June 24, 2008
Urinary Catheter-Related UTI’s: Bladder Bundles
Joint Commission has just released the 2009 National Patient Safety Goals. Major new features or changes include goals on prevention of hospital-associated infections, medication reconciliation, and an updated Universal Protocol. We’ll be discussing the new and modified NPSG’s in our July What’s New in the Patient Safety World column. But this week, our review of two new papers on prevention of catheter-related urinary tract infections led us to a hidden cache of great resources for prevention of catheter related UTI’s.
First is a new study on indwelling urinary catheter use in the postoperative period (Wald et al 2008). They looked at data from the National Surgical Infection Prevention Project and found that 86% of patients undergoing major surgery had perioperative indwelling urinary catheters and that in 50% of these the catheter duration was longer than 2 days. The latter group was twice as likely to develop UTI’s as those with catheters for less than 2 days. Those associations obviously suggest an opportunity to reduce nosocomial UTI’s by early removal of such indwelling catheters.
The second study was a randomized controlled trial of automatic stop orders to reduce inappropriate urinary catheterization in hospitalized patients (Loeb et al 2008). The intervention was successful in reducing the duration of both inappropriate and total urinary catheterization. However, there was no statistically significant reduction in the occurrence of UTI’s. Those results are similar to a study (Cornia et al 2003) that demonstrated CPOE could reduce duration of indwelling catherization in hospitalized patients but did not result in statistically significant reduction in the occurrence of UTI’s. Sample size may have precluded demonstrating a reduction in the more important outcome of UTI’s.
But our search into the references in these papers led us to a collaborative done by the Michigan Health & Hospital Association, the MHA Keystone: Hospital-Associated Infection Initiative: Catheter-Associated UTI (CAUTI) Prevention Bundle [aka Bladder Bundle]. That document includes not only facts about catheter-associated UTI’s but also points out many of the other downsides of urinary catheters (discomfort, delayed discharge, concept that the catheter acts as a “one point restraint” that limits activity and might lead to other complications of inactivity, etc.). It notes that 38% of attending physicians in one study were unaware their patients even had an indwelling catheter (Saint et al 2000). The MHA bundle cites those interventions shown to be effective (aseptic technique at insertion, closed drainage, various drainage bag issues, hand hygiene, avoiding unnecessary catheterization, use of alternatives to indwelling catheters, etc.). They provide a description of the intervention led by a nurse champion and provide tools for baseline and subsequent assessment, catheter reminder and removal prompts, and references on use of portable bladder ultrasound monitoring. If many of these sound familiar, its because Sanjay Saint whose work we’ve discussed in several of our Patient Safety Tips of the Week did much of his early work in Michigan. Our reference list below also includes many of the good background articles available through the MHA website.
Another good reference are the epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. These discuss the evidence base for catheter insertion, maintenance, and selection of catheter type and include not only which practices have been demonstrated to work but also which ones do not make a difference.
And don’t forget our multiple other columns on urinary catheter-associated UTI’s:
May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”
January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections”
April 2008 What’s New in the Patient Safety World column “More Neonatal Incubator Fires, More on Nosocomial UTI’s, More on 1000-Fold Heparin Overdoses”
April 21, 2009 Tip of the Week “Still Futzing with Foleys?”
June 9, 2009 Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”
Joint Commission 2009 National Patient Safety Goals
Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling Urinary Catheter Use in the Postoperative Period. Analysis of the National Surgical Infection Prevention Project Data. Arch Surg. 2008; 143(6): 551-557 http://archsurg.ama-assn.org/cgi/content/abstract/143/6/551
Loeb M, Hunt D, O'Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008; 23: 816-820 http://www.springerlink.com/content/yu12052813472672/
Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med. 2003; 114(5): 404-7 http://download.scientificcommons.org/337
MHA Keystone: Hospital-Associated Infection Initiative:
Catheter-Associated UTI (CAUTI) Prevention Bundle [aka Bladder Bundle]
Saint S, Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, Bernstein SJ, Lipsky BA, Hofer TP. Are Physicians Aware Of Which of Their Patients Have Indwelling Urinary Catheters? Am J Med. 2000; 109: 476–480 http://www.mha.org/mha/keystone/hai/conferencecalls/010407/Are%20Physicians%20Aware%20Of%20Which%20of%20Their%20Patients.pdf
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, McDougall C, Wilcox MH. epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection (2007) 65S, S1–S64 http://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2-final.pdf
Wald HL, Epstein AM, Radcliff TA, Kramer AM. Extended Use of Urinary Catheters in Older Surgical Patients: A Patient Safety Problem?. Infection Control & Hospital Epidemiology. 29(2):116-124, February 2008 http://www.journals.uchicago.edu/doi/abs/10.1086/526433?cookieSet=1&journalCode=iche
Nurse Initiated Discontinuance of Urinary Indwelling Catheters
MHA Foley catheter prevalence worksheet
Warren JW. Catheter-associated urinary tract infections. International Journal of Antimicrobial Agents 17 (2001) 299–303 http://www.mha.org/mha/keystone/hai/conferencecalls/010407/CAUTI.pdf
Wong ES, Hooton TM. Guideline for Prevention of Catheter-associated
Urinary Tract Infections. CDC February 1981
Saint S. Enhancing Patient Safety by Translating Nosocomial UTI Research Into Practice (slides) http://www.mha.org/mha/keystone/hai/workshops/041207/Sanjay%20Saint.ppt
Sanjay Saint, MD, MPH Clinical and economic consequences of nosocomial catheter-related bacteriuria. AJIC Am J Infect Control 2000; 28: 68-75
Gokula RRM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004; 32: 196-9
Maki DG, Tambyah PA. Engineering Out the Risk of
Infection with Urinary Catheters. Emerging Infectious Diseases 2001; Vol. 7, No. 2: 1-6
Urinary Catheterization: Insertion, Care and Maintenance of the Indwelling Catheter