We’ve done a host of columns on prevention of CAUTI’s and have always focused foremost on avoiding Foley catheters in the first place. In the last few months there have been several good articles focusing on eliminating unnecessary use of indwelling catheters.
While most studies have focused on catheter-association urinary tract infections (CAUTI’s) as the most undesirable outcome of catheterization, there are other untoward effects as well. We’ve previously mentioned other adverse effects, including GU trauma, reduced mobility (the “one-point restraint”), falls, and delirium. Recently a study (Leuck 2012) found that catheter-related GU trauma was as common as symptomatic UTI and also that catheterization led to frequent antibiotic treatment for asymptomatic bacteruria despite guidelines to the contrary.
The Michigan Keystone Project (Fakih 2012), a state-wide effort to reduce inappropriate urinary catheter use in Michigan, resulted in a 28% reduction in catheter use (from 18.1% at baseline to 13.8% after two years). In addition, the rates for appropriate catheter indications increased from 44.3% to 57.6%. Improvement began as soon as two weeks after initiation of the intervention(s) and continued to progress for two years. The intervention included buy-in from leadership, formation of improvement teams (with a nursing and physician champion, infection preventionist, and other stakeholders), dissemination of information about appropriate indications for catheters, various webinars, daily catheter rounds, proper insertion and maintenance techniques, data collection and feedback. However, the authors and the accompanying editorial (Mourad 2012) point out that there was substantial variability across the participating hospitals and some hospitals did not provide benchmarking data for the entire period. This highlights the need for continuing involvement of key stakeholders and champions.
Another recent article (Shimoni 2012) demonstrated that use of guidelines restricting catheter use to certain indications combined with daily chart rounds was successful in an Israeli hospital at reducing the overall rate of catheterization from 17.5% to 6.6%. The biggest reduction in catheter use was in 3 categories: (1) incontinent patients unable to provide a urine sample for culture (2) patients with CHF and (3) patients hospitalized for palliative care.
A comprehensive review (Bernard 2012) of various strategies to reduce the duration of indwelling catheter use and CAUTI’s was also just published. This summarizes the literature and highlights the successes of both nurse-led interventions and informatics-led interventions (alerts, stop orders, etc.) to reduce inappropriate catheter use and CAUTI’s.
In our prior columns we have stressed that in addition to strong leadership and buy-in from key stakeholders, the system you put in place should have both a pre-emptive component and a surveillance component. The pre-emptive component can be either low-tech or hi-tech. The simple colored sticker alert shown in our January 8, 2008 Patient Safety Tip of the Week “ ” has given way to computerized physician order entry (CPOE) order entry screens that request indication and expected duration any time someone orders a Foley catheter. Adding lines for indication and duration to standardized order sets or pre-printed order sheets can also be effective. Alternatives to Foley catheters may include condom catheters in males or intermittent catheterization and use of portable bladder scanners may reduce the need for any kind of catheter in the first place.
The second component of your system is the surveillance component. That means assessing all patients with urinary catheters to see if they still need them. We routinely look for unnecessary catheters during patient safety “walk rounds” and so should you. However, you need a system in place so they are looked for on a daily basis. Make this activity a “checklist” item on nursing rounds or teaching rounds. Also, if your hospital uses a barcode system to track inventory, adapt that system to alert you to every patient to whom a catheter was attached. Educating your patients to question why they need or still need a catheter should be part of your patient-oriented patient safety program.
And, of course, good nursing care for those catheters that are indicated is also crucial.
Be sure to include monitoring and measuring in your QI activities because the initial Hawthorne effect of implementing such a system often fades with time. Posters and screensavers about preventing CAUTI’s may generate some enthusiasm for your program early on but you need more to ensure durability of your program long-term. Feedback and celebrating success are important in that regard.
Our other columns on urinary catheter-associated UTI’s:
Leuck A-M, Wright D, Ellingson L, Kraeme L, et al. Complications of Foley Catheters—Is Infection the Greatest Risk? Jour Urol 2012; 187: 1662-1666
Fakih MG, Watson SR, Greene MT, et al. Reducing Inappropriate Urinary Catheter Use: A Statewide Effort. Arch Intern Med 2012; 172(3): 255-260
Mourad M, Auerbach A. Improving Use of the "Other" Catheter: Comment on "Reducing Inappropriate Urinary Catheter Use". Arch Intern Med 2012; 172(3): 260-261
Shimoni Z, Rodrig J, Kamma N, Froom P. Will more restrictive indications decrease rates of urinary catheterisation? An historical comparative study. BMJ Open 2012; 2: 2 e000473 doi:10.1136/bmjopen-2011-000473
Bernard MS, Hunter KF, Moore KN. A Review of Strategies to Decrease the Duration of Indwelling Urethral Catheters and Potentially Reduce the Incidence of Catheter-associated Urinary Tract Infections. Urol Nurs 2012; 32(1): 29-37