Catheter Associated

Urinary Tract Infections Prevention & Interventions

Natalie Alwin, Misa Berndt, Samantha Helms, Nick Mar, Johnathan Mougin, Emma Randall,
Emily St. Germain, Lisa Siewert, Jaime Varner

Background/Description

Catheter Associated Urinary Tract Infection (CAUTI)

Occurs when germs, usually bacteria, enter the urinary tract via urinary
catheter and cause infection.
15-25% of hospitalized patients may receive indwelling urinary catheters.
30% of infections reported by acute care hospitals are urinary tract infections,
making it the most common type of healthcare-associated infection.
CAUTIs have been associated with increased morbidity, mortality, hospital cost, and
length of stay.

(CDC, 2009)

Why Provide Direct Education to Nurses?

Nurses are

At the frontline of catheter care.

Directly responsible for catheter management, care and removal
Are able and amongst the first to recognize clinical change in patients

Since nurses directly interact with caring for the catheter, they are crucial for identifying the
signs of a CAUTIs.
Since nurses are at the frontline of care, providing education to these professionals can aid in
faster diagnosis of CAUTIs, and ultimately reduce the rate of occurrence.

(Boon et. al, 2009)

PICOT
In adult patients, will mandated professional
development education for registered nurses on catheter
related infection prevention and catheter care, compared
to no supplemental education, reduce the prevalence of
CAUTI in a cost effective manner in the acute care
setting?

Statistics

450,000 catheter-associated tract infection occur annually in hospitals in the

United States.
CAUTIs account for 4 of 10 HAIs in the US.
Indwelling catheters are inserted in between 25-33% of patients admitted to
the hospital
If a patient contracts a CAUTI there is an addition $1000 of healthcare costs
that are not covered by insurance.
This all adds up to an expense of $450,000,000 per year nationwide!
Nationally, an estimated 13,000 deaths each year are attributed to CAUTI
(Fuchs, Sexton, Thornlow & Champagne, 2011)

Current Practice
Appropriate use of urinary catheters:

Acute urinary retention or bladder outlet obstruction

Accurate measurements of urinary output in critically ill patient

Surgical patients- removed in PACU if applicable

Assist in healing of open sacral or perineal wounds in incontinent patients

Improve comfort for end of life care if needed

Inappropriate use of urinary catheters:

Substitute for nursing care of the patient or resident with incontinence

Obtaining urine for culture or other diagnostic tests when the patient can voluntarily void

Prolonged postoperative duration without appropriate indications

Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate

(CDC, 2009)

Current Practice
Primary CAUTI Prevention Measures

Insert catheters only for appropriate indications

Leave catheters in-place only as long as needed
Only properly trained persons insert and maintain catheters
Insert catheters using aseptic technique and sterile equipment
Maintain a closed drainage system
Maintain unobstructed urine flow
Hand hygiene and standard (or appropriate) isolation precautions

(CDC, 2009)

Arizona Current Practice

Statewide

The Standardized Infection Rate for CAUTI at Arizona hospitals is 11 percent higher than the
national baseline, according to data released by the CDC in March 2014
The Arizona Hospital and Healthcare Association (AzHHA) launched a collaborative effort with
member health organizations across the state to reduce CAUTIs in May 2014

Local

In an article from the Arizona Daily Star in 2015, according to the U.S. Centers for Medicare &
Medicaid Services (CMS) Banner-University Medical Center Tucson, Carondelet St. Josephs
Hospital and Tucson Medical Center were in the worst-performing 25 percent of hospitals
nationwide on a matrix of hospital-acquired conditions
(Azhha, 2014); (Innes, 2015)

Synopsis of Literature Results

The Keystone Bladder Bundle includes the following:

Alternatives to indwelling urinary catheterization

Urinary catheter reminders or removal prompts and nurse-initiated urinary catheter

discontinuation protocol
Portable bladder ultrasound monitoring
Insertion care and maintenance

Barriers to the Bladder Bundle

Difficulty with nurse and physician engagement

Patient and family request for indwelling catheters
Catheter insertion practices and customs in emergency department

Synopsis of Literature Results Cont.

Where are hospitals falling short?
Prevention methods for CAUTI:

Training was provided to 64% of hospitals on aseptic technique and CAUTI prevention
at time of initial nursing hire
Only 47% annually validated competency of indwelling catheter insertion
28% of respondents reported having no CAUTI prevention policy at all

Synopsis of Literature Results Cont.

How to decrease CAUTI rates?

Early engagement and targeted educational initiatives

Promoting Indwelling Urinary Catheter (IUC) tags: Tags use went from 4
as more education sessions occurred. Prevalence of CAUTIs went from 1
one year

CAUTI continuation checklist: Use of computer algorithms in combination with nurse

collected patient data to determine whether or not a catheter should be discontinued.

Clinical Nurse Specialist and physician on team to assess urinary catheter utilization: It
was found effective to address misinformation about use at meetings and on the
clinical units

CAUTI education fair: Reduced rates of CAUTI from 4.71 to 1.29 per 1000 patient device
days. This fair increases the understanding and adherence to EBP surrounding CAUTI
prevention. In-service education was implemented every year to reinforce EBP

Strengths of Articles

Many hospitals in the US do not have established systems that routinely

monitor the placement or duration of urinary catheters
CAUTI prevention educators were recruited from a variety of sources,
widening the knowledge base. This included nurse educators, faculty from a
local university, and the facilitys clinical nurse leader
The fair was flexible and accommodated varying schedules so that all ICU
and transplant staff members could receive EBP education
Peer-to-peer education provided a safe and non-threatening environment
to optimize learning

Limitations of Articles

Relationships between the use of various infection prevention practices and

CAUTI outcomes in the surveyed hospitals could not be directly explored
Potential for response bias. To minimize bias, interviewees must include a
diverse set of organizational roles and perspectives about the Bladder
Bundle initiative
Hospital sample was not representative of many hospitals because it was
not-for-profit, making it hard to generalize
Small sample sizes, questions how universal the results may be
The approach averages hospital quality, instead of directly taking into
account the quality of care or variation in underlying infection risks across
hospitals in computing estimated cost

Evidence-Based Nursing Recommendations

Each study indicated a possibility of improvement of CAUTI rates

Providing education is a critical component of all interventions

Based on the findings from the studies, we suggest that the hospital provides
a supplemental nursing education event annually to maintain competency of
nurses in the management of urinary catheters
This education event will include specific education on:

How to use the Bladder Bundle protocol, including improvement to the bundle system
The purpose of indwelling catheters and consequences of inappropriate use
The importance of protocol compliance in an engaging way
How to use tools and qualifications to determine when a catheter should be removed

Implementation

When: Bi-annual education (January and July), Everyone attends one hour
before or after their shift
Where: conference room within the hospital
How: Nurse educators will organize prior to the education fair and base
education material off of best evidence based practice (CAUTI bundle). Nurse
educators will be present at each booth of fair and present information to
the nurses, a quiz will be implemented directly after completion of the
education session to evaluate competency

Application

4 booths - 1 nurse educator per booth

Each nurse must attend a 10 minute educational session at each booth that discusses various EB
practices to implement into their care.
Topics to be discussed:
How to use bladder bundle protocol
Purpose of indwelling catheters, consequences of inappropriate use
The importance of protocol compliance
How to use tools and qualifications to determine when a catheter should be removed
Nurse Educators will use a variety of methods to appeal to all styles of learning:
Visual aids
Demonstrations
Fliers
Short Presentations
Interactive participation
At the end of the booth rotation, the nurse will have 20 minutes to take a competency quiz.
There will be three question per booth.

Timeline
-

December (year prior): Have a team meeting with nurse educators

December (year prior): Train them on the specific interventions
January: Education fair #1
- Quiz after fair
First week of March: Anonymous Post-Survey
- compliance, effectiveness, relevance, satisfaction, ease of use
Second-Fourth week of March: Analyze answers to surveys
May: Nurse Educator Rounding
June: Have a team meeting with nurse educators
June: Plan educational points and how to integrate nurses feedback into next educational fair
July: Educational Fair #2
- Quiz after fair
First week of September: Anonymous Post-Survey
Second-Fourth week of September: Analyze answers to surveys
October: Identify what needs to be focused on for the next year
November: Nurse Educator Rounding

December: End of the year analysis (CAUTI prevalence)

Cost Analysis

Average hourly wage per nurse X # of nurses employed X 1 hr = total cost per session
According to the Bureau of Labor Statistics (2012), the average nursing hourly wage in Arizona is
$34.78.
Hypothetically, if there were 342 acute care nurse being educated, the total hospital cost would be:
$34.78 X 342 nurses X 1 hr = $11,894.76 per education session

($23,789.52 per year)

There is no data regarding what it has cost other facilities to implement this EBP because no other
facilities have implemented this exact EBP.
As previously stated, one CAUTI costs an extra $1,000 per patient. Therefore, in the reduction of
just 24 CAUTIs the hospital would have made their money back. (*the 24 is based on the
hypothetical hospital cost per year*)
Nurse educators will not be included in the cost analysis because nurse education is included
within their job.

Risk vs benefit
Risks

The education requires the staff to set aside separate time to have urinary catheter education reinforced,
which can result in negative staff attitudes.
Staff does not comply with the education even after receiving it.
Staff fails the mandatory quiz after the education
Having too many qualifications for the use of a urinary catheter to reduce CAUTIs could prevent patients
who could benefit from the use of a urinary catheter from receiving proper care.

Benefits

The increased education would result in improved confidence of nurses when caring for patients with
indwelling catheters and making decisions related to indwelling catheters.
Reduces the long-term costs to the hospitals by preventing CAUTIs.
Reduces the length of time patients have an indwelling catheter which can be an uncomfortable
experience.
Reduces the cost for patients by preventing treatment costs of CAUTIs and lowering length of stay.

Evaluation of Intervention
1. Estimate CAUTI rates prior to implementation of education intervention
2. Follow up staff education with a quiz on CAUTI prevention protocol. After
training sessions are complete, examine quiz scores for competency
3. Six months following education intervention, administer a survey to
ascertain if nurses felt that they were more aware of following catheter care
protocols, as compared to before the education intervention was
implemented.
4. Compare statistics of how many CAUTIs occurred since educational
program (CAUTI fair)

Summary

Introduction: Catheter Associated Urinary Tract Infection (CAUTI)

Occurs when germs, usually bacteria, enter the urinary tract via urinary catheter and cause infection.

Description of Issue:

CAUTIs account for 4 of 10 HAIs that occur in our hospitals

Indwelling catheters are inserted in between 25-33% of patients admitted to the hospital

These infections are costing us as a nation approximately $450,000,000 per year!

Nationally, an estimated 13,000 deaths each year are attributed to CAUTI

Supportive Studies:

Main points:

Promoting Indwelling Urinary Catheter (IUC) tags

CAUTI continuation checklist
Clinical Nurse Specialist and physician on team to assess urinary catheter utilization
CAUTI education fair.
All studies supported our intervention with varying limitations.

Summary Continued

Discussion of Best Practice: A supplemental nursing education event

annually to maintain competency of nurses in the management of urinary
catheters

Application to facilities: In-Service education sessions put on by nursing

educators.

Cost Analysis: $34.78 X 342 nurses X 1 hr = $11,894.76 per education

session

$23,789.52 per year

Summary Continued

Risk vs. Benefit:

Risk
Non-compliance
Staff satisfaction
Benefit
Reduce rates of CAUTI saving lives, complications, and money

?????

References
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Bureau of Labor Statistics (2012). Occupational employment and wages, May 2011. Occupational Employment Statistics. Retrieved from http://www.bls.gov/oes/2011/may/oes291111.htm
CDC. (2009). Guideline for prevention of catheter-associated urinary tract infections, 2009. Retrieved from http://www.cdc.gov/hicpac/cauti/005_background.html
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