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388
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. de�ne catheter-associated urinary tract infection (CAUTI)
2. understand 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. understand how to engage an interdisciplinary team in the management of CAUTIs
OVERVIEW
Health care-associated infections (HAIs) have received increasing scrutiny over the last
decade and are now widely recognized as largely preventable adverse events related to
medical care. CAUTIs are the single most common HAI, accounting for 34% of all
HAIs (Klevens et al., 2007) and associated with signi�cant morbidity and excess health
care costs (Saint, 2000). CAUTI is disproportionately reported among older adults
(Fakih et al., 2010). Although once largely overlooked as part of the price of doing
business in hospitals, a signi�cantly changed regulatory environment has emerged that
will bring increased scrutiny to HAIs in general and CAUTIs in particular. Examples
of this oversight include process and outcome measurement and reporting and �nan-
cial incentives to improve these measures. Since 2008, the Centers for Medicare and
Medicaid Services (CMS) no longer reimburses for additional costs required to treat
hospital-acquired urinary tract infections (UTIs; CMS, Department of Health and
Human Services [DHHS], 2007). Long-term care facilities also follow CMS regula-
tory 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, DHHS, 2005). Enhanced public reporting and �nancial incen-
tives �gure prominently in the Patient Protection and A�ordable Care Act of 2010;
19
Heidi L. Wald, Regina M. Fink, Mary Beth Flynn Makic,
and Kathleen S. Oman
Catheter-Associated Urinary Tract
Infection Prevention
For description of Evidence Levels cited in this chapter, see Chapter 1, Developing and Evaluating
Clinical Practice Guidelines: A Systematic Approach, page 7.
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Catheter-Associated UTI Prevention 389
HAIs are singled out for inclusion in both types of initiatives (Patient Protection and
A�ordable Care Act, 2010). �erefore, it is imperative that health care professional sta�
in various settings develop strategies and interventions to reduce IUC duration and
prevent CAUTIs, thus bene�tting both patient and �nancial outcomes.
�is paradigm shift occurs as the evidence base for the prevention of CAUTI is
evolving. After 25 years of stasis in the �eld, multiple stakeholder organizations includ-
ing the Centers for Disease Control and Prevention (CDC) and several major profes-
sional societies have critically examined the literature on CAUTI prevention. Between
2008 and 2010, at least six evidence-based practice strategies, recommendations, and/
or guidelines for preventing CAUTI in hospitals and long-term care have been pub-
lished (Cottenden et al., 2005; Gould et al., 2009; Greene, Marx, & Oriola, 2008;
Hooton et al., 2010; Joanna Briggs Institute [JBI], 2000; Lo et al., 2008; see Resources
section). Prior to this proliferation of recommendations, the last evidence synthesis
for CAUTI prevention in the United States occurred in 1981. In addition, in 2009,
the CDC’s National Healthcare Safety Network signi�cantly revised the surveillance
de�nition for CAUTI (CDC, National Healthcare Safety Network, 2009). In light
of these rapid changes in the �eld, the review of policies, procedures, practices, and
products is imperative for all health care facilities. In this chapter, we will review the
rationale for CAUTI prevention strategies, suggest an approach to implementing 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 older adults (Saint, 2000). �ere are more than
500,000 hospital-acquired UTIs in the United States annually (Gould et al., 2009;
Klevens et al., 2007). At a mean cost of $589 per episode, this epidemic results in $250
million of excess health care costs each year (Tambyah, Knasinski, & Maki, 2002). Five
percent of UTIs lead to bacteremias, with signi�cantly increased mortality and costs.
�e vast majority of UTIs are associated with the ubiquitous IUC, also known as a
Foley catheter named 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 downsides, including the CAUTI. Other compli-
cations include delirium (Inouye, 2006), local trauma, encrustation, and restriction of
mobility (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 widespread. IUCs are used in
up to 25% of hospital admissions (Weinstein et al., 1999) and are more commonly
used in the older patient (Fakih et al., 2010). �irty percent of Medicare patients
have IUCs during their hospital stay (Zhan et al., 2009) and older women are dis-
proportionately likely to have no clear indication for catheterization (Fakih et al.,
2010). Of Medicare patients undergoing elective surgery, 86% have an IUC (Wald,
Ma, Bratzler, & Kramer, 2008) and nearly 50% continue to have a catheter in place
beyond 48 hours postoperatively (Wald, Epstein, & Kramer, 2005). According to the
Infectious Diseases Society of America (IDSA), 21%–54% of all IUCs are inappro-
priately placed and are not medically indicated (Hooton et al., 2010). Only 25% of
attending physicians in teaching hospitals are aware that their patients have urinary
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390 Evidence-Based Geriatric Nursing Protocols for Best Practice
catheters, and few hospitals have systematic methods for tracking which patients have
catheters placed (Saint et al., 2000; Saint et al., 2008). Clearly, interventions aimed
at evidence-based use of catheters are needed to prevent CAUTIs. To better under-
stand the potential approaches to prevention of CAUTIs, an understanding of CAUTI
pathogenesis is essential.
Catheter-Associated Urinary Tract Infection Pathogenesis
�e urinary tract is normally a sterile body site; therefore, any positive urine culture
(de�ned in Table 19.1) can be considered a UTI. �e IDSA distinguishes between
two categories of UTIs: the benign asymptomatic bacteriuria (ASB) and the clinically
important symptomatic UTI. Either of these conditions can occur in the presence of an
IUC (Hooton et al., 2010).
When a patient has 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 (Figure 19.1). Extraluminal infection can occur early if bacteria
are introduced during insertion, but more commonly, extraluminal infection occurs
later (Maki & Tambyah, 2001). Once they gain access to the urinary tract, micro-
organisms can thrive in a “bio�lm” layer on either the extraluminal or intraluminal
surface of the IUC. �e bio�lm, made up of bacteria, host proteins, and bacterial
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
after 48 hours of catheterization and increases approximately 5% per day (Schae�er,
1986; Stamm, 1975).
�e mechanisms described previously provide the rationale for evidence-based
care of IUCs and highlights three potential opportunities for intervention during
the use of IUCs (Figure 19.2). �e �rst opportunity is avoidance of catheters 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 education of providers and surveillance of processes and
outcomes. �is set of strategies can be applied at any of the opportunities for interven-
tion. A comprehensive program to eliminate CAUTIs includes elements of each of the
aforementioned strategies.
TABLE 19.1
Definition of a Positive Urine Culture
1. Greater than or equal to 10
5
microorganisms/cc of urine with no more than two species of
microorganisms.
OR
2. Greater than or equal to 10
3
and less than or equal to 10
5
CFU/ml with no more than two
species of microorganism.
AND
A positive urinalysis:
N Positive dipstick for leukocyte esterase and/or nitrite
N Pyuria (urine specimen with 5 10 WBC/mm
3
or 5 3 WBC/high power field of unspun urine)
N Organisms seen on Gram stain of unspun urine.
CFU 5 colony forming unit; WBC 5 white blood cell.
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Catheter-Associated UTI Prevention 391
Routes of entry of uropathogens to catheterized urinary tract.
FIGURE 19.1
Extraluminal
• Early, at insertion
• Late, by capillary action
Intraluminal
• Break in closed drainage
• Contamination of
collection bag urine
Source: Maki, D. G., & Tambyah, P. A. (2001). Engineering out the risk of infection with urinary
catheters. Emerging Infectious Diseases, 7(2), 342–347. Retrieved from http://www.cdc.gov/ncidod/eid/
vol7no2/makiG1.htm
Stages of catheter use and potential intervention strategies.
• Reminders and
stop orders
• Nursing-driven
removal protocols
• Audit and feedback
• Standardized order sets
Insertion Care Removal
1. Avoidance
2. Evidence-based
care practices and
product selection
3. Minimize duration
4. Education & Surveillance
• Protocols with explicit
criteria
• Utilize alternatives
(e.g., toileting regimens,
urinals, condom catheters,
commodes, absorbent
pads, intermittent
straight catheterization
with bladder scanner)
• Aseptic vs. sterile
insertion technique
• Routine meatal care
• Prevent urine reflux
• Maintain closed system
• Catheter material
• Catheter size
• Securement device
FIGURE 19.2
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392 Evidence-Based Geriatric Nursing Protocols for Best Practice
ASSESSMENT OF THE PROBLEM
Surveillance Definition of Catheter-Associated Urinary Tract Infection Pathogenesis
A CAUTI is a UTI that occurs while a patient has an IUC or within 48 hours of its
removal. Although the clinical diagnosis of CAUTI is in the eye of the clinician, the
CDC has developed explicit surveillance criteria for CAUTI for use by infection control
practitioners. In brief, the patient must have the following symptoms:
1. A positive urine culture sent more than 48 hours after admission to the health care
facility (Table 19.1)
2. An IUC at the time of or within 48 hours prior to the culture
3. One of the following: suprapubic tenderness, costovertebral angle pain or tender-
ness, or a fever higher than 38 °C without another recognized cause; or a positive
blood culture with the same organism as in the urine
�e CAUTI diagnosed within 48 hours of arrival to a location is attributed to the
prior location.
In nonbacteremic cases, this surveillance de�nition requires the patient have symp-
toms referable to the urinary tract or a fever without another cause. ASB is of ques-
tionable clinical signi�cance and should not be treated except in pregnant patients or
those undergoing urologic surgery (Nicolle et al., 2005). For the purposes of infection
control surveillance, new alterations in mental status do not meet the diagnostic crite-
ria for CAUTI.
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 hospital-
acquired infections, among them, many specify reporting of CAUTIs. Such reporting
of CAUTI rates is likely to increase.
Additional process measures that may be of interest include catheter days or hos-
pital days, catheter duration per episode of catheterization (may also be referred to as
dwell time), and proportion of catheterized or admitted patients from the emergency
department (ED) or operating room (OR). Since October 2009, the Surgical Care
Improvement Project collects a measure of postoperative catheter removal on post-
operative Day 1 or 2 and, as of October 2010, has expanded this measure to catheter
removal on catheterization Day 1 or 2 for all surgical patients (Surgical Care Improve-
ment Project, n.d.).
Indications for Indwelling Urinary Catheters
Avoidance of unnecessary IUCs may reduce CAUTI incidence with subsequent decreases
in length of stay, costs of hospitalization, and costs associated with CAUTI (Apisarn-
thanarak et al., 2007). Elpern et al. (2009) evaluated the inappropriate use of IUCs
among inpatients and found them to be more common in female, nonambulatory, and
medical ICU patients. Explicit criteria for appropriate insertion may result in signi�cant
reductions in catheter duration and CAUTI prevalence. �e University of Colorado
Hospital developed and disseminated an algorithm for appropriate insertion of IUCs in
the ED based on guidance from the published literature (Figure 19.3).
Similar criteria can also be developed speci�cally for the OR and postoperative
period. At the University of Colorado Hospital, a protocol for early postoperative
removal was developed and disseminated (Figure 19.4).
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Catheter-Associated UTI Prevention 393
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 appropriate indications, or routinely in
patients receiving epidural anesthesia and analgesia (see Protocol 19.1).
INTERVENTIONS AND CARE STRATEGIES
It is estimated that 20%–69% of CAUTIs are preventable (Gould et al., 2009). Speci�c
interventions to prevent CAUTIs are summarized in the subsequent text and organized
regarding the four strategies illustrated in Figure 19.2. Many of these recommendations
Algorithm for appropriate insertions of indwelling urinary catheters.
Admission/Shift change assessment of Urine Output Management
Is there a need for an indwelling urinary catheter?
YES, the reason appears above.
Insert catheter
NO, the reason does not appear
above. (A catheter may not be
indicated for this patient.)
Re-evaluate continued need
each shift.
Consider removal if indications
no longer met.
Consider:
1. Straight Catheterization (for
Sterile specimen if needed)
2. Commode
3. Urinal
4. Bed pan
5. Incontinence Pads
6. Toileting with assistance
Please read the following criteria for appropriate use of Foley catheter
and check your reason for ordering the Foley catheter for this patient.
Drainage:
# Urinar! •g����i�p•y ,kp��ft ��pyf�! ��fi�)
# Urinar! �l�ly�p•y ,y•� ufyfnlk p�o py�l�up��ly�
if�ol�l�p"f�p•yB
Monitoring:
# at�l�f�p•y py �ol gt••k ��l����l •� �•t�ul ��f���
,�y��fgtl �f�ply�B �l��p�pyn ��pyl �•t�ul ulf���luly�C
# aii��f�l u•yp�•�pyn •m py�fsl fyk •����� py f �f�ply�
�yfgtl �• i••�l�f�l p�o ��pyl i•ttli�p•y g! •�ol� ulfy�C
Periprocedure:
# d�l•�l�f�p�l py�l��p•y m•� lul�nlyi! ���nl�y
# cfr•� ��f�uf �f�ply��
# dtfiluly� g! ��•t•n! m•� ��•ilk��l •� ���nlry
Therapy:
# b•y�py�•�� gtfkkl� p��pnf�p•y
# cfyfnluly� •m ��pyf�! pyi•y�pylyil p�o stage 3 or
greater ��l����l �til�f�p•y�
# b•um•�� if�l m•� �ol �l�upyftt! ptt
FIGURE 19.3
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394 Evidence-Based Geriatric Nursing Protocols for Best Practice
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 “why” behind the clinical indication for the IUC. Clearly identifying the need
for the IUC can assist in the avoidance of inserting an IUC when other options for
Algorithm for postoperative removal of indwelling urinary catheter placed
for surgery
Upon completion of surgery
Can the indwelling urinary catheter be removed?
Indications for Postoperative
REMOVAL of Indwelling Urinary
Catheter
Indications for Postoperative
MAINTENANCE of Indwelling Urinary
Catheter
Consider postoperative removal in OR or PACU
using one of the following alternatives
1. Toileting with Assistance
2. Bladder Scan to assess urine volume
3. Straight Catheterization
4. Incontinence Pads
Re-evaluate in PACU for indications for
continued device use
Drainage: 8 Catheter inserted solely for
anticipated prolonged
duration of surgery
(> 2 hrs)
8 Less than 1500 cc infused
intraoperatively; only small
volume infusions
anticipated postoperatively
Periprocedure: 8 p 2'$2$0 (-1$02$# 1.+$+6 %.0
deflation of urinary
bladder during surgery
Drainage: 8 Anticipated continuous
large volume infusions or
diuretics in the
postoperative period
Monitoring: 8 Accurate postoperative
monitoring of urinary
output
Periproduce: 8 Urologic surgery or other
surgery on contiguous
structures of the
genitourinay tract
Therapy: 8 Need for prolonged
immobilization (e.g.,
potentially unstable
thoracic or lumbar spine,
multiple traumatic injuries
such as pelvic fractures)
8 Prolonged effect of
epidural anesthesia
(inhibiting walking)
YES NO
FIGURE 19.4
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Catheter-Associated UTI Prevention 395
elimination are available. �e use of an algorithm (Figure 19.3) to guide the insertion
decision may be of assistance. To avoid catheterizations, alternative strategies for man-
aging urine output are necessary. Completing a systems evaluation of available equip-
ment to provide alternatives to IUC for urinary elimination is an important �rst step
in reducing use. Developing toileting schedules incorporated with frequent nursing
sta� rounding is another strategy that can be used to reduce urgency and incontinence
episodes.
If the patient is mobile or has limited mobility, alternatives to an IUC include the
use of a bedside commode with a toileting schedule (Gray, 2010), condom catheters for
male patients (Dowling-Castronovo & Bradway, 2008; Saint et al., 2006), moisture-
wicking incontinence pads (BioRelief, n.d.; Cottenden et al., 2005; Medline Ultrasorb
Underpad, n.d.), intermittent straight catheterization with the use of a bladder scanner
to determine bladder urine volume (Hooton et al., 2010; Saint et al., 2006; Saint et
al., 2009), as well as urinals 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 stable (not easy to tip) and bariatric com-
modes; urinals need to �t snugly on bedrails.
For less mobile male patients, the condom catheter is an e�ective alternative to an
IUC. Research by Saint and colleagues (2006) found that the use of condom catheters
for elimination were e�ective in reducing CAUTIs (p 5 .04). In addition, the patients
in this study reported condom catheters to be more comfortable (p 5 2.02) and less
painful (p 5 .02) than an IUC. �e authors did not report an increase in adverse
skin breakdown associated with the use of the condom catheter. Moisture-absorbing
or -wicking underpads for incontinence management are a newer alternative for the
acute care environment. Incontinence underpad products pull e�uent moisture and
urine away from the skin and can absorb up to 2 L of �uid before becoming saturated
(Junkin & Selekof, 2008; Padula, Osborne, & Williams, 2008). For a full discussion of
incontinence management, please refer to Chapter 18, 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 bladder scanner, which utilizes ultrasound
technology, is clinically bene�cial in determining urinary retention, reducing unneces-
sary intermittent catheterizations, enhancing patient comfort, and saving costs associ-
ated with inappropriate catheterizations and possible CAUTIs (Lee, Tsay, Lou, & Dai,
2007; Palese, Buchini, Deroma, & Barbone, 2010; Sparks et al., 2004).
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 ( Johnson,
Kuskowski, & Wilt, 2006), the impact of antimicrobial catheters on symptomatic
CAUTIs remains unproven. Research syntheses have failed to conclusively demonstrate
the e�ectiveness of silver-coated or antibiotic-impregnated catheters on prevention
of CAUTIs for short-term catheterization of adult patients versus standard materials.
�ere is also insu�cient evidence to determine whether selection of a latex catheter, C
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396 Evidence-Based Geriatric Nursing Protocols for Best Practice
hydrogel-coated latex catheter, silicone-coated latex catheter, or all-silicone catheter
in�uences CAUTI risk (Cottenden et al., 2005; Hooton et al., 2010; Parker et al.,
2009; Patient Protection and A�ordable Care Act, 2010; Schumm & Lam, 2008). �e
decision to use a silver-coated or antibiotic-impregnated catheter should be made with
the understanding that it does not substitute for a comprehensive CAUTI prevention
program.
Selecting the smallest IUC size, when possible, is an additional consideration to
reduce the risk of infection (Gould et al., 2009; Greene et al., 2008; Hooton et al.,
2010). �e selection of a smaller catheter (e.g., less than 18 French) reduces irritation
and in�ammation of the urethra and reduces infection risk (Gray, 2010).
Placing an IUC is a fundamental skill for nurses; however, current evidence sup-
porting sterile versus aseptic technique for the procedure is inconclusive (Greene et
al., 2008; JBI, n.d.). Strict sterile technique involves using a sterile gown, mask, pro-
longed hand washing (more than 4 minutes), opening and using a sterile insertion kit,
donning sterile gloves, cleansing the urethral meatus and perineal area with an anti-
septic solution, and inserting the catheter using a no-touch technique (Gray, 2010).
Willson and colleagues (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
insertion. Current recommendations suggest an IUC insertion be placed under asep-
tic technique with sterile equipment (Gould et al., 2009; Greene et al., 2008; Hooton
et al., 2010).
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 bath-
ing with soap and water and as needed (e.g., following a bowel movement; Gould
et al., 2009; Greene et al., 2008; Hooton et al., 2010; Jeong et al., 2010; JBI, n.d.).
Meatal cleansing with antiseptics, creams, lotions, or ointments has been found to
irritate the meatus, possibly increasing the risk of infection (Jeong et al., 2010; Willson
et al., 2009).
Securing the IUC after placement to reduce friction from movement is an impor-
tant element of catheter management supported by current guidelines, researchers, and
expert opinion panels (Darouiche et al., 2006; Gould et al., 2009; Hooton et al., 2010;
Society of Urologic Nurses and Associates Clinical Practice Guidelines Task Force,
2006). Maintaining a closed catheter system is also supported by current guidelines
(Gould et al., 2009; Greene et al., 2008; Hooton et al., 2010) to eliminate the intro-
duction 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
minimizes re�ux into the catheter itself preventing retrograde �ow of urine (Gould
et al., 2009; Greene et al., 2008; Hooton et al., 2010). Establishing work �ow protocols
to routinely empty the drainage bag frequently and prior to transport are important 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 Co
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Catheter-Associated UTI Prevention 397
( Apisarnthanarak et al., 2007; Fernandez, Gri�ths, & Murie, 2003; Loeb et al., 2008;
Meddings, Rogers, Macy, & Saint, 2010). Meddings and colleagues (2010) conducted a
systematic review and meta-analysis and found that urinary catheter removal reminders
and stop orders appeared to reduce CAUTI rates. Implementing systems that provide
physicians and nurses routine reminders to evaluate the need for the IUC were found
to reduce the CAUTI rate by 56% (p 5 .005). In this study, automatic stop orders were
found to reduce the rate of CAUTI by 41% (p , .001). Overall, urinary catheter use
and mean duration of catheterization were also decreased in several studies analyzed
(Meddings et al., 2010).
Other valid approaches to reducing catheter days include audit and feedback
(Goetz, Kedzuf, Wagener, & Muder, 1999) and nurse-prompted reminders to recom-
mend reevaluation of the need for the IUC and early removal (Apisarnthanarak et al.,
2007; Greene et al., 2008). Some hospitals have explored nurse-driven catheter removal
protocols (Wenger, 2010).
Multiple studies have examined outcomes associated with early removal of IUCs
after surgery. Early removal of IUCs after uncomplicated hysterectomy decreased �rst
ambulation time and length of hospital stay (Alessandri, Mistrangelo, Lijoi, Ferrero, &
Ragni, 2006). Dunn, Shlay, and Forshner (2003) found that early removal postsurgery
was not associated with adverse events in patients and subjective pain was signi�cantly
less. Keeping the IUC as long as thoracic epidural analgesia is maintained may result in
a higher incidence of CAUTI and increased hospital stay. IUC removal on the morn-
ing after surgery while the thoracic epidural catheter is still in place does not lead to
urinary retention, infection, or higher rates of recatheterizations (Basse, Werner, &
Kehlet, 2000; Chia, Wei, Chang, & Liu, 2009; Ladak et al., 2009; Zaouter, Kaneva,
& Carli, 2009).
Strategy 4: Surveillance and Education
Ensuring leadership of organizations and systems are in place to e�ectively evaluate
and sustain practice change are essential to improving patient outcomes (Kabcenell,
Nolan, Martin, & Gill, 2010; Reinertsen, Bisognano, & Pugh, 2008). In particular,
surveillance is key to an e�ective infection control program. Metrics that are ame-
nable to performance measurement and feedback are discussed in the Assessment of
the Problem section and include process measures as well as outcomes. A 2005 sur-
vey demonstrated that only a minority of hospitals track urinary catheter use (Saint
et al., 2008).
Measurement must be accompanied by provision, knowledge, and skills to front-
line providers through appropriate education and training, which may be central
to a multicomponent CAUTI intervention. Huang et al. (2004) found that a mul-
tifaceted educational intervention incorporating the use of algorithms, automated
stop orders, and physician reminder prompts needed to be critically evaluated to
e�ectively decrease CAUTIs in all patients. 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. 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).Co
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398 Evidence-Based Geriatric Nursing Protocols for Best Practice
Approach to a Comprehensive Catheter-Associated Urinary Tract Infection Intervention
Evidence-based practice guidelines derived from valid, current research and other
evi dence 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 and safe care (Drekonja, Kuskowski, & Johnson, 2010).
To e�ectively facilitate the translation of best evidence into practice, processes
enhancing practice change must be embraced by the health care provider (Wallin,
Profetto-McGrath, & Levers, 2005). Understanding health care provider decisions,
experiences, practice processes, and barriers are considered essential elements that
must be explored to successfully implement practice change based on best evidence
(Titler & Everett, 2006).
Developing an interdisciplinary champion team and creating a multifaceted inter-
vention 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 cath-
eter 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 in the subsequent text. 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,
OR registered nurses [RNs], ED RNs); physicians (hospitalists, infectious disease
ED medical doctors [MDs], surgeons, anesthesiologists); rehabilitation therapists
and transport personnel; infection control preventionists; and quality improve-
ment, central supply, and clinical informatics 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 set-
ting. Re�ne product use based on the best evidence and cost analysis. Examine the
following:
N Urinary catheter materials, sizes, kits, and drainage bags
N Catheter securement device
N Urinals and bedpan availability
N Commodes (availability and size)
N Bladder scanners
N Alternatives (incontinence pads, condom catheters, etc.)
4. Identify barriers to optimal IUC care practices by surveying sta� or holding focus
groups throughout your health care setting.
5. Update your policy and procedures related to indwelling catheter insertion and care
based on the evidence.
6. Consider breaking 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, whereas removal occurs on inpatient �oors.
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Catheter-Associated UTI Prevention 399
7. Develop and use algorithms, decision aids, and factoid posters displaying evidence-
based caveats.
8. Update patient and family educational materials on the importance of prompt and
early removal of indwelling catheters.
9. Educate sta� (including radiology, transport, rehabilitation therapy sta� [PT,
physical therapist; OT, occupational therapist]) focusing on policy and pro-
cedure revision, insertion indication guidelines, insertion procedures, mainte-
nance and care, catheter bag placement, removal prompts, and bladder scanner
use and procedures.
10. Work with infection control and clinical informatics sta� to audit and measure
outcomes. Provide feedback to sta�. Potential measurable outcomes include the
following:
N CAUTIs/1,000 catheter days
N Catheter days and hospital days
N Postoperative catheter days and patient days
N Proportion of catheterized and admitted patients from ED or OR
11. Continually evaluate and update practice changes.
Mr. T is an 84-year-old male with a history of Alzheimer’s disease and incontinence
presenting to your hospital with failure to thrive. �e patient arrives to the medical
�oor with an IUC that was placed in the ED. Given the patient’s incontinence and
fall risk, the urinary catheter is left in place. �ree days after admission while awaiting
placement in a skilled nursing facility (SNF), he develops fever and delirium and is
diagnosed with a UTI. �is delays his transfer to the SNF.
Questions to Consider
1. Was the catheter placement medically indicated?
2. What could have been used as alternatives to indwelling catheter placement?
Discussion
Because incontinence and fall risk are not medically appropriate indications for a
urethral catheter, 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, incontinence pads or
diapers, or a condom catheter. Attentiveness 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.
CASE STUDY 1
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400 Evidence-Based Geriatric Nursing Protocols for Best Practice
SUMMARY
A rapidly changing evidence base and regulatory environment necessitates a renewed
focus on the prevention of CAUTI, which is informed by an understanding of CAUTI
pathogenesis and rational IUC use. Critical elements of a CAUTI prevention program
include maximizing catheter avoidance, ensuring evidence-based practice and product
use, and timely catheter removal. Additional strategies include sta� education, continu-
ing monitoring of CAUTI incidence, and catheter use. Multicomponent interventions
have been used successfully in the prevention of CAUTIs.
Mrs. G is a 69-year-old alert female with a diagnosis of nonsmall cell lung cancer is
admitted for a thoracotomy. �e patient is transferred from the postanesthesia care
unit (PACU) to the surgical intensive care unit (ICU) with an IUC that was placed
in the OR and a thoracic epidural for pain management with morphine and bupi-
vacaine infusion. Mrs. G is doing well 48 hours postoperatively, experiencing little
pain, and is able to cough and deep breathe. She 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 catheter before
removing the urinary.
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?
Discussion
�e IUC was probably indicated because of length of surgery (more than 2 hours)
and need for accurate monitoring for intake and output. �e misnomer that the IUC
needs to be in place as long as the thoracic epidural remains for pain management pur-
poses needs clari�cation. Multiple studies have supported IUC removal on the morn-
ing after surgery to decrease CAUTI risk (Basse et al., 2000; Chia et al., 2009; Ladak
et al., 2009; Zaouter et al., 2009). Early removal does not lead to urinary retention or
higher rates of recatheterization. Post-IUC removal, toileting with assistance, use of
a bedpan or urinal, placement of an incontinence pad or use of a bladder scanner for
post void residual volume assessment, and use of straight catheterization if indicated
are alternatives.
CASE STUDY 2
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Catheter-Associated UTI Prevention 401
Protocol 19.1: Prevention of Catheter-Associated
Urinary Tract Infection Prevention
I. GOALS: To ensure that nurses in acute care are able to:
A. De�ne catheter-associated urinary tract infection (CAUTI)
B. Understand the epidemiology of CAUTI
C. De�ne indications for indwelling urinary catheters (IUC)
D. Identify evidence-based strategies and interventions for the prevention of
CAUTI
E. Understand how to engage an interdisciplinary team in the management of
CAUTIs in your setting
II. OVERVIEW
A. CAUTIs are the single most common hospital-acquired infection (HAI),
accounting for 34% of all HAIs and associated with signi�cant morbidity and
excess health care costs.
B. Since 2008, the Centers for Medicare and Medicaid Services (CMS) no longer
reimburse for additional costs required to treat nosocomial urinary tract infec-
tions (UTIs).
C. Between 2008 and 2010, at least six evidence-based practice strategies, recom-
mendations, 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 AND STATEMENT OF PROBLEM
A. Introduction
1. �ere are more than 500,000 UTIs in the United States annually. At a
mean cost of $589 per episode, this epidemic results in $250 million of
excess health care costs each year.
2. Most UTIs are associated with the ubiquitous IUC, also known as a Foley
catheter.
3. According to the Infectious Diseases Society of America, 21%–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 symp-
toms with no other recognized cause: fever (higher than 38 °C), urgency,
frequency, dysuria, or suprapubic tenderness and positive urine culture (see
Table 19.1).
2. Asymptomatic bacteriuria. A positive urine culture in a patient who does not
have 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 or
within 48 hours of its removal.
NURSING STANDARD OF PRACTICE
(continued)
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402 Evidence-Based Geriatric Nursing Protocols for Best Practice
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 extralu-
minal 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 extraluminal 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 previously provide the rationale for evidence-
based care of IUCs. Four potential opportunities for intervention include
the following:
a. Avoid the use of catheters
b. Evidence-based care practices and product selection
c. Timely removal
d. Education and surveillance
IV. ASSESSMENT OF CAUTI
A. �e Centers for Disease Control and Prevention (CDC) has developed explicit
surveillance criteria for CAUTI. In brief, the patient must have the following:
1. A positive urine culture (see Table 19.1) sent more than 48 hours after
admission to the health care facility
2. An IUC at the time of or within 48 hours prior to the culture
3. One of the following: suprapubic tenderness, costovertebral angle pain or
tenderness, or a fever higher than 38 °C 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 and hospital days
b. Postoperative catheter days and patient days
c. Proportion of catheterized and admitted patients from emergency
department (ED) or operating room (OR)
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 evi-
dence-based care strategies.
A. Catheter Avoidance
1. Established insertion guidelines for ED and OR
2. Alternative strategies to manage urine output available:
a. Bedside commodes
b. Condom catheters
(continued)
Protocol 19.1: Prevention of Catheter-Associated
Urinary Tract Infection Prevention (cont.)
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Catheter-Associated UTI Prevention 403
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 is controversial:
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 catheter, 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.
6. Maintain a closed system at all times.
7. Keep drainage bag below level of bladder.
8. Empty the bag when two-third full and before transport.
C. Timely Removal
1. Systems that prompt providers to review the need for the catheter and
encourage early removal. Examples include stop orders and reminder sys-
tems: audit and feedback, nurse-prompted reminders, and nurse-driven
removal protocols.
2. Measure of removal: Surgical Care Improvement Project (SCIP), SCIP-9
measure; catheter removal on postoperative Day 1 or 2.
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 AND 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
Protocol 19.1: Prevention of Catheter-Associated
Urinary Tract Infection Prevention (cont.)
(continued)
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404 Evidence-Based Geriatric Nursing Protocols for Best Practice
5. Post residual void after catheter removal if patient is unable to void in
6–8 hours; bladder volume; intervention.
C. Catheter Utilization
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.
Protocol 19.1: Prevention of Catheter-Associated
Urinary Tract Infection Prevention (cont.)
ACKNOWLEDGMENTS
�e authors would like to thank the New York University (NYU) librarians for their
evidence-based search and Karis May for assistance with the formatting of this chapter.
RESOURCES
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prevention interventions in acute and long-term care settings.
http://www.apic.org/Content/NavigationMenu/PracticeGuidance/APICEliminationGuides/CAUTI_
Guide_0609.pdf
Centers for Disease Control and Prevention. (2009). Guideline for prevention of catheter- associated
urinary tract infections, 2009.
http://www.cdc.gov/hicpac/CAUTI/001_CAUTI.html
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & Healthcare Infection
Control Practices Advisory Committee. (2009). Guideline for prevention of catheter- associated
urinary tract infections 2009.
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009�nal.pdf
Hooton, T. M., Bradley, S. F., Cardenas, D. D., Colgan, R., Geerlings, S. E., Rice, J. C., . . . Nicolle,
L. E. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in
adults: 2009 international clinical practice guideline from the Infectious Diseases Society of America.
http://www.idsociety.org/content.aspx?id=4430#uti
International Continence Society (International Consultation on Incontinence Committee [an inter-
national group of continence researchers])
http://www.icso�ce.org
Joanna Briggs Institute
http://www.joannabriggs.edu.au/about/home.php
Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America
(SHEA-IDSA). (2008). Compendium of strategies to prevent healthcare-associated infections in
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http://www.shea-online.org/about/compendium.cfm
Wound, Ostomy, and Continence Nurses Society Evidence-Based Report Card (EBRC)
http://www.wocn.org/
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Catheter-Associated UTI Prevention 405
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Evidence Level IV.
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