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Guide to PreventingCatheter-AssociatedUrinary Tract InfectionsAbout APICAPIC’s mission is to create a safer world through prevention of infection. Theassociation’s more than 14,000 members direct infection prevention programsthat save lives and improve the bottom line for hospitals and other healthcarefacilities. APIC advances its mission through patient safety, implementationscience, competencies and certification, advocacy, and data standardization.

About the SponsorThe distribution of this APIC Implementation Guide as a full-access onlineresource is made possible by the Agency for Healthcare Research & Quality(AHRQ) through the national On the CUSP: Stop CAUTI project. This projectrepresents ARHQ's commitment to improving patient safety and preventinginfections. For more information about the On the CUSP: Stop CAUTI nationalproject, visit www.onthecuspstophai.org.About the Implementation Guide SeriesAPIC Implementation Guides help infection preventionists apply current scientific knowledge and best practices toachieve targeted outcomes and enhance patient safety. This series reflects APIC’s commitment to implementation scienceand focus on the utilization of infection prevention research. Topic-specific information is presented in an easy-tounderstand-and-useformat that includes numerous examples and tools.Visit www.apic.org/implementationguides to learn more and to access all of the titles in the Implementation Guide series.Printed in the United States of AmericaFirst edition, April 2014ISBN: 1-933013-57-5All inquiries about this guide or other APIC products and services may be directed addressed to:APIC1275 K Street NW, Suite 1000Washington, DC 20005Phone: 202-789-1890Fax: 202-789-1899Email: info@apic.orgWeb: www.apic.orgDisclaimer© 2014, Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) All rights reserved. Use of this APIC Guidedoes not grant any right of ownership or license to any user.The Association for Professionals in Infection Control and Epidemiology, its affiliates, directors, officers, and/or agents (collectively,“APIC”) provides this Guide solely for the purpose of providing information to APIC members and the general public. The materialpresented in this Guide has been prepared in good faith with the goal of providing accurate and authoritative information regarding thesubject matter covered. However, APIC makes no representation or warranty of any kind regarding any information, apparatus, product,or process discussed in this Guide and any linked or referenced materials contained therein, and APIC assumes no liability therefore.WITHOUT LIMITING THE GENERALITY OF THE FOREGOING, THE INFORMATION AND MATERIALS PROVIDEDIN THIS GUIDE ARE PROVIDED ON AN “AS-IS” BASIS AND MAY INCLUDE ERRORS, OMISSIONS, OR OTHERINACCURACIES. THE USER ASSUMES THE SOLE RISK OF MAKING USE AND/OR RELYING ON THE INFORMATIONAND MATERIALS PROVIDED IN THIS GUIDE. APIC MAKES NO REPRESENTATIONS OR WARRANTIES ABOUTTHE SUITABILITY, COMPLETENESS, TIMELINESS, RELIABILITY, LEGALITY, UTILITY OR ACCURACY OF THEINFORMATION AND MATERIALS PROVIDED IN THIS GUIDE OR ANY PRODUCTS, SERVICES, AND TECHNIQUESDESCRIBED IN THIS GUIDE. ALL SUCH INFORMATION AND MATERIALS ARE PROVIDED WITHOUT WARRANTYOF ANY KIND, INCLUDING, WITHOUT LIMITATION, ALL IMPLIED WARRANTIES AND CONDITIONS OFMERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, AND NON-INFRINGEMENT.IN NO EVENT SHALL APIC BE LIABLE FOR ANY INDIRECT, PUNITIVE, INCIDENTAL, SPECIAL, OR CONSEQUENTIALDAMAGES ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE USE OF THIS GUIDE OR FOR THE USE OFANY PRODUCTS, SERVICES, OR TECHNIQUES DESCRIBED IN THIS GUIDE, WHETHER BASED IN CONTRACT,TORT, STRICT LIABILITY, OR OTHERWISE.

Guide to Preventing Catheter-Associated Urinary Tract InfectionsTable of ContentsAcknowledgments ................................................................. 5Section 1: Epidemiology and Pathogenesis of Catheter-Associated Urinary Tract Infections .......... 7Section 2: National CAUTI Prevention Initiatives ........................................ 12Section 3: CAUTI Risk Assessment ................................................... 25Section 4: Definitions, Surveillance, and Reporting ....................................... 29Foley Catheter Prevalence Sheet ...................................................... 39Section 5: Patient Safety, CUSP, and Other Behavioral Models .............................. 43Section 6: Prevention .............................................................. 53Section 7: Preventing Catheter-Associated Urinary Tract Infections in Children ................. 69Section 8: Special Populations ....................................................... 76Appendix: Recommendations for Spinal Cord Injured Patients .............................. 834 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsAcknowledgmentsThe Association for Professionals in Infection Control and Epidemiology acknowledges the valuablecontributions from each of the following individuals:EditorLinda Greene, RN, MPS, CICManager, Infection PreventionHighland HospitalRochester, NYLead AuthorKristi Felix, BA, RN, CRRN, CICInfection Prevention CoordinatorMadonna Rehabilitation HospitalLincoln, NebraskaAuthorsMary Jo Bellush, RN, MSN, CICInfection PreventionistExcela Health Westmoreland HospitalGreensburg, PABarbara Bor, RN, BSN, CICInfection PreventionistGillette Children’s Specialty HealthcareSt. Paul, MNContributorsDonna Anderson, RN, CICInfection PreventionistBeebe HealthcareLewes, DEJennifer Boe, RN, BSN, CICInfection Prevention CoordinatorChildren’s Hospital of MinnesotaSt. Paul, MNGeri A. Brown, RN, CICInfection Control/Employee HealthStarr Regional Medical Ctr.Athens, TNBrooke Buras, RN, BSNInfection Prevention NurseNorth Oaks Health SystemHammond, LAHarriette Carr, RN, MSNInfection PreventionistCarmichael, CAMichael Cloughessy, MS, BSEH, REHS, CICSenior Infection Control PractitionerCincinnati Children’s HospitalCincinnati, OHPaula S. Forte, PhD, RN, CWCN, NEA-BCClinical Practice SpecialistGillette Children’s Specialty HealthcareSt. Paul, MNAssociation for Professionals in Infection Control and Epidemiology 5

Guide to Preventing Catheter-Associated Urinary Tract InfectionsMaxine Garcia, RNInfection Preventionist; Employee Health NurseBaylor Surgical Hospital at Las ColinasIrving, TXSusan A Grossberger, BSNInfection PreventionistUPMC MercyPittsburgh, PATheresa Houston, RN, BSN, CCRNCritical Care Nurse EducatorBeebe Medical CenterLewes, DESharon Nersinger RNInfection Control CoordinatorHighland HospitalRochester, NYConnie Steed, MSN, RN, CICGreenville Hospital SystemUniversity Medical CenterGreenville, SCJennifer Tuttle, RN, MSNEdNurse ManagerTuscon Medical CenterTucson, AZReviewersEvelyn Cook, RN, CICInfection PreventionistDuke Infection Control Outreach NetworkDuke University Medical CenterDurham, NCRussell Olmsted, MPH, CICDirector, Infection PreventionSt Joseph Mercy Health SystemAnn Arbor, MIProduction StaffMarilyn Hanchett, RN, MA, CPHQ, CICSenior Director, Professional PracticeAssociation for Professionals in Infection Controland EpidemiologyWashington, DCJim AngeloDirector, PublishingAssociation for Professionals in Infection Controland EpidemiologyWashington, DCAnna CongerAssociate Director, PublishingAssociation for Professionals in Infection Controland EpidemiologyWashington, DC6 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsSection 1: Epidemiology andPathogenesis of Catheter-AssociatedUrinary Tract InfectionsUrinary tract infections are one of the five mostcommon types of healthcare-associated infection(HAI), and along with other device-associatedinfections (e.g., central catheter-associatedbloodstream infections and ventilator-associatedpneumonia) account for 25.6 percent of allhospital HAIs. 1 Majority of healthcare-associatedUTIs are caused by instrumentation of the urinarytract. Catheter-associated urinary tract infection(CAUTI) has been associated with increasedmorbidity, mortality, hospital cost, and lengthof stay. 2 Bacteriuria also leads to unnecessaryantimicrobial use, and urinary drainage systemscan be reservoirs for multidrug-resistant bacteriaand a source of transmission to other patients.Catheter Utilizationand PrevalenceDuring hospitalization, from 12 to 16 percent ofpatients may receive short-term indwelling urinarycatheters. The prevalence of urinary catheter usein residents in long-term care (LTC) facilitiesin the United States is estimated to be around5 percent. 3 However, the overall prevalence oflong-term indwelling urethral catheterizationuse is unknown. The daily risk of acquisition ofurinary infection varies from 3 to 7 percent whenan indwelling urinary catheter remains in place. 4Although the mortality attributable to a singlecatheter episode is limited, the high frequency ofcatheter use in hospitalized patients creates a highcumulative burden of CAUTI. Urinary catheteruse is also associated with other noninfectiousoutcomes, such as urethral stricture, mechanicaltrauma, and immobility. 5 Indeed, the indwellingurinary catheter hs been called a “one pointrestraint” that often limits a patient’s mobility. 18In 2002, an estimate of the annual incidence ofHAIs and mortality based upon a survey of U.S.hospitals found that urinary tract infections madeup the highest number of infections comparedto other HAIs. 6 However, in a multistate pointprevalence ssurvey of U.S. hospitals conductedby the CDC and using 2011 data, CAUITranked fourth among the most commonlyreported HAIs. 1 Despite the fact that less than5 percent of patients with bacteriuria developsecondary bacteremia, CAUTI is the leading causeof secondary hospital-associated bloodstreaminfections. 7 It is estimated that 12.9 percent ofhospital-associated bacteremias are from a urinarysource. In a study of blood stream infectionsmanifesting in NH/SNF residents, 50 percentwere related to UTI. 19In April 2013, the Centers for Disease Controland Prevention (CDC) released the NationalHealthcare Safety Network (NHSN) datasummary report for 2011. The CAUTI pooledmeans for intensive care units (ICUs) rangedfrom 1.2 per 1,000 urinary catheter days inmedical surgical ICUs to 4.1 in burn ICUs.Non-ICU rates ranged from 1.3 to 1.5 per1,000 urinary catheter days in medical, surgical,or medical surgical units. 8 Although there hasbeen modest improvement in CAUTI rates,progress has been much slower than otherdevice-associated infections, such as central lineassociatedbloodstream infections (CLABSIs),where significant improvement has been made.An estimated 17 percent to 69 percent of CAUTIAssociation for Professionals in Infection Control and Epidemiology 7

Guide to Preventing Catheter-Associated Urinary Tract Infectionsmay be preventable with implementation ofevidence-based practices. This means that 380,000infections and 9,000 deaths related to CAUTI peryear could be prevented. 9Figure 1.1. Routes of Entry of Uropathogensto Catheterized Urinary TractPathogenesisThe source of microorganisms causing CAUTI can beendogenous—typically via meatal, rectal, or vaginalcolonization—or exogenous, such as via equipment orcontaminated hands of healthcare personnel.A urinary catheter provides a portal of entryinto the urinary tract. Bacteria may ascend intothe tract via the external or internal surface ofthe catheter. Characteristics of each methodof ascension are identified below: 10 (Also seeFigure 1.1.)External (extraluminal) bacterial ascension• Microorganisms colonize the external cathetersurface, most often creating a biofilm.• Bacteria tend to ascend early after catheterinsertion. This suggests a lack of asepsis duringinitial insertion.• Bacteria can also ascend one to three days aftercatheterization, usually due to capillary action.Internal (intraluminal) bacterial ascension• Bacteria tend to be introduced when openingthe otherwise closed urinary drainage system.• Microbes ascend from the urine collection baginto the bladder via reflux.• Biofilm formation occurs, and damage to bladdermucosa facilitates biofilm on this surface.Multiple factors contribute to CAUTI. A fishbonediagram describing the cause and effect of thesefactors is shown in Figure 1.2.The CDC reports that the most frequentpathogens associated with CAUTI in hospitalsreporting to NHSN between 2006 and 2007were Escherichia coli (21.4 percent) and Candidaspp (21 percent), followed by Enterococcus spp(14.9 percent), Pseudomonas aeruginosa (10Source: Catheter-associated Urinary Tract Infection(CAUTI) Toolkit. Available at: www.cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdfpercent), Klebsiella pneumoniae (7.7 percent),and Enterobacter spp (4.1 percent). A smallerproportion was caused by other gram-negativebacteria and Staphylococcus spp. 11The Role of BiofilmBacteria can establish colonization of a patient’sbladder within three days of their introductiononto the inner or outer surface of urinarycatheters. The introduction of bacteria withurinary catheter use is often associated withcatheter-related biofilms. Biofilms are complexstructures that include bacteria, host cells, andcellular by-products. 12 Biofilm formation withininvasive medical devices is proposed as a primarymechanism in the development of certain diseases,as well as CAUTI. The biofilm life cycle illustratedin three steps: initial attachment events, thegrowth of complex biofilms, and detachmentevents by clumps of bacteria or by a ‘swarming’phenomenon within the interior of bacterialclusters, resulting in so-called ‘seeding dispersal.’Biofilm plays a significant role in the pathogenesisCAUTI. The development of biofilms occurswhen free-floating (planktonic) cells come into8 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infectionscontact with a surface and become irreversiblyattached. Typically catheter surfaces are initallycolonized with a thin film of bacteria. As thebacteria continue to produce matrix material(extra-cellular polymeric substances) they are ableto develop thick, complex structures. This “slimeycoating” may be clearly visible upon catheterremoval on indwelling Foleys than have been inplace for extended periods of time. See Figure 1.3.Bacteria living in a biofilm can have significantlydifferent properties from free-floating bacteria, asthe dense extracellular matrix of biofilm and theouter layer of cells may protect the bacteria fromantibiotics and normal host defense mechanismsof the white blood cells, such as phagocytosis.Microorganisms may contain or produce toxinsand other substances that increase their ability toinvade a host, produce damage within the host,or survive on or in host tissue. Characteristics ofthe specific infecting microorganism, particularlyrelated to virulence as well as the ability to adhereto a foreign object, such as a urinary catheter, playa role in the presentation of infection. 13Antibiotic StewardshipBy definition, antimicrobial stewardship refersto coordinated interventions designed toimprove and measure the appropriate use ofantimicrobials by promoting the selection ofthe optimal antimicrobial drug regimen, dose,duration of therapy, and route of administration. 14As highlighted in the CDC’s campaign toprevent antimicrobial resistance, a program forantimicrobial stewardship in any healthcare setting(acute and LTC) has the potential for positiveimpact on all HAIs. The development of biofilms,colonization, asymptomatic bacteriuria, andFigure 1.2. Factors Contributing to CAUTIFOLEY RELATED URINARY TRACT INFECTIONSCause and Effect DiagramPATIENT RELATED FACTORSCAREGIVER RELATED FACTORSPrimary Risks Secondary RisksDehydrationAge > 50yrsSickle-cell anemiaDiabetesNo hand washing prior tocatheter manipulationInappropriate use ofcathetersPoor insertion techniquesBreaks in closed systemUrethralcolonizationIndications for appropriatecatheter use not followedLack of supplies tomanage incontinenceRoutine catheterchangesNo cathetersecuring devicesNurse DrivenCatheter UseProtocollackingDebilitated healthImmobilityIncomplete emptying ofbladderFecal incontinenceInappropriateantibiotic useNo policy andproceduresLack of preconnectedurine metersLimited variety of trays/Foleysizes availableOther sites of infectionPrevious UTIColonization with resistantorganismsPoor personal hygieneOpen drainage systemsBacterial adherence tocatheter surfaceNo antiseptic coatingsbonded to catheterNo BladderScannersDrainage bag spigot/tubecontaminatedNo closed systemNo sample portCatheter not secured tobodyCatheter left in place longer thannecessaryStanding columns of urine(dependent loops)Unsterile insertionsBreaks in closedsystemDrainage bagstouching floorOther methods to controlincontinence not usedFoley bag raised above level ofbladderClustering ofcatheterized patientsImproper placement ofdrainage bag during transportMulti-patient use ofmeasuring devicesFoley CatheterRelated UTISYSTEMS / HOSPITALSYSTEMS / EQUIPMENTSYSTEMS / ENVIRONMENT© Harriette A. Carr. Used with permission.Association for Professionals in Infection Control and Epidemiology 9

Guide to Preventing Catheter-Associated Urinary Tract InfectionsFigure 1.3Source: Montana State University Center for Biofilm Engineering, P Dirckx. Used with permission.symptomatic urinary tract infections are commonto urinary catheter use. 15 Antimicrobial stewardshipcan play a role in minimizing the potential adverseoutcomes of these occurrences. Inappropriatechoice and utilization of antimicrobials haswell‐documented effects on patients and residentsand can lead to development of multidrugresistance in a healthcare setting. Preparing a facilityor unit-based antibiogram can demonstrate thechanges in antimicrobial resistance that developover time and can be used to track and monitorchanges. The Association for Professionals inInfection Control (APIC) and the Society forHealthcare Epidemiology of America (SHEA)collaborated to outline the roles of healthcareepidemiologists and infection preventionists(IPs) in antimicrobial stewardship programs,and their report was published in the AmericanJournal of Infection Control in March of 2012. 16IPs can play an important role in antimicrobialstewardship through several strategies, whichinclude identification of multiply drug resistantorganisms, compliance with hand hygiene, andstandard and transmission-based precautions. Byusing surveillance data to develop a comprehensiverisk assessment, IPs can educate care providers onappropriate and judicious use of antimicrobialsand implementation of strategies aimed at theprevention of HAIs. Clearly, the prevention ofCAUTI through evidence-based strategies focusedon early removal and appropriate indications forinsertion can have a major impact on these efforts.10 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsReferences1. Magill S, Edwrads JR, Bamberg W, et al. Multistatepoint prevalence survey of health care assoicatedinfections. NEJUM 2014; 370:1198-1208/2. Gould C, Umscheid C, Agarwal R, et al., and theHealthcare Infections Control Practices AdvisoryCommittee (HICPAC). Guideline for preventionof catheter-associated urinary tract infections 2009.Available at: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.3. Ibid.4. Maki DG,Tambyah PA. Engineering out the risk ofinfection with urinary catheters. Emerg Infect Dis 2001;7(2): 342–347. Available at: www.cdc.gov/ncidod/EiD/vol7no2/pdfs/maki.pdf.5. Hollingsworth JM, et al. Determining thenoninfectious complications of indwelling urethralcatheters: a systematic review and meta-analysis. AnnIntern Med 2013 Sept 17; 159(6): 404-410.6. Lo E, Nicole L, Classen D, et al. Strategies toprevent urinary catheter-associated urinary tractinfections in acute care hospitals. Infect Control HospEpidemiol 2008 October; 29 Supp 1: S41–50.7. Gould C, Umscheid C, Agarwal R, et al., and theHealthcare Infections Control Practices AdvisoryCommittee (HICPAC). Guideline for preventionof catheter-associated urinary tract infections 2009.Available at: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.8. Dudek M, Horan T, Peterson K, et al. NationalHealth Care Safety Network (NHSN) Report, DataSummary for 2011, Device-associated Module.Available at: www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report-2011-Data-Summary.pdf.9. Umscheid C, Mitchell M, Doschi J, et al. Estimatingthe proportion of infections that are reasonablypreventable and related mortality and cost. InfectControl Hosp Epidemiol 2011 February; 32(2):101–14.11. Gould C, Umscheid C, Agarwal R, et al., andthe Healthcare Infections Control Practices AdvisoryCommittee (HICPAC). Guideline for preventionof catheter-associated urinary tract infections 2009.Available at: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.12. Donlan RM. Biofilms and device-associatedinfections. Emerg Infect Dis 2001 March–April;7(2):277.13. Trautner B, Darouche R. Role of biofilm incatheter-associated urinary tract infections. Am J InfectControl 2004; 32(3):177–83.14. MacDougall C, Polk RE. Antimicrobialstewardship programs in health care systems. ClinMicrobiol Rev 2005 October; 18(4):638–56.15. Dellit T, Owens R, McGowan J, et al. InfectiousDiseases Society of America and the Society forHealthcare Epidemiology of America guidelinesfor developing an institutional program to enhanceantimicrobial stewardship. Clin Infect Dis 2007 January15; 44(2):159–77.16. Moody J, Cosgrove S, Olmstead R, et al.Antimicrobial stewardship: a collaborative partnershipbetween infection preventionists and health careepidemiologists. Am J Infect Control 2012 Mar;40(2):94–95.17. Magill SS, et al. Prevalence of healthcare-associatedinfections in acute care hospitals in Jacksonville,Florida. Infect Control Hosp Epidemiol 2012; Mar;33(3): 283-29118. Saint S, Lipsky BA, Goold SD. Indwelling urinarycatheters: A one-point restraint? Ann Intern Med 2002.Jul 16; 137(2): 125-127.19. National Action Plan to prevent Health Care-Associated Infections: Road Map to Elimination. April2013. Available at: www.health.gov/hai/prevent_hai.asp.10. Centers for Disease Control and Prevention(CDC). Catheter-associated Urinary Tract InfectionTookit. Available at: www.cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf.Association for Professionals in Infection Control and Epidemiology 11

Guide to Preventing Catheter-Associated Urinary Tract InfectionsSection 2: National CAUTIPrevention InitiativesGiven the incidence of CAUTI across thecontinuum of care as well as supportive literatureto suggest that CAUTI may be the mostpreventable HAI, it is no surprise that severalfederal initiatives aimed at reducing CAUTI haveevolved. Attributable costs associated with CAUTIrange from $758 to $1,006. 18 Although theindividual cost per case is lower than other HAIs,the cumulative cost of these infections given theirprevalence, places a substantial financial burdenon the healthcare community.Federal InitiativesHHS Action PlanThe Action Plan developed by the U.S.Department of Health and Human Services(HHS) came in response to a 2008 GovernmentAccountability Office report that highlighted thefact that multiple HHS programs collect data onHAIs. 1 However, the scope of information andlack of integration across the multiple databases,as well as a lack of high level prioritization ofCDC-recommended practices has hinderedimplementation. This prompted the establishmentof the HHS Steering Committee for thePrevention of Healthcare-Associated Infectionsin July of 2008. 2 The Steering Committee,along with experts and program officials acrossHHS, developed the HHS Action Plan to PreventHealthcare-Associated Infections. The plan providesan initial roadmap for HAI prevention. Theobjectives included the following:• Establish national goals for reducing HAIs.• Include short- and long-term benchmarks.• Outline opportunities for collaboration withexternal stakeholders.• Coordinate and leverage HHS resources toaccelerate and maximize impact.This roadmap projected five-year targetedpriorities for HAI reduction. 3 One of the targetedareas for reduction was CAUTI. In April 2013,HHS released an update to the plan, emphasizingthe importance of HAI prevention across thecontinuum of care and highlighting current gapsin knowledge and practice:• Basic and/or Laboratory Science––Facilitate research to enhance ourunderstanding of factors leading to thedevelopment of CAUTI and the optimalmodes of prevention, diagnosis, and therapy.A logical area for attention is biofilms.––Identify methods to differentiate bladdercolonization from CAUTI in patientswith catheters.• Epidemiology––Explore the epidemiology of CAUTIand asymptomatic bacteriuria, includingincidence, outcomes, and relativecontributions to the use of antimicrobials.––Identify methods to improve the surveillanceof CAUTI, including determining theaccuracy of surveillance definitions in selectpopulations (e.g., elderly patients) anddeveloping methods for electronic captureof CAUTI.––Study the epidemiology of antimicrobialresistance in uropathogens, considering therole of different urinary catheter systemsas reservoirs for resistant bacteria and thepresence of resistance to antimicrobial/antiseptic coatings.12 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infections––Quantify the unnecessary use of urinarycatheters and its consequences (trauma,encrustation).Additionally, phase 3 of this action plan focuseson preventing HAIs in long-term care setting. Itextends earlier efforts that focused on acute-carehospitals (Phase 1), ambulatory surgical centersand end-stage renal disease facilities (Phase 2),and influenza vaccination of healthcare personnel(Phase 2). A major focus of the LTC chapter isprevention of CAUTI. Although LTC facilitieshave made significant progress in reducingurinary catheter device days, CAUTI is themost commonly reported and treated infectionin nursing homes and skilled nursing facilities.It is also a leading cause of 30-day hospitalreadmissions from those facilities.Clearly, prevention of CAUTI has become anational priority with a measurable improvementtarget described in the HHS National Action Plan.The 2013 National Prevention Target was a 25percent reduction in CAUTI in ICU and wardlocatedpatients or a 0.75 standardized infectionratio (SIR). However, ongoing measurementsindicate that CAUTI prevention initatives arenot currently on track to meet this target.HHSis currently considering the next phase of theHAI Action Plan and proposed targets for 2020.Due to the many challenges of reducing and/oreliminating CAUTI, IPs should expect that itwill remain a national priority among theprevention goals.Partnership for PatientsIn April 2011, the Obama administrationlaunched a public/private initiative calledPartnership for Patients. This partnership involveshospitals, consumers, employers, unions, andhealth plans, among others, all working togetherin an effort to improve patient safety. 4 The goal ofthis is to make healthcare safer, more reliable, andless costly by doing the following:• Preventing harm. Reducing preventablecomplications of care by 40 percent of 2010rates by the end of 2013.• Decrease preventable complications duringa transition of care from one care setting toanother by 20 percent by the end of 2013.Twenty-six state, regional, national, or hospitalsystem organizations received $218 million tobecome Hospital Engagement Networks (HENs).As HENs, these organizations help identifysolutions already working to reduce healthcareassociatedconditions and work to spread themto other hospitals and healthcare providers.They lead learning collaboratives and providetechnical assistance for hospitals as well as developmechanisms for monitoring hospitals’ progresstoward providing safer care for their patients.The Partnership for Patients has identified theprevention of CAUTI as one of the 10 focusedhospital-associated conditions to be reduced by40 percent by 2013, representing a very ambitiousand aggressive focus on HAI reduction. CaseStudy 1 describes the success achieved by an acutecarecommunity hospital’s participation in theVMS Partnership for Patients program.Association for Professionals in Infection Control and Epidemiology 13

Guide to Preventing Catheter-Associated Urinary Tract InfectionsCase Study 1: Partnership for PatientsAn increased incidence of catheter-associated urinary tract infections (CAUTI) at a Louisianacommunity hospital triggered a prompt response from the facility’s Infection Prevention department.CAUTI are associated with higher morbidity and mortality rates and may affect a hospital’sreimbursement because it is a process measure in Value-Based Purchasing. This infection accountedfor nearly 40 percent of the facility’s hospital-acquired infections (HAIs).To resolve the issue, a CAUTI Reduction Team was established in the summer of 2012 as part ofthe facility’s participation in the Centers for Medicare & Medicaid Services Partnership for PatientsCampaign. The team, comprised of a nursing representative from each major patient-care area and aninfection prevention nurse, achieved a dramatic reduction in the number of CAUTI within two monthsand sustained that decrease throughout the next year.A major challenge of the CAUTI Reduction Team was to bring CAUTI awareness to the forefront ofnurses’ minds, despite all their other tasks and responsibilities. Here, Implementation Science proveduseful. This action-oriented model uses “The Four Es”—Engage, Educate, Execute, and Evaluate—tocreate an operational framework that integrates research and evidence into practice—also known asimplementation science. 19Engage: Nurses were successfully engaged by forming a crew of high performers who are wellrespected by their peers to act as role models in delivering excellent care. Once members of theteam consistently exhibited exemplary professional practice relating to CAUTI prevention, their peersfollowed suit. To facilitate a sustained, meaningful change, the CAUTI Reduction Team memberscontinue to serve as resources and role models for other staff. Furthermore, staff exhibited ownershipof CAUTI preventative efforts and the outcomes thereof. Combining model professional practice withownership and accountability for the process facilitated nursing engagement.Educate: The CAUTI team carried out a massive educational agenda to ensure everyone was awareof the CAUTI prevention initiative. Team members attended every nursing unit’s staff meeting topromote CAUTI awareness. This initial step was followed by another round of meetings to explain thenewly approved nurse-driven protocols. When opportunities for improvement are identified, specificpatient case studies are presented during staff meetings and/or staff huddles on the unit. Key CAUTIprevention strategies have been incorporated into nursing orientation for new hires and are reinforcedduring annual competency evaluations. Posters displaying CAUTI prevention measures are rotatedthroughout departments to allow individuals to learn at their own pace.Execute: The team investigated evidence-based interventions. A Foley catheter securementdevice, a nurse-driven Foley catheter removal protocol, and a post-catheter removal protocol wereimplemented. These protocols grant the nurse autonomy to remove a Foley catheter, dependingon specific criteria outlined in the protocol. Additionally, the nurse can perform one straightcatheterization if the patient has not voided within the determined time frame outlined in the protocol.The team utilized the quality improvement methodology of Rapid-Cycle Change to guide implementationof the two nurse-driven Foley catheter protocols. This methodology uses the traditional Plan-Do-Study-Act (PDSA) cycle to facilitate rapid improvement through small scale test interventions.If the intervention provided favorable results, then the change was applied to a larger population.Directly applying the PDSA cycle, the two nurse-driven Foley catheter protocols were first introducedto the hospital’s three surgery units. Within a month, those units’ device days decreased significantly.The next month it was rolled out to the remaining seven nursing units.14 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsEvaluate: The team chose infection rates as an outcome measure because the CDC providesstandardized, scientifically rigorous definitions. Each month, department managers share data oninfection rates and device days. Surgical Care Improvement Project statistics and Partnership forPatients comparative data also are evaluated to determine progress and are shared monthly with theteam and other administrators. Concurrent audits on the use of nurse-driven protocols are completed,random audits determine if protocols are being used appropriately and feedback is given to staff.Future team goals relate to continuously evaluating current processes, as well as validating that staff isinserting catheters aseptically.Since the team was established, the facility has seen a 74 percent decrease in the incidence ofCAUTIs compared to the prior year. Implementing effective evidenced-based interventions and usingImplementation Science were crucial in achieving the team’s mission to reduce this prevalent hospitalacquiredinfection.Additional Information:North Oaks Medical Center is a 330-bed acute care community hospital located in Tangipahoa parish,which is between New Orleans and Baton Rouge. The infection prevention department consists of twofull-time RNs, the department director, a surveillance nurse, and a secretary. The department director iscertified in infection control, and the surveillance nurse is preparing to take the certification exam. Theinfection prevention team is supported by two infectious disease physicians.Contributed by: Brooke Buras, RN, BSN, Infection Prevention Nurse, North Oaks Medical CenterCDC HICPACThe Healthcare Infection Control PracticesAdvisory Committee (HICPAC) is a federaladvisory committee made up of 14 externalinfection control experts who provide advice andguidance to the CDC and the HHS secretaryregarding the practice of healthcare infectioncontrol, strategies for surveillance and prevention,and control of HAIs in U.S. healthcare facilities.The committee has liaison representatives fromprofessional organizations and other federalagencies—including APIC, the Society forHealthcare Epidemiology of America, theAssociation of periOperative Registered Nurses, theCenters for Medicare & Medicaid Services (CMS),the Food and Drug Administration (FDA), andsuch other nonvoting liaison representatives as thesecretary deems necessary to effectively carry outthe functions of the committee. 5The 14 members include the chair and cochair.Members are recommended by theCDC and appointed by the HHS secretaryfrom experts in the fields of infectious diseases,healthcare-associated infections, nursing, surgery,epidemiology, public health, health outcomes,and related areas of expertise. In 2009, HICPACreleased the Guideline for Prevention of Catheter-Associated Urinary Tract Infections. This guidelineupdated and expanded the original CDCguideline published in 1981. 6Although CDC guidelines have long beenconsidered the gold standard in infection preventionstrategies, the science is constantly evolving. It isimportant that infection preventionists and othersresponsible for implementing evidence-basedrecommendations pay close attention to peer reviewpublications, particularly where well-developed,randomized control studies have provided new oremerging evidence.Association for Professionals in Infection Control and Epidemiology 15

Guide to Preventing Catheter-Associated Urinary Tract InfectionsCAUTI in the SHEA/IDSACompendiumIn 2014 the Society for Healthcare Epidemiologyof America (SHEA) and the Infectious DiseaseSociety of America (IDSA) released the firstupdate to their 2008 A Compendium of Strategiesto Prevent Healthcare-Associated Infections in AcuteCare Hospitals. The first update addressed CAUTI.The compendium, including the 2014 updates,is the product of a collaborative effort led bySHEA and IDSA with support from the AmericanHospital Association (AHA), the Associationfor Professionals in Infection Control andEpidemiology (APIC), and The Joint Commissionwith major contributions from representativesof a number of organizations and societies withcontent expertise.According to SHEA and IDSA, the Compendiumsynthesizes best evidence for the prevention ofsurgical site infections, central line-associatedbloodstream infections, catheter-associated urinarytract infections, ventilator-associated pneumonia,Clostridium difficile, and MRSA. It alsohighlights basic HAI prevention strategies plusadvanced approaches for outbreak managementand other special circumstances and recommendsperformance and accountability measures forinfection prevention practices.Learn More About theCompendium UpdatesFor more information about the SHEA/IDSACompendium, be sure to read Maintaining theMomentum of Change: The Role of the 2014Updates to the Compendium in PreventingHealthcare-Associated InfectionsEdward Septimus, MD; Deborah S. Yokoe,MD, MPH; Robert A. Weinstein, MD; TrishM. Perl, MD, MSc; Lisa L. Maragakis, MD,MPH; Sean M. Berenholtz, MD, MHSSource: Infection Control and HospitalEpidemiology, Vol. 35, No. 5 (May 2014),pp. 460-463The Compendium does not reflect a completesystematic review of the literature and is notintended to replace previously publishedguidelines such as those released by the CDC.Instead the goal of the Compendium is to provideacute care hospitals with a summary of practical,concise guidance based primarily on existingauthoritative guidance documents. 22The CAUTI update is available as an open accesspublication at the SHEA website:www.shea-online.org/PriorityTopics/CompendiumofStrategiestoPreventHAIs.aspxAHRQ CAUTI CUSPThe Agency for Healthcare Research and Quality(AHRQ) (formerly known as the Agency forHealth Care Policy and Research) is one of 12agencies within the HHS. The purpose of theagency is to enhance the quality, appropriateness,and effectiveness of healthcare services, and accessto such services through the establishment of abroad base of scientific research and through thepromotion of improvements in clinical practiceand delivery of healthcare services. 7 As part ofthe National Action Plan, the AHRQ has fundeda nationwide effort to promote the use of theComprehensive Unit-based Safety Program(CUSP) to prevent CAUTI in U.S. hospitals.This project combines the implementation ofgeneral socio-adaptive approaches to improvecare in a particular unit or hospital coupled withevidence‐based interventions focusing on thetechnical aspects of CAUTI prevention. 8CUSP is a five-step program designed to change aunit’s workplace culture to bring about significantsafety improvement through empowering staffto assume responsibility for safety in theirenvironment. This is achieved through education,awareness, access to organization resources, anda toolkit of interventions.The CAUTI-CUSP initiative, applied lessons andexperience from CLABSI prevention collaborativethat was piloted in Michigan, which resulted in a16 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infections66 percent decrease in CLABSI rates over the first18 months and a sustained reduction in CLABSIover 3 years. 20 The goals of the national On theCUSP: Stop CAUTI project are to accomplishthe following:1. Reduce mean CAUTI rates in participatingclinical units by 25 percent over 18 months.2. Improve patient safety by disseminatingthe CUSP model and tools as evidenced byimproved teamwork and communication.3. Promote the coordination of state-basedefforts to eliminate HAIs.Figure 2.1. CUSP Implement ModelThis work is now spreading across the UnitedStates. This national program seeks to leveragethe expertise of different stakeholder groups andorganizations for the unified goals of reducingurinary catheter-related harm. 9*Details on Patient Safety, CUSP Methodology,Toolkits and other resources are provided inSection 5.Case Study 2: CAUTI CUSP at the University Medical Center of Southern NevadaAshley Komacsar, BSN, RN, was still in orientation at her new job in the surgical intensive care unit andneuroscience care unit (SICU/NSCU) at University Medical Center of Southern Nevada (UMC) whenher interim manager suggested she attend a presentation about catheter-associated urinary tractinfections (CAUTIs). “I figured it was a conference learning session—I didn’t realize it was getting onboard for an 18-month commitment,” Komacsar said with a laugh.Komacsar eventually became the team leader for UMC’s On the CUSP: Stop CAUTI program, under thedirection of Clinical Manager Marlon “Jon” Medina, RN, BSN. In a hospital that faces particular infectioncontrol challenges, Komacsar and Medina came to welcome the solutions that comprehensive unitbasedsafety program (CUSP) offered.Located in Las Vegas, the 564-bed UMC is the only level-one trauma center in Nevada and frequentlyreceives transfer patients from Arizona, California, and Utah. It’s also a nonprofit operated by ClarkCounty and thus serves a diverse population that includes the transient and indigent. Finally, UMC isa teaching hospital for University of Nevada medical students.Both Medina and Komacsar believe staff buy-in was key to the success of their CUSP program. “Inanother unit with a very high CAUTI rate that was supposed to be involved in the program, they hada fractious team member and it didn’t work out,” Komacsar said.Association for Professionals in Infection Control and Epidemiology 17

Guide to Preventing Catheter-Associated Urinary Tract InfectionsBut in Komacsar’s and Medina’s SICU/NSCU unit, the charge nurses took the lead in helping othernurses get on board. The executive champion, UMC Chief Financial Officer Stephanie Merrill, broughtin the hospital administration and the physician champion, Matthew Schreiber, MD, who was key incommunicating the value of the program to residents.“It was so important to find people who were going to be invested and committed in the program, andto not just make them do it,” Komacsar said. Added Medina: “It was particularly important to get buyinfrom the charge nurses, especially the ones on the night shift, because they collect the data.” Medinahelped accomplish this by juggling the census and staff ratio to clear time for CUSP team members toparticipate in monthly meetings, national content calls, and state coaching calls.There were 10 people on UMC’s CUSP team: Medina and Komacsar, Schreiber, an infectionpreventionist, four charge nurses, and two staff nurses. They relied on the CUSP toolkit to helporganize and define team members’ roles.Komacsar said CUSP helped them recognize how much indwelling urinary catheter use can increaseCAUTIs, so the team focused on reducing Foley catheter use and on proper insertion when thecatheters were deemed necessary. They began by reviewing current catheter and physician order sets,and established care bundles for the nurses to follow. “We also refined rules like ‘Every ICU patientneeds a Foley,’” Komacsar said.The CUSP team then conducted a hospital-wide Foley training session. The future goal is to do thesetwo-hour sessions quarterly, over a three-day period, to help ensure all staff can participate. “We don’thave yearly competencies, so this makes sure our skills are up to par,” Komacsar said.The CUSP team also created a PowerPoint presentation on Foley use that is mandatory for all medicalstaff and placed Foley Decision Trees in every patient room, listing the insert date, catheter indications,and maintenance. For staff, the team created CUSP information boards, along with printed CAUTIalerts, listing the date and reason for the incident.The CUSP team also reinforced the use of catheter alternatives. They educated staff on the properapplication technique for condom catheters, and conducted a pilot program with a female urinal. “Wefemale nurses realized we didn’t even know how to use it, so we made it a CUSP team project to figureit out,” Komacsar said. “Then we did a 220-employee in-service on it for the other floors. The nursesappreciated us teaching them, and as a result of that education other units ordered female urinals.”While UMC’s CAUTI rates have actually risen since the CUSP program began, (from 4.16 in 2012 to9.08 in the first three quarters of 2013), Foley-device utilization has decreased from 73 percent ofpatient days to 62 percent during that same time frame. “As the [Foley usage] numbers decrease, theinfection rate increases because there is less of a sample size. This phenomenon is seen nationwide inthis project as we use less Foley catheters,” Medina said.Overall, Medina and Komacsar view their CUSP program as a success. “We want to use the CUSPmethodology on other projects because it makes a program comprehensive,” Komacsar said. “It bringsin everyone and bridges departments from the executives to the staff nurses. It uses the hospitalsystem to its advantage.”From Prevention Strategist, Spring 2014; vol. 7, number 1.18 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsTable 2.1. Reportable HAIsHAI Events Facility Reporting Start DateCLABSI Acute-Care Hospital ICUs Jan 2011CAUTI Acute-Care Hospital ICUs (except NICUs) Jan 2012SSIsColon Surgeries and Abdominal Hysterectomies in Jan 2012Acute Care HospitalsDialysis Events End-Stage Renal Disease Facilities Jan 2012CLABSI Long-Term Care Hospitals Oct 2012CLABSI Cancer Hospitals Oct 2012CAUTI Long-Term Care Hospitals Oct 2012CAUTI Inpatient Rehab Facilities Oct 2012CAUTI Cancer Hospitals Oct 2012MRSA Bacteremia LabID Events Acute-Care Hospitals Jan 2013C. Difficile LabID Events Acute-Care Hospitals Jan 2013HCP Influenza Vaccination Acute-Care Hospitals Jan 2013HCP Influenza Vaccination Long-Term Care Hospitals Oct 2013SSIsColon Surgeries and Abdominal Hysterectomies in Jan 2014Cancer HospitalsHCP Influenza Vaccination Ambulatory Surgical Centers Oct 2014HCP Influenza Vaccination Hospital Outpatient Departments Oct 2014HCP Influenza Vaccination Inpatient Rehab Facilities Oct 2014CLABSIAcute Care hospital medical, surgical and medical/ Jan 2015surgical unitsCAUTIAcute Care hospital medical, surgical and medical/ Jan 2015surgical unitsMRSA Bacteremia LabID Events Long-Term Care Hospitals Jan 2015C. Difficile LabID Events Long-Term Care Hospitals Jan 2015Centers for Medicare & Medicaidand ReimbursementNew attention to HAIs has underscored the needfor comprehensive and systematic surveillanceand prevention programs that are tied to publicreporting and reimbursement. See Table 2.1.The CMS has increased scrutiny of practicesand implemented financial incentives for theprevention of HAIs. Media and public attentionto HAIs has also increased, as many HAIs,once seen as an unfortunate consequence ofreceiving healthcare, are now considered largelypreventable. 10Infections associated with devices have receivedclose attention as a result of their escalating useand increased evidence of preventability whenevidence-based guidelines are implemented. Ina 2009 report issued by Scott et al., CAUTIcontinued to be the most prevalent devicerelatedinfection. The annual cost per case hasbeen estimated to be between $789 and $1,003,and the cumulative burden of these infectionswas estimated at an annual cost to the nation’shealthcare system of from $390 to $450 millionbased upon the consumer price index. 11The passage of the Deficit Reduction Act of 2005required the HHS secretary to select at least twoconditions that (a) are high cost, high volume, orboth; (b) result in the assignment of a case to adiagnostic related group that has a higher paymentwhen present as a secondary diagnosis and couldAssociation for Professionals in Infection Control and Epidemiology 19

Guide to Preventing Catheter-Associated Urinary Tract Infectionshave reasonably been prevented through theapplication of evidence-based guidelines. The FiscalYear 2008 Inpatient Prospective Payment System(IPPS) was published by the CMS in August2007. Of the hospital-acquired conditions (HACs)originally selected, three are related to infections notconsidered present on admission: CAUTI, vascularcatheter-associated infection, and mediastinitis aftercoronary artery by-pass graft surgery. Identificationof HACs is based upon coding of claims forreimbursement of care involving hospital-acquiredconditions and does not necessarily match criteriathat infection preventionists use in surveillance ofHAIs. Subsequent analysis of frequency of claimsusing the code for CAUTI found it was almostnever used. 21In 2010, Congress incorporated HAI preventioninto the Affordable Care Act. The CMS haselected to implement the requirement byincluding national public reporting of HAIs, aspart of the Hospital Inpatient Quality ReportingProgram (IQR), beginning with ICU CLABSIs in2011 and ICU CAUTI (except NICU) in January2012 followed by CAUTI reporting in longtermacute hospitals and inpatient rehab units inOctober 2012 (see Table 2.1 for complete list ofreportable HAIs). Unlike the HACs, reporting ofCAUTI information in the IQR Program requiresfacilities to apply NHSN definitions and reportinfections through the NHSN network. 12 CMShas continued to expand the scope of surveillancein the IQR program by adding CAUTI in non-ICU locations beginning in January 2015. 23 Inaddition, the original HACs, including CAUTI,were added to the value-based purchasingincentive program as a process measure beginningin FY 2013.APIC, as well as other professional societies, hasexpressed growing concern over the confusionregarding two separate reporting measures usingseparate HAI definitions and criteria. In the 2013Inpatient Prospective Payment Systems (IPPS)final rule, CAUTI will be removed from thehospital-acquired conditions beginning 2014 forfiscal year 2015. This change ensures that clearlydefined, risk adjusted data will be utilized forpublic reporting and eventual pay for performancemeasures.National Quality ForumThe National Quality Forum (NQF) is a nonprofitorganization based in Washington, DC, that isdedicated to improving the quality of healthcare inthe United States. To that end, the NQF embodiesa three-part mission:• to set goals for performance improvement,• to endorse standards for measuring andreporting on performance, and• to promote educational and outreach programs.NQF members include purchasers, physicians,nurses, hospitals, certification bodies and fellowquality improvement organizations. Generally,the CMS seeks to include measures that are NQFendorsed in its proposed IPPS rulemaking. 13Accrediting AgenciesIn 2008, the CMS enacted a new law requiringthat any accrediting body seeking deemingstatus must apply to the CMS. The four majoraccrediting bodies are The Joint Commission(TJC), Det Norske Veritas Healthcare (DNV),and Healthcare Facilities Accreditation Program(HFAP), and the Accreditation Associationfor Ambulatory Healthcare (AAAHC). Theseaccrediting organizations vary in the types ofinstitutions for which they hold “deemed status.”The Conditions of Participation (COPs) (orfor some nonhospital Medicare providersthe Conditions for Coverage (CfC) ) [e.g.,ambulatory surgery centers] are the federalhealth and safety requirements that hospitals andother providers must meet to participate in theMedicare and Medicaid programs. The COPsare intended to ensure that high-quality care isprovided to all patients. Compliance with theCOPs is determined by State Survey Agencies(SAs) or Accreditation Organizations. The SAssurvey hospitals to assess compliance with the20 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsCOPs. Hospitals are deemed to have met therequirements in the COPs if they are accreditedby national accreditation programs approved byCMS. All Medicare- and Medicaid-participatinghospitals are required to be in compliance withCMS COPs regardless of their accreditation status.The COPS require that the hospital infectioncontrol program specifically address the reductionof HAIs through the implementation of evidencebasedpractices. Consistent with these standardsfor reduction of HAIs is an emphasis on reductionof CAUTI. 14DNV Healthcare is a worldwide company initiallyfocused on risk management. In the United States,DNV integrates ISO 9001 quality compliancewith the CMS COPs. Infection-preventionstandards, which include program managementand standard operating procedures, are all part ofthe DNV accreditation process. An organizationalrisk assessment that includes CAUTI reductionis part of the accreditation process. 15 The DNVManaging Infection Risk Standard was developedto provide a modern, comprehensive and practicalframework to help organizations improvetheir management of infection risk. It adopts astructure based upon 18 elements addressing allareas associated with the design, operation andmanagement of healthcare facilities. The standardis compatible with the World Health Organization(WHO), the Centers for Disease Controland Prevention (CDC) and other nationalguidelines to allow better integration and ease ofimplementation.HFAP standards also include nationally recognizedstandards and evidence-based best practices forpatient safety and infection prevention. Originallycreated in 1945 to conduct an objective reviewof services provided by osteopathic hospitals,HFAP has become a recognized accreditor forall hospitals. HFAP has maintained its deemingauthority continuously since the inception ofCMS in 1965 and meets or exceeds the standardsrequired by CMS.The Accreditation Association for AmbulatoryHealth Care Inc. holds “deemed status” fromCMS to survey ambulatory surgery centers(ASCs) for Medicare. However urinary catheteruse in ASCs is limited both in frequency andduration, making it less urgent issue for patientsin these settings where prevention targets focuson the identification and reduction in surgicalsite infections.TJC focuses on infection prevention through itsspecific elements of performance as well as itsNational Patient Safety Goals (NPSGs), whichinclude targeted interventions to reduce patientharm. One particular area identified as high riskfor harm is HAIs. NPSGs specific to preventionof HAIs address, hand hygiene, prevention ofsurgical site infections (SSIs), prevention ofCLABSI, MDROprevention, and CAUTI. TheNPSG 07.06.01 specific to CAUTI requiresimplementation of evidence-based practices toprevent CAUTI. 16NPSG 7.06.01 Elements of Performance includethe following:• Limiting use and duration to situationsnecessary for patient care• Using aseptic techniques for site preparation,equipment, and suppliesManage indwelling urinary catheters accordingto established evidence-based guidelines thataddresses the following:• Securing catheters for unobstructed urine flowand drainage• Maintaining the sterility of the urine collectionsystem• Replacing the urine collection system whenrequired• Collecting urine samplesAssociation for Professionals in Infection Control and Epidemiology 21

Guide to Preventing Catheter-Associated Urinary Tract InfectionsMonitor:• Select measures using evidence based guidelines• Monitor compliance with evidence basedguidelines• Evaluate effectivenss of prevention effortsSurvey ProcessThe tracer methodology is widely used invarious accrediting survey processes. The tracermethodology provides a means to analyze anorganization’s system of providing care, treatmentand services by using actual patients as a frameworkfor the review. Tracers engage staff whoprovide care, observe handoffs and transitions,review critical environmental issues, and evaluateemployee knowledge and performance. 17Example:Mrs. X is a patient on your high-volume medicalunit. She has a urinary catheter in place and hasdeveloped a CAUTI, caused by vancomycinresistantEnterococcus (VRE), which is healthcareassociated.Possible questions from the surveyor:• When was the catheter inserted?• Where was the catheter inserted?• What were the indications for insertion?• What is this unit doing to prevent CAUTI?• Have you received education regarding insertionand maintenance of CAUTI?• What is your CAUTI incidence on this unit?Observations:• Is the catheter bag below the level of thebladder?• Is the catheter secured and flow uninterrupted?• Did the nurse practice appropriate handhygiene?Record Review:• May request competency and in-service recordsfor this individualOther Issues:• May review where supplies are stored• If catheter was inserted in other area, such asemergency department (ED), may visit area• May ask to review catheter insertion andmaintenance policy and standardExample developed and provided with permission byLinda Greene, RN, MPS, CIC, Highland Hospital,Rochester, NYThe tracer methodology has now been adoptedby the CMS and tested in facility surveys. Anexample of a CAUTI tracer tool developed bythe CMS is shown in Figure 2.2. Survey tools,including tracers, undergo periodic updates.Check with the state survey agency for the mostcurrent forms applicable in any specific state.Documentation review:• Is the insertion documented?• Is there ongoing assessment of the need for thecatheter?• What criteria are utilized for continuingcatherization?• Is there documentation that the patient hasreceived education relative to the VRE?22 Association for Professionals in Infection Control and Epidemiology

Figure 2.2. A Urinary Catheter TracerGuide to Preventing Catheter-Associated Urinary Tract InfectionsReferences1. Government Accountability Office (GAO).HealthCare-Associated Infections in Hospitals: LeadershipNeeded from HHS to Prioritize Prevention Practices andImprove Data on These Infections. GAO-08-673T, April16, 2008. Available at: www.gao.gov/products/GAO-08-673T.2. U.S. Department of Health and Human Services(HHS). Organizational Structure of the HHSInitiative for the Prevention of Health Care-AssociatedInfections. Available at: www.hhs.gov/ash/initiatives/hai/orgstructure/index.html.3. U.S. Department of Health and Human Services(HHS). National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination.Available at: www.hhs.gov/ash/initiatives/hai/actionplan/index.html.4. Available at: www.partnershipforpatients.cms.gov/.5. Available at: www.cdc.gov/hicpac/.6. Gould C, Umscheid C, Agarwal R, et al., and theHealthcare Infections Control Practices AdvisoryCommittee (HICPAC). Guideline for preventionof catheter-associated urinary tract infections 2009.Available at: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.Association for Professionals in Infection Control and Epidemiology 23

Guide to Preventing Catheter-Associated Urinary Tract Infections7. Available at: www.ahrq.gov/.8. Available at: www.onthecuspstophai.org/on-thecuspstop-cauti/.9. Fakih MG, George C, Edson BS, et al.Implementing a national program to reducecatheter-associated urinary tract infection: aquality improvement collaboration of state hospitalassociations, academic medical centers, professionalsocieties, and governmental agencies. Infect ControlHosp Epidemiol 2013 Oct; 34(10): 1048–54.10. McKibben L, Horan T, Tokars J, et al. Guidanceon public reporting of healthcare-associated infections,recommendations of the healthcare infection controladvisory committee. Am J Infect Control 2005 May;33:217–26.11. Scott D. The Direct Costs of Healthcare AssociatedInfections in US Hospitals and the Benefits of Prevention.Available at www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf.12. U.S. Department of Health and Human Services(HHS). “The Affordable Care Act helps statesprevent, fight infectious diseases,” news release,August 16, 2012. Available at: www.hhs.gov/news/press/2012pres/08/20120816a.html.13. Available at: www.qualityforum.org/about/.14. Centers for Medicare & Medicaid Services(CMS). Memorandum to State Survey AgencyDirectors, February 11, 2009. Available at: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter09-08.pdf.15. Available at: www.dnvusa.com/focus/hospital_accreditation/.16. The Joint Commission (TJC). New 2012 NationalPatient Safety Goal – Catheter-Associated UrinaryTract Infections (CAUTI). May 17, 2011. Available at:haifocus.com/joint-commission-approves-cauti-2012-npsg/.17. The Joint Commission (TJC). Facts about TracerMethodology. Available at: www.jointcommission.org/facts_about_the_tracer_methodology/.18. Zimlichman E, Henderson D, Tamir O, et al.Health care-associated infections: a meta-analysisof costs and financial impact on the US health caresystem. JAMA Intern Med 2013; (172): 2039-2046.19. Saint S, et al. Implementation science: how tojumpstart infection prevention. Infect Control HospEpidemiol. 2013 Nov; 31 (Suppl 1): S14-S17.20. Pronovost P, et al. An intervention to decreasecatheter-related bloodstream infections in the ICU.N Engl J Med 2006. Dec; 28; 355 (26): 2725-2732.21. Meddings, J, Saint S, McMahon L. Hospitalacquiredcatheter-associated urinary tract infection:documentation and coding issues may reduce financialimpact of Medicare’s new payment policy. InfectControl Hosp Epideminol 2010; 31 (6): 627-633.22. Yokoe DS, Anderson DJ, Berenholtz SM, et al.Introduction to a compendium of strategies to preventhealthcare-associated infections in acute care hospitals:2014 updates. Infect Control Hosp Epidemiol. May2014; 35 (5): 455-459.23. Centers for Medicare & Medicaid Services (CMS).Federal Register. Vol. 78, No. 160/Monday, August19, 2013/Rules and Regulations. Regulation NumberCMS-1599-F. Available at: www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf.24 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsSection 3: CAUTI Risk AssessmentThe risk assessment is a thoughtful, systematicprocess of assessing potential negative outcomesin the environment. The CAUTI risk assessmentis part of the overall infection prevention riskassessment. 1 An example of surveys of professionalsin a large integrated network to assess status ofCAUTI prevention program has been described inpublished literature.The following steps outline tips for conducting aCAUTI risk assessment and may be helpful fororganizations:Step 1: Assess whether an effectiveorganizational program exists.Questions may include any of the following:• Are there policies or guidelines that definecriteria for insertion of a urinary catheter?• Has the organization established criteria forwhen a catheter should be discontinued?• Is there a process to identify inappropriate usageor duration of urinary catheters?• Is there a program or are there guidelines toidentify and remove catheters that are no longernecessary, e.g., physician reminders, automaticstop orders or nurse-driven protocols?• Are there policies or guidelines for use of aportable ultrasound bladder scanner for postvoidresidual prior to insertion of a catheter forurinary retention?• Are there mechanisms to educate care providersabout use and care of urinary catheters?• Are functional alternatives to indwellingcatherization available?• Overall Assessment: Is there an effectiveorganizational program in place?Step 2: Assess population at risk.The primary at-risk population can be determinedby identifying areas of high urinary catheter usage.These areas include critical care areas, medical andsurgical units, nursing homes, etc.It is also important to assess the intensity of deviceuse, either organizationally or by high-risk area.Studies to determine the frequency of deviceuse can be readily performed in each high-riskor problem-prone setting. These studies wouldinclude assessment for appropriate use of thecatheter and patient care practices as defined bythe facility’s nursing and/or infection preventionand control policies.When data concerning device use days are notreadily available, a point prevalence study isuseful to determine opportunities to enhancecompliance with facility “best practice” policies,and/or to identify areas where specific targetedinterventions are needed. To perform this typeof study, staff members from the various careunits could be recruited to perform and tally therequired observations. This would provide theadded benefit of rapid feedback of findings toparticipating units.It is important to note that this type of studyis only a “snapshot in time” and may not berepresentative of the actual practices and actionson all units all of the time. However, observationalstudies of this type can be readily performed asneeded, and they can provide baseline data tocomplete the risk assessment, monitor trends incare practices, and identify outliers per unit, shift,or service.Association for Professionals in Infection Control and Epidemiology 25

Guide to Preventing Catheter-Associated Urinary Tract InfectionsThe point prevalence survey questions mayinclude any of the following as appropriate tofacility policy or protocols:• Is there a Foley catheter in use?• Where was the foley inserted?• What type of Foley catheter is in use (e.g.,three-way catheter, temperature-sensingcatheter, Coude catheter, impregnated vs.nonimpregnated with an antimicrobial, etc.)?• Is this the type of catheter normally used in thisfacility?• Is a closed system being maintained? Is tamperresistantseal intact?• Is the Foley inserted using a tray wherepreconnectionss are in place between thecatheter and the bag?• Is the Foley secured to the patient’s body toprevent urethral tension?• How is it secured (e.g., tape, securement device,etc.)?• Is the bag below the level of the patient’sbladder?• Is the tubing from the catheter to the bag free ofdependent loops? Would a picture be helpful fornew infection preventionists?• Is the tubing secured to the bed or chair toprevent pulling on the entire system?• Is the bag hanging free without touching thefloor?• Does the patient have an individual urineoutput measuring device marked with his or hername and room number?The denominator for this monitor is the numberof patients who have urinary catheters duringthe surveillance period on the unit or in thepopulation being monitored.Consider obtaining catheter usage data fromfacility’s Materials Management Department inorder to identify high-volume usage areas.• Assess baseline outcome data. Organizationsmay elect to collect and assess baseline outcomedata either facilitywide or by high-risk area.Step 3: Assess baseline outcome data.Baseline data can be collected utilizing thesurveillance methods described in Section 4 ofthis guide. If these options are not feasible, thereare a few other options for establishing baselineoutcome data for comparison purposes:• Examine facility- or setting-specific CAUTIcaused by epidemiologically importantpathogens based on other HAI surveillance dataor experience. Consider crude uropathogenanalysis of urines obtained > 48 hours afteradmission. (Note: NSHN critata state day ratherthan greater 48 hours.)• Assess location, frequency, and prevalence ofMDROs or other epidemiologically significantorganisms associated with UTIs. Thisinformation may be obtained by working withyour facility’s Microbiology Department orthrough the usage of electronic data systems.• Use NHSN definitions of bloodstreaminfections, which meet criteria as beingattributable or secondary to CAUTI. Determinefrequency and overall impact of these infections.Step 4: Determine financial impact.Several methods exist to identify the financialimpact of these infections:Method 1:Obtain a list of patients who met one of the UTIcodes and the 999.64 catheter-association codein which the UTI was coded “not present onadmission.” Identify direct revenue loss. (Referto text on value-based purchasing in Section 2.)However, this method is used very infrequently soyield may be artificially low. 3Method 2:Utilize published data to estimate financialimpact, based on average frequency and cost ofUTIs. In 2005, Stone and colleagues publisheda review of the current literature addressing the26 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infectionseconomic ramifications of adverse events, suchas HAIs. 2 They examined more than 150 studiesconducted from 2001 to 2004 that looked atthe simple cost of infections or performed a costanalysis of interventions. 4Method 3:Calculate actual excess costs of infections andexcess length of stay. Resources, such as APIC’sHAI Cost Calculator Tool, are available and cangenerate tables and graphs that can help describethe impact of a urinary tract infection in yourown organization.The HAI Cost Calculator Tool is included as partof APIC’s Dispelling the Myths: The True Costof Healthcare-Associated Infections, available atwww.apic.org/store.Type of Risk AssessmentThe risk assessment may be either qualitative,quantitative, or a combination of both. The riskassessment should drive the infection preventionplan and help establish goals. The qualitative riskassessment uses an approach that assesses the riskbased upon written descriptions. One exampleof a qualitative risk assessment is described inTable 3.1.Alternate Risk AssessmentA quantitative RA uses scores, usually stratifiedin a defined and systematic way, to integrate themany types of risks that can potentially contributeto infection. An example of this RA model isshown in Figure 3.1.Table 3.1. Example of Qualitiative Risk AssessmentAreas/ Topic Current Status Goals Identified Gap Actions PriorityCAUTI7 actualinfections vs.3.7 expected(NHSN)Reduce CAUTIrates by 30percentImproveadherence todiscontinuingpostoperativecatheters within48 hoursNo standardorder sets orpathways fordiscontinuingFoley cathetersin surgicalpatientsNo nurse-drivenprotocols forremovalNo standardorders forappropriateinsertionprotocolsSource: Adapted from the APIC/JCR Infection Prevention and Control Workbook, 2nd EdIncorporatediscontinuingcatheters post-opinto standardorder sets andpathwaysDevelop nursedrivenprotocolsand vet withstakeholdersReport incidenceto units as soonas possibleUse learningfrom defects orother tools toanalyze issuesHIGH (rateshave increasedsince theprevious year)Now a CMSreportedmeasure in ICU,Rehab, andLTACHAssociation for Professionals in Infection Control and Epidemiology 27

Guide to Preventing Catheter-Associated Urinary Tract InfectionsFigure 3.1. Quantitive RA ModelRisk CriteriaMitigationCriteriaProgramElementsHigh VolumeNew Initiative /GuidelineContinued Initiative/GuidelineRequired by LawMorbidity / MortalityFinancial RiskInstitutional RiskRisk ScoreProgram in PlaceObjective Met orProgram EffectiveMitigated ScoreTarget Objective/PrioritizationNumericalWeightYes=3N/A orNo=0Yes=13No=0Yes=5No=0Yes=15No=0N/A=0Low=1Med=3High=5N/A=0Low=1Med=3High=5N/A=0Low=1Med=3High=5Sumof RiskCriteriaYes=3No=0Yes=15No=0Risk -MitigationY=YesN=NoC=ConsiderDevice Related InfectionsCLABSIUTIVAPSource: Used with permission by Connie Steed, MSN, RN, CIC, Greenville Hospital System University Medical Center,Greenville, SCReferences1. Arias K, Soule B. The APIC/JCR Infection Preventionand Control Workbook, 2nd ed. Joint Commissionon Accreditation of Healthcare Organizations andAssociation for Professionals in Infection Controland Epidemiology. Washington, DC: 2010.2. Stone PW, Braccia D, Larson E. Systematic review ofeconomic analysis of health care-associated infections.Am J Infect Control 2005 November; 33(9):501–09.3. Meddings J, Rogers, M, Macy M, et al. Systematicreview and meta-analysis: Reminder systems to reducecatheter-associated urinary tract infections and urinarycatheter use in hospitalized patients. Clin Infect Dis.2010 Sep 1;51(5): 550-560.4. Zimlichman MD, Henderson D, Tamir O, et al.Heath care-associated infections: A meta-analysisof costs and financial impact on the US health caresystem. JAMA Intern Med 2013. Dec; 173(22):2039-2046.28 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsSection 4: Definitions, Surveillance,and ReportingClinical and SurveillanceDefinitionsSurveillance includes ascertainment of HAIs withthe use of standardized definitions, aggregationof the data, analysis of the data, and feedback tokey stakeholders. In addition to CMS reportingrequirements, the NHSN definitions perform acrucial function by allowing hospitals to comparetheir data to aggregate data from other hospitals.However, the accuracy of this comparisonrequires a high degree of validity and reliability inapplying the definitions. Current uses of NHSNbeyond internal quality improvement requirethat hospitals and payers have confidence inthe data reported. Infection preventionists andothers responsible for data collection and analysismust also understand the difference betweensurveillance and clinical definitions. 1Surveillance definitions establish uniformcriteria to be used to report a disease or to betterensure usefulness in aggregating and analyzingpopulation-based data. These types of definitionsshould not be used as the sole criteria forestablishing clinical diagnoses or for determiningthe standard of care necessary for a particularpatient.Clinical definitions are specific to a patient andcan manifest progressively during an illness. Theuse of additional clinical, epidemiological, and labdata may enable a provider to diagnose a diseaseeven when the formal surveillance definitionmay not be met. Failure to meet the surveillancecriteria of the formal case definition should neverimpede or override clinical judgment during thediagnosis, management, or treatment of patients.NHSN DefinitionsSurveillance definitions have been repeatedlyrevised in order to enhance their reliability,validity, and reproducibility as new knowledge andexperience is gained. It is important, however, toremember that these definitions were primarilyintended for internal performance improvementactivities and eventually have progressed tofacilitate inter-hospital comparisons, improveinfection prevention and quality improvementefforts, and provide information for preventionresearch, mandatory public reporting, and publichealth surveillance. Inter-hospital comparisonsof infection rates, however, are valid only if themethods of surveillance are uniform and reliableacross institutions. 2The NHSN definitions for CAUTI in acute carehave undergone considerable revisions. See Figure4.1. The charts below reflect current definitions aspublished in July 2013. NHSN is in the processof making additional revisions based upon userfeedback and input from subject matter experts.The anticipated time frame for the reviseddefinitions is unknown, but expectations are thatit may not occur until 2015. Users should checkthe NHSN website to ensure that they have themost current definitions. 3NHSN reporting in LTC facilities is currentlyavailable for certified skilled nursing facilities/nursing homes and intermediate/chronic carefacilities for the developmentally disabled.Surveillance definitions specific to LTC aresummarized in Table 4.1.Association for Professionals in Infection Control and Epidemiology 29

Guide to Preventing Catheter-Associated Urinary Tract InfectionsIf a resident is transferred from an acute-carefacility and develops signs/symptoms of a UTIwithin the first 2 calendar days of admission(where date of admission = day 1) to the LTCfacility, it would be considered present at the timeof transfer to the LTC facility. An event present atthe time of transfer should be reported back to thetransferring facility and not reported to NHSNas an LTC facitility UTI event. Only UTI eventspresenting > 2 calendar days after admission(where date of admission= day 1) are consideredfacility onset events. 4 See Figures 4.2, 4.3, and 4.4.Figure 4.1. Urinary Tract Infection CriteriaCriterion1aUrinary Tract Infection (UTI)Symptomatic UTI (SUTI)Must meet at least 1 of the following criteria:Patient had an indwelling urinary catheter in place for >2 calendar days, with day of device placementbeing Day 1, and catheter was in place on the date of eventandat least 1 of the following signs or symptoms: fever (>38°C); suprapubic tenderness*; costovertebralangle pain or tenderness*anda positive urine culture of ≥10 5 colony-forming units (CFU)/ml and with no more than 2 species ofmicroorganisms. Elements of the criterion must occur within a timeframe that does not exceed a gapof 1 calendar day between two adjacent elements.----------------------------------------------------OR----------------------------------------------------Patient had an indwelling urinary catheter in place for >2 calendar days and had it removed the dayof or the day before the date of eventandat least 1 of the following signs or symptoms: fever (>38°C); urgency*; frequency*; dysuria*; suprapubictenderness*; costovertebral angle pain or tenderness*anda positive urine culture of ≥10 5 colony-forming units (CFU)/ml and with no more than 2 species ofmicroorganisms. Elements of the criterion must occur within a timeframe that does not exceed a gapof 1 calendar day between two adjacent elements.*With no other recognized cause1bPatient did not have an indwelling urinary catheter that had been in place for >2 calendar days andin place at the time of or the day before the date of eventandhas at least 1 of the following signs or symptoms: fever (>38°C) in a patient that is ≤65 years of age;urgency*; frequency*; dysuria*; suprapubic tenderness*; costovertebral angle pain or tenderness*anda positive urine culture of ≥10 5 CFU/ml and with no more than 2 species of microorganisms. Elementsof the criterion must occur within a timeframe that does not exceed a gap of 1 calendar day betweentwo adjacent elements.*With no other recognized cause30 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsCriterion2aUrinary Tract Infection (UTI)Patient had an indwelling urinary catheter in place for >2 calendar days, with day of device placementbeing Day 1, and catheter was in place on the date of event.andat least 1 of the following signs or symptoms: fever (>38°C); suprapubic tenderness*; costovertebralangle pain or tenderness*andat least 1 of the following findings:a. positive dipstick for leukocyte esterase and/or nitriteb. pyuria (urine specimen with ≥10 white blood cells [WBC]/mm3 of unspun urine or >5 WBC/high power field of spun urine)c. microorganisms seen on Gram’s stain of unspun urineanda positive urine culture of ≥103 and 2 calendar days and had it removed the dayof or the day before the date of eventandat least 1 of the following signs or symptoms: fever (>38°C); urgency*; frequency*; dysuria*; suprapubictenderness*; costovertebral angle pain or tenderness*andat least 1 of the following findings:a. positive dipstick for leukocyte esterase and/or nitriteb. pyuria (urine specimen with ≥10 WBC/mm3 of unspun urine or >5 WBC/high power field ofspun urinec. microorganisms seen on Gram’s stain of unspun urineanda positive urine culture of ≥10 3 and 2 calendar days and inplace at the time of, or the day before the date of eventandhas at least 1 of the following signs or symptoms: fever (>38°C) in a patient that is ≤65 years of age;urgency*; frequency*; dysuria*; suprapubic tenderness*; costovertebral angle pain or tenderness*andat least 1 of the following findings:a. positive dipstick for leukocyte esterase and/or nitriteb. pyuria (urine specimen with ≥10 WBC/mm 3 of unspun urine or >5 WBC/high power fieldof spun urinec. microorganisms seen on Gram’s stain of unspun urineanda positive urine culture of ≥10 3 and

Guide to Preventing Catheter-Associated Urinary Tract InfectionsCriterionUrinary Tract Infection (UTI)3 Patient ≤1 year of age with** or without an indwelling urinary catheter has at least 1 of the followingsigns or symptoms: fever (>38°C core); hypothermia (2 calendar days, with day of deviceplacement being Day 1 and catheter was in place on the date of event.4 Patient ≤1 year of age with** or without an indwelling urinary catheter has at least 1 of the followingsigns or symptoms: fever (>38°C core); hypothermia (5 WBC/high power fieldof spun urinec. microorganisms seen on Gram’s stain of unspun urineanda positive urine culture of between ≥103 and 2 calendar days, with day of deviceplacement being Day 1 and catheter was in place on the date of event.32 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsCriterionUrinary Tract Infection (UTI)4 Patient with* or without an indwelling urinary catheter has no signs or symptoms(i.e., for any age patient, no fever (>38°C); urgency; frequency; dysuria; suprapubic tenderness;costovertebral angle pain or tenderness OR for a patient≤1 year of age; no fever (>38°C core); hypothermia (2 calendar days, with day of device placementbeing Day 1, and catheter was in place on the date of event.**Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus spp., yeasts, beta-hemolyticStreptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae, and Corynebacterium (ureasepositive) + .+ Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or asC. urealyticum (CORUR) if so speciated.(See complete list of uropathogen microorganisms at www.cdc.gov/nhsn/XLS/master-organism-Com-Commensals-Lists.xlsx#uropathogens)Comments• Laboratory cultures reported as “mixed flora” represent at least 2 species of organisms. Therefore anadditional organism recovered from the same culture, would represent >2 species of microorganisms.Such a specimen cannot be used to meet the UTI criteria.• Urinary catheter tips should not be cultured and are not acceptable for the diagnosis of a urinarytract infection.• Urine cultures must be obtained using appropriate technique, such as clean catch collection orcatheterization. Specimens from indwelling catheters should be aspirated through the disinfectedsampling ports.• In infants, urine cultures should be obtained by bladder catheterization or suprapubic aspiration;positive urine cultures from bag specimens are unreliable and should be confirmed by specimensaseptically obtained by catheterization or suprapubic aspiration.• Urine specimens for culture should be processed as soon as possible, preferably within 1 to 2 hours.If urine specimens cannot be processed within 30 minutes of collection, they should be refrigerated,or inoculated into primary isolation medium before transport, or transported in an appropriate urinepreservative. Refrigerated specimens should be cultured within 24 hours.• Urine specimen labels should indicate whether or not the patient is symptomatic.• Report only pathogens in both blood and urine specimens for ABUTI.• Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or asC. urealyticum (CORUR) if speciated.Available at: www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf.Association for Professionals in Infection Control and Epidemiology 33

Guide to Preventing Catheter-Associated Urinary Tract InfectionsTable 4.1. Surveillance Definitions for Urinary Tract Infections (UTI) in Long-Term CareCriteriaA. For residents without an indwelling catheter (bothcriteria 1 and 2 must be present)1. At least 1 of the following sign or symptomsubcriteriaa. Acute dysuria or acute pain, swelling, or tenderness ofthe testes, epididymis, or prostateb. Fever or leukocytosis (see Table 2) and at least 1 of thefollowing localizing urinary tract subcriteriai. Acute costovertebral angle pain or tendernessii. Suprapubic painiii. Gross hematuriaiv. New or marked increase in incontinencev. New or marked increase in urgencyvi. New or marked increase in frequencyc. In the absence of fever or leukocytosis, then 2 or moreof the following localizing urinary tract subcriteriai. Suprapubic painii. Gross hematuriaiii. New or marked increase in incontinenceiv. New or marked increase in urgencyv. New or marked increase in frequency2. One of the following microbiologic subcriteriaa. At least 10 (5) cfu/mL of no more than 2 species ofmicroorganisms in a voided urine sampleb. At least 10 (2) cfu/mL of any number of organisms in aspecimen collected by in-and-out catheterB. For residents with an indwelling catheter (bothcriteria 1 and 2 must be present)1. At least 1 of the following sign or symptomsubcriteriaa. Fever, rigors, or new-onset hypotension, with noalternate site of infectionb. Either acute change in mental status or acute functionaldecline, with no alternate diagnosis and leukocytosisc. New-onset suprapubic pain or costovertebral angle painor tendernessd. Purulent discharge from around the catheter or acutepain, swelling, or tenderness of the testes, epididymis, orprostate2. Urinary catheter specimen culture with at least 10 (5)cfu/mL of any organism(s)CommentsUTI should be diagnosed when there are localizinggenitourinary signs and symptoms and a positive urineculture result. A diagnosis of UTI can be made withoutlocalizing symptoms if a blood culture isolate is thesame as the organism isolated from the urine and thereis no alternate site of infection. In the absence of a clearalternate source of infection, fever or rigors with a positiveurine culture result in the noncatheterized resident oracute confusion in the catheterized resident will often betreated as UTI. However, evidence suggests that most ofthese episodes are likely not due to infection of a urinarysource.Urine specimens for culture should be processed as soonas possible, preferably within 1–2 h. If urine specimenscannot be processed within 30 min of collection, theyshould be refrigerated. Refrigerated specimens should becultured within 24 h.Recent catheter trauma, catheter obstruction, or newonsethematuria are useful localizing signs that areconsistent with UTI but are not necessary for diagnosis.Urinary catheter specimens for culture should be collectedfollowing replacement of the catheter (if current catheterhas been in place for >14 d).NOTE: Pyuria does not differentiate symptomatic UTI from asymptomatic bacteriuria. Absence of pyuria indiagnostic tests excludes symptomatic UTI in residents of long-term care facilities. cfu, colony-forming units.34 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsFigure 4.2. Criteria for Defining UTI Events in NHSN LTCF ComponentFigure 4.3Association for Professionals in Infection Control and Epidemiology 35

Guide to Preventing Catheter-Associated Urinary Tract InfectionsFigure 4.4LTC facility protocols can be found at:www.cdc.gov/nhsn/PDFs/LTC/LTCF-UTIprotocol_FINAL_8-24-2012.pdf.Use of Laboratory DataThe quality of the urine specimen for culture isimportant when determining if a true infectionis present. The specimen of choice is the firstmorning void because it is generally moreconcentrated as a result of the length of time theurine was in the bladder. The preferred collectionmethod is a midstream, clean-catch specimen.Techniques for this type of collection can be foundin a standard nursing text and laboratory manuals.Specimens collected from a newly insertedurine catheter are reliable, providing that properinsertion technique had been followed. Onlyspecimens collected from a specifically designedsampling port or from the catheter directly shouldbe submitted for analysis. Under no circumstancesshould a sample from a drainage bag be submittedfor analysis. Urinary catheter tips should not besubmitted for microbiologic analysis.Appropriate urine specimen collection andtransport is key to accurate urine cultureresults. Accurate results enable the clinician toappropriately treat the patient and also avoidovertreatment or a delay in culture results due to acontaminated specimen.Bacteria reproduce by binary fission, a processwhere one parent cell divides to form two progeny(offspring of an organism) cells. 5 Since one cellresults in two progeny cells, exponential growthoccurs and can be illustrated in the following way:Number of cells 1 2 4 8 16Exponential 2 0 2 1 2 2 2 3 2 4In this way, one bacteria will produce 16 bacteriaafter four generations. The doubling (generation)time of bacteria ranges from as little as 20 minutesfor Escherichia coli (E. coli) to as long as 18 hoursfor Mycobacterium tuberculosis. Therefore, E. coliwill reproduce more than 1,000 progeny in about3 hours and approximately 1 million in about 7hours. 6The ease with which some bacteria grow makesit imperative that specimens are sent to thelaboratory in a timely manner. Physicians must besure that the results provided by the microbiologylaboratory are accurate, significant, and clinicallyrelevant. Result interpretation depends entirely36 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsTable 4.2. When to Obtain or Not Obtain a Urine Culture in a Patient with an IndwellingUrinary CatheterDiscourage urine culture UseUrine quality: color, smell sediments, turbidity (do notconstitute signs of infection)Screening urine cultures (whether on admission of beforenon-urologic surgeries)Standing orders for urinalysis or urine cultures without anappropriate indication“PAN” culturing (mindfulness in evaluating sourcesis key)Obtaining urine cultures based on pyuria in anasymptomatic patientsAsymptomatic elderly and diabetics (high prevalence ofasymptomatic bacteriuria)Repeat culture to document clearing of bacteriuria (noclinical benefit to patients)Appropriate urine culture usePart of an evaluation of sepsis without a clear source(CAUTI is often diagnosed by exclusion)Based on local findings suggestive of CAUTI (example:pelvic discomfort or flank pain)Prior to urologic surgeries where mucosal bleeding isanticipated or transurethral resection of the prostateEarly pregnancy (avoid urinary catheters if possible)Source: Fakih, M. Principles of highly reliable care: improving the culture of culturing: avoiding unnecessary urinecultures in catheterized patients. Ascension Health. Clinical Excellence Feb 2014 p.5on the quality of the specimen submitted foranalysis. 7Specimen CollectionThe Clinical and Laboratory Standards InstituteGuidelines recommend that the urine specimenis cultured within 2 hours of its collection.If the specimen cannot be cultured within 2hours of collection, there are two options formaintaining the specimen integrity: collection ofthe urine specimen in a container with a chemicalpreservative (most commonly, buffered boricacid); 2 holding the urine specimen at a controlledtemperature (2–8° C) until the specimen can becultured. Overgrowth of bacteria can readily occurwith mishandled specimens, and this will cause afalse positive or unreliable culture result.The collection container should be sterile and holdat least 50 mL of specimen. It should have a widemouth for easy collection, a wide base to preventspillage, and secure lid closure. Proper labelingon the container (not on the lid) includes thepatient’s name and/or unique identifier, collectiondate and time.Because urine is so easily contaminated withcommensal flora (normal bacteria), specimensfor culture of bacterial urinary pathogens shouldbe collected with attention to minimizingcontamination from the perineal area and fromsuperficial mucosa. When obtaining a clean-catchspecimen, skin cleansing is still recommended.Obtaining a specimen from a straight or “inand out” catheterization may provide a viablespecimen if collected using aseptic techniques. Formore information on this technique see appendix. 8Guidance on the collection of specimens fromurinary catheters is limited two main authoritativesources:1. CDC HICPAC Guideline for the Preventionof Catheter Associated Urinary TractInfections, 2009This guideline states that a small volumeof fresh urine for urinalysis or culture canbe aspirated from the sampling port of thedrainage system. The port must be cleansedwith a disinfectant before accessing it with asterile syringe/cannula adapter. Large volumesof urine for special analyses (not culture) canbe obtained aseptically from the drainage bag.Association for Professionals in Infection Control and Epidemiology 37

Guide to Preventing Catheter-Associated Urinary Tract InfectionsThe guideline does not address the length oftime a urinary catheter has been in place at thetime of specimen collection.The same guidelines are also found in:The SHEA/IDSA Practice RecommendationStrategies to Prevent Catheter-Associated UrinaryTract Infections in Acute Care Hospitals: 2014Update mirrors the information presented inthe CDC HICPAC CAUTI Guideline.2. Diagnosis, Prevention and Treatment ofCatheter Associated Urinary Tract Infection inAdults: 2009 International Clinical PracticeGuidelines published by the Infectious DiseaseSociety of America.This document states that if an indwellingcatheter has been in place for > 2 weeks atthe onset of CAUTI and is still indicated,the catheter should be replaced to hastenresolution of symptoms and to reduce the riskof subsequent catheter-associated bacteriuriaand CAUTI. The guidance also states thata urine culture should be obtained from afreshly placed catheter prior to the initiation ofantimicrobial therapy to help guide treatment. 16Another important aspect of specimencollection is the risk of fungal contamination.According to A Guide to Utilization of theMicrobiology Laboratory for Diagnosis ofInfectious Diseases: 2013 Recommendations,published by the Infectious Diseases Society ofAmerica (IDSA) and the American Society forMicrobiology (ASM), yeast in urine must becarefully evaluated. Recovery of yeast, usuallyCandida spp, even in high cfu/mLis is notinfrequent from patients who do no actuallyhave yeast UTI. For that reason, interpretationof cultures yielding yeast is not as standardizedas that for bacterial pathogens. Yeast in urinemay rarely indicate systemic infection forwhich additional tests must be performed forconfirmation (e.g., blood cultures, beta-glucanlevels). 17A urinalysis is frequently used as ascreening tool to determine the general healthof the urinary tract, including potentialpresence of infection.Urinalysis Interpretation 9• Assessment of color, clarity, presence of proteins,glucose, ketones, blood, nitrite, and leukocyteesterase• Microscopic examination of red blood cells(RBC), white blood cells (WBC), casts, crystals,bacteria, or yeast• Positive leukocyte esterase (LE) indicating thepresence of WBCs or debris from rupturedWBCs in the urine, with 90 percent accuracy• If LE positive, microscopic examination may beperformed to determine number of RBC andWBC casts present• Possible infection if 10 or more WBC in urine• Possible infection of the kindey if 10 or moreWBC casts (WBC cast formation in urine maybe indicative of inflammation or infection) 10Data Analysis and ReportingOne of the basic tenets of an effective infectionprevention program is the ability to use datato drive improvement. The NHSN providesan excellent opportunity to aggregate, analyze,and benchmark important infection preventioninformation. In order to generate risk-adjustedincidence rates, standardized infection ratios,and other data for analysis, it is important tohave accurate denominator data reflective of thepopulation at risk. Collection of urinary catheterdays may be manual or automated. Automateddata must be validated prior to routine use. TheNHSN allows the collection of denominatordata electronically, but stipulates that electronicand manual data collection should take placesimultaneously for a period of time and that theresulting difference between the two methodsshould not exceed ±5 percent. Alternately, ifautomated data are not available, staff shouldcollaborate with others to obtain the data. Forexample, a ward clerk or other ancillary personnelmight be trained to collect these data. Studiesdemonstrating automatio of collection of devicedays from electronic medical record systems havebeen published. 1838 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsOrganizations may generate line lists, rate tables,and standardized infection ratios. An example of aFoley catheter line list is shown in Figure 4.6. Foran example of prevalence, see Figure 4.5.The CAUTI rate per 1,000 urinary catheter daysis calculated by dividing the number of CAUTI bythe number of catheter days and multiplying theresult by 1,000. The urinary catheter utilizationratio is calculated by dividing the number ofurinary catheter days by the number of patientdays. These calculations will be performedseparately for the different types of ICUs, specialtycare areas, and other locations in the institution,except for neonatal locations. 10Figure 4.5. Foley Catheter Prevalence SheetUnitDateWeek 1 Pre-InterventionRoom/bed Patient #Foley Catheter Prevalence SheetFoley Present? Need IndicationNo=0Yes=1No need=0Needed=1Urinary Tract Obstruction=1Neurogenic Bladder=2Urologic Study/Surgery=3Stage 3 or 4 Sacral Decubitus=4Hospice/Comfort Care/Palliative=5Not Indicated Foley Reasons:Nephrology=6From ICU=7Pt. Request=8Confused=9Incontinent=10Other=11Foley Present: 0=No; 1=YesNeed: 0= No Need; 1= Need.Indication: 1=Urinary Tract Obstruction; 2=Neurogenic Bladder; 3=Urologic Study/ Surgery; 4=Stage 3 or 4Sacral Decubitus; 5=Hospice/Comfort Care/Palliative; 6=Nephrology; 7=From ICU; 8=Pt Requests; 9=Confused;10=Incontinent; 11=OtherUse one sheet per day of Week 1Figure 4.6. Example of Data Elements in a Line ListPatient IDDate of urinecultureOrganismUrinarycatheteryes/noDateinsertionTemperature >38 degrees CSuprapubictenderness orcostovertebralangle pain ortendernessXXXXXXXX 5/23/2013 E. coli Yes 5/19/2013 38.9 No YesSource: Table created and published with permission Mary Jo BellushHAIAssociation for Professionals in Infection Control and Epidemiology 39

Guide to Preventing Catheter-Associated Urinary Tract InfectionsPlan: Calculate the monthly rate of CAUTI in themedical ICU for calendar year 2007.Criteria: NHSN criteria for CAUTIData Collection: Active surveillance of ICU patientsNumerator: Number of new CAUTI cases per monthDenominator: Number of urinary catheter days inmedical ICUCalculation of Incidence Rate:Medical ICU CAUTI rate =Number of new CAUTI case(s) x 1,000Number of catheter daysExample: 2 UTI / 702 catheter days = .002847 x 1,000= 2.8 per 1,000 urinary catheter daysPopulation-Based CAUTIOne paradox of improved stewardship of urinarycatheters is that as this increases the prevalenceand frequency of use decreases. This lowers thedevice days in the denominator of the traditionalNHSN defined CAUTI rate and as a result ratescan appear to be increasing after implementationof a CAUTI prevention project. [see case studyfrom Nevada; and Wright MO, et al. InfectControl Hosp Epidemiol. 2011 Jul;32(7):635-40.]Fakih and others have published a modeling studythat demonstrated a population CAUTI rate (i.e.,number of CAUTIs identified in a populationin a month / total number of patient days in thesame month x 1,000) is less susceptible to thisparadox. 19 It is an alternative to the traditionalNHSN rate and can be used as an alternative oradditional metric to assess impact of preventionstrategies on outcome. See Figure 4.7.Device Utilization RatioDevice utilization (DU) ratios can be important insurveillance methodology as another componenttoward the goal of reducing CAUTI. Calculationof this ratio over time allows for outcome orprocess methodology to be used to attempt todecrease urinary catheter days. 11 It is important tocount device days at the same time daily (within a24 hour period). Calculation of device utilizationratio requires collection of patient days for aselected time period. Patient days are the totalnumber of days patients are in a location duringa selected time period. For example, 20 patientswere on a unit on the first day of the month;22 on day 2; 20 on day 3; and so on. By adding20+22+20, there would be a total of 62 patientdays for the first 3 days of the month. This wouldbe continued for the entire month in order toobtain the patient days for that month.Figure 4.7 Rate of CAUTI per 1,000 Urinary Catheter days 2013 MICU4.543.532.521.510.50Jan Feb March April May JuneNurse Driven Urinary Catheter RemovalProtocolsCAUTI RateNHSN MeanSource: Graph created and reprinted with permission Linda Greene, Highland Hospital Rochester, NY40 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsDU ratio can be calculated by using the followingformula:DU ratio = Number of device-daysNumber of patient-daysStandardized Infection RatioThe standardized infection ratio (SIR) is asummary measure used to track HAIs at anational, state, or facility level over time. The SIRadjusts for the fact that each healthcare facilitytreats different types of patients. This indirectstandardization method calculates the numberof expected infections based upon a specific timeframe known as the referent period. 12The method of calculating a SIR is similar tothe method used to calculate the standardizedmortality ratio, a statistic widely used in publichealth to analyze mortality data. In HAI dataanalysis, the SIR compares the actual number ofHAIs in a facility or state with the baseline U.S.experience (i.e., standard population), adjustingfor several risk factors that have been found to bemost associated with differences in infection rates.SIR is the number of observed infections dividedby the number of expected infections. See Table4.3. The expected number is based on the nationalaverage, the number of urinary device days,and historical data for those procedures. Thismethod is helpful when small numerators anddenominators are present.• A SIR of 1 means the observed number ofinfections is equal to the number of expectedinfections.• A SIR greater than 1 means that the infectionrate is higher than that found in the “standardpopulation.” For HAI reports, the standardpopulation comes from data reported bythe hundreds of U.S. hospitals that use theNHSN system. The difference above 1.0 is thepercentage by which the infection rate exceedsthat of the standard population.• A SIR less than 1 means the infection rate islower than that of the standard population. Thedifference below 1 is the percentage by whichthe infection rate is lower than that of thestandard population.How the SIR is used: The 2011 National andState Healthcare-associated Infections StandardizedInfection Ratio Report (Jan.–Dec. 2011) presentsa comprehensive summary of HAI data collectedin the NHSN. Healthcare facilities using theNHSN have real-time access to their data forlocal improvement efforts. The annual reportprovides analysis of national and state-level HAIdata to help identify gaps in HAI prevention andis used by HHS to measure progress towards HAIreduction goals. 13In March 2014, updated state SIR resultswere released in the CDC’s National and StateHealthcare-Associated Infections Progress Report.This report is based on 2012 data from acutecarehospitals. The report is intended to helpmeasure progress toward the five year HAIprevention goals outlined in the National ActionPlan to Prevent Healthcare-Associated Infections:Road Map to Elimination (HHS HAI ActionPlan) initially developed in 2009. According tothis report, U.S. hospitals reported a significantincrease in CAUTIs between 2011 and 2012.Thirteen percent of hospitals have a CAUTI SIRsignificantly worse then the national SIR of 1.03.The full report can be downloaded at: www.cdc.gov/HAI/pdfs/progress-report.pdf.Table 4.3. Understanding the SIRSIR less than 1 SIR greater than 1Fewer infections thanwould have beenpredicted during abaseline periodInfections prevented sincethe baseline periodMore infections thanwould have beenpredicted during abaseline periodMore infections since thebaseline periodSource: CDC. Available at: www.cdc.gov/HAI/surveillance/QA_stateSummary.html#a6.Association for Professionals in Infection Control and Epidemiology 41

Guide to Preventing Catheter-Associated Urinary Tract InfectionsReferences1. Centers for Disease Control and Prevention(CDC). Outline For Healthcare-Associated InfectionsSurveillance; April 2006. Available at: www.cdc.gov/nhsn/PDFS/OutlineForHAISurveillance.pdf.2. Centers for Disease Control and Prevention(CDC). Device-associated Module, CAUTI;January 2014. Available at: www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf.3. Centers for Disease Control and Prevention (CDC).Urinary Tract Infection (UTI) for Long-term CareFacilities; n/d. Available at: www.cdc.gov/nhsn/PDFs/LTC/LTCF-UTI-protocol_FINAL_8-24-2012.pdf.4. Available at: www.meriam-webster.com.5. Levinson W. Review of Medical Microbiology andImmunology, 12th ed., New York: The McGraw-Hill,2012.6. Baron E, Miller JM, Weinstein MP, et al. A Guideto Utilization of the Microbiology Laboratoryfor Diagnosis of Infectious Diseases: 2013Recommendations by the Infectious Diseases Societyof America (IDSA) and the American Society ofMicrobiology (ASM) Clin Infect Dis 20137. APIC Text of Infection Control and Epidemiology,3rd edition, Association for Professionals in InfectionControl and Epidemiology, Inc. (APIC), Washington,DC, 2014.8. Paralyzed Veterans of America and the Consortiumfor Spinal Cord Medicine. Bladder Management forAdults with Spinal Cord Injury: A Clinical PracticeGuideline for Health-Care Providers. Washington, DC:2006.9. Garcia L., ed. Clinical Microbiology ProceduresHandbook, American Society for Microbiology,Washington, DC, 2010.10. Centers for Disease Control and Prevention(CDC). Device-associated Module, CAUTI;January 2014. Available at: www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf.11. National Healthcare Safety Network. Protocolsand Definitions, Device-associated Module, CatheterassociatedUrinary Tract Infections; n/d. Available at:www.cdc.gov/nhsn/PDFs/slides/CAUTI.pdf.12. National Healthcare Safety Network. Your guideto the standard infection ratio. NHSN e-News: SIRsSpecial Edition; December 10, 2010. Available at:www.cdc.gov/nhsn/PDFs/Newsletters/NHSN_NL_OCT_2010SE_final.pdf.13. National Healthcare Safety Network. First State-Specific Healthcare-Associated Infections Summary DataReport January–June, 2009. Available at: www.cdc.gov/hai/QA_stateSummary.html.14. Centers for Disease Control and Prevention(CDC). National and State Healthcare-associatedInfections Standardized Infection Ratio Report usingData Reported to the National Healthcare SafetyNetwork January–December 2011. Available at: www.cdc.gov/hai/national-annual-sir/results.html.15. Rodak S. Cauti Reduction Progress by State. Becker’sASC Review; 2012. Available at: www.beckersasc.com/lists/cauti-reduction-progress-by-state.html.16. Hooton TM, et al. Diagnosis, prevention, andtreatment of catheter-associated urinary tract infection inadults: 2009 International Clinical Practice Guidelinesfrom the Infectious Diseases Society of America.ClinInfect Dis 2010; March 1; 50 (5) 625-663.17. Baron EJ, et al. Executive summary: a guide toutilization of the microbiology laboratory for diagnosisof infectious diseases: 2013 recommendations by theInfectious Diseases Society of America (IDSA) andthe American Society for Microbiology (ASM)(a).Cln Infect Dis 2013. Aug; 57 (4) 485-488.18. Wright MO, et al. The electronic medical record asa tool for infection surveillance: successful automationof device-days. Am J Infect Control 2009; Jun; 37 (5):364-370.19. Fakih MG, et al. Introducing a population-basedoutcome measure to evaluate the effect of interventionsto reduce catheter-associated urinary tract infection.Am J Infect Control 2012. May; 40 (4): 359-364.42 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsSection 5: Patient Safety, CUSP,and Other Behavioral ModelsOnce considered an inevitable consequenceof receiving healthcare, HAIs are receivingconsiderable attention as a major cause of patientharm leading to increased morbidity, mortality,cost, and length of stay. The shift in the perceptionof patient harm started with the publication ofthe Institute of Medicine (IOM) report To Erris Human in 1999. 1 This report revealed thatthousands of patients in U.S. hospitals wereinjured or died each year because of medicalerrors—and many of these injuries and deathswere preventable. HAIs were recognized as aleading cause of these preventable harm events.The IOM report was followed by articles in theChicago Tribune that chronicled observed lapsesin evidence-based infection prevention practices,such as hand hygiene. During 2005–2006, thepublication of two studies about the preventionof CLABSIs brought increasing awareness tothe magnitude of the HAI problem. Both thePittsburgh Regional Healthcare Initiative and acollaborative project between The Johns HopkinsHospital and the Michigan Hospital Associationdemonstrated consistent results that manyCLABSIs could be prevented through team work,communication, feedback, and transparency.These projects helped highlight that a substantialportion of these infections could be preventedthough implementation of a combination oftechnical evidence-based infection-preventionpractices and socio-adaptive interventions. 2There are considerable data to suggest that,although evidence-based interventions exist,there is often lack of implementation at the unitor organizational level. In recent years, it hasbecome clear that driving change and improvingpatient outcomes requires a combination of bothtechnical and socio-adaptive skills. The success ofthe CLABSI project in Michigan was based largelyon CUSP, the relatively new five-step programdesigned to change a unit’s workplace culture,and in so doing bring about significant safetyimprovements by empowering staff to assumeresponsibility for safety in their environment.This is achieved through education, awareness,access to organization resources, and a toolkit ofinterventions. 3Adopted by about 40 units at The Johns HopkinsHospital—and hundreds of units outside ofHopkins—CUSP has been used to target a widerange of problems: for example, patient falls,hospital-associated infections, and medicationadministration errors.This five-step program has also provided aframework to get units involved with, andcommitted to, organization- and national-levelsafety goals. One of the main tenets of CUSP isthat it focuses on cultural change.CUSP tools and techniques:The CAUTI CUSP tool kit contains specificpolicies, tools for implementation, and otherstrategies for overcoming barriers.www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/index.htmlAssociation for Professionals in Infection Control and Epidemiology 43

Guide to Preventing Catheter-Associated Urinary Tract InfectionsCUSP Focuses on Five Steps:1. Educate staff on the “science of safety.”2. Identify defects.3. Assign executive to adopt unit.4. Learn from defects.5. Implement tools team work tool.CUSP and CAUTIThe HHS action plan specifically addressesimplementation science and barriers toinitiating evidence-based practices. The needfor a better understanding of the human andorganizational factors that affect the adoptionand implementation of evidence-based practicesis germane to the CUSP methodology. Giventhe success of the CLABSI CUSP projectin demonstrating how a structured strategicframework for safety can result in dramaticimprovements in care, the CUSP initiative hasbeen expanded to CAUTI as well as units outsideof the ICU. 5Implementation of standard processes is oftendifficult. Nurses are generally responsible not onlyfor catheter insertion but also for ongoing cathetermanagement and removal. Although nurses donot make the decision to insert a urinary catheter,they may have some influence on catheter use. 6Indeed, there is evidence that nurses can havesignificant impact on use of urinary cathetersand serve as effective stewards of appropriateuse of this device. Requests from nurses toplace a catheter for nursing convenience are notuncommon and represent a misuse of urinarycatheters. Barriers to implementation of evidencebasedpractices include patients of size, patientswith incontinence or ambulation difficulties, andconsensus regarding the need for ongoing stricturinary output.From Evidence to ImplementationPeter Pronovost and colleagues described aconceptual model used to translate evidenceinto practice. This model consists of a series ofsteps that include summarizing the evidence,Figure 5.1. The 4 Es of Translating Evidenceinto PracticeEngageEducateExecuteEvaluate• Explain why the interventionsare important• Connect the dots to outcomes• Share the evidence• Use toolkits, checklists, etc.• Measure Progress toward goals• Regularly assess performanceidentifying local barriers to implementation,measuring performance, and ensuring that allpatients receive the intervention. Central tothis model is the 4 E’s, a method to increasereliability and to engage frontline staff. The 4E’s are described in Figure 5.1. 4 This conceptualmodel has been applied successfully to severalprojects and applies cultural change to rigorousinterventions. Also see Table 5.2.CUSP Implementation: Storiesfrom the Front LineThe team at the Tucson Medical Center’s 16-bedICU (neuro/neurosurgical, medical, pulmonary,vascular, and general surgery) decided toimplement the CUSP program because of a needfor improvement in CAUTI rates. They viewedthe CUSP program as a venue for support andstructure.The Tuscon team engaged the staff with real-lifestories of patients who were harmed and provideeducation on the “science of safety.” They executedtheir plan with several actions and interventions.44 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsThe team developed an audit tool, which wasutilized to identify defects. See Table 5.1.Audit Process• Customizing tool to evaluate deficits• Identifying barriersCase Reviews - Team• Isolating root cause• Review processes/practices• Identifying vented patient populations –developed guidelineDuring case reviews, they identified process issuesand noted that their device utilization was high.However, their policy had no specific guidelinesfor catheter use in patients on the ventilator. Asa team, they engaged staff members and medicalstaff to develop catheter insertion guidelines forpatients on the ventilator. See Figure 5.2.The team also began collaboration with otherdepartments, such as the emergency room, surgery,transport, and radiology to share their processand standards and to ensure that insertion andmaintenance standards were shared and adheredto. Additionally, the team began product trials andevaluation of alternatives to urinary catheters inorder to effectively reduce catheter days.ResultsLessons learned: The team continues to decreaseurinary catheter utilization and has foundeffective ways to gain staff input on barriers toimplementation, identify that staff can changebehavior when given the tools to change, gainphysician “buy-in,” and continue with constantconversations.Other CUSP toolsLearning from Defects ToolOne helpful tool that is highlighted in the CUSPframework is the Learning from Defects (LFD)Tool. The tool is used when events (knownas defects) occur. This tool can be utilized byTable 5.1.Source: Chart and data created and published with permission Jennifer Tuttle, Tucson Medical CenterAssociation for Professionals in Infection Control and Epidemiology 45

Guide to Preventing Catheter-Associated Urinary Tract InfectionsTable 5.2. Example of Applying the 4 E’s to a CAUTI intervention.Fields have been completed using examples and are not intended as a comprehensive list.GeneralactivityEssentialsof CAUTIprevention(evidence based)Rationalepresented to allstakeholders.Case forprevention isclear, concise,compellingRationale is partof Patient SafetyProgram.Active, visibleparticipation bysenior leadersand institutionalchampions (alllevels).Adaptation ofinterventions forthis organizationIdentified gaps(knowledge,skills, behavior,resources, etc.)Check to see thatall stakeholders areinvolved. Groupsoften overlookedinclude thelab, EVS, andpatient transport.Determine ifgaps may beassociated withmisperceptions,e.g. CAUTIis primarily anursing issue,use of antibioticseasily mitigatesany larger clinicalrisks, etc.Measures toaddress gapsKey resources forimplementationEngageExplainwhy theinterventionsare important.Determinewhich groups arealready engagedand if othersneed greaterinvolvement.Verify thatCAUTIprevention hasa high profile/priority withinthe organization’ssafety program.Consider novel,creative waysto showcase theinvolvement ofsenior leaders,including medicalstaff.Teach andreinforce correctindications forcatheter use,insertion andmaintenance.Reinforceprevious practicesthat should bediscontinuedTeach andreinforceorganizationstandards fordocumentation.Note: Fullengagement isrequired for theremaining threegeneral activities(educate, execute,and evaluate) tobe successful.Address any gapswith a targetedplan, include timeframes.HHS HAI ActionPlan (2009)See also CDC HAIincidence data,progress reports atwww.cdc.govEducateShare evidencesupporting theinterventions.Share CAUTIdata, includingmorbidity,mortality and costdata.Educate regardinguse of preventiontechniques.Describe need forthorough, accuratemedical recorddocumentation.Compare newcontent to whatmay have beenused in thepast. Addressdiscrepancies,includingpractices nolonger used. Verifyaccurate baselineknowledge amongstaff beforeproceeding.Note: Do notassume that carestaff familiarwith cathetersknows currentbest practices.Outdatedinformation canbe difficult toeradicate; longstanding careroutines areoften resistant tochange.HICPACGuideline forthe Prevention ofCAUTI (2009)SHEA/IDSACompendiumof Strategies toPrevent HAIsin Acute CareHospitals (2014)46 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsGeneralactivityEssentialsof CAUTIprevention(evidence based)ImplementCAUTI bundleProvide staff/patient/familyeducation.Conduct rigorousmonitoring andoffer frequentfeedback.Adaptation ofinterventions forthis organizationIdentified gaps(knowledge,skills, behavior,resources, etc.)Bundles andchecklist areimportantbut must beanalyzed interms of attitudeand behavior.Determine ofthe structural,programmatic aswell as behavioralelements arealigned forsuccessfulimplementation.Measures toaddress gapsKey resources forimplementationExecuteDesign aninterventiontoolkit.Consider use of aCAUTI checklistas part of aCAUTI bundleapproach.Determineneed for alertsto physicianand nurses re:potential catheterremoval.Add catheterreview to dailyrounds. Considernurse removalprotocols tosupport timelydiscontinuation.Describe bothprocess andoutcome measuresfor CAUTIShare progresstowards goals atleast once permonth.Compare progressto other local,regional, andnational measures.Show how resultsdemonstrate theorganization’scommitment topatient safetyand overall safetyculture.Note: Encouragecare staffto suggestimprovementsto theimplementationplan. Smalladjustments canoffer large benefitsin the overallsuccess of theprogram.APICImplementation(formerlyElimination)Guide, CAUTI(2014)AHRQ CAUTIToolkit (2013)EvaluateRegularly assessperformancemeasures andunintendedconsequences.Identify measuresof success andreport progressper schedule.Investigate errorsand lapses asopportunity toimprove.Include patients/families inevaluation process.Communicate,celebrate success.Evaluate boththe programstatistics as wellas proceduralcompliance.Include studentsif they handlecatheters. Donot overlookthe opportunityfor ongoingunderstandingand use of correctaseptic technique.Anticipate theneed for followup and periodicreminders.Note: Usestatistics wisely;do not overwhelmstaff with data.Follow up onany complaintsor adverseevents in a nonpunitivemeasure.Consider use ofRCA as needed.Combiningquantitativeand qualitativeinformationmay be helpfulwhen evaluatingprogram impact.Compareorganizationalresults to state,regional andnational data, asavailable.Consider use ofCDC NHSNInclude CAUTISIR reporting inresults.Include trenddata from staffcompetency basededucation andtraining activitiesas available.Adapted from Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scaleknowledge translation. BMJ. 2008 Oct 6;337:a1714*Implementation science: the use of scientifically valid methods to promote the integration of research findings andother best practices into the evolving standard of care. In this way, research not only moves from the laboratory to thebeside, but also results in improved, safer and more cost effective healthcare.Additional reference: Saint S, Howell J Krein SL, Implementation Science: How To Jumpstart Infection Prevention InfectControl Hosp Epidemiol. 2010 November; 31(Suppl 1): S14–S17Table created by Marilyn Hanchett, RN, MA, CPHQ, CIC, from Prevention Strategist, Fall 2012Association for Professionals in Infection Control and Epidemiology 47

Guide to Preventing Catheter-Associated Urinary Tract InfectionsFigure 5.2. Urinary Catheter Guidelines for Critically Ill Patients on a Ventilator.Conditions that require a Foley Conditions that do not require a Foley Case dependent conditionsSepsis (first 24 hours)CRRTARFPressors with titrationArtic SunIABPSAH with triple H therapyMIVTube feedingPressors with minimal titrationLasixMild sedation or drowsinessARDSParalysis or SedationAlternates to FoleyIncontinence Pad= P Condom Catheter = C Brief= BSource: Chart and data created and published with permission Jamie Tuttle, Tucson Medical CenterFigure 5.3. ACCU Device Utilization Percentilehealthcare personnel to reduce the probabilitythat a future patient will be harmed. A number oforganizations have found that the tool is helpfulin investigating CAUTI events. The tool promptscare providers to look at what happened and why ithappened and helps them to develop a frameworkfor a structured approach to analyzing events andidentifying opportunities for improvement.See example A for tool and example B for acompleted LFD on pages 49 and 50.HuddlesGenerally any member of the team may call ahuddle to address a new or changing circumstance.The huddle may be called when a single significantinfection or increased incidence of infectionoccurs, such as CAUTI or increased incidence ofCAUTI. The focus may be to heighten awarenessof a situation or to enhance prevention efforts.The team huddle is powerful and effective and canwork in real time, but the keys are short, patientfocused,efficient, problem solving, informationsharing, and action oriented. The huddle isa tool for getting the team to work togethereffectively. Huddles can change a practice andimprove teamwork and communication. Theseteam events become partial solutions to real-timeevents, such as HAIs, clarifying patient care issues,and providing back-up behaviors with nurses,technicians, and providers, as well as helping eachother with error avoidance. The huddle is a usefulvenue to begin utilizing the LFD tool. See SIRTracking, Figure 5.4.48 Association for Professionals in Infection Control and Epidemiology

Example A: CUSP Learn from Defects Tool WorksheetGuide to Preventing Catheter-Associated Urinary Tract InfectionsAvailable at: www.onthecuspstophai.org/Association for Professionals in Infection Control and Epidemiology 49

Guide to Preventing Catheter-Associated Urinary Tract InfectionsExample B: Completed CUSP Learn from Defects Tool Worksheet50 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsTeam Check-up ToolOn the CUSP: Stop CAUTI collaborative hasdeveloped a team check-up tool (TCT) for useto facilitate identification of possible barriers torealizing success and to sustain the infrastructureto support an effective CUSP culture.Key LessonsAlthough CUSP offers a standard model, eachfacility will adapt it to its unique circumstances.To help ensure successful implementation, keyCUSP-CAUTI lessons from early adopters aresummarized in Table 5.4.Figure 5.4. TMC CAUTI—Standardized Infection Ratio (SIR)Source: Charts and data created and published with permission Jamie Tuttle, Tucson Medical CenterTable 5.4. Key Lessons for Success in Reducing CAUTI1. Be clear in internal and external messages that CAUTI reduction is a priority for the organization, and whenoperational changes are made based on input from the front line, ensure that this is communicated to theunit teams.2. All culture is local, and the best collective decisions are made when there is diverse and independent input.Make sure that front-line nurses nurse managers and physicians are at the table.3. Ensure that all unit staff understands the Science of Safety (the complex systems in which care is delivered andhow to improve these systems to make care safer). Encourage the front line to train other team members toencourage ownership.4. Work with each unit team to build a system for collecting outcome data that will work best for the unit, andintegrate data collection into existing unit workflows.5. Allow teams to set aside designated staff time to collect and share data, and encourage cross-departmentalcollaboration, such as IT initiatives.6. Work with the risk management team and talk with front-line staff to reveal stories of actual CAUTI cases tomake the challenge real for the project team at all levels.7. Front line staff will gain courage to speak up when granular, process-oriented gains are celebrated as successes.Widely communicating sustained rates of zero CAUTIs can set long-term goals that will help drive sustainability.Source: Eliminating Catheter-associated urinary tract infections. Health Research & Educational Trust, Chicago:July 2013.Association for Professionals in Infection Control and Epidemiology 51

Guide to Preventing Catheter-Associated Urinary Tract InfectionsReferences1. Institute of Medicine (IOM). To Err is Human:Building a Safer Healthcare System. November 1, 1999.Available at: www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx.2. McKibben L, Horan T, Tokars J, et al. Guidance onpublic reporting of healthcare-associated infections:recommendations of the Healthcare Infection ControlAdvisory Committee, Am J Infect Control 2005;339(4):217–22.3. OntheCUSPStopHAI.org. Available at: www.onthecuspstophai.org/on-the-cuspstop-cauti/about-theproject/overview/.4. Pronovost P, Berenholtz S, Needham D. Translatingevidence into practice: a model for large scaleknowledge translation. BMJ 2008; 337a1714.5. Berenholtz SM et al. Eliminating central lineassociatedbloodstream infections: a national patientsafety imperative. Infect Control Hosp Epidemiol 2014.Jan; 35 (1): 56-62.6. Fakih MG, et al. Sustained reductions in urinarycatheter use over 5 years: bedside nurses viewthemselves responsible for evaluation of catheternecessity. Am J Infect Control 2013. Mar; 41 (3):236-239.52 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsSection 6: PreventionBest practices are most often summarized inguideline documents published by professionalorganizations. These types of documents aredeveloped using the most current scientificresearch; often the recommendations are rankedaccording to the strength of the research supporttheir use. The CDC issues a wide range ofguidelines, including the prevetnion of CAUTI.All of these guidelines are available online atwww.cdc.gov/hicpac.The CDC HICPAC Guideline has outlined somecore strategies for CAUTI prevention:• Insert catheters only for appropriate indications.• Leave catheters in place only as long as needed.• Ensure that only properly trained persons insertand maintain catheters.• Insert catheters using aseptic technique andsterile equipment (acute-care setting).• Following aseptic insertion, maintain a closeddrainage system.• Maintain unobstructed urine flow.• Practice hand hygiene and standard (orappropriate isolation) precautions according tothe CDC HICPAC Guideline.The HICPAC Guideline identifies the followingappropriate indications for insertion of aurinary catheter: 11. Acute urinary retention or obstruction—Urinarycatheters are indicated for the managementof acute urinary retention due to mechanicalobstruction. Urethral or bladder outletobstruction is commonly related to benignprostatic hypertrophy, severe edema withpenile swelling, urethral stricture or urinaryblood clots. Urinary catheters also areindicated for acute urinary retention relatedto a neurogenic bladder most often related tospinal cord injury or progressive neurologicaldisease or to medications that reduce bladdermuscle contractility or sensation.2. Accurate measurement of urinary output incritically ill patients—Catheters are indicatedwhen accurate measurement of urinaryoutput is required in critically ill patientsreceiving care in the intensive care setting.ICU patients who are hemodynamically stableand cooperative often do not require urinarycatheters and are appropriate candidates foralternate means of measuring urine output3. Perioperative use in selected surgeries—Urinarycatheters are indicated perioperatively forselected surgical procedures. Cathetersshould be used when a surgery is expectedto be prolonged, when a patient will requirelarge volume infusions during surgery, orwhen there is a need for intraoperativeurinary output monitoring. Catheters alsoare indicated for urologic surgeries or othersurgeries on contiguous structures of thegenitourinary tract.4. To assist healing of perineal and sacral woundsin incontinent patients—This is a relativeindication for urinary catheter use when thereis concern that urinary incontinence is leadingto worsening skin integrity in areas wherethere already is skin breakdown. Urinarycatheters should not be used as a substitute forthe use of skin care, skin barriers, and othermethods to manage incontinence and limitskin breakdown.5. Hospice/comfort/palliative care—This is anacceptable indication for catheter use in endof-lifecare, if it helps with patient comfort.6. Required immobilization for trauma orsurgery—Urinary catheters may be usedAssociation for Professionals in Infection Control and Epidemiology 53

Guide to Preventing Catheter-Associated Urinary Tract InfectionsTable 6.1. Summary Prevention Practice Issues Addressed in GuidelinesInterventionCDCHICPACIDSASHEACompendiumSHEA/APICPreventionof Infectionsin LongTerm CareEPIC 2 2007Use the smallest bore catheter possible Y N Y Y Y- recommend10 ml Baloonfor adultsMeatal cleaningAddress indications for appropriate insertionof a catheterDo not routinely change catheters at fixedintervalsChange indwelling urinary catheter beforeadministering treatment for CAUTIY- RoutinewithoutantisepticsYYNY- Routine withoutantisepticsN – Recommend thatorganizations developlist of appropriateindicationsYInsufficient evidence tomake recommendationon long term cathetersY * Note greater than2 weeksRecommend thatinitial urine specimenbe obtained from afreshly placed catheterin cases where a longterm urinary catheterhas been in placeY- RoutinewithoutantisepticsNY N NY Y YN Y NProperly Secure Catheters Y N Y N NReplace catheter in breaks in aseptic technique Y N Y N Nor disconnectionOnly trained personnel to insert catheters Y Y Y Y YMaintain hydration N N N Y NKeep collection bag below the level of the Y Y Y Y YbladderAvoid Routine Irrigation Y Y Y Y YCare of leg bags N N N Y NMaintain closed collection system Y Y Y Y YY- RoutinewithoutantisepticsAdapted From:• CDC Guidelines for Prevention of Catheter – Associated Urinary Tract Infections Available at: www.cdc.gov/hicpac/cauti/001_cauti.html• SHEA Compendium of Strategies to Prevent CAUTI-www.shea-online.org/HAITopics/CompendiumofStrategiestoPreventHAIs.aspx• Diagnosis, Prevention and Treatment of Catheter-Associated Urinary Tract Infections in Adults: 2009 International PracticeGuidelines Available at: www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Comp%20UTI.pdf• SHEA/ APIC Guideline: Infection Prevention and Control in the Long- Term Care Facility www.apic.org/Resource_/TinyMceFileManager/Practice_Guidance/id_APIC-SHEA_GuidelineforICinLTCFs.pdf• epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England• Journal of Hospital Infection(2007) S1-S64Source: Used with permission, Linda Greene, RN, MPS, CIC, Highland Hospital, Rochester, NY54 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infectionswhen patients require requires prolongedimmobilization following trauma or surgery.Examples include instability in the thoracicor lumbar spine, multiple traumatic injuries,such as pelvic fractures, and acute hip fracturewhen there is risk of displacement withmovement. 2In addition to documents developed andpublished by the CDC, other stakeholder groups,typically professional associations, may issuegudielines. Whitepapers and postion statemenstmay also be used to communicate practicerecommendations. A comparison of CAUTIprevention interventions among the majorgudielines is shown in Table 6.1.Primary Prevention:Avoiding Unnecessary Useof Urethral CathetersMeddings and others recently reviewed availableevidence on avoiding unnecessary use of urethralcatheters as well as other key prevention strategies.Figure 6.1 identifies key aspects of urinary catheteruse that can be targeted for prevention:Figure 6.1. Lifecycle of the Urinary CatheterIf no urinary catheter is placed then the risk ofCAUTI has been eliminated. This key point inmedical decsion making is best informed by highlevel of awareness of appropriate indications forthis device. HICPAC Guidelines offers useful,albeit not necessarily comprehensive of highenough descriptive elements to optimize urinarycatheter stewardship. The challenge for providers,therefore, is to establish and sustain adherencewith appropriate use at point of provider order.Once placed, the key awareness of the presenceof the device in the patient. In this same review,Meddings summarized that reminders, automaticstop orders, or a combination are associated witha significant reduction in the icidence of CAUTI.Prevention BundlesThis “bundle” concept, has been reported inthe prevention of Central CLABSI, ventilatorassociatedpneumonia, and SSI and has beenapplied with some demonstrated success in someCAUTI prevention. Combining a set of processmeasures together to improve care may enhanceinterdisciplinary communication and facilitateprocess improvement. However, there is noconsensus on which elements are to be includedin a bundle, and individual elements vary acrossfacilities. Bundles may be helpful in intrafacilitycare coordination and communication. Evidenceon bundles is limited to before and after studies. 3An example of a bundle is described in Figure 6.2.Table 6.2 presents an example of how bundledinterventions can be incorporated into a standardclinical protocol.Source: Medding J, Rogers M, Krein S, et al. Reducingunnecessary urinary catheter use and other strategies toprevent catheter-associated urinary tract infection: Anintegrative review. BMJ Qual Saf May 2014.Physician Reminder SystemsQuality improvement projects have been effectivein reducing CAUTI. 4 To reduce the incidenceand duration of catheter use, it is importantto assess and communicate the presence ofa urinary catheter to the medical team on adaily basis. Physicians are often unaware that apatient has an indwelling urinary catheter. Onestudy in an ICU demonstrated that a simple,Association for Professionals in Infection Control and Epidemiology 55

Guide to Preventing Catheter-Associated Urinary Tract Infectionscontinuous quality improvement program basedon nursing staff reminding physicians to removeunnecessary catheters significantly reducedthe duration of urinary catheterization as wellas the rate of catheter-associated urinary tractinfections. 5 Similar results were obtained whena specially trained nurse participated in dailymultidisciplinary rounds on 10 medical/surgicalunits. Patients with catheters were assessed, andif any failed to meet appropriate criteria, thepatient’s nurse was requested to obtain an order toremove the catheter. 6In another study, automated reminders tophysicians were generated through a computerizedmedical record. The study concluded that theaverage length of catheterization was decreased,although there were insufficient data to determineif there were a corresponding decrease in urinarytract infections. 7 A similar study used a simplewritten reminder in a pretest/posttest design witha nonequivalent control group. The interventionnotification, which was attached to patients’charts, was designed to remind the care providersthat the patient had a urinary catheter. Theprimary outcome measure was the number ofFigure 6.2. Bladder Bundle ExampleBladder Bundle• Aseptic insertion and proper maintenance isparamount.• Bladder ultrasound may avoid indwellingcatheterization.• Condom or intermittent catheterization inappropriate patients.• Do not use the indwelling catheter unless youmust!• Early removal of the catheter using reminders orstop orders appears warranted.Jt Comm J Qual Patient Saf. 2009 September; 35(9):449–455.catheter days and the rate of recatheterization.After adjusting for age, gender, and length ofstay, the proportion of time patients werecatheterized increased in the control group butdecreased significantly in the intervention group.There was no significant difference in the rateof recatheterization. 8Table 6.2. CAUTI Maintenance BundleDATEDAILY DOCU-MENTEDASSESSMENTOF NEEDTAMPEREVIDENTSEAL ISINTACTCATHETERSECURED—SECUREMENTDEVICE INPLACEBUNDLE CRITERIAHANDHYGIENEPERFORMEDFOR PATIENTCONTACTDAILYMEATALHYGIENEPERFORMEDWITH SOAPAND WATERDRAINAGEBAG EMPTIEDUSING ACLEANCONTAINERUNOB-STRUCTEDFLOWMAINTAINEDYES NO YES NO YES NO YES NO YES NO YES NO YES NOYES NO YES NO YES NO YES NO YES NO YES NO YES NOYES NO YES NO YES NO YES NO YES NO YES NO YES NOYES NO YES NO YES NO YES NO YES NO YES NO YES NOYES NO YES NO YES NO YES NO YES NO YES NO YES NOYES NO YES NO YES NO YES NO YES NO YES NO YES NOACTIONREMOVE ORCONTINUEREMOVECONTINUEREMOVECONTINUEREMOVECONTINUEREMOVECONTINUEREMOVECONTINUEREMOVECONTINUEUse with permission from: George Allen, PhD, CIC, CNOR, Downstate Medical Center, Brooklyn, NY56 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsAthens Regional Medical CenterNON-SURGICAL PATIENT NURSING PROTOCOLFOR INDWELLING FOLEY CATHETER DISCONTINUATION(NOTE: Surgical patients will have foley D/C’d on POD 1 or 2 unless physician documents otherwise)Instructions:• Indications for an indwelling urinary catheter are to be evaluated upon insertion (use Foley InsertionCriteria & Documentation note template) and daily (use Daily Need for Indwelling Catheter note template)• Remove foley catheter as soon as possible: If patient does not meet criteria, check the box in thediscontinuation section below and REMOVE the indwelling urinary catheter.Note: Do not use this form for suprapubic catheters.CRITERIA FOR INDWELLING FOLEY CATHETERMark the appropriate indication for foley catheter:• Acute urinary retention or bladder outlet obstruction• Strict urinary output measurement• Incontinence in patients with open sacral or perineal wounds (Key Point: Incontinence in general is notan indication)• Prolonged immobilization (e.g., unstable thoracic or lumbar spine, pelvic fractures, etc.)• Improve comfort for end of life careDISCONTINUATION OF INDWELLING URINARY CATHETERDoes not meet above criteria: Remove indwelling urinary catheter• Document removal in HMS (use Foley Catheter Discontinued note template)• Monitor patient’s ability to urinate post-catheter removal.RN Signature:__________________________________________Removal Date___________________________________________Time_____________________Sample policy provided with permission by Linda Greene, Highland Hospital, and Rochester, NYUsed with permission from Geri A. Brown, RN, CIC, Starr Regional Medical Ctr., Athens, TNAssociation for Professionals in Infection Control and Epidemiology 57

Guide to Preventing Catheter-Associated Urinary Tract InfectionsNurse-Driven ProtocolsTwo of the most important strategies for prevention ofCAUTI are to limit insertion to only those conditionsfor which there is an indication and to removecatheters as soon as possible. Although the indwellingurinary catheter may be indicated in critically ill orperioperative patients, the timing of removal is ofteninfluenced by nurse or physician convenience ratherthan individual care needs. One of the strategiesthat has proven successful is the implementation ofnurse-driven protocols for removal. These protocolsallow a nurse to remove a urinary catheter when preestablishedcriteria are met. Multiple studies supportnurse-driven protocols and have demonstrated arelationship between the implementation of suchprotocols and CAUTI reduction. 9, 10, 11 Case Study 3describes the importance of nurse participations andaccountability in a systemwide CAUTI preventioninitaitives.CASE STUDY 3: Down with CAUTIS Was Our Battle Cry!BackgroundThe Centers for Disease Control and Prevention’s (CDC) January 2013 CAUTI (catheter-associatedurinary tract infections) event statistics reported that urinary tract infections (UTIS) account for morethan 15 percent of all hospital-acquired infections. Approximately 75 percent of all those documentedUTIS are associated with use of urinary catheters (CAUTIs). These infections can result in seriouscomplications for the hospitalized patient including increased length of stay and risk of sepsis in thesetting of financial loss for the institution. CAUTIS at our hospital represented 11.89 percent of the totalnumber of infections for fiscal year (FY) 11. While this percentage was lower than the national averageof 15 percent it pointed to an increase from the previous year. In light of these events, we developeda plan to reduce our CAUTI rate by engaging our nurses to assume ownership of the CAUTI problem.Our hypothesis for a CAUTI reduction initiative was that the combined ownership of a program by aShared Governance Practice Council (SPGC) of nurses with adherence to evidence-based practices,along with a nurse driven protocol to remove Foley catheters would decrease the number of CAUTISwithin 1 year (see Figure 1). We needed a battle plan.ProjectAs part of a large multi-hospital health system we follow the Health System’s quality initiatives.The System initiatives included the following:• Develop and validate accurate electronic data collection system• Development of a mandatory online educational program for all nurses, nursing assistants,and technicians• Reduce Foley catheter days• Develop and initiate a nurse-driven protocolWhile we used the above concepts and were part of the System process, we needed to identify amechanism to make these processes work in our institution. Our hospital-based battle plan wasdeveloped over two years. The focus of the first year was to decrease catheter days through dailyrounding on all patients with urinary catheters. This task was the responsibility of the Unit director.During the first year of the initiative, the number of CAUTIS was reduced from 55 to 44 with anassociated rate of 1.71 per 1,000 catheter days.58 Association for Professionals in Infection Control and Epidemiology

Figure 1. CAUTI Initiative Rate of Change3.00Guide to Preventing Catheter-Associated Urinary Tract Infections2.50Rate per 1,000 device days2.001.501.000.500.00FY2011TOTALSJul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12Rate 1.71 0.50 1.02 2.53 0.00 0.48 1.49 0.00 0.54 1.01 1.34 1.22 0.87 0.92Util. 0.18 0.18 0.18 0.17 0.18 0.19 0.18 0.17 0.16 0.16 0.20 0.20 0.19 0.18FY2012TOTALSThe second year of the initiative, the responsibility for further reducing CAUTIS was given to theSGPC. SGPC was charged with process improvement by the hospital nursing leadership. TheSGPC is composed of nursing representatives from all of the nursing units and is given structuralempowerment to identify problems and develop solutions for these problems. A select subgroup ofthe SGPC was formed to develop and drive our hospital based initiative. The group also included anursing administrator, a quality person, and an Infection Preventionist (IP).MethodsComponents of the initiative included the following:• Involve the Shared Governance Practice Council to identify risk factors for CAUTIS within our hospital;develop mandatory competencies for all nurses, nursing assistants, and technicians; perform processimprovements; and empower the nursing representatives to identify strategies to prevent CAUTIs• Develop and initiate a nurse-driven protocol to remove the catheters to reduce Foley daysProcessThe IP presented information about CAUTIS to the members of subgroup. This education included,the NHSN definition for a CAUTI, evidence-based reduction strategies, and the importance of properhandling of devices and sterile technique. Each member was given a packet of information to sharewith their units. The subgroup then discussed possible issues and decided to round on all nursing unitsto identify current practices regarding urinary catheters on their individual units. They developed anaudit tool to standardize their observations.The group discussed their strategies for reducing CAUTIs and identified their main focus. Theyidentified several risk factors related to CAUTIs as a result of their rounding and chart audits.The review process looked at multiple strategies through monthly rounding and auditing of nursesnotes by chart review:• Review of daily documentation of catheter necessity using a standardized electronic medical record (EMR)• Daily rounding by the charge nurse or the unit director focus on Foley necessity to prompt early removalAssociation for Professionals in Infection Control and Epidemiology 59

Guide to Preventing Catheter-Associated Urinary Tract Infections• Examining compliance with catheter care and maintenance practices, including use of propersecurement devices• Focusing attention on locations where catheters were being inserted (e.g., OR, Emergency Department)• Auditing the EMR for the required order to place a Foley• Monthly review of all CAUTIS identified during the month and possible problems associated with themTheir first focus was on education and re-education of the nursing staff related to catheter insertions,maintenance of the catheter, catheter necessity, and sterile technique. Recognizing that ancillary staffwas also responsible for positioning and moving patients they developed education for this group aswell. Special in-services for the transport department were conducted to ensure that the Foley bagwas kept below the level of the bladder during transportation of the patient. Each unit based CAUTIleader provided feedback to their units regarding infections and the catheter days.Results: FY 11 CAUTI rate was 1.71 and FY 12 rate decreased to 0.92/1,000 Foley days (p=0.0106).Overall infection numbers decreased from 44 to 23 (47.7 percent decrease). Device utilization rateremained the same at 0.18/1,000 patient days.ConclusionsSuccess occurred when the nurses accepted responsibility and ownership for the processimprovement on their own units. Holding each staff member accountable helped promote betterpractices for Foley placement and care. Their excitement with each success led to enthusiasm andsupport from the whole staff. Nursing leadership’s support to unit management further infused energyinto the initiative. Each unit identified and developed strategies to address their own needs. Mandatorycompetencies improved catheter care.While a decrease in catheters days was not seen during the second year of the initiative, implementingchanges in use of and care of catheters did result in a significant decrease in infections.Decrease in catheter days was not seen, in part due to a change in data collection methodology duringthis time period. Nurses and medical staff need further education in promoting use of the nurse-drivenremoval protocol.Additional InformationUPMC Mercy is a 495-bed acute care tertiary facility with 53 intensive care unit beds, a combined Level 1Regional Resource Trauma and Comprehensive Burn Center and includes 76 rehabilitation beds includinggeneral rehabilitation, traumatic brain injury, stroke, and a spinal cord injury unit. We are part of a largehealth system involving 23 hospitals, most of those located in western Pennsylvania. The InfectionPrevention Department consists of 4 full-time Infection Preventionists, 1 Coordinator, a Medical Directorwho is an infectious disease physician, a part-time data analyst, and an administrative assistant.Contributed by Susan A. Grossberger, BSN, Infection Preventionist60 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsPolicy for Early RemovalOrganizations that wish to develop policies forearly removal need to ensure that the protocol isdeveloped collaboratively with medical staff input.An example of a successful collaborative approachis described in Case Study 4.An example of an early removal protocol isprovided in Figure 6.4.Figure 6.4. Early Removal of Urinary Catheter ProtocolSource: Protocol published with permission from Shari Nersinger, Highland Hospital, Rochester, NYCASE STUDY 4: How the Implementation of Nurse-Driven Catheter-AssociatedUrinary Tract Infection (CAUTI) Prevention Measures Resulted in ImprovedPatient OutcomesUrinary tract infections (UTIs) are the most common type of reported healthcare-associated infection,with 75 percent attributed to the presence of an indwelling urinary catheter. Catheter-associated UTIs(CAUTIs) result in increased morbidity, mortality, length of stay, healthcare costs, and patient pain andinconvenience. Evidence has shown that implementing and following recommended best practicesresults in decreased infection rates and improved patient outcomes.In 2010, with the support of hospital leadership, a multidisciplinary CAUTI Prevention team was formedto research and review nursing best-practices, guidelines, and evidence-based recommendations forthe prevention of CAUTIs. The primary objective of this team was to identify and implement bestpracticenursing initiatives for the reduction of CAUTIs throughout the organization. The CAUTIAssociation for Professionals in Infection Control and Epidemiology 61

Guide to Preventing Catheter-Associated Urinary Tract Infectionsprevention team included nursing representation from Critical Care, Medical Services, Surgical Services,Quality Department, Infection Prevention, and also included a Physician Champion.The team started by developing and carrying out organization-wide education to heighten awarenessand highlight important CAUTI prevention strategies. Education was delivered using a variety ofmethods, including placing informative table tents in the staff cafeteria, hanging posters in stafflounges, presentations at unit/department staff meetings, articles written in the organizationnewsletter, and providing educational information to the medical staff.Prevention Initiatives by the CAUTI Prevention Team• A nursing assessment tool that included set criteria for catheter continuation (named C.H.O.R.U.S.;see below), daily assessment of all urinary catheters by nursing staff, and documentation correlatingwith the catheter continuation criteria (C.H.O.R.U.S.) was developed for the Electronic MedicalRecord (EMR) and implemented.• A nurse-driven urinary catheter discontinuation protocol for the early removal of unnecessary urinarycatheters was developed based on the CDC recommended best practice guidelines.• Additional bladder scanners were purchased by nursing administration to support the elements ofthe urinary catheter discontinuation protocol.• A nursing educational competency for use of the bladder scanner was developed and implementedand is now completed yearly by all in-patient nursing staff.62 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infections• The Intensive Care Unit (ICU) was chosen to conduct a two-month trial of the nurse-drivendiscontinuation protocol, followed by a two-month trial on all in-patient units.• Full implementation of the discontinuation protocol occurred after final approval by the MedicalExecutive Committee and Nursing Shared Leadership Committees in December of 2011.• CAUTI rates and catheter utilization ratios are now reported to each patient care unit on a quarterlybasis and shared with team members during staff meetings.• Infection Prevention began sending CAUTI Review Letters to unit nurse managers when a CAUTIwas identified so that a drill down and review of practices can be done for each infection reported.CAUTI rates throughout the organization were reduced following implementation of evidence-basedprevention measures, including the nurse-driven discontinuation protocol. Initiatives resulted in anoverall 44 percent reduction in the number of CAUTIs from the beginning of prevention initiativesin 2010 until December 2012. To date, there have been zero CAUTIs identified in our ICU for morethan 38 months (last CAUTI reported June, 2010). The ICU was the lead unit in implementing CAUTIprevention initiatives, trialing the nurse driven protocol, and helping to educate other patient care unitsthroughout the hospital. Also, as of July 2013, our hospital has had only one CAUTI reported for theyear. Our goal is to have zero CAUTIs.Lessons LearnedLeadership and staff buy-in were both essential components for the success of our CAUTI preventioninitiatives and required ongoing education and support throughout the process.We learned that we should not assume fundamental infection prevention strategies were beingfollowed at all times (e.g., proper hand hygiene, safe handling of indwelling catheters, aseptictechnique for catheter insertion, and daily catheter care). Reinforcement of these important nursingconcepts had to be included early and throughout implementation of the CAUTI prevention project.For optimal success of CAUTI prevention initiatives, the urinary catheter discontinuation protocolmust be truly nurse-driven and supported by medical staff. Orders to initiate the nurse-drivendiscontinuation protocol need to be included on all provider order sets, and provider educationmust be ongoing to improve compliance with ordering the protocol. Nursing staff need continuedencouragement to take ownership of their practice and understand the important role they have inpatient safety initiatives.Additional InformationBeebe Medical Center is a not-for-profit community healthcare system with a charitable mission toencourage healthy living, prevent illness, and restore optimal health for the people residing, working,or visiting in the communities we serve. It offers multiple services throughout Southern Delawareincluding a 210-licensed-bed hospital, a cancer center, and outpatient facilities at multiple sitesproviding lab, imaging, physical rehab services, and walk-in care. The Medical Center has received theHeathgrades® Distinguished Hospital Award for Clinical Excellence for four years in a row (2010-2013). It is certified by the Joint Commission as an Advanced Primary Stroke Center, and for hip andknee replacement surgical programs. It is designated as a Breast Imaging Center of Excellence by theAmerican College of Radiology (ACR), and named a Center of Excellence in Women’s Health by theAmerican Institute of Minimally Invasive Surgery (AIMIS). The infection Prevention department consistsof 1 full-time and 1 part-time Infection Preventionist (IP) and is supported by an Infectious DiseaseMedical Director.By: Theresa Houston, RN, BSN, CCRN, Critical Care Educator, and Donna Anderson, RN, CIC, Infection PreventionistAssociation for Professionals in Infection Control and Epidemiology 63

Guide to Preventing Catheter-Associated Urinary Tract InfectionsIn addition, an example of a nurse-driven urinary catheter protocol in policy and procedure format isshown below:Baylor Orthopedic and Spine Hospitalat ArlingtonINFECTION CONTROLPOLICIES AND GUIDELINESNurse-Driven Urinary Catheter ProtocolISSUED: July 2012REVISED:NUMBER: 35PURPOSE:To reduce the incidence of catheter-associated urinary tract infections (CAUTI).POLICY:Patients will be assessed on admission for symptoms of existing urinary tract infection and patientsmeeting specific criteria will have their urinary catheter removed by the nurse.DEFINITION:Catheter-Associated Urinary Tract Infection: A hospital-acquired infection that can develop in patients whohave had an indwelling urinary catheter.PRINCIPLES:• Urinary tract infection is the most common hospital acquired infection; 80 percent of these infectionsare attributable to an indwelling urethral catheter.• The duration of catheterization is the most important risk factor for development of infection.PROCEDURE:Assessment for Pre-existing UTI:1. Obtain urine specimen on admission from any patient admitted with an existing urinary catheter.2. Obtain urine specimen for symptoms of urinary tract infection (i.e. dysuria, frequency, urgency,nocturia, suprapubic pain, or hematuria).3. Promptly transport urine samples to the laboratory for culture to prevent inaccurate culture results.4. Document indications for catheter insertion (if not inserted intraoperatively).Basic Practice for Prevention of CAUTI:1. Insert urinary catheters only when necessary for patient care and leave them in place only as long asindicated.2. Consider other methods for management, including condom catheters or straight catheterizationafter bladder scan.3. Practice hand hygiene immediately before insertion of the catheter and before and after anymanipulation of the catheter site or apparatus.4. Insert by use of aseptic technique and sterile equipment.5. Use as small a catheter as possible, which is consistent with proper drainage, to minimize urethral trauma.6. Properly secure indwelling catheters after insertion to prevent movement and urethral traction.7. Maintain a sterile, continuously closed drainage system unless the catheter must be irrigated.64 Association for Professionals in Infection Control and Epidemiology

8. Replace system if a break in asepsis occurs.9. Maintain unobstructed urine flow.10. Keep collection bag below the level of the bladder at all times.11. Provide routine hygiene for meatal care.Guide to Preventing Catheter-Associated Urinary Tract Infections12. Empty collecting bag regularly, using a separate collecting container for each patient, and avoidallowing the drainage spigot to touch the collecting container.13. Obtain urine samples aseptically using catheter-sampling port.Nurse-Driven Urinary Catheter Assessment and Catheter Removal:1. The RN will assess the need to continue urinary catheter every 12 hours as a part of the RN shiftassessment.2. If none of the indications for continued catheter use are met:a. The RN will discontinue the catheter.b. The RN will continue to reevaluate and assess the need to reinsert the catheter following removal.c. Notify the physician if the patient is unable to void within 8 hours or as ordered.d. The RN will document the assessment and removal of the urinary catheter and continuedreassessment post removal, in the patient’s medical record.3. If indications for urinary catheter are present:a. Continue catheter care per policy.b. Place form behind the Physician Order tab in the Medical Record if the catheter is continued pastPOD #2.c. Ensure securing device is used (e.g., Stat-lock).d. No dependent loops.e. Secure tubing to bed.f. Drainage bag is not overfilled or touching the floor.4. Handoff communication for readiness to discontinue catheter to on-coming shift RN.Patient Education:1. The RN will educate the patient on:a. The risk associated with indwelling urinary catheters.b. Importance of adequate fluid intake after catheter removal.c. Measurement of intake and output to be done to assess the patient’s ability to empty bladder afterremoval of urinary catheter.2. Patient education after catheter removal will include:a. Importance of calling for assistance for toileting.b. Importance of activity: up in chair, ambulating in room and around unit.c. Reinforce safety precautions: “Call don’t Fall”Addapted from: HICPAC. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 20092009, used with permission from Maxine Garcia, RN, Irving, TXAssociation for Professionals in Infection Control and Epidemiology 65

Guide to Preventing Catheter-Associated Urinary Tract InfectionsCoated CathetersUse of an antiseptic or impregnated coatedcatheter is an area that has received considerableattention. The 2009 HICPAC Guidelineidentified low-quality evidence to support theuse of antiseptic or antimicrobial catheters. Mostof the studies were observational studies thatinvolved relatively small populations in whichasymptomatic bacteriuria was an outcome.Considerable doubt and controversy remainas to whether silver-coated catheters reduceCAUTI rates. In 2012, Pickard published alarge randomized control study that showed nobenefit with the use of silver catheters. Patientsrequiring short-term urinary catheterizationwere randomly allocated 1:1:1 to receive a silveralloy-coated catheter, a nitrofural-impregnatedcatheter, or a Polytetrafluoroethylene (PTFE)-coated catheter (control group). Comparedwith 271 (12.6 percent) of 2,144 participants inthe control group, 263 (12.5 percent) of 2,097participants allocated a silver alloy catheterdeveloped a symptomatic CAUTI by 6 weeks,as did 228 (10.6 percent) of 2,153 participantsallocated a nitrofural catheter. They concludedthat silver alloy-coated catheters were not effectivefor reduction of the incidence of symptomaticCAUTI and that the reduction in CAUTIassociated with nitrofural-impregnated catheterswas not significant enough to be consideredclinically important. Routine use of antimicrobialimpregnatedcatheters is not supported by thistrial. 12 Trautner and colleagues also studied E.coli adherence to silver catheters and concluded,“Silver impregnation had little effect on bacterialadherence in our model and nitrofurazoneimpregnation had a significant effect only forthe first 5 days. Our results do not support a rolefor silver urinary catheters to prevent catheterassociated urinary tract infection by decreasingbacterial adherence.” 13Drainage System SafetySterile, continuously closed drainage systemsbecame the standard of care based on anuncontrolled study published in 1966demonstrating a reduction in the risk of infectionin short-term catheterized patients with the useof a closed system. Recent data also include thefinding that disconnection of the drainage systemis a risk factor for bacteriuria. The catheter tubingshould allow free flow of urine and kinking oftubing should be avoided. The urine bag shouldbe kept below the level of the bladder and keptoff the floor. Urine samples should be obtainedaseptically. If breaks in aseptic technique,disconnection, or leakage occur, the catheter andcollecting device should be replaced. 14The following represents a summary of preventionpractices outlined in the 2009 HICPAC Guideline:Programs, Practices, and Interventions thatMay Be Implemented in CAUTI PreventionEfforts (2009 HICPAC Guideline)• Perform hand hygiene immediately beforeand after insertion or any manipulation of thecatheter device or site.• Use indwelling catheters only when medicallynecessary.• Use aseptic insertion technique and sterileequipment with standard precautions to includehand hygiene and gloves.• Allow only trained healthcare providers, familymembers, or patients to insert catheter.• Properly secure catheters after insertion toprevent movement and urethral traction.• Maintain a sterile closed drainage system.• Maintain good hygiene at the catheter-urethralinterface.• Maintain unobstructed urine flow by keepingthe catheter and collecting tube free fromkinking.66 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infections• Maintain drainage bag below level of bladder atall times. Do not rest the bag on the floor.• Remove catheters when no longer needed.• Do not change indwelling catheters or urinarydrainage bags at arbitrary fixed intervals.• Document indication for urinary catheter oneach day of use.• Use reminder systems to target opportunities toremove catheter.• Use external (or condom-style) catheters ifappropriate in men without urinary retention orbladder outlet obstruction.• Consider alternatives to indwelling urethralcatheters, such as intermittent catheterization,performed at regular intervals to prevent bladderdistension. Some studies have reported fewercomplications with use of a suprapubic catheter,but the surgical procedure required to insert thesuprapubic catheter is associated with additionalrisks. Current evidence is not sufficient to supportthe routine use of a suprapubic catheter for shorttermcatheterization to prevent symptomaticurinary infection or other complications.• If breaks in aseptic technique, disconnection, orleakage occur, replace the catheter and collectingsystem using aseptic technique and sterileequipment.Saint, et al. have recently borrowed a page fromnavigation tools and developed a guide to patientsafety (GPS) assessment tool to assist providerswith prevention of CAUTI. 15 This tool, providedbelow, has been tested and was able to identifybarriers to realizing improvement in performance aswell as “diagnose” on a macro level the behavioralaspects limiting progress in prevention of CAUTIs.This study identifies that prevention of CAUTI ismore reliant on changing behavior and beliefs ofproviders in contrast to CLABSI, where technicalelements like specific skin antiseptic and aseptictechnique during insertion yield significantimprovement. The GPS is also available fromthe author’s web-based knowledge resource onCAUTI prevention [www.catheterout.org]References1. Gould C, Umscheid C, Agarwal R, et al., and theHealthcare Infections Control Practices AdvisoryCommittee (HICPAC). Guideline for preventionof catheter-associated urinary tract infections 2009.Available at: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.2. Available at: catheterout.org/.3. Saint S, Olmstead R, Fakih M, et al. Translatinghealth care-associated urinary tract infection preventionresearch into practice via the bladder bundle. Int J QualHealth Care 2013 Feb; 25(1):43–49.4. Apisarnthanarak A, Thongphubeth K, SirinvaravongS, et al. Effectiveness of a multifacted hospitalwidequalitywide quality improvement programs featuringan intervention to remove unecessary urinary cathetersat a tertiary care center in Thailand. Infect Control HospEpidemiol 2012; 28:791–98.5. Reilly L, Sullivan P, Ninni S, et al. Reducing Foleycatheter device days in an intensive care unit: using theevidence to change practice. AACN Advanced CriticalCare 2006; 17(3):272–83.6. Fakih M, Dueweke C, Meisner S, et al. Effectof nurse-led multidisciplinary rounds on reducingthe unnecessary use of urinary catheterization inhospitalized patients. Infect Control Hosp Epidemiol2008; 29(9):815–19.7. Cornia PB, Amory JK, Fraser S, et al. Computerbasedorder entry decreases duration of urinarycatheterization in hospitalized patients. Am J Med 2003April; 114(5):404–07.8. Saint S, Kaufman S, Thompson M, et al. A reminderreduces urinary catheterization in hospitalized patients.Jt Comm J Qual Patient Saf 2005 August; 31(8):455–61.9. Oman KS, Makic M, Fink R, et al. Nurse-directedinterventions to reduce catheter-associated urinarytract infections. Am J Infect Control 2012 August;40(6):548–53.Association for Professionals in Infection Control and Epidemiology 67

Guide to Preventing Catheter-Associated Urinary Tract Infections10. Wenger JE. Cultivating quality: reducing rates ofcatheter-associated urinary tract infection: One magnethospital implemented a nurse-managed approach. Am JNurs 2010; 110 (8):40–45.11. Reilly L, Sullivan P, Ninni S, et al. Reducing Foleycatheter device days in an intensive care unit: using theevidence to change practice. AACN Adv Crit Care 2006July–September; 17(3): 272–83.12. Pickard R, Thomas L, Mac Lennan G, et al.Antimicrobial catheters for reduction of symptomaticurinary tract infection in adults requiring shorttermcathererisation in hospital: a multicentrerandomsied controlled trial. Lancet 2012 December 1;380(9857):1927–35.13. Desai DG, Liao KS, Cevallos ME, et al. Silver ornitrofurazone impregnation of urinary catheters hasa minimal effect on uropathogen adherence, J Urol.2010 Dec; 184(6):2565–71.14. Gould C, Umscheid C, Agarwal R, et al., andthe Healthcare Infections Control Practices AdvisoryCommittee (HICPAC). Guideline for preventionof catheter-associated urinary tract infections 2009.Available at: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.15. Saint S, Gaies E, Fowler K, et al. Introducing acatheter-associated urinary tract infection (CAUTI)prevention guide to patient safety (GPS). AJIC May2014. Vol. 42, issue 5: 548-550.68 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsSection 7: Preventing Catheter-AssociatedUrinary Tract Infections in ChildrenThe prevention of CAUTI in children, especiallyHAIs is not procedurally different from theconcerns confronted in serving adult patients.While CAUTI is known to be the leading causeof HAIs in adults, CAUTI incidence rate andrelative significance in pediatrics is only nowbeing established. According to the 2011 dataof the Ohio Children’s Hospitals’ Solutions forPatient Safety (OCHSPS) National Children’sNetwork,* CAUTI is the third most frequent HAIin children, after CLABSI and SSI.In pediatrics, the rationale for catheter insertion,catheter size, attention to aseptic technique oninsertion, and the reliance on a “bundle” strategyfor quality of care in managing the device are allnecessary to prevent these infections. Childrenare, however, not merely small adults. Those whocare for them, especially in a hospital setting,must appreciate that there are several additionalissues and concerns related specifically to theirage. For patients of any age there are potentialadverse consequences of an indwelling catheterincluding trauma, discomfort, immobility, lossof dignity, increased antimicrobial use, and thecreation of reservoirs for pathogens. However, theadditional concerns specifically inherent in thecare of children include, but are not limited to,the following for the clinician’s consideration:1. The child’s age and the use ofdevelopmentally appropriate approaches tocare are essential considerations and shouldbe addressed in every aspect of the child’s care.Consider using a textbook reference, such asthe table “Age-Specific Approaches to PhysicalExamination During Childhood,” in Wong’sNursing Care of Infants and Children. 1 Further,it is not developmentally inappropriate foryoung children to be incontinent of bothurine and stool; even children who haveattained continence as a developmentalmilestone may regress when confronted withillness or hospitalization.2. Attention to family-centered care, culturalcompetency of the clinicians, and healthliteracy of the family can create a morecooperative and collaborative patientexperience. Family-centered care, a commontenant in pediatric care, reminds cliniciansto learn the child’s particular worries andbehavior patterns. This is information bestobtained from a family-identified expert,including family members in the child’s care,to the degree that they wish to participate, andis an essential ingredient in gaining the child’strust and cooperation. Consider a tool, suchas “The Evolution of Family-Centered Care”published in Pediatric Nursing in 2009, as aguide. 2 A sample tool is shown in Figure 7.1.*Ohio Children’s Hospitals’ Solutions for Patient Safety (OCHSPS), a nonprofit corporation, collects and analyzespatient safety data to improve children’s safety and healthcare outcomes, and the quality of pediatric healthcare deliveryoverall. OCHSPS is funded in part through the Partnership for Patients initiative, a public-private collaboration to improvethe quality, safety, and affordability of healthcare for all Americans and led by HHS. OCHSPS was founded in January 2009by Ohio’s eight children’s hospitals to improve quality and safety in children’s hospitals statewide. It is now one of 26 HENsfunded under this federal initiative, and the only one specifically addressing the health of children.Association for Professionals in Infection Control and Epidemiology 69

Guide to Preventing Catheter-Associated Urinary Tract InfectionsFamily-centered care also requires culturalcompetency on the part of the clinicians andan assessment of the family’s health literacy inorder to advance a bond of partnership andcooperation with families. Failure to considerthe cultural implications of care could easilyput the clinician at odds with the patient andor the family. Health literacy is central toenhancing the involvement of patients andfamilies in their care. The clinician should tryto use any care delivery moment, especiallyone as intimate as the provision of indwellingurinary catheter care, as an opportunity toincrease the family’s understanding of thechild’s needs and condition.Related patient education must be deliveredto and comprehended by the child’s caregivers,not only the child him/herself who may ormay not be mature enough to understandsuch information. A well-informed andthoughtfully participative family acting asthe child’s advocate contributes to preventinginfections in any healthcare situation. The useof creative tools with cheerful illustrations andwell-selected, simple language can enhance thechild’s and family’s learning.3. Provision of emotional comfort (presence ofparent, comforting objects, music, positivedistraction) can be of enormous support tochildren in an unfamiliar, uncomfortable, orfrightening situation. Hospital procedurescan induce great anxiety in children, which,if not managed well, can interfere with thesafe completion of the procedure. Havingtoys, especially the child’s own favoritetoys, blankets, or objects, can provide safeand helpful comfort and distraction so thatthe procedure can be completed safely andefficiently. 3 If possible, any invasive proceduresshould be performed in a procedure roomseparate from the child’s hospital bed so thatthe child may perceive the hospital room as asafe, nonthreatening environment.4. Daily care and assessment for allergies,skin sensitivities, especially in the choiceof cleansing agents and issues of cathetersecurement are common concerns in the careof children.a. Allergies and skin sensitivities areproblematic especially in infantswhere the skin has unique and specificmicrostructures. Infant stratum corneumis a full 30 percent thinner and infantepidermis is as much as 20 percent thinnerthan in adults. 4 These differences inskin microstructure explain some of thefunctional differences, such as healingtimes, heat loss, and easy tearing of theyoung child’s skin.b. Given the physiological differences seen inpediatrics, greater precaution is requiredin the selection and use of preparation andmaintenance solutions used on the skinand mucous membranes. Iodine sensitivityis a common concern. The clinician maysubstitute an approved, antiseptic towelette,such as the benzalkonium chloridetowelettes frequently used in cleansingprior to capture of a clean-catch specimenin adults. Regular cleansing of the meatuswith mild soap and water is recommended.Only one published study has assessed thedifference in effectiveness in the selection ofperiurethral cleaning solutions in children. 5Additional research is warranted.c. Securement of the catheter can beproblematic. The most commonsecurement devices have proven themselvesdifficult to use, especially on very smallchildren. They may slip, failing to preventcatheter movement; their adhesives maycause a rash; and their friction may leadto excoriation. Clinicians must not takefor granted that the tools which work onlarger children or adults will be adequatefor use in young children. Adaptation,experimentation, and resourcefulness maybe necessary to secure a indwelling urinarycatheter in pediatrics where limiting the70 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsFigure 7.1. CAUTI PreventionCatheter-Associated Urinary TractInfection (CAUTI) PreventionYour child’s doctor has recommended a Foleycatheter for your child. A Foley catheter is a tubeinserted through the urethra into the bladder to allowurine to drain out. It is also called an indwellingurinary catheter. A Foley is useful in situationsrequiring careful checking of how much urine ismade, immobilization for a long period of time, incertain types of surgery, with certain types ofmedication, and to help with the healing of somewounds near the buttocks. Your child’s doctordetermines how long your child will need the Foleycatheter.Foley catheters are helpful for taking care of yourchild; however, they can increase the risk ofinfections when germs grow in or on the catheterand travel to the bladder. When this happens, it iscalled a catheter-associated urinary tract infectionor CAUTI. A CAUTI can be serious and treatmentmay require extra medications or a longer hospitalstay.Fortunately, there are steps we can take to preventCAUTIs. The most important step is handwashing. At Children’s, we check all Foleycatheters for signs of infection every day. We alsotake steps to keep infections from happening by:• Washing our hands and/or using alcoholbasedhand rub frequently;• Using antiseptic soap on the skin beforeinserting the Foley catheter;• Careful handling of the Foley catheter, thetubing and the collection bag;• Securing the Foley catheter so it doesn’ttug or pull;• Ensuring unobstructed urine flow bycarefully positioning the tubing andcollection bag;• Emptying the collection bag at least everyeight hours;• Checking Foley catheters daily for signs ofinfection;• Checking daily to see if the Foley catheteris still needed.We also follow strict protocols when insertingFoley catheters as recommended by the Centers forDisease Control and Prevention (CDC).How should I care for my child?Parents and patients also have a role to play inpreventing CAUTIs:• Wash your hands with soap and water, or usealcohol-based hand rub found in each room,when you enter and leave your child’s room;• Wash your hands with soap and water beforeand after you prepare food, eat or feed yourchild and before and after you use thebathroom or change a diaper.• Ask your child’s visitors to wash their handswhen they enter and exit your child’s room.• Do not allow visitors to touch the Foleycatheter, tubing or collection bag.• Watch your nurses and doctors to make surethey wash their hands before and afterhandling the Foley catheter. Do not be afraidto remind them to wash their hands!• Keep the Foley catheter clean when changingthe diaper, and always clean in the directionfrom the body towards the Foley catheter.• Help make sure the collection bag is alwaysbelow the level of your child’s belly button.• If you have any concerns about your child’sFoley catheter, or the way it is cared for, talkto your child’s doctor or nurse.We value providing safe care for your child duringtheir illness. Thank you for your help in providinga safe environment for your child’s Foley catheter.If you have any questions, ask your child’s nurseor doctor.Children’s – MinneapolisPatient/Family Education2525 Chicago Avenue SouthMinneapolis, MN 55404childrensMN.org04/2013Association for Professionals in Infection Control and Epidemiology 71

Guide to Preventing Catheter-Associated Urinary Tract InfectionsTable 7.1. Urinary Catheter Size Selectionexcursion of the device and preventingits accidental and traumatic removal isperhaps even more critical than in adults.Newer designs are entering the market thatmay permit the clinician to anchor underthe catheter at the access valve side of thetubing bifurcation, providing a gentleadherence to the child’s skin and preventionof migration of the indwelling urinarycatheter itself.5. Anatomic or positional issues (such as alteredanatomy within the genitourinary systemor elsewhere) whether encountered in theinitial attempts to insert an indwellingurinary catheter or discovered on imagingstudies can certainly complicate the clinician’sability to protect the child from injuryor infection. Altered anatomy may be asstraightforward and visible as the presentationof a child in lower extremity casts that whiletherapeutically positioning the legs, may causepotential interference with safe technique forcatheterization. If adequate visualization oraccess is complicated and/or distraction andother comfort techniques prove unsuccessful,the child may require insertion of the catheterunder analgesia or even anesthesia. Pediatricfacilities might use conscious sedation ornitrous oxide administration to help thechild relax.6. Appropriate assessment and managementof the child’s pain, neurological function,and hydration status, including possibledehydration and urinary retention, isimportant prior to placing an indwellingurinary catheter.a. Assessing the child’s pain, especially withnonverbal children, can be challenging foreven the most seasoned pediatric clinician.Relying on the parent to report the child’stypical discomfort behaviors may help.b. Assessing neurologic function is essential.Certain medications can impedeneurological function causing urinaryretention. Neurogenic bladder withsymptoms of overactivity or underactivitycan be chronic in children with underlyingneurological diagnoses. Clinicians shouldtake into consideration the neurologicbladder function before inserting ordiscontinuing an indwelling urinarycatheter especially in children. The child orthe family tired of dealing with intermittentcatheterization may even request theplacement of an indwelling urinarycatheter, but the inherent risks of placing itoutweigh their preference for convenience.c. Assessing the cause of urinary retentionrequires the assurance of adequatehydration. Accurate assessment relieslargely on clinical examination, includingpalpation, and the careful observance offluid intake and urine output, which canbe difficult to measure. Weighing diapersand guessing at the intake of breastfeedinginfants are only two of the hindrancesto accuracy. Some clinicians, eager to dowhat works in adult medicine, turn to thebladder scanner for more accurate results,but studies show that such techniquesmay be less reliable in pediatrics. 6 One72 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infectionssignificant consideration is the concurrentadministration of medications with urinaryretention as an adverse side effect.7. Sizes and lengths of catheters appropriate forchildren should be available at all times. Alltoo often having an insufficient selection ora lack of familiarity with selecting the sizeof the equipment required can delay thesuccess of the catheterization procedure andincrease the pediatric patient’s discomfort.In a study published in 2012, data from2006 demonstrated that “roughly one-halfof emergency departments had 85 percent ormore of recommended pediatric supplies, butonly 7.2 percent of emergency departmentshad all recommended pediatric supplies,suggesting that inventories could be improvedat most emergency departments.” 7 Hospitalswith pediatric intensive care units fared betterthan hospitals without a high acuity pediatricservice, but if your emergency department seeschildren, being well supplied is imperative.Table 7.1 is a quick guide to the selection ofan appropriately sized catheter: 8On every insertion, the clinican is remindedto adhere to these standards:a. Don’t test the balloon prior to insertion; thedeflated balloon may cause a harmful ridgeon the catheter.b. Fill the balloon per manufacturer’s guide.c. Insert the catheter into the urethral meatusand gently advance for child’s age andgender. The female urethra is approximately3.5 to 4 cm long. Advance the catheter atleast 2 to 3 cm beyond the point at whichurine flow is noted. The male adult urethrais 18 to 20 cm in length. Introduce andadvance the catheter the entire length ofthe catheter,(up to the juncture of theconnector or to the two-way bifurcation),wait for spontaneous urine passage,confirming proper placement of thecatheter to prevent damaging urethra.d. Assess patient for proper size catheter toprevent leakage.e. Remember to prewash patient beforeprepping for insertion.f. If a catheter cannot be passed successfully,consider urology consult. Switching to asmaller catheter may not be helpful and canbe harmful.g. Use a new catheter if sterility of catheter isjeopardized or female urethral meatus is notaccessed with the first try. See Figure 7.2 foran example of CAUTI prevention tool.8. The risk of self-contamination to theindwelling catheter is prevalent withchildren. Practical issues of hand hygiene foreveryone, the child included, and the risk ofthe child’s curiosity with or playing with thecatheter requires extra vigilance. Attentionto stool incontinence and the potential formigration of pathogens up the catheter iscritical. The child’s anxiety with the devicecould lead the child to take it apart, disruptingthe closed system. This eventuality requiresremoval and reinsertion. The catheter maylimit the child’s mobility leading to manycomplications. Finally, the duration ofcatheter’s presence in the child should belimited to prevent infection; this requires dailyreassessment of the need for the device.In some cases, clinicians may be tempted tosee the young child with an indwelling urinarycatheter as requiring hand or arm restraints.Before turning to restraints, consider theuse of distraction and emotional support,especially engaging the child’s parent(s). Theclinician is urged to always include the familyin hand hygiene instruction, to utilize theirunique relationships with the child to keep hisor her hands clean and away from the catheter.The family can also learn to spot the visitoror even the clinician who fails to observe safehand hygiene when entering the room and canthereby add an important layer of protectionfor the child.Association for Professionals in Infection Control and Epidemiology 73

Guide to Preventing Catheter-Associated Urinary Tract InfectionsFigure 7.2. CAUTI Prevention StandardCA-UTI Prevention StandardKEY PROCESS DETAILS TIPS FOR PRACTICE RATIONALEIdentifyIndicationUse indwelling catheter ONLY when clinically necessary Identify clinical indication prior to insertion and daily Discuss need for catheter during rounds- If catheter not removed, discuss criteria for removal- Consider proper time for removal so that replacement ofcatheter is NOT necessaryUsing catheters only whenclinically necessary will reducethe population at risk for CA-UTIHand Hygiene Hand hygiene BEFORE and AFTER patient care Hand sanitizer: Cover all surfaces, rub together until dry Soap and water: wet hands before applying soap, wash for 15-20seconds (sing ABCʼs), thoroughly rinse hands under runningwater, dry hands with a paper towel and use to turn off manuallyoperated faucet or use hands free technique (e.g. forearm orelbow)Insertion Prior to insertion, cleanse perineum with soap and water gauze/cloth,comfort bath, baby wipes – Do NOT use antimicrobial soap/wipesUse ASEPTIC technique with sterile gloves and fieldUse Prepackaged Insertion KitSecureCatheterSecure catheter to inner thigh Catheter is secured at the BIFURCATION There is NO tension on catheter with leg movement Flexitrak is the preferred method of securement- Visibly Soiled Hands Require Soap and Water- Wash hands/change gloves after contacting dirty surfaces inthe room (diaper, computer keyboard, plugs, etc.)- Use standard precautions with ALL catheter interventions- Do NOT inflate balloon prior to insertion- Lubricate catheter generously- If unsuccessful, use NEW catheter- Insert to hub PRIOR to inflating balloon- Use only STERILE WATER to inflate balloon- Check securement and tension with EVERY assessment- Preventing tension will prevent pressure-related injury of theMeatus- Alternate methods of securement may be indicated for smallpatients and non-balloon cathetersHand hygiene is the #1prevention of the spread ofgerms.Reduce risk of injury to urethra &bladderLimits movement and migrationthat could damage tissues andpermit bacterial invasionPerineal &Catheter CareDrainageSystemCleanse perineum PRIOR to catheter care Do NOT use anti-microbial soap on perineumCleanse catheter a minimum of EVERY 12 hours at 0800 & 2000, afterbowel movements or if secretions develop around meatus Use soap and damp gauze/cloth, comfort bath/baby wipes Cleanse about 4 inches of catheter, from meatus stroking towarddrainage bagInspect meatus for any signs of pressure-related injuryChange ONLY with catheter changes and/or when soiledKeep drainage device below level of bladderEmpty drainage device using clean container: EVERY 8 hours When more than ½ to ¾ full PRIOR to transport/transfer- Females: retract labia, clean from pubis to anus, use cleanside of cloth which each wipe- Males: gently retract foreskin, clean around catheter firstTHEN wipe in circular motion around meatus and glans- Catheter care should be done at set times regardless ofinsertion time.- Preventing tension will prevent pressure-related injury of themeatus- Keep tubing below bladder AND above bag- Keep tubing FREE of kinks- Ensure free-flow of urine without stasisDecreases chance of bacteriamigrating up the catheterMaintains the drainage devise asa closed systemAllows urine to free flow anddecreases chance of urinebackflowv.3.13.1374 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infections9. Possibility of pregnancy in girls is oftenoverlooked as a concern when deciding tocatheterize a female child. Many pediatrichospitals require girls of childbearing age(post menarche), even if she is not known tobe sexually active, to have a urine pregnancytest prior to surgery or any invasive oranesthetized procedure. Any chance that shecould be pregnant creates a complicationfor the clinician. Pregnancy could be thereason the child presents seemingly in needof catheterization. Pregnancy can cause stress,incontinence, or overactive bladder, and thepressure of an expanding uterus on the bladdersphincter could mimic the discomfort andurgency of a bladder infection and shouldbe considered prior to placing an indwellingurinary catheter in any girl of child-bearing age.References1. Hockenberry MJ, Wilson D, Wong DL. Wong’snursing care of infants and children, 9th ed. St. Louis,MO: Mosby/Elsevier, 2011.2. Jolley J, Shields L. The evolution of family-centeredcare. J Pediatr Nurs 2009 April; 24(2):164–70.3. Kleiber C., McCarthy AM. Parent behavior andchild distress during urethral catheterization. J SocPediatr Nurs 1999 July–September; 4(3): 95–104.4. Stamatas, GN, Nikolovski J, Luedtke, MA, et al.Infant Skin Microstructure Assessed In Vivo Differsfrom Adult Skin in Organization and at the CellularLevel. Pediatr Dermatol 2010 Mar–Apr; 27: 125–31.5. Al-Farsi, S., Olivia M, Davidson R, et al..Periurethral cleaning prior to urinary catheterizationin children: sterile water versus 10% povidone-iodine.Clin Pediatr (Phila.) 2009 July; 48(6): 656–60.6. National Institute for Health and Care Excellence(NICE). Urinary tract infection in children August2007. Available at: www.guidance.nice.org.uk/CG54.7. Schappert S, Bhuiya F. Availability of pediatricservices and equipment in emergency departments:United States, 2006. National Health Statistics Reports2012 March 1; No. 47.8. Verger JT, Lebet RM, eds. AACN proceduremanual for pediatric acute and critical care. St.Louis: Saunders, 2008; 816. Available at: mns.elsevierperformancemanager.com/NursingSkills/ContentPlayer/SkillContentPlayerIFrame.aspx?KeyId=749&Id=CCP_108A&IsConnect=False&bcp=SearchOp~0~urinary catheter size selection~False&Section=6.Association for Professionals in Infection Control and Epidemiology 75

Guide to Preventing Catheter-Associated Urinary Tract InfectionsSection 8: Special PopulationsSurgery PatientsRecent evidence has suggested limited use ofurinary catheters in surgery patients. The SurgicalCare Improvement Project (SCIP) Inf-9 guidelinepromotes removal of indwelling urinary catheterswithin 48 hours of surgery. 1Catheters will be removed on postoperative dayone or postoperative day two with day of surgerybeing day zero. Patients who had urological,gynelogical, or perineal surgery are excluded fromthis measure.In 2006, a study demonstrated a 60 percentreduction of CAUTI using a multifacetedintervention for orthopedic surgery patients.An early intervention in the study was to removeindwelling catheters by post-op day two fortotal hip replacements and day one for totalknee replacements. 2The SCIP measure requires that if the patientmeets criteria for extended catheter use, thephysician must document the justification.However, some data suggest that currentexemptions may still contribute to postoperativeCAUTI. A 2012 report published in the Archievesof Surgery assessed whether an association existsbetween UTI rates and SCIP Inf-9 exemptionstatus. This retrospective case control studyreviewed 2,459 patients, SCIP Inf-9 complianceincreased over time, but this was not correlatedwith improved monthly UTI rates. Sixty-oneof the 69 UTIs (88.4 percent) were compliantwith SCIP Inf-9; however, 49 (71 percent) ofthese were considered exempt from the guidelineand, therefore, the urinary catheter was notremoved within 48 hours of surgery. Retrospectivereview of 100 random controls showed a similarcompliance rate (84 percent, P = .43) but a lowerrate of exemption (23.5 percent, P < .001). Theodds of developing a postoperative UTI wereeight times higher in patients deemed exemptfrom SCIP Inf-9.The authors concluded that mostUTIs occurred in patients deemed exempt fromSCIP Inf-9. They also concluded that althoughcompliance rates remained high, practices werenot actually improving. The authors suggested thatSCIP Inf-9 guidelines should be modified withfewer exemptions to facilitate earlier removal ofindwelling urinary catheters. 3Wald and colleagues noted that extended use ofurinary catheters in the postoperative period inelderly patients is associated with poor outcomes.A total of 170,791 Medicare patients ages 65years or over who were admitted to skillednursing facilities after discharge from a hospitalwith a primary diagnosis code indicating majorcardiac, vascular, orthopedic, or gastrointestinalsurgery in 2001. A total of 39,282 (23 percent)of the postoperative patients discharged to skillednursing facilities had indwelling urinary catheters.After adjusting for patient characteristics, thepatients with catheters had greater odds ofrehospitalization for UTI and death within 30days than patients who did not have catheters. 4Historically, urinary catheters have often beenused in orthopedic patients who received spinalanesthesia.The use of spinal anesthesia, commonlyused for elective joint arthroplasty, has alsoconsidered to be an indication for the use ofa urinary catheter. The rationale is that spinalanesthesia can lead to the loss of the ability tosense bladder distention, which may then lead toneurogenic bladder problems.76 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsA recent study published in the Journal of Boneand Joint Surgery randomized patients into twogroups; 200 patients were included in the study.The catheter group was subjected to a standardpostoperative protocol, with postoperativeremoval of the indwelling catheter within 48hours. The experimental group was monitored forurinary retention and, if necessary, had straightcatheterization up to two times prior to theplacement of an indwelling catheter. There wasno significant difference between the two groupsin terms of the prevalence of urinary retention,prevalence of urinary tract infection, or length ofstay. Nine patients in the no-catheter group andthree patients in the catheter group (followingremoval of the catheter) required straightcatheterization because of urinary retention. Threepatients in the catheter group developed UTI;none in the no-catheter group did. The studyconcluded that a routine catheter is not neededfor patients for patients undergoing total hipreplacement who receive spinal anesthesia giventhat the risk of urinary retention is low. 5The CDC HICPAC Guideline evidencesuggested some benefit to the use of intermittentcatheterization over indwelling urethral cathetersin selected populations. This was based on adecreased risk of SUTI and bacteriuria/unspecifiedUTI but an increased risk of urinary retentionin postoperative patients with intermittentcatheterization. In one study, urinary retention andbladder distension were avoided by performingcatheterization at regular intervals (every 6 to 8hours) until return of voiding. 6 Studies in operativepatients whose catheters were removed within 24hours of surgery found no differences in bacteriuriawith intermittent vs. indwelling catheterization,while studies where catheters were left in for longerdurations had mixed results. 7Protocols to SupportEarly RemovalA number of hospitals have developed protocolsthat do not include the use of a urinary catheteras a routine standard of care in select surgicalpopulations. Often, if a catheter is used, it isremoved in surgery or in the post-anesthesia careunit as soon as the patient is awake. Protocolsfor removal of catheters postoperatively shouldbe part of standard order sets. As hospitals havetransitioned to electronic health records (EHRs),the potential for electronic reminders and orderssets has intensified. Examples of a post-surgeryprotocol and an electronic order are shown inFigure 8.1.Spinal Cord InjuryUTI is responsible for major morbidity in patientswith spinal cord injury (SCI). Although thereare improved treatments, UTI still ranks as thesecond leading cause of death in SCI patients.Spinal cord injury alters lower urinary tractfunction, producing elevated intravesical pressure,incontinence, reflux, stones, and neurologicalobstruction. These commonly found conditionsin the SCI population increase the risk of UTI.Incomplete voiding and catheter use contribute toan increased risk of symptomatic UTI. 8In patients practicing clean intermittentcatheterization, the mean incidence of UTIs is10.3 per 1,000 catheter days; after 3 months, therate is fewer than 2 per 1,000 catheter days. Oncea urethral catheter is in place, the daily incidenceof bacteriuria is 3 to 10 percent. 9Organisms that commonly cause infectionsinclude Proteus, Pseudomonas, Klebsiella, Serratia,and Providencia species, along with enterococciand staphylococci. Approximately 70 percent ofinfections are polymicrobial. 10The 2009 CDC HICPAC CAUTI preventionrecommendations cite low-quality evidencesuggesting the avoidance of urinary catheters.Intermittent catherization is generally associatedwith lower rates of CAUTI. It is often a preferredmethod of catherization for patients who canperform this function independently. However, itmay not be suitable for all patients. 11Association for Professionals in Infection Control and Epidemiology 77

Guide to Preventing Catheter-Associated Urinary Tract InfectionsFigure 8.1. Electronic Order for Removal as per ProtocolSource: Sample provided with permission by Shari Nersinger, Highland Hospital Rochester, NY.Certain patients with spinal cord injury may requirean indwelling urinary catheter or a suprapubiccatheter. Although the incidence of CAUTI maybe somewhat lower in patients with a suprapubiccatheter, the decision on the appropriate strategy isdetermined on a case-by-case basis. The most recentHICPAC recommendations call attention to thefact that the studies indicating preferential use of asuprapubic catheter were based upon decreased riskof bacteriuria, unspecified UTIs, reduced strictures,need for recatheterization, and patient satisfaction.There was not a decreased risk of SUTI.Because nearly all patients with chronic indwellingcatheters will develop bacteriuria, it is extremelyimportant to instruct patients and their familieson CAUTI prevention. In addition to preventionstrategies described in previous sections, hydrationand encouragement of fluids is important inpatients with chronic catheters. 12 Catheters shouldbe changed only when necessary; however, someexperts recommend that catheters be changedprior to the collection of a urine specimen fora suspected CAUTI. The 2009 Clinical PracticeGuidelines of the Infectious Diseases Societyrecommend replacing an indwelling urinarycatheter if it has been in place for more than 2weeks prior to starting antibiotic therapy forCAUTI or to obtaining a culture for suspectedCAUTI. The presence of cloudy or odorous urineshould not be used as criteria for routine urineculturing or antibiotic treatment. 13Intensive Care Unit PatientsThe ICU represents a juncture between themost seriously ill patients receiving aggressivetherapy and the most resistant pathogens,which are selected by the use of broad spectrumantibiotic therapy. ICU patients require invasivedevices, putting them at risk for infection andoften limiting mobility. The ICU is a particularchallenge for CAUTI prevention. Patients who arecritically ill often require strict intake and outputmonitoring and are limited in often limited intheir mobility. 1478 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsCAUTI in ICUs is often associated with a highermortality and excess cost. Risk factors include femalegender, comorbidities, location of insertion (ED vs.ICU), and excess duration of the urinary catheter.In April of 2013, the NHSN posted its 2011device-associated module infection report. Pooledmeans for CAUTI ranged from 1.2 in medicalsurgicalICUs with fewer than 12 beds to 4 inburn ICUs. 15On September 24, 2013, The AHRQ releasedan interim reportrelated to the On the CUSP:Stop CAUTI initiative. The report, “EliminatingCAUTI: A National Patient Safety Imperative—Interim Data Report on the National Project,”describes a 16 percent average reduction inCAUTI rates among hospital units that havecompleted 14 months of CUSP implementation.However, the report noted that the mostsignificant reductions occurred in non-ICUsettings and that there was no significantreduction in device utilization. 16Although other methods of urinary drainage,such as condom catheters, frequent toileting,earlier ambulation of ventilator patients, andincontinence products, can assist in earliercatheter removal in acutely ill patients, minimaldata have been collected in ICUs to assess thesealternatives. 17A prospective prevalence study of unjustifieduse of urinary catheters in 202 medical patients,of whom 135 were admitted to the medicalICU, was conducted at a large tertiary carecenter. Patients were evaluated for appropriateinsertion and timely removal of urinary cathetersby a trained observer applying predeterminedcriteria. The independent observer assessed theindication for initial catheterization by chartreview and interview with the patient and thenurse. The need for continued catheterizationwas assessed daily by the same observer, who alsodocumented complications as a result of urinarycatheterization. Of the 202 patients who werestudied, the initial indication for the placementof the urinary catheter was found to be unjustifiedin 21 percent (95 percent confidence interval[CI], 15 percent to 27 percent). Continuedcatheterization was unjustified in 47 percent(95 percent CI, 42 percent to 57 percent) of912 patient-days with a catheter studied. Inthe medical ICU, 64 percent (95 percent CI,58 percent to 70 percent) of the total unjustifiedpatient-days with a urinary catheter resultedfrom its excessively prolonged use for monitoringurine output. 18Although prevention efforts in ICUs arechallenging, a number of reports havedemonstrated improvement through theapplication of evidence-based practices, earlyremoval, and implementation of CAUTI bundles.Tisworth and colleagues reported a significantand sustainable reduction in a neurosurgical ICUthrough a comprehensive program of education,feedback, rounding, and timely removal ofcatheters. Urinary catheter use fell by 25 percentand Infection rates 13.3 to 4 per 1,000 urinarycatheter days. 19 Summary of prevention strategiesin the ICU are reviewed in Table 8.1.Long-Term CareLong-term care facilities (LTCFs) may be definedas institutions, such as nursing homes and skillednursing facilities that provide healthcare to peoplewho are unable to manage independently in thecommunity. This care may include custodialor chronic care management or short-termrehabilitative services. Efforts to reduce healthcarecosts have led to fewer hospitalizations and shorterhospital lengths of stay resulting in increasedoutpatient, home care and LTCF stays. As aconsequence nursing homes and rehabilitationunits are seeing patients with higher acuity anduse of more invasive devices such as indwellingurinary catheters, feeding tubes, and centralvenous catheters. Urinary tract infections areone of the most common infections in LTCFsand account for 20 to 30 percent of reportedinfections. Although the prevalence of indwellingurinary catheters is lower than the acute careAssociation for Professionals in Infection Control and Epidemiology 79

Guide to Preventing Catheter-Associated Urinary Tract InfectionsTable 8.1. Prevention Strategies in the ICUICU strategiesEducate nursing staff and providers.Develop ICU specific indications forinsertion.Consider annual competencies for asepticinsertion and maintenance.Consider flags, nurse-driven protocols, orother removal reminders. Discuss duringmultidisciplinary rounds.Specimen collectionLeg bags are often used for patients toimprove ambulationConsider alternatives to cathetersAssure staff are competent to insertcathetersCommentsNursing staff and providers often view ICU patients as requiring a urinarycatheter during their entire ICU stay.Review CAUTI cases with caregivers as they occur.Help staff “connect the dots” to other harm events, such as decubiti orClostridium difficile, after treatment for CAUTI fails.Consider using huddles or other methods to review events as a team.Ensure that providers understand the difference between symptomatic andasymptomatic bacteriuria and avoid treating asymptomatic bacteriuria.Utilize infectious disease (or other experts) and pharmacy to reviewCAUTI treatment and importance of inappropriate treatment ofasymptomatic bacteriuria.Give immediate feedback when this[[antecedent?]] occurs.Consider circumstances where a catheter may not be necessary.Incorporate indications into protocols, policies, and procedures.Give feedback on inappropriate insertion.Assess need and develop competency as appropriate. Develop and monitormaintenance bundle.Quality improvement examples support this approach.Minimally, discontinue on transfer to floor care when possible.Process urine specimens as soon as possibleIf urine cannot be processed within 30 min. – refrigerate urineRefrigerated specimens should be processed within 24 hoursIf catheter has been in place for more than 14 days, replace catheter priorto specimen collectionLeg bags may increase the risk of UTI because of reflux and potential forcontaminating portDisinfect ports with alcoholChange bags at regular intervalsDisinfect with dilute vinegar 1:3, and allow to dry thoroughlyCondom catheter, toileting protocols, incontinence products, intermittentcatheterizationStaffing and turnover issues create challengesConsider annual competency or training requirementsSource: Developed and printed with permission from Linda Greene, RN, MPS, CIC, Highland Hospital, NY80 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infectionssetting, CAUTIs can lead to complicationssuch as cystitis, pyelonephritis, bacteremia andsepsis. CMS requirements for detailed careplans for urinary incontinence and catheter usenecessitating documentation of appropriateinsertion and removal protocols have beeninstrumental in promoting the use of cathetersonly when indicated and the prompt removal ofcatheters when no longer needed.The prevalence of indwelling urinary catheters Inthe LTCF has been reported at 5 percent. Residentsin the LTCF are colonized with bacteria mainlyattributable to biofilm on the catheter. The mostcommon pathogen associated with CAUTI in theLTCF is Escherichia coli. E. coli accounts for about40 percent of infections in these settings. Otherpathogens frequently found in this population areKlebsiella sp., Proteus and Morganella.In 2012, the Mc Geer Infection Surveillancedefinitions for long term care facilities wererevised. An expert consensus panel updatedthese definitions based upon current literature.Significant changes were made to the criteria forurinary tract infections. The revised definitionsrequire clinical criteria in addition to the need formicrobiologic confirmation for diagnosis. TheMc Geer definitions can be located at www.jstor.org/stable/full/10.1086/667743. New NHSNLTCF surveillance definitions have recently beenreleased by NHSN and are discussed in Section 4of this Guide.Prevention of CAUTI remains a challenge inthe LTCF. Unlike the acute care setting, urinarycatheters are usually placed for appropriatereasons such as urinary obstruction, impairedbladder emptying secondary to benign prostatichypertrophy and other acceptable reasons.Therefore, many patients with indwelling cathetersmay require long term catheterization. Urinarycatheter maintenance is of upmost importance inthis setting. Although strategies for prevention ofCAUTI in acute care are applicable to the LTCF,some strategies need special attention and arereflected in Table 1.References1. Agency for Healthcare Quality and Research.Surgical care improvement project: percent ofsurgical patients with urinary catheter removed onpostoperative day 1 or postoperative day 2 with theday of surgery being day zero. Available at: www.qualitymeasures.ahrq.gov/content.aspx?id=35534.2. Stéphan F, Sax H, Wachsmuth M, et al. Reductionof urinary tract infection and antibiotic use aftersurgery: a controlled, prospective, before-after study.Clin Infect Dis 2006 June 1; 42(11): 1544–51.3. Owen R, Perez S, Bornstein W, et al. Impact ofsurgical care improvement project inf-9 on postoperativeurinary tract infections: do exemptionsinterfere with quality patient care? Arch Surg 2012October; 147(10):946–53.4. Wald H, Epstein A, Radcliff T, et al. Extended useof urinary catheters in older surgical patients: a patientsafety problem? Infect Control Hosp Epidemiol 2008February; 29(2):116–24.5. Miller A, McKenzie J, Greenky M, et al. Spinalanesthesia: Should everyone receive a urinarycatheter? A randomized, prospective study of patientsundergoing total hip arthroplasty. J Bone Joint Surg Am2013 August 21; 95(16): 1498–1503.6. Gould C, Umscheid C, Agarwal R, et al., and theHealthcare Infections Control Practices AdvisoryCommittee (HICPAC). Guideline for preventionof catheter-associated urinary tract infections 2009.Available at: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.7. Wald H, Ma A, Bratzler D, et al. Indwelling urinarycatheter use in the postoperative period: analysis ofthe national surgical infection prevention project. ArchSurg 2008; 143(6):551–57.8. Brusch J. Urinary tract infections in spinal cordinjury. Medscape. Available at: www.emedicine.medscape.com/article/2040171-overview.9. Ibid.10. Siroky M. Pathogenesis of bacteruria and infectionin the spinal cord injured patient. Am J Med July 2002;113(1) Suppl 1A:67S–79S.Association for Professionals in Infection Control and Epidemiology 81

Guide to Preventing Catheter-Associated Urinary Tract Infections11. Gould C, Umscheid C, Agarwal R, et al., andthe Healthcare Infections Control Practices AdvisoryCommittee (HICPAC). Guideline for preventionof catheter-associated urinary tract infections 2009.Available at: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf.12. University of Washington. Preventing UTIsthrough patient education: results of a NorthwestRegional SCI System study. SCI Update Newsletter Fall2002; 11(2). Available at: www.sci.washington.edu/info/newsletters/articles/02fall_prevent_uti.asp.13. Hooten T, Bradley S, Cardenas D, et al. Diagnosis,prevention, and treatment of catheter-associatedurinary tract infection in adults: 2009 internationalclinical practice guidelines from the Infectious DiseasesSociety of America. Clin Infect Dis 2010; 50:625–63.14. Barsanti M, Woeltje K. Infection prevention inthe ICU. Infect Dis Clin North Am September 2009;23(3):703–25.16. Agency for Healthcare Research and Quality(AHRQ). Eliminating CAUTI, Interim Data Report.Available at: www.ahrq.gov/professionals/qualitypatient-safety/cusp/cauti-interim/cauti-interim4a.html.17. Conway L, Pogorzelska M, Larson E, et al.Adoption of policies to prevent catheter-associatedurinary tract infections in United States intensive careunits. Am J Infect Control 2012; 40(8): 705–10.18. Jain P, Parada J, David A, et al. Overuse of theindwelling urinary tract catheter in hospitalizedmedical patients. Arch Intern Med 1995;155(13):1425–29.19. Titsworth W, Hester J, Correia T, et al. Reductionof catheter-associated urinary tract infections amongpatients in a neurosurgical intensive care unit: asingle institution’s success. J Neurosurg 2012 April;116(4):911–92.15. Dudek M, Horan T, Peterson K, et al. NationalHealth Care Safety Network (NHSN) Report, DataSummary for 2011, Device-associated Module.Available at: www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report-2011-Data-Summary.pdf.82 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract InfectionsAppendix: Recommendations for SpinalCord Injured Patients*Intermittent CatheterizationIntermittent catheterization is a method by whichan individual with SCI or his or her caregiverempty the bladder at a specified time frequencyby inserting a catheter into the bladder, drainingthe bladder, and then removing the catheter.Intermittent catheterization does not requirean intact sacral micturition reflex to be present.The method is an effective alternative duringspinal shock when the bladder is not contracting.Intermittent catheterization provides completebladder emptying and offers a practical means ofobtaining a catheter-free state.1. Consider intermittent catheterization forindividuals who have sufficient hand skills or awilling caregiver to perform the catheterization.(Scientific evidence–III;Grade of recommendation–C;Strength of panel opinion–Strong).Rationale: Intermittent catheterization providesa method of emptying the neurogenic bladderwithout leaving an indwelling catheter and lessensthe frequency of long-term complications suchas hydronephrosis, bladder and renal calculi, andautonomic dysreflexia encountered with othermethods of neurogenic bladder management(Bennett et al., 1995; Chai et al., 1995; Chua,Tow, and Tan, 1996; Dmochowski, Ganabathi,and Leach, 1995; Giannantoni et al., 1998;Perkash and Giroux, 1993). Intermittentcatheterization should not be used in individualswho do not have adequate hand function toperform the procedure themselves or who donot have a caregiver willing and able to performthis function. Additionally, an alternative tointermittent catheterization may be needed inindividuals with:Abnormal urethral anatomy such as stricture, falsepassages, and bladder neck obstruction. Bladdercapacity less than 200 ml. Poor cognition, littlemotivation, inability or unwillingness to adhereto the catheterization time schedule or the fluidintake regimen, or adverse reaction toward havingto pass the catheter into the genital area multipletimes a day.2. Consider avoiding intermittentcatheterization in individuals with SCI whohave one or more of the following:• Inability to catheterize themselves. A caregiverwho is unwilling to perform catheterization.Abnormal urethral anatomy, such as stricture,false passages, and bladder neck obstruction.• Bladder capacity less than 200 ml. Poorcognition, little motivation, or inability orunwillingness to adhere to the catheterization*Reprinted with permission from the Paralyzed Veterans of America (PVA). From the Consortium for Spinal CordMedicine Clinical Practice Guidelines Bladder Management for Adults with Spinal Cord Injury: A Clinical PracticeGuidelines for Health-Care Professionals.Washington, DC: ©2006 Paralyzed Veterans of AmericaCopies of PVA’s Guidelines are available at www.pva.org or through the PVA Distribution Center (toll free 888-860-7244).Association for Professionals in Infection Control and Epidemiology 83

Guide to Preventing Catheter-Associated Urinary Tract Infectionstime schedule. High fluid intake regimen.Adverse reaction to passing a catheter into thegenital area multiple times a day. Tendency todevelop autonomic dysreflexia with bladderfilling despite treatment.(Scientific evidence–III;Grade of recommendation–C;Strength of panel opinion–Strong)Rationale: Intermittent catheterization requiresinsertion of a catheter into the bladder at aroutine time interval to prevent over distentionof the bladder. Inability to catheterize oneselfand/or lack of a willing caregiver to performthe catheterization may lead to bladder overdistention. Urethral abnormalities may make itdifficult to pass the catheter into the bladder toprevent bladder over distention. High fluid intakemay require frequent catheterization, which maynot be practical. Aversion to passing a catheterinto the bladder may lead to over distention.Upper tract complications can still occur withintermittent catheterization in the presence ofhigh bladder pressures (Dmochowski, Ganabathi,and Leach, 1995; Giannantoni et al., 1998;Weld and Dmochowski, 2000; Weld et al., 2000;Zermann et al., 2000).3. Advise individuals with SCI of thepotential for complications with intermittentcatheterization, such as:• Urinary tract infections.• Bladder over distention.• Urinary incontinence.• Urethral trauma with hematuria.• Urethral false passages.• Urethral stricture.• Autonomic dysreflexia (in those with injuries atT6 and above).• Bladder stones.Rationale: The normal capacity of the bladder isless than 500 ml. Catheterizing the bladder every4–6 hours prevents over distention of the bladder.4. If bladder volumes consistently exceed 500ml, adjust fluid intake, increase frequencyof intermittent catheterization, or consideralternative bladder management method.(Scientific evidence–None;Grade of recommendation–None;Strength of panel opinion–Strong)Rationale: Keeping bladder volumes below 500ml will usually prevent over distention of thebladder. Limiting fluid intake will decrease theamount of urine produced and can be helpful indecreasing the frequency needed for intermittentcatheterization. Limiting fluids after dinner mayprevent the need for intermittent catheterizationin the middle of the night.5. Institute clean intermittent catheterizationteaching and training for individualsprior to discharge from the acute phase ofrehabilitation.(Scientific evidence–III;Grade of recommendation–C;Strength of panel opinion–Strong)Rationale: Waiting until fluid resuscitationis complete before starting intermittentcatheterization will prevent over distention ofthe bladder. Clean intermittent catheterizationprovides a successful long-term option that isless cumbersome and costly than the steriletechnique (Chang et al., 2000; Chua, Tow,and Tan, 1996; Dmochowski, Ganabathi, andLeach, 1995; Giannantoni et al., 1998; Mitsuiet al., 2000; Perkash and Giroux, 1993; Weldand Dmochowski, 2000; Weld, Graney, andDmochowski, 2000).(Scientific evidence–None;Grade of recommendation–None;Strength of panel opinion–Strong)84 Association for Professionals in Infection Control and Epidemiology

Guide to Preventing Catheter-Associated Urinary Tract Infections6. Consider sterile catheterization forindividuals with recurrent symptomaticinfections occurring with clean intermittentcatheterization.(Scientific evidence–III;Grade of recommendation–C;Strength of panel opinion–Strong)Rationale: Lower infection rates can be achievedwith sterile techniques and with prelubricated selfcontainedcatheter sets (Giannantoni et al., 2001;Waller et al., 1995).7. Investigate and provide treatment forindividuals on intermittent catheterization wholeak urine between catheterizations.(Scientific evidence–III;Grade of recommendation–C;Strength of panel opinion–Strong)Rationale: Individuals may leak urine betweencatheterizations for various reasons, such asurinary tract infections, problems with the bladderor sphincter, or problems with fluid intake. Uppertract complications still occur with intermittentcatheterization in the presence of high bladderpressures (Dmochowski, Ganabathi, and Leach,1995; Giannantoni et al., 1998; Weld andDmochowski, 2000; Weld et al., 2000; Zermannet al., 2000). Bladder capacity can be increased,and uninhibited contractions can be decreased,with the use of anticholinergic medications orwith botulinum toxin injections (see BotulinumToxin Injection).8. Monitor individuals using this method ofbladder management.(Scientific evidence–None;Grade of recommendation–None;Strength of panel opinion–Strong)Rationale: Routine urologic follow-up is centralto any bladder-management program to monitorcomplications, such as urinary tract infections,bladder or kidney stones, hydronephrosis,vesicoureteral reflux, and autonomic dysreflexia.The specific tests for monitoring and thefrequency of those tests vary among practitioners.One approach is suggested by the VA SCI annualexamination recommendations (VHA Handbook1176.1 Spinal Cord Injury and Disorders Systemof Care). Many centers evaluate the upperand lower tracts of a person with a neurogenicbladder on a yearly basis. This may be done morefrequently if a person is having a problem.Nursing Considerations forIntermittent CatheterizationIndividuals who choose intermittentcatheterization for bladder management willneed education on proper techniques and careas well as routine follow-up to detect potentialcomplications. There are many variations onintermittent catheter technique and care. Oneexample follows.Catheter selection: The catheter should be easyto insert without trauma or curling in the urethra.If a latex allergy is present, nonlatex cathetersmust be used. A nonlatex product with straighttip is recommended. (For types of catheters andeconomic considerations, see appendix A.)Hand washing. Hands should be washed oraseptic towelettes used both before and aftercatheterization.Technique. Follow the procedure recommendedby the prescribing institution, health-careprofessional, national guideline, or health-careorganization.Catheter care. To control introduction of bacteriainto the bladder, catheters must be washed afterevery use. Rinsing and allowing catheters to airdrybetween each use was found to be the mosteffective means of keeping the bacteria count lowon catheters (Lavallee et al., 1995). Cathetersshould be cleaned with mild soap and water,air-dried, and placed in a paper bag until readyAssociation for Professionals in Infection Control and Epidemiology 85

Guide to Preventing Catheter-Associated Urinary Tract Infectionsto reuse. If recurrent urinary tract infections area problem, latex catheters can be sterilized byheating them in a microwave oven (Mervine andTemple, 1997).Recurrent urinary tract infections. Symptomsof UTIs need to be investigated and documentedas follows:Technique and bladder check: Thecatheterization technique should be assessedand the bladder checked for stones, mucus,or other debris.Single-use catheter: If no reason for UTIs canbe found, a single-use catheter may be used tosee if UTIs subside.Single-use hydrophilic catheter: If urethralirritation appears to be the cause, a singleusehydrophilic catheter may be tried. Sterilewater for injection, which may or may not beincluded with the catheter, needs to be used toactivate this type of catheter.Antibacterial catheter: If UTIs continue,a single-use catheter impregnated with anantibacterial substance may be tried.Touchless catheter. When toilet facilities are notreadily available, such as during sports activitiesor travel, a touchless catheter with a collectiondevice may be a good alternative. These catheters,which are contained within the collection device,lubricate themselves as they are introduced intothe urethra by a prelubricated outlet on the bag.When the bladder is drained, the catheter iswithdrawn from the urethra and returned to thecollection device, the top is capped, and the entiredevice discarded without ever being toucheddirectly by the hands.Fluids. Fluid consumption should be moderateand spaced throughout the day.Timing. Catheterization typically occurs every 4–6hours so that the amount of urine obtained witheach collection is less than 500 ml. Individuals mayneed to awaken at night to catheterize.Assistance required. Adequate hand functionand sufficient cognitive ability are needed to insertthe catheter or else a caregiver must be availableto do so.Cosmesis. No changes will be noted.Interference with social/sexual functioning.None.Medications. If urinary leakage and ahighpressure bladder (as determined byurodynamic studies) are creating difficulties,medications will be prescribed to help withoveractive bladder. If urinary leakage is theresult of an incompetent sphincter, additionalmedication may be prescribed. If the problemis catheterization at the bladder neck, an alphablockermay be prescribed to relax the bladderneck and facilitate catheterization.Reversibility. This method can be discontinued atany time.Adapted from Joseph, A.C., A. Hixon, J. Giroux,D. Briggs, M. Gardenhire, D. Diaz, and J. Wells.Nursing clinical practice guideline: neurogenicbladder management. Spinal Cord Injury Nursing15 (2) (1998): 21–56.86 Association for Professionals in Infection Control and Epidemiology

Credé and ValsalvaCredé is a method of applying suprapubicpressure to express urine from the bladder. Credéis usually used when the bladder is flaccid or abladder contraction needs to be augmented. Theeffectiveness of Credé is limited by sphincterpressure. Valsalva is a method in which anindividual uses the abdominal muscles and thediaphragm to empty the bladder. Valsalva is usedwhen the bladder is flaccid from spinal cord injuryaffecting the sacral reflex arc or when the bladdercontracts but does not empty completely. Valsalvaincreases intraabdominal pressure but does notensure complete bladder emptying.Guide to Preventing Catheter-Associated Urinary Tract InfectionsAssociation for Professionals in Infection Control and Epidemiology 87