Running head: CAUTI PREVENTION

Catheter-Associated Urinary Tract Infection Prevention

Brad Abernethy, Suzanne Boothe, Erica Brown, Karen Cheeks, and Alicia Craft
Old Dominion University

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CAUTI Prevention

Urinary catheters are used daily in various patient care situations. Catheter-associated
urinary tract infections (CAUTIs) are common occurrences and much research has been done on
reduction and prevention. If proper care is not used with catheterization, a urinary tract infection
(UTI) can occur. A few ways to prevent UTIs include: proper hand washing, safe handling of
equipment, and sterile technique when inserting urinary catheters. Urinary tract infections can
cause other major medical complications. Common health care environments where urinary
catheters are used frequently are medical-surgical units, labor and delivery units, intensive care
units, and surgical units. Patients who require urinary catheters are those that are incapable of
voluntary bladder emptying, chronic nephrology patients, individuals with extensive pressure
ulcers or wounds where urine will inhibit healing, and patients who deliver by cesarean section.
As illustrated, catheters are used for a wide range of reasons. Thus, prevention of CAUTIs is a
major issue.
Patient Outcomes
Catheter-associated urinary tract infections (CAUTIs) have several patient outcomes
associated with this preventable condition. Some of these include the absence of significant
morbidity, discomfort, fever, and malaise. Adverse outcomes are increased chances of catheter
blockage, urinary tract stones, and increased risk of malignancy of the urinary tract (Jain, Dogra,
Mishra, Thakur, & Loomba, 2015). Additional undesirable outcomes for a patient with a CAUTI
are added health care costs and increased hospitalization (Daniels, Lee, & Frei, 2014).
Type and Quantity of Available Research
The majority of research studies focused on CAUTI prevention would classify as
quantitative research. The studies examined to develop guidelines have included evidence from

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randomized clinical trials, prospective cohort studies, case-controlled studies and other
descriptive studies (Hooton et. al., 2010). The Center for Disease Control (CDC) has been the
leading authority on setting guidelines for CAUTI prevention (Falkin et al., 2012). The CDC
was able to complete a comprehensive analysis of available research studies that focused on
CAUTI prevention. From this analysis, the CDC compiled a set of guidelines to be used by
healthcare professionals. The CDC has stated there is a lack of sufficient research on studies
addressing the prevention of CAUTIs (Gould et al., 2009). They have recommended that future
research of CAUTI prevention be primarily analytic research, which would include: systematic
reviews, meta-analyses, interventional studies, and observational studies (Gould et al., 2009).
Gould et al. state that research studies used to develop the CDC guidelines on CAUTI prevention
were primarily analytic research, systematic reviews or meta-analyses (2009).
Research Article Synthesis
Carter, Reitmeier, & Goodloes (2014) article addresses the question, Is there an
effective evidence-based bundle that will reduce the incidence of CAUTIs on an acute-care
general medicine/telemetry unit? (p. 239). This study is a quasi-experimental interrupted time
series (Penfold & Zhang 2013). It follows one specific hospital unit and is not randomly
controlled. It is an interrupted time series experiment because data is continually collected but
the independent variable is implemented at a specific time to interrupt the data. The
independent variable was the implementation of a CAUTI prevention bundle, or collection of
interventions determined to be useful through evidence-based practice grounded in the authors
research. The dependent variable was the CAUTI rates for a medicine/telemetry unit (a 28 bed
acute medicine unit) for eight quarters before the CAUTI bundle implementation and eight
quarters after. There was no sample size indicated only that it was a 28 bed unit. After the

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implementation of the bundle, the units incidence of CAUTIs greatly diminished. A spike in
CAUTI rates in one quarter was attributed to transfers from another unit. This was corrected
with early removal of catheters from other units. The authors acknowledge the lack of a
substantial population with which to draw significant conclusions. They indicate a need to study
CAUTIs related to total catheter days verses total catheters on the unit. This study led to a
hospital-wide adoption of many aspects of the CAUTI bundle. The authors also expressed intent
to continue following their CAUTI rates and adjust their practice accordingly (Carter et al.,
2014).
Moris article (2014) uses a retrospective chart review, to evaluate the effectiveness of a
nurse-driven indwelling urinary catheter removal protocol in an acute care setting (p. 15). This
study is similar to Carter et al. (2014) in that it is a quasi-experimental interrupted time series
study (again without randomized sampling) and uses a retrospective chart review to gather data.
The independent variable is the implementation of a nurse-driven catheter removal protocol. The
dependent variables are catheter usage, catheter dwell time, and CAUTI rates; all measured three
months before and after implementation of the protocol. The population includes any inpatient
with a urinary catheter inserted during admission at a specific 150 bed community hospital. The
sample size includes 389 patients before implementation and 282 after. The study found a
reduction in urinary catheter use and the hospitals CAUTI rate (from 0.77% to 0.35%). However
average dwell time did increase (from 3.35 to 3.46 catheter days). Though the author did not
address this, it could be that by reducing unnecessary catheters, those which were necessary
stayed in longer. Mori mentions a need to follow up the study with a larger sample size and to
find a way to exclude chronic catheter use patients from the study (2014).

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The purpose of the Leblebicioglu et al. (2013) article was a multidimensional infection
control approach for the reduction of catheter-associated urinary tract infections (CAUTIs) in 13
intensive care units (ICUs) in 10 hospital members of the International Nosocomial Infection
Control Consortium (INICC) from 10 cities of Turkey (p. 885). Much like the first two articles
this was another quasi-experimental interrupted time series study (though the sample size is
much larger it is still not random and only reflects participating hospitals). The independent
variable was the implementation of a CAUTI prevention bundle. The dependent variable was
CAUTI rates. The study included 4,231 patients from 13 ICUs at 10 hospitals in 10 cities in
Turkey. They included 5,080 catheter days observed for 3 months before implementation and
36,791 catheter days observed following 3 months after implementation and continued on for an
average of 22.4 months (2 to 60 months). The authors wanted to start the intervention quickly;
thus, there was more data following the intervention. However, the data before the intervention
was large enough to be statistically relevant. The study found a reduction in CAUTI rates from
10.63 per 1,000 catheter-days to 5.65 per 1,000 catheter-days. The authors acknowledge that
their data could not be generalized to other intensive care units but does contribute to quality
improvements throughout Turkey. They also acknowledge that the study failed to evaluate
individual interventions in reducing CAUTIs. The authors state it is important for ongoing
studies similar to theirs in other countries (Leblebicioglu et al., 2013).

Summarization of Research
The Centers for Disease Control and Prevention created a guideline to prevent CAUTIs
(Gould et al., 2009). Most sources site this as the guideline for best practice in CAUTI
prevention. It is a 67 page document focusing on answering questions associated with catheter

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utilization, maintenance, and CAUTI prevention. It systematically proposes evidence-based

practice and indicates the strength of supporting individual interventions based from metaanalysis of research. Displayed in a bullet point form from pages 8 to 17, this document explains
best practice in catheter use, catheter alternatives, insertion, management, and systematic
interventions. It also expands on recommendations for further research.
Willson et al. (2009) use a systematic review of articles from 1980 to the current date to
answer 10 questions related to CAUTI prevention. Each one is answered by evaluating those
articles which relate to a specific question. Through assessment of the supportive research, the
authors make suggestions grounded in the strength and findings of the research. Wilson et al.
(2009) determined sterile insertion techniques, antiseptic ureteral meatus care solutions, 2chambered drainage bags, antiseptic filters, catheter irrigation, frequent urinary bag changes, and
antiseptic solutions in the urinary bag to be interventions which lacked supportive evidence.
From this study, the authors feel that a quality CAUTI prevention protocol should include: staff
education on catheter use and CAUTI prevention; catheter use monitoring, review, and early
removal of unnecessary catheters; regular maintenance of the catheter including ureteral meatus
cleaning with soap and water (not antiseptic solutions); and consideration of antiseptic catheter
use (such as silver alloy or antibiotic coated catheters) (Wilson et al., 2009).
Recommendations for Nursing Interventions and Discussion
The Healthcare Infection Control Practices Advisory Committee (HICPAC), funded by
the Centers for Disease Control and Prevention (CDC), issued a guideline for prevention of
catheter-associated urinary tract infections (CAUTIs) in 2009. The report summarizes
recommendations for those receiving catheterization and the procedures to be performed.
Guidelines recommended for catheter use include: patients with acute urinary retention or

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bladder obstruction, improvement of comfort for end of life care, to assist with wound healing in
incontinent patients, select perioperative patients, and accurate intake and output monitoring in
the critically-ill (Gould et al., 2009).

Using the Joanna Briggs Institute Levels of Evidence, this

patient list is considered a level 4 (Hopp & Rittenmeyer, 2012, p. 145). The list was developed
based on expert opinion (Gould et al., 2009).
HICPAC gives a breakdown of recommended procedures for different types of
catheterizations for CAUTI prevention. The committee primarily focused on indwelling and
intermittent catheterizations, since these procedures are the most commonly used in healthcare
settings. For indwelling catheters it is recommended to use aseptic technique and sterile gloves
for insertion, keep a closed drainage system, and to secure the catheter after insertion to prevent
movement (Gould et al., 2009). Intermittent catheterization is recommended for patients with
neurogenic bladders or spinal cord injury versus the placement of an indwelling catheter.
Research shows patients are less prone to infection if catheterization occurs at set intervals to
prevent over-distension of the bladder (Gould et al., 2009). The 2009 International Clinical
Practice Guidelines from the Infectious Diseases Society of America supports these
recommendations and offers the use of automatic stop dates for catheter orders to prevent misuse
(Hooton et al., 2010). The level of evidence for these recommendations is a level 3 using Joanna
Briggs Institute guidelines (Hopp & Rittenmeyer, 2012, p. 145). The GRADE Working Group
Classification of the Quality of Effectiveness Evidence would give the evidence of this
recommendation a moderate rating (Hopp & Rittenmeyer, 2012). A moderate rating states
further research is likely to have an important impact on the confidence in the estimate of effect
and may change the estimate (Hopp & Rittenmeyer, 2012, p. 144).

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After reviewing the policies and procedures of two facilities (a rural hospital and a
nursing home), it was found most recommendations were in use. The hospitals policy on
CAUTIs is very strict. The hospital protocol cited the HICPAC 2009 Guidelines in the policy. It
was impressive to find the utilization of an automatic discontinue order. After 48 hours, the
catheter is to be removed and the physician reevaluates the need for continued catheterization.
However, the rural nursing home was not as current on the present literature. Some staff
members were not familiar with the CAUTI abbreviation. The nursing homes policy was
extremely vague. The insertion procedure lacked important details recommended for CAUTI
prevention. The procedure was a basic instruction of aseptic technique. Lack of instruction also
made it easy for a patient to have a catheter that is no longer needed. It was impressive to find a
physician ordered an intermittent catheterization of a patient with a neurogenic bladder every
eight hours. This order was an example of evidence-based practice in action. A section on
intermittent catheterization should be added to the policy and procedure handbook for the
nursing home. Evidence-based practice is gradually being implemented into rural communities.
The research is strong enough to warrant a change in policy and procedure due to the high cost of
treating CAUTIs. Prevention saves lives, money, and time.
Conclusion
Research has illustrated several ways to help prevent CAUTIs. An informed patient and
care-giver should explore options to avoid the use of urinary catheters and reduce his or her risk
of infection. Greater precautions must be applied to prevent poor patient outcomes. More
research needs to be done to aid in the reduction of urinary catheter use and CAUTI prevention.
Research has already shown that infections are avoidable. However, by expanding on current
research, exceptional patient care and financial savings can be fully realized.

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References

Carter, N.M., Reitmeier, L & Goodloe, L.R. (2014). An evidence-based approach to the
prevention of catheter-associated urinary tract infections. Urologic Nursing, 34(5), 238245. doi:10.7257/1053-816X.2014.34.5.238
Daniels, K. R. , Lee, G. C. , & Frei, C. R. (2014). Trends in catheter-associated urinary tract
infections among a national cohort of hospitalized adults, 2000-2010. American Journal
of Infection Control, 42(1), 17-22. doi:10.10161j.ajic.2013.06.026
Fakih, M. G., Greene, T. M., Kennedy, E. H., Meddings, J. A., Krein, S. L., Olmsted, R. N., &
Sanjay, S. (2012). Introducing a population-based outcome measure to evaluate the effect
of interventions to reduce catheter-associated urinary tract infection. American Journal of
Infection Control, 40(4), 359-364. doi:10.4103/0972-52290151014
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D., & The Healthcare
Infection Control Practices Advisory Committee (HICPAC). (2009). Healthcare infection
control practices advisory committee (HICPAC) guideline for prevention of catheterassociated urinary tract infections 2009. Centers for Disease Control and Prevention, , .
Retrieved from http://www.cdc.gov/hipac/pdf/CAUTI/CAUTIguidelines2009final.pdf
Hooton, T. M., Bradley, S. F. , Cardenas, D. D., Colgan, R., Geerlings, S. E., Rice, J. C., &
Nicolle, L. E. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary
tract infection in adults: 2009 International Clinical Practice Guidelines from the
Infectious Disease Society of America. Clinical Infectious Diseases, 50(5), 625-663.
doi:10.1086/650582
Hopp, L., & Rittenmeyer, L. (2012). Introduction to Evidence-Based Practice: A Practical
Guide for Nursing. Philadelphia, PA: F.A. Davis Company.

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Jain, M. , Dogra, V., Mishra, B., Thakur, A. , & Loomba, P. S. (2015). Knowledge and attitude of
doctors and nurses regarding medication for catheriz ation and prevention of catheterassociated urinary tract infection in tertiary care hospital. Indian Journal of Critical Care
Medicine, 19(2), 76-81. doi:10.4103/0972-5229.151014
Willson, C. V., Wilde, M., Webb, M. L., Thompson, D., Parker, D., Harwood, J.,...Gray, M.
(2009). Nursing interventions to reduce the risk of catheter-associated urinary tract
infection: Part2: Staff education, monitoring, and care techniques. Journal of Wound,
Ostomy, & Continence Nursing, 36(2), 137-154.
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Leblebicioglu, H., Ersoz, G., Rosenthal, V. D., Nevzat-Yalcin, A., Akan, . A., Sirmatel, F.,...
Bacakoglu, F. (2013). Impact of a multidimensional infection control approach on
catheter-associated urinary tract infection rates in adult intensive care units in 10 cities of
Turkey: International Nosocomial Infection Control Consortium findings (INICC). AJIC:
American Journal of Infection Control, 41885-891. doi:10.1016/j.ajic.2013.01.028
Mori, C. (2014). A-voiding catastrophe: Implementing a nurse-driven protocol. MEDSURG
Nursing, 23(1), 15-28.
Penfold, R. B., & Zhang, F. (2013). Use of interrupted time series analysis in evaluating health
care quality improvements. Academic Pediatrics, 13(6), 38-44.
doi:10.1016/j.acap.2013.08.002

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Honor Code:
I pledge to support the Honor System of Old Dominion University. I will refrain from
academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member
of the academic community it is my responsibility to turn in all suspected violators of the Honor
Code. I will report to a hearing if summoned.
Brad Abernethy
Suzanne Boothe
Erica Brown
Karen Cheeks
Alicia Craft