Reduction in Catheter Associated Urinary Tract Infection Rates and Device Utilization in a Medical and a Respiratory Stepdown Unit

Primary Author: Marie K. Moss, MPH, RN, CIC

Co-Authors: Aileen Tanafranca, MSN, RN, CCRN, NE-BC; Brian Koll, MD,FIDSA, Executive Director, Infection Prevention; Margaret Amato-Hayes, CNO, MSN,RN,NE-BC; Barbara Barnett, MD, CMO; Leslyn Williamson, RN, MPH, MSN, DNP, RN, NEA-BC, Director, PCS; Robbie Freeman, MSN, RN-BC Floor Leadership: Samuel Acquah, MD, Medical Director 5 Linsky, Joanna Mecca, MD, Physician Leader, Mary Harris, MD, Physician Leader, Irene Jankowski, RN, Director, WOCN, Ryu Peter Hambrook Tofts, MD, Pulmonary Fellow, Jason Filopei, MD, Pulmonary Fellow

Background

• Hospital acquired urinary tract infections are the third most

common nosocomial infection

• 75% are associated with a urinary catheter

• A framework for daily inter-disciplinary communication of catheter

necessity and monitoring of maintenance bundle practices is

needed to reduce catheter utilization and the risk for catheter

associated urinary tract infections (CAUTIs)

• Effective communication strategies and monitoring tools will

decrease CAUTI and device utilization rates

Methods

• Two units with fluctuating CAUTI rates, standardized infection ratios (SIR),

and device utilization rates were chosen as the study units

• Patients with indwelling urinary catheters were followed on a daily basis for

a period of two years

• The first year established baseline rates which were compared to post-

intervention rates during the second year of the project

• All rates, SIRs, and percentiles were compared to NHSN benchmarks using

the “Rate Table for Catheter-Associated UTI Data” and the "SIR for All

Catheter-Associated UTI Data“ analysis reports

The CAUTI Prevention Team

4

Mount Sinai / Presentation Slide / December 27, 2012 5

Interdisciplinary CAUTI Prevention Education CUSP Education

CAUTI Prevention SLMs for Nursing, PCAs, and transporters

CAUTI Prevention Presentation to Nursing Quality Champions at the Patient Quality and Safety Workshop

Monthly CAUTI prevention education classes for Skin Saver Champions

5 Linsky “Bladder Bulletin”

TeamStepps™ Training

Self-Learning Module Post Test --- URINARY CATHETERSExercising Care to Prevent Complications of Infection

 Post Test for Transporters and Technicians

You keep the catheter secured safely by:

1. Pulling it taut and taping to leg

2. Securing the catheter at connection site to thigh

3. Allowing enough loop in catheter to prevent kinking or pulling

4. All of the above

5. B and C  

The urinary drainage bag must be kept: 1. At the level of the bed2. Below the upper side rail3. Below the level of the bladder4. on the abdomen

Urinary drainage bag must never be:• Above the level of bladder• On the abdomen• Raised across the abdomen when

moving patient• Touching the floor

a. All of the aboveb. 1 and 2c. 1, 2, and 4d. 2 and 3 When transferring a patient with an indwelling urinary catheter from bed to stretcher:• Keep bag in low position during

transfer • Place the bag on patient’s abdomen• Let the bag hang loose on opposite

side of bed• Hang the bag form the IV pole

TeamStepps™Training

CAUTI Scenarios

The Two Challenge Rule Scenario Information Conflict

Jay Stewart RN, believes that his patient, Mrs. K, no longer needs to have a Foley catheter. Using the urinary catheter algorithm, he determines that the patient no longer meets criteria.

Jay approaches the patient’s MD, Dr. Gray, and states, “Dr. Gray, Mrs. K no longer needs to have a Foley. Can you write an order for D/C?”

Dr. Gray responds, “Mmm…she has a Foley? Wow, look at the time! Got to run - I’m really late for Grand Rounds.” Dr. Gray quickly turns and starts to walk away.

How can the Two Challenge Rule be used to resolve this situation? Role play using the Two Challenge Rule

(Remember: This is used when an initial assertion is ignored) It is your responsibility to assertively voice your concern at least two times

to ensure that it has been heard. The member being challenged must acknowledge If the outcome is still not acceptable:

Take a stronger course of action Use supervisor or chain of command

TeamSTEPPS™

The DESC ScenarioPersonal Conflict

Laura the PCA is happy that her patients’ Foleys are being removed when no longer necessary. Although this is great for the patients, she now has several incontinent patients on her assignment each day. She feels that the nurses ignore her when she asks them for help.One day Laura, feeling overwhelmed, asks Martha the RN to help her change a patient. Martha responds that she can’t do it at that moment because she is giving out meds. Laura responds angrily, raising her voice in front of the visitors and other staff in the room.

How can DESC script be used to resolve this situation? Role play using DESC:

D — Describe the specific situation E — Express your concerns about the actionS — Suggest other alternativesC — Consequences should be stated

Ultimately, consensus shall be reached.

TeamSTEPPS™

Urinary Catheter Assessment Tools

Mount Sinai / Presentation Slide / December 27, 2012 11

Urinary Catheter Maintenance Assessment Tool

UNIT: DATE:

Answer 'Yes', 'No', or 'N/A' to the questions below. Provide comments as applicable. Assessments made 3x/week.

 

MR# MR# MR# MR# MR# MR# MR# MR#

           

Is hand hygiene performed before and after handling the urinary catheter? (Observation)              

Are gloves worn when handling the urinary catheter? (Observation)              

Is the closed system continuously maintained? (Observation)              

Is the urinary catheter bag positioned below the level of the bladder for effective drainage? (Observation)

             

Is the urinary catheter secured to the thigh allowing enough loop in the catheter to prevent kinking or pulling? (Observation)

             

Are sterile catheter urine specimens taken aseptically using the needle port? (Observation)              

COMMENTS:                

 

 

 

Mount Sinai / Presentation Slide / December 27, 2012 12

Daily Assessment of Need for Urinary Catheter

Mount Sinai / Presentation Slide / December 27, 2012 13

Urinary Catheter Removal Algorithm for Nurses

Urinary CatheterStop Orders

Stop Orders for Urinary Catheters in the Electronic Medical Record

Short Term Urinary Catheter(Good for < 48 hours) • Acute Urinary Retention

• I and O’s on a critically ill patient

• < 48 hours post-op  

Prolonged Urinary Catheter (Good for < 7 days)

• Terminal Care

• Neurogenic bladder

• Post–op urological procedure

• Assist in healing an open sacral wound

• Prolonged immobilization

ResultsUnit CAUTI

Rate2013

CAUTI Rate2014

CAUTI SIR2013

CAUTI SIR2014

DU2013

DU 2014*

5 Linsky 1.5 0 0.9 0 22nd

Percentile9th

Percentile

5 LinskyStepdown

2.8 0 1.5 0 70th

Percentile38th

Percentile

16

5 Linsky Respiratory Step Down unit has achieved and maintained a zero CAUTI rate for the year 2014 to date. Catheter device utilization decreased from the 70th to the 38th percentile.

5 Linsky Medical Unit has achieved and maintained a zero CAUTI rate for the year 2014 to date. Catheter device utilization decreased from the 22nd to the 9th percentile.

*Significant reduction in DU for both units: p < 0.00001

Pulmonary Step Down SurveillanceCatheter Associated Urinary Tract Infections

2013 – 2014

Q12013 Q22013 Q32013 Q42013 Q12014 Q220140

2

4

6

8

10

12

Foley Catheter Assoc UTI NHSN

Rat

e p

er 1

,000

Fo

ley

Day

s

Medical Unit SurveillanceCatheter Associated Urinary Tract Infections

2013 – 2014

Q12013 Q22013 Q32013 Q42013 Q12014 Q220140

1

2

3

4

5

6

7

Foley Catheter Assoc UTI NHSN

Rat

e p

er 1

,000

Fo

ley

Day

s

Conclusions

• Implementation of daily interdisciplinary communication strategies

and bundle monitoring tools led to a significant decrease in CAUTI

rates, SIRs, and device utilization on both units

• Tools that guide health care providers to ensure compliance with

maintenance bundles and removal of urinary catheters in a timely

manner leads to the prevention of CAUTIs in hospitalized patients