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Prevention of Catheter-Associated Urinary Tract Infection Full Guideline

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363
OVERVIEW
Health care–associated infections (HAIs) have received
increasing scrutiny over the past decade. It is now widely
recognized that HAIs are often preventable adverse events
related to medical care. CAUTIs are among the most com-
mon HAIs, occurring at a rate of 0.2 to 4.8 infections per
1,000 catheter days for adult inpatient units (Centers for
Disease Control and Prevention [CDC], 2013), CAUTIs
are associated with signi�cant morbidity and excess health
care costs (Klevens et al., 2007; Tambyah, 2002). Catheter
use and CAUTIs are disproportionately reported among
older adults (Fakih et  al., 2010; Vincitorio et  al., 2014).
Although once largely overlooked as part of the price of
doing business in hospitals, a signi�cantly changed regula-
tory environment has emerged that has brought increased
scrutiny to HAIs in general, and CAUTIs in particular.
Examples of this oversight include process and outcome
measurement and reporting and �nancial incentives to
improve these measures. Since 2008, the Centers for Medi-
care & Medicaid Services (CMS) no longer reimburses for
additional costs required to treat hospital-acquired urinary
tract infections (UTIs; CMS, 2007). Long-term care facili-
ties also follow CMS regulatory guidance and their federal
regulations (F-315 Tag) mandate that IUC use must be
medically justi�ed and care rendered to reduce infection
risk in all residents with or without an IUC (CMS, 2005).
Enhanced public reporting and �nancial incentives �gure
prominently in the Patient Protection and A�ordable Care
Act of 2010; HAIs were singled out for inclusion in both
of these initiatives (Patient Protection and A�ordable Care
Act, 2010). In related rulemaking, CAUTI is included as a
measure in the new HAI reduction program and the value-
based purchasing composite measure (PSI 90) for acute
care hospitals (Agency for Healthcare Research and Quality,
22
Prevention of Catheter-Associated
Urinary Tract Infection
Heidi L. Wald, Regina M. Fink,
Mary Beth Flynn Makic, and Kathleen S. Oman
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. De�ne catheter-associated urinary tract infection (CAUTI)
2. Describe the epidemiology of CAUTI
3. De�ne indications for indwelling urinary catheters (IUC)
4. Identify evidence-based strategies and interventions for the prevention of CAUTI
5. Describe key components of a nurse-driven protocol for IUC removal
6. Understand how to engage an interdisciplinary team in the prevention and management of CAUTIs
For a description of evidence levels cited in this chapter, see Chapter 1, “Developing and Evaluating Clinical Practice Guidelines:
A Systematic Approach.”
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Boltz, M. P. R. G. F., Capezuti, E. P. R. F., Fulmer, T. T. P. R. F., & Zwicker, D. D. A. B. (Eds.). (2016). Evidence-based geriatric nursing protocols for best practice, fifth
edition
. Retrieved from http://ebookcentral.proquest.com
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364  III: Clinical Interventions
2013a; CMS, 2007, 2008). �erefore, it is imperative that
health care professionals in all settings develop strategies and
interventions to reduce IUC duration and prevent CAU-
TIs, thus bene�tting both clinical and �nancial outcomes.
�is focus on reducing harm occurs even as the evi-
dence base for the prevention of CAUTI continues to
evolve. Between 2008 and 2014, multiple stakeholder orga-
nizations, including the CDC, and several major profes-
sional societies critically examined the literature on CAUTI
prevention (Cottenden et  al., 2005; Gould et  al., 2010;
Greene et  al., 2008; Hooten et  al., 2010; Joanna Briggs
Institute, 2010; Lo, Nicolle, & Classen, 2008; Lo et  al.,
2014; Society of Urologic Nurses, 2006; see Resources
section). Also, the CDC’s National Healthcare Safety
Network (NHSN) signi�cantly revised the surveillance
de�nition for CAUTI several times since 2009, including a
major revision in January 2015, with the cumulative e�ect
of focusing surveillance e�orts on only the most clinically
important events (CDC, 2015). Despite this attention,
CAUTI rates have been stable. A 2012 data report showed
an overall 3% increase in CAUTIs reported to the CDC
nationwide, even as rates of other HAIs decline (CDC,
2013). However, a large national collaborative reported
preliminary success in CAUTI reduction by pairing a tech-
nical bundle with a socio-adaptive change model (Agency
for Healthcare Research and Quality, 2013b).
In light of these rapid changes in the �eld and the regu-
latory focus on CAUTI, the regular review of policies, pro-
cedures, practices, and products is imperative for all health
care facilities. In this chapter, we review the rationale for
CAUTI prevention strategies, suggest an approach to imple-
menting a comprehensive CAUTI prevention program, and
catalog the most important CAUTI prevention strategies.
BACKGROUND AND STATEMENT OF PROBLEM
Health care–associated UTIs are frequent and costly,
resulting in increased morbidity and possible mortality in
hospitalized elders.

�ere are estimated to be more than
400,000 hospital-acquired UTIs in the United States
annually (Klevens et  al., 2007; Scott, 2009; Tambyah
et  al., 2002). At a mean cost of $589 per episode, this
epidemic results in $250 million of excess health care
costs each year (Tambyah et al., 2002). In a multihospital
study in Quebec, 21% of bacteremias were from a urinary
source, with 71% associated with IUCs. �us, CAUTI is
an important cause of hospital-acquired bacteremia (For-
tin, Rocher, Frenette, Tremblay, & Quach, 2012).
�e majority of UTIs are associated with the ubiquitous
IUC, also known as a Foley catheter, after urologist Frederick
Foley who developed the modern device. Urinary catheters
are among the most widely used medical devices. Despite
their utility in acutely ill patients, they have many down-
sides, including the CAUTI. Other complications include
delirium (Inouye, 2006), accidental removal, gross hematu-
ria, leakage, urethral injury, and restriction of mobility. Taken
together, these complications of IUCs occur as frequently
as CAUTI (Hollingsworth et  al., 2013; Saint, Lipsky, &
Goold, 2002). �erefore, the bene�ts of managing urinary
output with an IUC must be weighed against the many risks.
Unfortunately, the indiscriminate use of IUCs is wide-
spread. IUCs are used in up to 16% of adult hospital inpatients
and are more commonly used in the older patient (Vincitorio
et  al., 2014). Older age and female sex are risk factors for
catheterization, and older women are more likely to have
no clear indication for catheterization than other patients
(Vincitorio et al., 2014).

Of Medicare patients undergoing
elective surgery, 86% have an IUC (Wald, Ma, Bratzler, &
Kramer, 2008). According to the Infectious Diseases Society
of America, 21% to 54% of all IUCs are inappropriately
placed and are not medically indicated (Fakih et al., 2010;
Gokula, Murthy, Hickner, & Smith, 2004; Hooten et  al.,
2010). �us, interventions aimed at evidence-based use of
catheters are needed to reduce unnecessary catheter days,
and to prevent CAUTIs. To better understand the potential
approaches to prevention of CAUTIs, an understanding of
CAUTI pathogenesis is essential.
CAUTI Pathogenesis
�e urinary tract is normally a sterile body site, therefore,
any positive urine culture can be considered abnormal.
Asymptomatic bacteriuria is of questionable clinical sig-
ni�cance, however, and should not be treated except in
pregnant patients or those undergoing urologic surgery
(Nicolle et  al., 2005). �e CDC’s surveillance de�ni-
tion therefore only focuses on symptomatic or bactere-
mic infections, which occur in the presence of an IUC
(CDC, 2015).
When a patient has an IUC, microorganisms can gain
access to the urinary tract on either the extraluminal sur-
face of the IUC or intraluminal surface through breaks in
the catheter system (Figure 22.1). Extraluminal infection
can occur early if bacteria are introduced during insertion,
but more commonly, extraluminal infection occurs later
(Tillekeratne et al., 2014). Once they gain access to the uri-
nary tract, microorganisms can thrive in a “bio�lm” layer
on either the extra- or intraluminal surface of the IUC.
�e bio�lm, made up of bacteria, host proteins, and bacte-
rial slime, is thought to be important in the development
of late CAUTIs. Because the formation of a bio�lm and
colonization with bacteria takes time, most CAUTI occurs
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Boltz, M. P. R. G. F., Capezuti, E. P. R. F., Fulmer, T. T. P. R. F., & Zwicker, D. D. A. B. (Eds.). (2016). Evidence-based geriatric nursing protocols for best practice, fifth
edition
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22: Prevention of Catheter-Associated Urinary Tract Infection  365
after 48 hours of catheterization and increases approxi-
mately 5% per day (Schae�er, 1986; Stamm, 1975).
�e mechanisms described earlier provide the rationale
for evidence-based care of IUCs and highlights four poten-
tial opportunities for intervention during the use of IUCs
(Figure  22.2). �e �rst opportunity is avoidance of cath-
eters at the time of the decision for insertion, the second is
evidence-based product selection and care practices regarding
IUCs (including insertion and maintenance), and the third
is minimizing duration through timely removal. A fourth set
of additional strategies for CAUTI prevention includes edu-
cation of providers, surveillance of processes, and reporting
practice outcomes and CAUTI rates. �is set of strategies
can be applied at any of the opportunities for intervention.
A comprehensive program to eliminate CAUTIs includes ele-
ments of each of the aforementioned strategies.
ASSESSMENT OF THE PROBLEM
Surveillance Definition of CAUTI
Although clinical diagnosis of CAUTI allows for clinical
judgment, the CDC has developed explicit surveillance cri-
teria for CAUTI in acute care for use by infection control
practitioners (CDC, 2015). In brief, the patient must have:
1. An IUC for at least 2 days, which is either still in place
or removed within 1 day before the date of the event.
2. One of the following: fever more than 38°C, suprapu-
bic tenderness, costovertebral angle pain, or tenderness,
(additional symptoms may include urinary urgency,
frequency, or dysuria if the catheter has already been
Extraluminal
s “Early “ A T “ I N S E R T I O N
s “Late “by “ C A P I L L A R Y “ A C T I O N
Intraluminal
s “ " R E A K “ I N “ C L O S E D “ D R A I N A G E
s “ # O N T A M I N A T I O N “ O F
“ “ “ C O L L E C T I O N “ B A G “ U R I N E
Routes of entry of uropathogens to catheterized
urinary tract.
Source: Maki and Tambyah (2001).
FIGURE 22.1
Insertion� Care � Removal
1. Avoidance
2. Evidence-based
care practices and
product selection
3. Minimize duration
4. Education and Surveillance
s “ 0 R O T O C O L S “ W I T H “ E X P L I C I T
“ “ C R I T E R I A “
s “ 5 T I L I Z E “ A L T E R N A T I V E S
“ “ “ E G “ T O I L E T I N G “ R E G I M E N S,
“ “ “ U R I N A L S “ C O N D O M “ C A T H E T E R S
“ “ “ C O M M O D E S “ A B S O R B E N T
“ “ “ P A D S “ I N T E R M I T T E N T “ S T R A I G H T
“ “ “ C A T H E T E R I Z A T I O N “ W I T H
“ “ “ B L A D D E R “ S C A N N E R)
s “ ! S E P T I C “ V E R S U S “ S T E R I L E “ I N S E R T I O N
“ “ “ T E C H N I Q U E
s “ 2 O U T I N E “ M E A T A L “ C A R E
s “ 0 R E V E N T “ U R I N E “ R E F L U X
s “ - A I N T A I N “ C L O S E D “ S Y S T E M
s “ # A T H E T E R “ M A T E R I A L
s “ # A T H E T E R “ S I Z E
s “ 3 E C U R E M E N T “ D E V I C E
s “ 2 E M I N D E R S “ A N D “ S T O P
“ “ O R D E R S
s “ $ O C U M E N T A T I O N “ O F
“ “ C O N T I N U E D “ ) 5 # “ I N D I C A T I O N
s “ . U R S I N G D R I V E N “ R E M O V A L
“ “ P R O T O C O L S “
s “ ! U D I T “ A N D “ F E E D B A Ck
s “ 3 T A N D A R D I Z E D “ O R D E R “ S E T S
Stages of catheter use and potential intervention strategies.

FIGURE 22.2
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Boltz, M. P. R. G. F., Capezuti, E. P. R. F., Fulmer, T. T. P. R. F., & Zwicker, D. D. A. B. (Eds.). (2016). Evidence-based geriatric nursing protocols for best practice, fifth
edition
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366  III: Clinical Interventions
removed); or a positive blood culture with the same
organism as in the urine.
3. A positive urine culture sent more than 48 hours after
admission to the health care facility. A positive urine
culture is de�ned as having no more than two species
of microorganism, at least one of which is a bacteria of
greater than or equal to 10 colony-forming units/mL
of urine (CMS, 2005).
All elements of the de�nition must occur within a
7-day window. A CAUTI diagnosed within 48 hours of
arrival to a health care facility or unit is attributed to the
previous location.
In nonbacteremic cases, this surveillance de�nition
requires that the patient have symptoms referable to the
urinary tract or a fever without another cause. For the
purposes of infection-control surveillance in acute care,
new alterations in mental status do not meet the diagnos-
tic criteria for CAUTI. Of note, the CDC’s surveillance
de�nition for UTI in long-term care facilities di�ers sub-
stantially from the acute care de�nition. Practitioners in
long-term care facilities should acquaint themselves with
that de�nition (Stone et al., 2012).
CAUTIs are generally reported as infections per
1,000 catheter days on a given patient care unit. More
than half of all states require public reporting of HAIs,
among them many specify reporting of CAUTIs.
Hospitals participating in the Medicare program must
report all CAUTIs to the CDC’s NHSN for the purposes
of surveillance, public reporting on Hospital Compare,
and incentive programs.
Additional important process measurement includes
the catheter usage ratio reported as catheter days per patient-
days. Since October 2009, the Surgical Care Improvement
Project (SCIP) collects a measure of postoperative catheter
removal on catheterization day 1 or 2 for all surgical patients
(�e Joint Commission, n.d.).
Indications for IUC
Avoidance of unnecessary IUCs may reduce CAUTI inci-
dence and complications such as bloodstream infections.
A decrease in IUC use is expected to result in decreases in
length of stay, cost of hospitalization associated with treat-
ment of CAUTI and bloodstream infections (Apisarn-
thanarak et al., 2007b; Meddings et al., 2014).

Elpern et al.
(2009) evaluated the inappropriate use of IUCs among
inpatients and found them to be more common in female,
nonambulatory, and medical intensive care unit (ICU)
patients. Risk factors associated with the development
of CAUTI in hospitalized patients include older age, not
maintaining a closed drainage system, neutropenia, renal
disease, and male gender (Greene et al., 2012; Lo et al.,
2014). Explicit criteria for appropriate insertion may result
in signi�cant reductions in catheter duration and CAUTI
prevalence. �e University of Colorado Health System
developed criteria for appropriate insertion of IUCs in
hospitalized patients based on evidence (Chenoweth et al.,
2014; Fuchs, Sexton, �ronlow, & Champagne, 2011; Lo
et al., 2014; Mori, 2014)

and disseminated this informa-
tion to nursing and physician sta� through the integration
of a nurse-driven protocol for IUC removal within the
electronic health record (EHR; Figure 22.3).
An IUC should not be used for routine care of
patients who are incontinent, as a means to obtain urine
culture or other diagnostic tests in a patient who can void,
for prolonged postoperative duration without appropri-
ate indications, or routinely in patients receiving epidural
anesthesia/analgesia.
INTERVENTIONS AND CARE STRATEGIES
It is estimated that 20% to 69% of CAUTIs are prevent-
able (Gould et al., 2009). Speci�c interventions to prevent
CAUTIs are summarized as follows and organized with
regard to the four strategies illustrated in Figure  22.2.
Many of these recommendations are supported by low-
quality evidence and expert opinion. Further study may
impact these recommendations. A proposed approach to a
comprehensive CAUTI intervention follows.
Strategy 1: Avoidance
To reduce the incidence of CAUTI, it is important to
rethink practice, systems, and examine the “why” behind
the clinical indication for the IUC. Elimination options
other than an IUC should be explored before insertion.
Similarly, providing documentation of a clear indication
for the IUC can reduce inappropriate device use (Lo et al.,
2014; Uberoi et al., 2013). �e use of explicit criteria (as
in Figure 22.3) to guide the insertion decision may be of
assistance. If an IUC is placed, an algorithm may be used
to determine continued need for the device or promote
prompt removal.
To avoid catheterizations, alternative strategies for
managing urine output are necessary. Completing a sys-
tems evaluation of available equipment to provide alter-
natives to IUC for urinary elimination is an important
�rst step in reducing use. Developing toileting schedules
and providing assistance with toileting incorporated into
frequent nursing sta� rounding is another strategy that
can be used to reduce urgency and incontinence episodes
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Boltz, M. P. R. G. F., Capezuti, E. P. R. F., Fulmer, T. T. P. R. F., & Zwicker, D. D. A. B. (Eds.). (2016). Evidence-based geriatric nursing protocols for best practice, fifth
edition
. Retrieved from http://ebookcentral.proquest.com
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22: Prevention of Catheter-Associated Urinary Tract Infection  367
Does patient meet criteria to leave IUC in?
Continue to assess
and document
at every shift
RN removes IUC per protocol
1. Remove IUC
2. Document removal date and time before
completing LDA
3. Educate patient on importance of adequate
hydration and patient voiding trial after catheter
removal
4. Assess and observe post-IUC removal every 4 hours
Bladder scan less than 500 mL
1. Monitor patient for additional
2 hours for spontaneous void; if no
void, repeat bladder scan
2. If 2nd bladder scan shows < 500 mL
call health care provider for further
orders
End protocol; Maintain patient population
specific protocols for PVR or other concerns
Yes No
No
Yes
Bladder scan greater than 500 mL
1. Straight catheterize patient;
document amount of output in LDA
2. Contact health care provider for
further orders if patient has been
straight catheterized twice in 12 hrs
RN begins bladder scan protocol
Is the patient able to spontaneously void within 4 to 6 hours?
Is the urine volume less than 400 mL?
Yes
No
1. Urologic or gynecological surgery and/or need for continuous bladder irrigation
2. Prolonged immobilization (unstable spine, multiple trauma (e.g., pelvic fracture)
3. Hemodynamic instability with need for accurate I&O (e.g., sepsis)
4. Lumbar or low thoracic (≤T9) epidural
5. Assist in healing of open sacral/perineal wounds (stage III and IV) in incontinent patients
6. Urinary obstruction or retention (not managed with intermittent catheterization)
7. Placed by urology, difficult placement, special purposes (e.g., chemotherapy)
8. Palliative/comfort care for terminal patients
9. Health care provider order with documented rationale
University of Colorado Health System nurse-driven indwelling urinary catheter removal protocol.
I&O, input and output; IUC, indwelling urinary catheter; LDA, lines, drains, airways; PVR, postvoid residual.
' 2015. University of Colorado Hospital Authority. All information contained on this form is copyright protected and may only be
downloaded and/or reprinted for personal use. Permission to use these materials in whole or in part for any commercial use is expressly
prohibited unless prior written consent is granted by the Department of Professional Resources, University of Colorado Hospital, Mail
Stop 901, 12401 E. 17th Ave., Aurora, CO.
FIGURE 22.3
Boltz_71665_PTR_22_363-380_02-29-16.indd 367 3/3/2016 5:42:11 PM
Boltz, M. P. R. G. F., Capezuti, E. P. R. F., Fulmer, T. T. P. R. F., & Zwicker, D. D. A. B. (Eds.). (2016). Evidence-based geriatric nursing protocols for best practice, fifth
edition
. Retrieved from http://ebookcentral.proquest.com
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368  III: Clinical Interventions
(Uberoi et al., 2013).

If the patient is mobile or has lim-
ited mobility, alternatives to an IUC include the use of a
bedside commode with a toileting schedule (Gray, 2010;
Uberoi et al., 2013), condom catheters for male patients
(Dowling-Castronovo & Bradway, 2008; Saint et  al.,
2013),

moisture-wicking incontinence pads (Covidien
Maxicare Underpad; Medline Ultrasorb Underpad), inter-
mittent straight catheterization with the use of a bladder
scanner to determine bladder urine volume (Hooten et al.,
2010; Parry et al., 2013; Saint et al., 2013), as well as uri-
nals and bedpans. Careful consideration of products and
how and where they are stocked is essential to success. For
instance, commodes need to be available in multiple sizes
and need to include bariatric commodes; urinals need to
�t snugly on bedrails; bladder ultrasound needs to be read-
ily available for assessment.
For less mobile male patients, the condom catheter is
an e�ective alternative to an IUC, although there is still a
small risk of infection with condom catheters (Saint et al.,
2013). Moisture-absorbing or wicking underpads for incon-
tinence management are an alternative for the acute care
environment (Covidien Maxicare Underpad, n.d.; Medline
Ultrasorb Underpad n.d.) and long-term care or home envi-
ronments (NAFC.org). Incontinence underpad products
pull e�uent moisture/urine away from the skin and can
absorb up to 2 L of �uid before becoming saturated (Junkin
& Selekof, 2008; Padula Manish, Makic, & Sullivan, 2011).
For a full discussion of incontinence management, please
refer to Chapter 21, “Urinary Incontinence.”
Urinary retention postsurgery or after initial IUC
removal may pose clinical care challenges. To prevent
IUC insertion or reinsertion, intermittent catheterization
should be considered as an avoidance strategy. �e blad-
der scanner, which uses ultrasound technology, is clini-
cally bene�cial in determining urinary retention, reducing
unnecessary intermittent catheterizations, enhancing
patient comfort, and saving costs associated with inap-
propriate catheterizations, and possible CAUTIs (Palese,
Buchini, Deroma, & Barbone, 2010; Saint et al., 2013).
Strategy 2: Evidence-Based Product Selection,
Insertion, and Routine Care
If an IUC is determined to be clinically indicated, selection
of the right catheter, proper technique during insertion of
the device, and evidence-based ongoing care management
are needed to reduce infection.
Catheter material remains an area of ongoing debate.
Although antimicrobial catheter materials have been
shown to reduce catheter-associated bacteriuria (Lo et al.,
2014; Pickard et  al., 2012), the impact of antimicrobial
catheters on symptomatic CAUTIs remains unproven.
Research syntheses have failed to conclusively demon-
strate e�ectiveness of silver-coated or antibiotic impreg-
nated catheters on prevention of CAUTIs for short-term
catheterization of adult patients versus standard materials
(Pickard et al., 2012). �ere also is insu�cient evidence
to determine whether selection of a latex catheter, hydro-
gel-coated latex catheter, silicone-coated latex catheter, or
all-silicone catheter in�uences CAUTI risk (Hooten et al.,
2010; Lo et al., 2014). �e decision to use a silver-coated
or antibiotic impregnated catheter should be made with
the understanding that it does not substitute for a compre-
hensive CAUTI prevention program.
Selecting the smallest IUC size, when possible, is an
additional consideration to reduce the risk of infection
(Gould et  al., 2009; L. Greene, Marx, & Oriola, 2008;
Hooten et  al., 2010). �e selection of a smaller catheter
(e.g., less than 18 French) reduces irritation and in�amma-
tion of the urethra and reduces infection risk (Gray, 2010).
Placing an IUC is a fundamental skill for nurses; how-
ever, current evidence supporting sterile versus aseptic tech-
nique for the procedure is inconclusive (Lo et al., 2014).
A strict sterile technique involves using a sterile gown,
mask, prolonged hand washing (greater than 4 minutes),
opening and using a sterile insertion kit, donning sterile
gloves, cleansing the urethral meatus and perineal area with
an antiseptic solution, and inserting the catheter using a
no-touch technique (Gray, 2010). Wilson et  al. (2009)
reviewed the literature and found that most clinicians
employ an aseptic technique, which was most frequently
de�ned as the use of sterile gloves, sterile barriers, perineal
washing using an antiseptic cleanser, and no-touch inser-
tion. Current recommendations suggest an IUC insertion
be placed under aseptic technique with sterile equipment
(Gould et  al., 2009; Greene et  al., 2008; Hooten et  al.,
2010; Joanna Briggs Institute, 2010; Lo et al., 2014).
Once an IUC is placed, optimal management
includes care of the urethral meatus according to “routine
hygiene” (e.g., daily cleansing of the meatal surface during
bathing with soap and water and as needed following a
bowel movement; Gould et al., 2009; Greene et al., 2008;
Hooten et al., 2010; Joanna Briggs Institute, 2010). Metal
cleansing with antiseptics, creams, lotions, or ointment
has been found to irritate the meatus, possibly increas-
ing the risk of infection (Jeong et al., 2010; Joanna Briggs
Institute, 2010; Lo et al., 2014).
Securing the IUC after placement to reduce friction
from movement is an important element of catheter man-
agement supported by current guidelines, researchers, and
expert opinion panels (Clarke et  al., 2013; Darouiche et
al., 2006; Gould et al., 2009; Hooten et al., 2010; Joanna
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edition
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22: Prevention of Catheter-Associated Urinary Tract Infection  369
Briggs Institute, 2010). Maintaining a closed catheter sys-
tem is also supported by current guidelines (Gould et al.,
2009; Greene et  al., 2008; Hooten et  al., 2010; Joanna
Briggs Institute, 2010; Lo et  al., 2014) to eliminate the
introduction of microbes that occurs when breaking the
prepackaged seals on the IUC. A systems analysis should
be conducted to purchase and stock the most commonly
needed IUC insertion and drainage-bag kits to optimize
the maintenance of a closed system. Similarly, maintaining
the urine-collection bag below the level of the bladder min-
imizes re�ux into the catheter itself preventing retrograde
�ow of urine (Clarke et al., 2013; Gould et al., 2009; Greene
et al., 2008; Hooten et al., 2010; Joanna Briggs Institute,
2010).

Establishing work�ow protocols to routinely empty
the drainage bag frequently and before transport are impor-
tant in reducing urine re�ux and opportunities for CAUTI.
Strategy 3: Timely Removal
Developing systems that prompt health care providers to
review the need for the IUC and encourage early removal
have been found to reduce IUC use and CAUTI rates (Ales-
sandri, Mistrangelo, Lijoi, Ferrero, & Ragni, 2006; Alexaitis
et al., 2014; American Nurses Association CAUTI Prevention
Tool, 2015; Andreessen, Wilde, & Herendeen, 2012; Carter,
Reitmeier, & Goodloe, 2014; Fakih et al., 2012; Fuchs et al.,
2011; Knoll et al., 2011; Marigliano et al., 2012; Meddings
et  al., 2014; Mori, 2014; Parry, Grant, & Sestovic, 2013;
Purvis et al., 2014; Rosenthal et al., 2012; Saint et al., 2013;
Titsworth et al., 2012). Meddings et al. (2014) updated an
earlier systematic review and meta-analysis and found that
urinary catheter removal reminders and stop orders appeared
to reduce CAUTI rates. Implementation of systems that
provide physicians and nurses with routine reminders to
evaluate the need for the IUC or automatic stop orders were
found to reduce the CAUTI rate by 53% (p ≤ .0001). In
this study, automatic stop orders were more e�ective than
reminders in reducing catheter duration (p < .0001 and
p = .071, respectively).
Other approaches to reducing catheter days include
audit and feedback

and reminders to recommend reevalu-
ation of the need for the IUC (Marigliano et  al., 2012;
Meddings et  al., 2014; Parry et  al., 2013; Purvis et  al.,
2014; Saint et al., 2013) and early removal (Alexaitis et al.,
2014; American Nurses Association CAUTI Prevention
Tool, 2015; Fuchs et  al., 2011; Meddings et  al., 2014;
Mori, 2014; Parry et al., 2013; Saint et al., 2013; Titsworth
et al., 2012). EHR icons (Purvis et al., 2014) or �ags that
calculate the number of days the IUC has been placed
are e�ective forms of electronic reminders that can easily
be incorporated into the EHR. Automatic stop orders or
IUC orders that expire in a de�ned time frame have shown
to reduce both catheter usage and CAUTI (Fuchs et al.,
2011; Knoll et al., 2011; Saint et al., 2013). Daily nursing
rounds (Alexaitis et  al., 2014; Fakih et  al., 2012; Purvis
et al., 2014), and the use of checklists (Andreessen et al.,
2012; Fuchs et al., 2011) have also been shown to reduce
catheter usage and CAUTI.
Nurse-driven catheter removal protocols are being
developed and implemented successfully in many acute care
settings (Andreessen et al., 2012; Carter et al., 2014; Fakih
et al., 2012; Knoll et al., 2011; Purvis et al., 2014; Saint et al.,
2013; Titsworth et al., 2012). Protocols range in degree of
nurse autonomy in catheter removal decision making; some
require a physician order, most allow the nurse to remove
the catheter when there is no evidence-based indication for
continuation. Protocols also di�er in complexity, with some
only addressing the IUC removal aspect of the protocol and
others that address follow-up bladder management strate-
gies with bladder scanning guidelines (Alexaitis et al., 2014;
American Nurses Association CAUTI Prevention Tool
2015; Carter et al., 2014; Mori, 2014; Purvis et al., 2014;
Saint et  al., 2013). Figure 22.3 is an example of a nurse-
driven IUC removal protocol developed and implemented
by the University of Colorado Hospital.
If premature, early removal of IUCs poses the risk of
unnecessary recatheterization. It is important to monitor
the need for recatheterization to avoid unintended harm.
In the meta-analysis conducted by Meddings et al. (2014),
low recatheterization rates were noted in studies using
reminders and automatic stop orders.
Most of the implementation and quality-improvement
research employs multiple interventions (or bundles), as
CAUTI prevention is a multifaceted issue. �ese bundled
approaches are also e�ective and are providing explicit
criteria for catheter usage and structured approaches to
CAUTI reduction (Andreessen et al., 2012; Fakih et al.,
2012; Knoll et  al., 2011; Purvis et  al., 2014; Rosenthal
et al., 2012; Titsworth et al., 2012).
It is well established that duration of IUC increases
CAUTI risk. �e SCIP is a national quality partnership
of organizations interested in improving surgical care by
signi�cantly reducing surgical complications (�e Joint
Commission, n.d.). One of the key performance mea-
sures in this program is CAUTI prevention; speci�cally
that IUCs be removed by postoperation day 2, also known
as SCIP-inf-9. �is SCIP performance measure has had
signi�cant impact on decreasing catheter usage in surgical
patients (CMS, 2015).
Keeping the IUC as long as thoracic epidural analgesia
is maintained (higher than T9) may result in a higher inci-
dence of CAUTI and increased hospital stay. IUC removal
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edition
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370  III: Clinical Interventions
on the morning after surgery while the thoracic epidural
catheter is still in place does not lead to increased incidence
of urinary retention, infection, or higher rates of recatheter-
izations (Basse, Werner, & Kehlet, 2000; Chia, Wei, Chang,
& Liu, 2009; Stubbs et al., 2013; Zaouter, Kanera, & Carli,
2009; Zaouter, Wuethrich, Miccoli, & Carli, 2012).
Strategy 4: Surveillance and Education
Ensuring that leadership of organizations and systems are
in place to e�ectively evaluate and sustain practice change is
essential to improving patient outcomes (Kabcenell, Nolan,
Martin, & Gill, 2010; Reinertsen, Bisognano, & Pugh,
2008). In particular, surveillance is a cornerstone of CAUTI
prevention but is resource intensive, typically relying on
manual surveillance by trained infection prevention person-
nel (Wald, Bandle, & Richard, 2014). �ere is emerging
evidence that electronic surveillance, using EHR algorithms,
are e�ective in increasing the e�ciency of CAUTI identi�-
cation (Shepard et al., 2014; Wald et al., 2014). Catheter
usage data and CAUTI rates are key data elements to col-
lect and trend. IUC usage is determined by the number of
catheter days divided by the number of patient days and
is expressed as a ratio. CAUTI rate is determined by the
number of CAUTIs divided by 1,000 catheter days. Both
data elements can then be benchmarked against the NHSN
pooled means to assess unit level performance. However, the
use of a catheter days denominator can produce unstable
CAUTI rates when catheter usage is low (Wright, Kharasch,
Beaumont, Peterson, & Robicsek, 2011).
Measurement must be accompanied by provision of
knowledge and skills to frontline providers through appro-
priate education and training, which may be central to a
multicomponent CAUTI intervention. Multiple studies
and quality-improvement projects found that multifac-
eted educational interventions bundled with the use of
algorithms/checklists, automated stop orders, physician
EHR reminder prompts, and/or nurse-driven removal
protocols are e�ective in decreasing CAUTIs and cath-
eter usage (Alexaitis & Broome, 2014; Andreessen et al.,
2012; Apisarnthanarak, 2007a; Carter et al., 2014; Knoll
et al., 2011; Marigliano et al., 2012; Mori, 2014; Purvis
et  al., 2014; Roser et  al., 2012). Ongoing system evalu-
ation, nursing reeducation, practice reminders, and pub-
lic reporting of unit-based CAUTI rate data are strategies
to inform the health care team of current practice out-
comes and e�ectiveness of CAUTI prevention strategies.
Implementing systems that encompass the whole health
care team to question the need for the IUC and, when
indicated, ensuring proper care and early removal can be
pivotal in reducing CAUTI rates (Wenger, 2010).
Approach to a Comprehensive CAUTI Intervention
Evidence-based practice (EBP) guidelines derived from
valid, current research and other evidence sources can
successfully improve patient outcomes and quality care.
However, simply disseminating scienti�c evidence is often
ine�ective in changing clinical practice. Learning how to
implement �ndings is critically important to promoting
high-quality, safe care. How EBPs are adopted in practice
depend on the type, complexity, and strength of the evi-
dence and how the knowledge is communicated to clini-
cians (Titler, 2011). �ere are a number of models that
can guide the implementation of EBP (Rycroft-Malone &
Bucknall, 2010) but there is not a single way to imple-
ment new �ndings into practice. What works in one set-
ting may need modi�cation to be successful in another
context (Titler, 2011). Understanding health care provider
decisions, experiences, practice processes, and barriers is
considered essential. �ese elements must be explored to
successfully implement practice change based on best evi-
dence (Melnyk & Fineout-Overholt, 2011).
�e explicit use of a socio-adaptive model has been
employed in large-scale HAI prevention activities, includ-
ing the Agency for Healthcare Research and Quality’s On
the Comprehensive Unit-based Safety Program (CUSP):
STOP CAUTI initiative. Here, the technical interventions
for CAUTI reduction were paired with the CUSP devel-
oped by Pronovost et al., which provides tools for improv-
ing safety climate on clinical units (Pronovost et al., 2005).
�e preliminary results of this work are promising for a
decrease in CAUTI, but show no change in IUC usage
(Agency for Healthcare Research and Quality, 2013a).
At a minimum, the development of an interdisciplin-
ary champion team and the creation of a multifaceted
intervention to implement evidence-based procedures for
IUC insertion and maintenance must be a priority in all
practice settings. �e ultimate goals are to reduce routine
catheter insertions, provide evidence-based catheter care,
and prompt early removal when possible, thus decreasing
the risk of and prevention of CAUTI.
Steps used for protocol development at the University
of Colorado Hospital are highlighted as follows. Improved
patient outcomes (decreased catheter days, decreased
CAUTIs) and decreased costs have been realized.
Protocol Development
1. Recruit an interdisciplinary champion team to include
nurses (clinical, educators, operating room [OR] RNs,
emergency department [ED] RNs); physicians [hos-
pitalists, infectious disease, ED MDs, surgeons, anes-
thesiologists]); rehabilitation therapists and transport
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edition
. Retrieved from http://ebookcentral.proquest.com
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22: Prevention of Catheter-Associated Urinary Tract Infection  371
personnel; infection control preventionists; and qual-
ity-improvement, central supply, and clinical informat-
ics representatives.
2. Examine and synthesize the evidence (search, review,
critique, and hold journal clubs in various care areas to
present the evidence).
3. Identify and understand product use, availability,
and costs in your health care setting. Re�ne prod-
uct use based on the best evidence and cost analysis.
Examine:
� Urinary catheter materials, sizes, kits, drainage bags
� Catheter securement device
� Urinal and bedpan availability
� Commodes (availability and size)
� Bladder scanners
� Alternatives (incontinence pads, condom catheters,
etc.)
4. Identify barriers to optimal IUC care practices by sur-
veying sta� or holding focus groups throughout your
health care setting.
5. Update your policy and procedures related to IUC
insertion and care based on the evidence.
6. Consider dividing the project into manageable phases.
Avoidance strategies may require a di�erent approach
than care or removal strategies. For instance, avoidance
starts in the ED and OR; removal occurs on inpatient
�oors.
7. Develop and use algorithms, decision aids, and factoid
posters displaying evidence-based caveats.
8. Development of a nurse-driven IUC removal protocol.
� Recruit an interdisciplinary team to include nurses
(clinical educators, physicians [hospitalists, infec-
tious disease physicians, surgeons, anesthesiolo-
gists]) and clinical informatics representatives.
� Examine and synthesize the evidence (search,
review, critique) and protocol examples.
� Develop protocol with interdisciplinary and key
stakeholder (clinical nurses, charge nurses, educa-
tors, physicians [all specialties], midlevel providers,
regulatory personnel) input and feedback
� Incorporate protocol into hospital policy/proce-
dure.
� Develop EHR interface.
� Plan education and implementation procedures.
a. Identify champions to assist with implementa-
tion: infection control champions, nurse educa-
tors, clinical nurse educators, and specialists.
b. Journal club presentations, RN tip sheets, pro-
vider tip sheets, EHR screenshot tip sheets,
nursing unit posters/clings, PowerPoint
presentations.
� Plan evaluation strategies
a. Verbal feedback from clinicians
b. EHR reports on protocol usage/documentation
c. Audits
9. Update patient and family educational materials on
the importance of prompt and early removal of IUCs.
10. Educate sta� (including radiology, transport, reha-
bilitation therapy sta� [physical therapy, occupational
therapy]) focusing on policy and procedure revision,
insertion indication guidelines, insertion procedures,
maintenance and care, catheter-bag placement,
removal prompts or removal protocols, and bladder
scanner use and procedures.
11. Work with infection control and clinical informatics
sta� to audit and measure outcomes. Provide feed-
back to sta�. Potential measurable outcomes include:
� CAUTIs/1,000 catheter days
� Catheter days/hospital days
� Postoperative catheter days/patient
� Proportion of catheterized/admitted patients from
ED or OR
12. Continually evaluate and update practice changes
based on new evidence.
CASE 1
Mrs. F is an 87-year-old female with a history of
Alzheimer’s dementia, incontinence, and a recent fall
at home. She presents to your hospital with failure to
thrive, increased pain on movement, and a Stage II
pressure ulcer on her coccyx. Mrs. F lives at home alone;
her daughter frequently checks on her condition.
Mrs. F arrives to your medical unit with an IUC
that was placed in the ED. Given the patient’s incon-
tinence, fall risk, pain, and concern about pressure
ulcer progression, the IUC is left in place. After sta-
bilization of her pain (no fractures are present), Mrs.
F is able to ambulate with assistance. �ree days after
admission while awaiting placement in a skilled nurs-
ing facility (SNF), Mrs. F develops fever and delirium
and is diagnosed with a UTI. �is delays her transfer
to the SNF.
Questions to Consider
1. Was the IUC placement medically indicated? If so,
what were the indications?
CASE STUDY
(continued)
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edition
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372  III: Clinical Interventions
4. If the patient does not void after the IUC is
removed, when is a bladder scanner indicated?
What are the indications for recatheterization?
Discussion
�e IUC was probably indicated because of the length
of surgery (greater than 2 hours) and need for accurate
monitoring for intake and output. �e misconception
that the IUC needs to be in place as long as the tho-
racic epidural remains for pain management purposes
needs clari�cation. Multiple studies have supported
IUC removal on the morning after surgery to decrease
CAUTI risk in the setting of a thoracic epidural higher
than the T9 level (Stubbs et al., 2013; Zaouter et al.,
2012). Early removal typically does not lead to urinary
retention or higher rates of recatheterization. After
IUC removal, toileting with assistance, use of a bedpan
or urinal, placement of an incontinence pad, or use of
a bladder scanner for postvoid residual volume assess-
ment and use of straight catheterization if indicated are
alternatives.
If the patient is unable to spontaneously void 4 to
6 hours post-IUC removal, a bladder scanning proto-
col should be instituted to determine the amount of
urine in the bladder. If the bladder scan indicates less
than 400 mL of urine, then Mr. B should be monitored
for 2 additional hours postvoid. If he is still unable to
void, the bladder scan is repeated. If the second bladder
scan shows greater than 400 mL postvoid, the nurse
needs to straight catheterize the patient, documenting
the amount of output in the EHR. Additional orders
will be necessary if Mr. B has been straight catheterized
twice or more within 12 hours.
2. What could have been used as alternatives to IUC
placement?
3. Discuss various strategies that may have been used
to remind the nursing team to remove the patient’s
IUC in a timely manner.
Discussion
As incontinence, fall risk, pain, and a Stage II pressure
ulcer are not medically appropriate indications for an
IUC, it should have been avoided in the ED or removed
as soon as the patient arrived to the �oor. Alternatives
to indwelling catheterization in this patient would
include a bedside commode with nursing assistance
and/or moisture-wicking incontinence pads. Atten-
tiveness to the appropriate medical indications for
catheter use, familiarity with catheter alternatives, and
recognition of the clinical and economic impacts may
have prevented the infection and eased the placement
of this patient. �e use of a nurse-driven IUC removal
protocol, automatic stop orders in the EHR, and daily
nursing rounds on patients with IUCs may call atten-
tion to the unnecessary use of the IUC and encourage
timely removal.
CASE 2
Mr. B is a 69-year-old alert male with a diagnosis of
nonsmall cell lung cancer admitted for a thoracotomy.
�e patient is transferred from the postanesthesia care
unit to the surgical ICU with an IUC that was placed
in the OR and a thoracic epidural for pain manage-
ment with morphine and bupivicaine infusion. Mr. B
is doing well 48 hours postoperatively, experiencing
little pain and is able to cough and breathe deeply. He
is transferred out of the ICU to the surgical �oor with
the urinary catheter and thoracic epidural still in place.
When prompted by nursing sta� to write an order for
urinary catheter removal, the surgeon says he is waiting
for the anesthesiology team to pull the epidural cath-
eter before removing the urinary catheter.
Questions to Consider
1. Was the IUC placement surgically indicated?
2. When should the IUC be removed?
3. When the IUC is removed what can be used as
alternatives?
CASE STUDY (continued)
SUMMARY
A rapidly changing evidence base and regulatory envi-
ronment necessitates a continued focus on the preven-
tion of CAUTI, which is informed by an understanding
of CAUTI pathogenesis and rational IUC use. Critical
elements of a CAUTI prevention program include maxi-
mizing catheter avoidance, ensuring EBP and product
use, and timely catheter removal. Additional strate-
gies include sta� education, continuing monitoring of
CAUTI incidence, and catheter use. Multicomponent
technical interventions have been used successfully in
the prevention of CAUTIs when paired with a socio-
adaptive change strategy.
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edition
. Retrieved from http://ebookcentral.proquest.com
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22: Prevention of Catheter-Associated Urinary Tract Infection  373
Protocol 22.1: Prevention of Catheter-Associated Urinary Tract Infection
I. GOALS
To ensure that nurses in acute care are able to
A. De�ne CAUTI
B. Describe the epidemiology of CAUTI
C. De�ne indications for IUC
D. Identify evidence-based strategies and interventions for the prevention of CAUTI
E. Describe key components of a nurse-driven protocol for IUC removal
F. Understand how to engage an interdisciplinary team in the prevention and management of CAUTIs in the setting
II. OVERVIEW
A. CAUTIs are the single most common HAI, accounting for 34% of all HAIs and associated with signi�cant morbid-
ity and excess health care costs.
B. Since 2008, the CMS no longer reimburses for additional costs required to treat nosocomial UTIs.
C. Multiple EBP strategies, recommendations, and/or guidelines for preventing CAUTI in hospitals and long-term
care have been published.
D. In light of these rapid changes in the �eld, the review of policies, procedures, practices, and products is imperative
for all health care facilities.
III. BACKGROUND/STATEMENT OF PROBLEM
A. Introduction
1. It is suggested that there are more than 449,000 health care–associated CAUTIs annually. At an approximate cost of
$749 to $1,007 per hospital admission, this epidemic results in $452 million of excess health care costs each year.
2. �e vast majority of UTIs are associated with the ubiquitous IUC, also known as a Foley catheter.
3. According to the Infectious Diseases Society of America 21% to 54% of all IUCs are inappropriately placed and
are not medically indicated.
B. De�nitions
1. Symptomatic UTI: A patient has at least one of the following signs or symptoms with no other recognized cause:
Fever (more than 38ºC), urgency, frequency, dysuria, or suprapubic tenderness and a positive urine culture; may
or may not be catheter associated.
2. Asymptomatic bacteriuria: A positive urine culture in a patient who does not have fever or symptoms referable
to the urinary tract; may or may not be catheter associated.
3. CAUTI: A symptomatic UTI that occurs while a patient has an IUC inserted for at least 2 days or within
24 hours of its removal.
C. Essential elements
1. �e urinary tract is normally a sterile body site. In the presence of an IUC, microorganisms can gain access to
the urinary tract on either the extraluminal surface of the IUC or intraluminal surface through breaks in the
catheter system.
2. Once bacteria gain access to the urinary tract, microorganisms can thrive in a “bio�lm” layer on either the extra-
or intraluminal surface of the IUC.
3. Because the formation of a bio�lm and colonization with bacteria takes time, most CAUTI occurs after
48 hours of catheterization and increases approximately 5% per day.
4. �e mechanisms described earlier provide the rationale for evidence-based care of IUCs. Four potential oppor-
tunities for intervention include:
a. Avoid the use of catheters
b. Evidence-based care practices and product selection
NURSING STANDARD OF PRACTICE
(continued)
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edition
. Retrieved from http://ebookcentral.proquest.com
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374  III: Clinical Interventions
c. Timely removal
d. Education and surveillance
IV. ASSESSMENT OF CAUTI
A. �e CDC has developed explicit surveillance criteria for CAUTI. In brief, the patient must have:
1. A positive urine culture sent more than 48 hours after admission to the health care facility
2. An IUC at the time of or within 24 hours before the culture
3. One of the following: suprapubic tenderness, costovertebral angle pain or tenderness, or a fever more than 38ºC
without another recognized cause; or a positive blood culture with the same organism as in the urine
B. Measures
1. Outcomes
a. CAUTIs/1,000 catheter days
2. Processes
a. Catheter days/hospital days
b. Patients with catheter removed on postoperative day 1 or 2 eligible surgical patients
C. Indications for IUCs can be operationalized using algorithms or protocols.
V. NURSING CARE STRATEGIES
Twenty percent to 69% of CAUTIs are preventable through the application of evidence-based care strategies.
A. Catheter avoidance
1. Established insertion guidelines
2. Alternative strategies to manage urine output available:
a. Bedside commodes
b. Condom catheters
c. Moisture-wicking incontinence pads
d. Intermittent straight catheterization
e. Bladder scanner for monitoring and assessment
f. Bedpans and urinals that are functional
3. Toileting schedules and frequent nursing rounds
B. Product selection and routine care
1. Catheter material:
a. Antimicrobial catheter materials have been shown to reduce catheter-associated bacteriuria (colonization),
but impact on prevention of symptomatic CAUTIs during short-term insertions is unproven.
b. �ere is insu�cient evidence to determine whether selection of a latex catheter, hydrogel-coated latex cath-
eter, silicone-coated latex catheter, or all-silicone catheter in�uences CAUTI risk.
2. Select the smallest size possible (less than 18 French).
3. Use aseptic technique and sterile product during catheter insertion.
4. Routine urethral meatus cleansing with soap and water during bath and after bowel movement.
5. Secure catheter to leg using a catheter securement device.
6. Maintain a closed system at all times.
7. Keep drainage bag below level of bladder.
8. Empty the bag when two thirds full and before transport.
C. Timely removal
1. Systems that prompt providers to review need for the catheter and encourage early removal. Examples
include stop orders and reminder systems; audit/feedback, nurse-prompted reminders, nurse-driven removal
protocols.
2. Measure of removal: SCIP, SCIP-inf-9 measure; catheter removal on postoperative day 1 or 2.
(continued)
Protocol 22.1: Prevention of Catheter-Associated Urinary Tract Infection (continued)
Boltz_71665_PTR_22_363-380_02-29-16.indd 374 3/3/2016 5:42:14 PM
Boltz, M. P. R. G. F., Capezuti, E. P. R. F., Fulmer, T. T. P. R. F., & Zwicker, D. D. A. B. (Eds.). (2016). Evidence-based geriatric nursing protocols for best practice, fifth
edition
. Retrieved from http://ebookcentral.proquest.com
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22: Prevention of Catheter-Associated Urinary Tract Infection  375
D. Surveillance and education
1. Measurement of processes and outcomes
2. Ongoing system evaluation, nursing reeducation, practice reminders, and public reporting of unit-based
CAUTI-rate data are strategies to inform the health care team of current practice outcomes and e�ectiveness of
CAUTI prevention strategies.
VI. EVALUATION/EXPECTED OUTCOMES
A. Plan of care
1. Assessment that patient meets established insertion criteria
2. Adherence to prompts for early catheter removal
3. Standardized catheter care guidelines followed
B. Documentation
1. Dates of insertion and removal
2. Type of catheter (new indwelling, chronic indwelling, reinsertion, change of device)
3. Reason for catheter insertion
4. Justi�cation that catheter is still necessary
5. Postvoid residual catheter removal if patient is unable to void in 4 to 6 hours; bladder volume; intervention
C. Catheter usage
1. Monitor unit-speci�c CAUTI rates.
2. Monitor average catheter duration (catheter days).
3. Monitor SCIP postoperative catheter removal on catheterization day 1 or 2.
4. Trend unit-speci�c IUC usage.
ABBREVIATIONS
CAUTI Catheter-associated urinary tract infection
CMS Centers for Medicare & Medicaid Services
EBP Evidence-based practice
HAI Health care–associated infection
IUC Indwelling urinary catheters
SCIP Surgical Care Improvement Project
IUC Indwelling urinary catheter
Protocol 22.1: Prevention of Catheter-Associated Urinary Tract Infection (continued)
ACKNOWLEDGMENTS
We thank Lilian Ho�ecker, MLS, Research Librarian, Health
Sciences Library at the University of Colorado Anschutz
Medical Campus for her evidence-based search and Cynthia
Drake, MA, for assistance with the formatting of this chapter.
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