Reducing Catheter Associated Urinary Tract Infections

A urinary tract infection (UTI) is an infection that occurs in any part of the urinary system. Patients with indwelling urinary catheters have an increased risk of acquiring a urinary tract infection. Seventy-five percent of hospital acquired urinary tract infections are associated with patients that have or have had an indwelling urinary catheter during their hospital stay. Approximately 15-25% of hospital patients receive urinary catheters during their hospital stay (Centers for Disease Control and Prevention, 2010). The amount of time the catheter remains inserted is the major risk factor for acquiring a UTI (Elpern et al., 2009). A catheter-associated urinary tract infection (CAUTI) occurs when bacteria enters any part of the urinary system causing an infection due to the catheter’s presence. Catheter associated urinary tract infections cause unnecessary risks to patients including the risk of death, increase their time spent in the hospital and increased cost of their hospital stay. Problem Statement/Study Purpose

Urinary tract infections account for 32% of all hospital acquired infections (Elpern et al., 2009). In the Medical Intensive Care Unit of Rush University Medical Center the National Healthcare Safety Network (NHSN) data indicated that the unit’s monthly rates of CAUTIs in 2006 exceeded the NHSN 50th percentile (Elpern et al.). The unit wanted to determine if decreasing the urinary catheter device days whether that would cause the CAUTI rates to decrease. This study was relevant because it attempted to evaluate an intervention determined by the nursing unit as to the inappropriate use of urinary catheters. The unit wanted to study to see if decreasing the device days would decrease the rate of catheter associated urinary tract infections, and if proven to be significant would affect all nursing unit’s protocols of urinary catheter use. Research Question/Hypothesis

The study by Elpern, et al. titled “Reducing Use of Indwelling Urinary Catheters and Associated Urinary Tract Infections” the study hypothesis is that the reduction of urinary catheter device days will decrease the rate of CAUTIs on the unit during the intervention period compared to the 11 months before the study. Protection of Human Participants

The study obtained the approval from the Institutional Review Board prior to commencement. Informed consent was deemed unnecessary. There were no benefits or risks of participation as identified by the study, but having the daily evaluation of appropriateness of the urinary catheter was indeed a benefit for patients as evidenced by the outcome of the study. Method

This study was based on a before and after evaluation of an intervention. The researchers consisted of 3 senior staff nurses, 2 advanced practitioners and the unit’s medical director. The first step of the study was to determine what the appropriate indications for indwelling catheter insertion would be for the unit. The study population consisted of all patients admitted to the unit between the dates of December 1, 2007 to May 2009 who had an indwelling urinary catheter. Every day the number of patients with urinary catheters was recorded. The reason for the catheter was evaluated each day by consulting the primary nurse of each patient, and then deemed appropriate or inappropriate by the researchers this step was repeated each day until the catheter was removed. Data management and Analysis

CAUTI rates were defined as the number of CAUTIs divided by the number of device days, multiplied by 1000. The number of monthly device days before the intervention was 311.7 compared to 238.6 during the intervention which represented a decrease of 73.1. Of the 238.6 device days, 32% were considered to be inappropriate. During the study intervention period there were zero CAUTIs compared to 2.5 in the period before the study which indicates a significant difference supporting the hypothesis (Elpern et al., 2009).

The results of the study indicated that the duration of urinary catheterization and the number of CAUTIs can be reduced with the implementation of protocols related to the need for indwelling urinary catheters. These protocols should be reviewed daily for each patient to determine appropriateness. This is a change in model compared to the unit’s current practice. During the study period it was also found that due to less indwelling catheter insertions that the unit needs additional resources as a result such as increased need for alternatives to indwelling catheters, linens, and bath and skin care products. Study Strength/Weakness

The strength of the study is that the data of inclusion or exclusion into the study was clear; if the patient had an indwelling catheter they were included in the study there was no bias involved. One identified weakness of the study is that the study was limited to only one unit; there was no control group in the study. The device days and infection rates were compared to a time period before the intervention which there is no way of knowing whether other factors were present to influence the rate of infection. Also the variables of determining what was considered appropriate use of indwelling catheters was not based on evidenced based practice, but the opinion of the researchers involved in the study. Study Implication/Conclusion

As indicated by the 2009 Centers for Disease Control’s updated guidelines for prevention of catheter related urinary tract infections, which was released after the date of this study, also reflected many of the same indications of the appropriate and inappropriate use of urinary catheters (Centers for Disease Control and Prevention, 2009) as was used in this study. The study did not address any techniques for insertion nor any specific type of antimicrobial catheters. Bedside nurses play a major role in surveillance and removal of inappropriate use of indwelling urinary catheters and decrease of catheter associated urinary tract infections. Recommendation for further studies would be the investigation of the use of indwelling urinary catheters in association with incontinence and the development of pressure ulcers; do the benefits outweigh the risk of catheter associated urinary tract infection? Does the insertion technique for insertion of the indwelling urinary catheter play a significant role in the CAUTI rates? Hospital acquired infections are a direct reflection of nursing care, and nurses play a major role in reducing the rates of infection.

References

Centers for Disease Control and Prevention (2009). Guideline for prevention of catheter-associated urinary tract infections, 2009. Retrieved November 27, 2012, from http://www.cdc.gov/hicpac/cauti/002_cauti_toc.html Centers
for Disease Control and Prevention (2010). Catheter-associated urinary tract infections (CAUTI). Retrieved November 27, 2012, from http://www.cdc.gov/HAI/ca_uti/uti.html Elpern, E. H., Killeen, K., Ketchern, A., Wiley, A., Patel, G., & Lateef, O. (2009). Reducing use of indwelling urinary catheters and associated urinary tract infections. American Journal of Critical Care, 18(6), 535-542. Retrieved November 18, 2012 from CINAHL Plus database.