Frequency--Dysuria

PLUS1 of the following--Positive dipstick--Positive pyuria

--Fails NHSN defPLUS

1 of the following--MS changes--Urine character--PVR/retention--CBC leukocytosis

PLUS1 of the following--Positive dipstick--Positive pyuria

PLUS--Physician treated

--No symptoms--Matched BC(at least 1 org)

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What are clinically relevant infections?8

◦ Clinical indicators◦ Physician diagnosis/treatment

8 McGeer A., et al.. Definitions of Infections for Surveillance in Long Term Care

Facilities, Am J Infect Control 1991; 19(1); 1-7.

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Examples of programs that have been demonstrated to be effective include:

◦ A system of alerts or reminders to identify all patients with urinary catheters and assess the need for continued catheterization

◦ Guidelines and protocols for nurse-directed removal of unnecessary urinary catheters

◦ Education and performance feedback regarding appropriate use, hand hygiene, and catheter care

◦ Guidelines and algorithms for appropriate peri-operative catheter management, such as: Procedure-specific guidelines for catheter placement and

postoperative catheter removal Protocols for management of postoperative urinary

retention, such as nurse-directed use of intermittent catheterization and use of ultrasound bladder scanners

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• Although there have been several articles related to decreasing catheter usage, not all of these studies measured CAUTI as an outcome

– At urinary catheter removal, 51 participants (19%) in the stop-order group developed urinary tract infection compared with 51 (20%) in the usual care group, relative risk 0.94, (95% CI, 0.66 to 1.33), P=0.71

– At 7 days post catheterization, 28 of those tested (21.1%) in the stop-order group compared to 19 (16.7%) in the usual care group had urinary tract infections, relative risk 1.26 (95% CI, 0.75 to 2.14), P=0.38.

• Study demonstrated that Foley catheter stop orders safely reduced Foley catheter usage but failed to reduce CAUTI

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If the CAUTI rate is not decreasing after implementing a

comprehensive strategy to reduce rates of CAUTI, consider using antimicrobial/antiseptic-impregnated catheters. The comprehensive strategy should include, at a minimum, the high priority recommendations for urinary catheter use, aseptic insertion, and maintenance (Category IB)

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• CAUTI Prevention Techniques– Appropriate Foley catheter Utilization– Proper Foley catheter Insertion, Maintenance, Removal– Monitoring Compliance – Continuing Education and Training

• CAUTI Prevention Technology– Bladder Scanners– Antimicrobial Foley Catheters

Its not about what type of CAUTI prevention method works best; its about using every available method to try and prevent every CAUTI

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PURPOSEPURPOSE

To provide evidence-based practice guidance for the prevention of Catheter Associated Urinary Tract Infection (CAUTI) in acute and long term settings.

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“Although infection control measures are the mainstay approach for preventing device-

related infection, adherence to such measures is often inconsistent. That is why infection

control measures need to be complemented with truly protective technology.”

- Rabih O. Darouiche, M.D.

Taken From Medical Devices Pose Big Infection Threat Copyright 2009 by Virgo Publishing. By: By Michelle Beaver Posted on: 08/28/2008

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The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications. 10

The SCIP goal is to reduce the incidence of surgical complications nationally by 25 percent by the year 2010.

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SCIP-Inf-9◦ Urinary catheter removed on Postoperative Day

(POD) 1or 2.

3 data elements added◦ Urinary Catheter◦ Catheter removal◦ Reasons for continuing urinary catheterization

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For Infection Preventionist Direct Patient Caregiver

Policy and best practice expertise

Provision of surveillance data and risk assessment

Consultation on infection prevention interventions

Facilitation of CAUTI-related surveillance improvement projects.

• Proper insertion of the Foley catheter

• Proper care and maintenance of the

Foley catheter system

• Must be held accountable for compliance with interventions.

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Purpose◦ To develop a surveillance, prevention and control

plan based on facility specific data and conditions

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Assess whether an effective organizational program exists.

Assess population at risk ◦ Point Prevalence Survey

Assess baseline outcome data Determine financial impact

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Criteria for CAUTI Coding HAI Surveillance Data

Physician documentation of UTI, cystitis, urethritis or pyelonephritis

Used to establish UTI Surveillance definition must be used

Documentation or clarification UTI associated with catheter

MD must document

Code 996.64 assigned

Documentation by MD not used.Presence of catheter is documented by direct observation or in chart

Antibiotic Treatment Not sole criteria but coder may seek MD clarification

Not used. Must use surveillance definition

Lab Data Not used to establish UTIMay be used to seek clarification by coder

Surveillance definition.Combined with other criteria in some cases

Clinical Signs and Symptoms

No coder may query MD for clarification but may query for cause of S/S

Surveillance definition. Combined with other criteria.

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• Assess need for Foley on a daily basis

• Implement early removal processes– Physician reminder systems– Nurse driven protocols– Automatic stop orders

• Early Foley removal for the surgical patient

• Consider routine use of bladder scanners

• Consider technology as addition to the comprehensive prevention plan

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• Aseptic insertion and maintenance• Bladder ultrasound may avoid indwelling

catherization• Condom or intermittent catherization in

appropriate patients• Do not use the indwelling catheter unless

you must.• Early removal of the catheter using

reminders or stop orders.

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Are CAUTIs a Target for Improvement?◦ Change in CDC Definition/Reporting to NHSN◦ Changes in CMS Reimbursement◦ Guidelines

SHEA Compendium HICPAC/CDC SCIP APIC Guide to Elimination of CAUTIs

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CAUTIs Are Important CAUTIs Have Serious Clinical and

Economic Consequences Actions Can be Taken to Reduce CAUTIs

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QUESTIONS?

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1. Weinstein RA. Nosocomial Infection Update. Emerging Infectious Diseases. 1998; 4(3): 416-420.

2. Salgado CD, Karchmer TB, and Farr BM. Prevention of Catheter-Associated Urinary Tract Infection. In Prevention and Control of Nosocomial Infections, 4thEd. Wenzel RP Ed. Philadelphia: Lippincott, Williams, and Wilkins, 2003.

3. Saint S and Chenoweth CE. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin N Am. 2003; 17:411-432.

4. Public health focus: surveillance, prevention and control of nosocomial infections. MMWR Morb Mortal Wkly Rep. 1992; 41:783-787.

5. Classen D. Assessing the effect of adverse hospital events on the cost of hospitalization and other patient outcomes. University of Utah, 1993.

6. SHEA Compendium, Strategies to Prevent Catheter Associated Urinary Tract Infections in Acute Care Hospitals. Infect Control Hospital Epidemiol 2008; 29: S41-S0.

7. National Healthcare Safety Network (NHSN) Manual, March 2009.8. McGeer A., et al.. Definitions of Infections for Surveillance in Long Term

Care Facilities, Am J Infect Control 1991; 19(1); 1-7.9. HICPAC. Guideline for Prevention of Catheter-Associated Urinary Tract

Infections; 2009.10. Surgical Care Improvement Project., 2010; Version 3.0a.11. APIC Guide to the Elimination of Catheter-Associated Urinary Tract Infections

(CAUTIs), 2008.

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www.APIC.org

www.SHEA-online.org

www.cfmc.org/hospital/hospital_SCIP.html

www.cdc.gov/ncidod/dhap/hicpac_pub.html

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Compliance with hand hygiene Compliance with educational program Compliance with documentation of catheter

insertion and removal Compliance with documentation of

indications for catheter placement

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Intermittent catheterization – consider for:◦ Patients requiring chronic urinary drainage for

neurogenic bladder Spinal cord injury Children with myelomeningocele

◦ Postoperative patients with urinary retention◦ May be used in combination with bladder

ultrasound scanners External (i.e., condom) catheters –

consider for:◦ Cooperative male patients without obstruction

or urinary retentionhttp://www.cdc.gov/hicpac/cauti/001_cauti.html

Consideration of alternatives to indwelling urinary catheterization (II)

Use of portable ultrasound devices for assessing urine volume to reduce unnecessary catheterizations (II)

Use of antimicrobial/antiseptic-impregnated catheters (IB, after first implementing core recommendations for use, insertion, and maintenance )

The following slides will provide further details on supplemental strategies…

httpwww.cdc.gov/hicpac/cauti/001_cauti.html ://

Implement quality improvement programs to enhance appropriate use of indwelling catheters and reduce risk of CAUTIExamples:

―Alerts or reminders―Stop orders―Protocols for nurse-directed removal of

unnecessary catheters―Guidelines/algorithms for appropriate

perioperative catheter management

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Maintain unobstructed urine flow◦ Keep catheter and collecting tube free from

kinking◦ Keep collecting bag below level of bladder at all

times (do not rest bag on floor)◦ Empty collecting bag regularly using a

separate, clean container for each patient. Ensure drainage spigot does not contact nonsterile container.

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Following aseptic insertion, maintain a closed drainage system◦ If breaks in aseptic technique, disconnection, or

leakage occur, replace catheter and collecting system using aseptic technique and sterile equipment

◦ Consider systems with preconnected, sealed catheter-tubing junctions (II)

◦ Obtain urine samples aseptically

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Insert catheters using aseptic technique and sterile equipment (acute care setting)◦ Perform hand hygiene before and after insertion◦ Use sterile gloves, drape, sponges, antiseptic or

sterile solution for periurethral cleaning, single-use packet of lubricant jelly

◦ Properly secure catheters

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Insert catheters only for appropriate indications◦ Minimize use in all patients, particularly those

at higher risk of CAUTI and mortality (women, elderly, impaired immunity)

◦ Avoid use for management of incontinence◦ Use catheters in operative patients only as

necessary

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Insert catheters only for appropriate indications

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Insert catheters only for appropriate indications

Leave catheters in place only as long as needed

Ensure that only properly trained persons insert and maintain catheters

Insert catheters using aseptic technique and sterile equipment (acute care setting)

Following aseptic insertion, maintain a closed drainage system

Maintain unobstructed urine flow Hand hygiene and Standard (or

appropriate isolation) Precautions

http://www.cdc.gov/hicpac/cauti/001_cauti.html

Core Strategies◦ High levels of

scientific evidence

◦ Demonstrated feasibility

Supplemental Strategies◦ Some scientific

evidence◦ Variable levels of

feasibility

*The Collaborative should at a minimum include core prevention strategies. Supplemental prevention strategies also may be used. Most core and supplemental strategies are based on HICPAC guidelines. Strategies that are not included in HICPAC guidelines will be noted by an asterisk (*) after the strategy. HICPAC guidelines may be found at www.cdc.gov/hicpac

Symptomatic UTI Bacteriuria

Prolonged catheterization* Disconnection of drainage system*Female sex† Lower professional training of inserter*Older age† Placement of catheter outside of OR†

Impaired immunity† Incontinence†

Diabetes

Meatal colonization

Renal dysfunction

Orthopaedic/neurology services

* Main modifiable risk factors † Also inform recommendations