Urinary tract infections are the most common Healthcare Associated Infections in the United States. Each year there are over 560,000 reported Urinary Tract Infections⁵. Over 75% of these Urinary Tract Infections are directly associated with a urinary catheter⁵. In the United States over 30 million indwelling catheters are inserted annually⁷. However, it is estimated that inappropriate catheter use in Acute Care Hospitals ranges from 21% to over 50%¹³. Healthcare providers nationwide have been slow to implement comprehensive Catheter Associated Urinary Tract Infection (CAUTI) reduction programs.

The single most effective way to reduce the amount of Catheter Associated Urinary Tract Infections in a healthcare organization is to reduce the amount of unnecessary urinary catheters³. Therefore, it is crucial to only insert catheters when absolutely necessary and to remove catheters promptly when they are no longer indicated. Although this seems obvious, understanding the indications for catheter use is crucial to reducing unnecessary urinary catheters.

The evidence based indications for indwelling catheters are:

• Patient has acute urinary retention or bladder outlet obstruction⁵.
• There is a need for accurate measurements of urinary output in critically ill patients and the patient cannot use a urinal or bedpan⁷.
• Perioperative use for selected surgical procedures⁵:
  • Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract.
  • Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in the Post Anesthesia Care Unit).
  • The patient is anticipated to receive large-volume infusions or diuretics during surgery⁷.
• Need for intraoperative monitoring of urinary output⁹.
• Major trauma or the management of Stage III pressure ulcers (especially in perineal region)⁵.
• To assist in healing of open sacral or perineal wounds in incontinent patients.
• Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)⁸.
• To improve comfort for end of life care if needed⁵.

Listed below are several common reasons for catheter insertion that are not supported by research and evidence.

• Fall prevention – there is no evidence that catheter insertion can reduce falls and no evidence that catheter insertion to reduce fall risk improves patient safety^{5, 3}.
• Routine Urine Specimens – although this may save health care provider time, it is an unnecessary reason for a catheter insertion¹².
• Staff / Patient Request – Catheter insertion should only be performed when indicated and necessary⁵.
• Excoriated Skin – Rather than a catheter insertion (and the risk of a CAUTI) alternative interventions may be necessary.
• Altered Mental Status – Unless other indications exist, an altered mental status is not a proper indication. Recent studies have found that catheter insertions for patients with delirium have been associated with a higher risk of falls and subsequent catheter dislodgement and urethral trauma³.
• As a substitute for nursing care of the patient or resident with incontinence⁵.

A note on external catheters:
External catheters have been found to have a lower rate of associated urinary tract infections than indwelling catheters in male patients with temporary or chronic urinary incontinence². Mechanical failures can significantly increase the risk of external catheter associated urinary tract infections^5,12. Mechanical failures can include: tubes becoming tangled, urine not flowing to the collection device correctly, or the catheter become unsecured. Typical use times range from 7 to 72 hours and non-latex options do exist for patients with suspected latex allergies².

Risk factors for Catheter Associated Urinary Tract Infection:
Listed below are several risk factors that correlate to a higher risk of a catheter associated Urinary Tract Infection:

• Prolonged Catheterization (> 6 Days)
  • Bacteriuria has been found to be nearly universal after 30 days of catheterization¹.
• Female Gender ^{5, 3}.
• Catheter was inserted outside of the operating room.
• Other sites of infection.
• Catheter care violations (issues in aseptic technique during insertion and maintenance).
• Patients with impaired immune systems.
• Elderly patients (> 65 years old).

Inserting a Catheter:
If the health care provider team has determined that an indwelling catheter is indicated, then proper insertion practices must be followed in order to minimize the risk of infection. Proper insertion practices should be taught to each member of the staff that is involved with a catheter insertion. Associated staff members should be regularly tested in order to show compliance with all steps of a catheter insertion process⁵. The proper insertion process may include:

• Proper hand hygiene is required for all staff members involved in a catheter insertion or manipulation of any kind. Proper hand hygiene is the single most effective way to reduce the bacteria transmission from staff member to patients⁵.
• Health care team members who have been trained and tested in regards to aseptic catheter insertion and maintenance should be the only individuals authorized to perform a catheter insertion or educate a patient^{5, 7}.
• Complete aseptic technique and sterile equipment must be used. This can include: sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion⁷.
• In order to prevent movement or possible urethral traction, indwelling catheters should be properly secured⁵.
• If a portable ultrasound device is available, it can be used to assess urine volume in patients undergoing intermittent catheterization. Assessing urine volume can help reduce potentially unnecessary catheterizations⁵.
  • Note: if Ultrasound devices are utilized ensure that the staff is properly trained in their use, their use is clearly indicated, and that the equipment is properly cleaned and disinfected between patients ³.
• The smallest bore catheter should be used that will allow good drainage and minimize urethral trauma while being large enough to prevent any leakage.
• Closed drainage systems are recommended. They reduce the chances for damage to the catheter, and reduce the amount of situations where a health care provider must break the system for a task (taking a metered urometer reading for hourly analysis in a system without a metered drainage collection device) ⁵.

Once the catheter has been correctly inserted, the catheter must then be properly maintained until it can be removed. Again, a closed drainage system is recommended in that it can reduce the amount of system manipulation needed by the health care team. If a break in aseptic technique (at any point during insertion or maintenance), catheter disconnection or dislodgement, or a leakage occurs, replace the catheter and collection system using aseptic technique ^{5, 7}. Other evidence based maintenance points include:

• Maintain unobstructed urine flow at all times ⁴.
• The catheter and collecting tube should be unkinked at all times ⁵.
• The collecting bag should be lower than the level of the bladder. Do not rest on the floor (bacteria risk) or set the bag in between a patient’s legs during transport. The bag should not be hung over a patients chair, headboard, or walker. The bag should constantly be lower than the level of the bladder.
• The collection bag should be emptied regularly using a separate clean collecting container for each patient ⁷ . Splashing should be avoided and be careful to avoid contact between the drainage spigot and the collection container. All standard precautions should be practiced: hand washing before and after, gloves, gowns, etc.
• Systemic antimicrobial use as a routine UTI prevention method should be avoided unless a clinical indication exists ¹. When possible, the indwelling catheter should be removed, and the patient should receive clean intermittent catheterization to reduce the risk of symptomatic UTI ⁵. A possible clinical indication for antimicrobial treatment could be: high risk patients with bacteriuria upon catheter removal.
• Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is still in place ^{5, 7}. Cleaning the metal surface during daily bathing or showering is appropriate.
• Should obstruction occur and it is likely that the catheter material is contributing to obstruction, the catheter should be changed ⁷.
• All urine samples should be obtained aseptically ^{1, 9}.
• Urine can be aspirated from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant.
• Large volumes of urine can be obtained aseptically from the drainage bag ⁵.
• Drainage bags and catheters should only be changed based on clinical indications (rather than at regular pre-determined intervals) ^{5, 7, 4}. Clinical indications for a change could be: obstruction or when the closed system is compromised ⁷.

During the maintenance stage of catheter use, the continual need for the catheter must be continually reviewed. A note or alarm in the patient’s chart could require the nurse to continually review the need for a catheter during routine rounds. If there are no longer any indications for the continual need of a catheter, the nurse should then begin the process for the removal of the catheter (depending on the process of the health care institution, a physician order may be necessary). These types of reminder practices and systems have been found to significantly reduce the duration of indwelling catheters. Some potential indications for the continued use of an indwelling catheter may be:

• The patient has a pelvic fracture or pelvic crush injury ³.
• The patient has a head injury.
• The patient is chemically paralyzed or sedated.
• The patient has an epidural catheter.
• Intake and output is needed for patients who are hemodynamically unstable or on strict hourly urine outputs ⁷.
• Assistance in pressure ulcer healing for incontinent patients ⁵.
• Inability to void or urine retention.

Again, the continual need for a catheter should be regularly reviewed by the health care provider team and the removal of a catheter should be recommended once it is no longer indicated. The most significant risk factor of Catheter Associated Urinary Tract infections
is the prolonged use of a catheter ⁵.

Implementing a Quality Improvement Program in order to reduce the rates of CAUTI’s:

Urinary Tract Infections are the most prevalent healthcare acquired infections in the United States health care system. The Joint Commission’s National Patient Safety Goals for 2014 identified reducing the CAUTI rates as a key patient safety improvement focus for the coming years ¹¹.

A successful reduction program will:

• Create, implement and enforce evidence-based written guidelines for catheter use, insertion, maintenance, and removal. Buy-in will be needed from all levels of staff (physicians, nurses, transport staff, etc.)
• Consider the education needs of all involved providers.
• Ensure that catheters are being utilized only when clinically indicated.
• Incorporate the above listed aseptic methods, best practice techniques, and hygiene practices for insertion and maintenance.
• Ensure that catheters are only being inserted by trained and dedicated personnel.
• Implement a system for documenting the indications for catheter insertion, date and time of catheter insertion, the name of the individual who inserted the catheter and the date and time of catheter removal. This documentation should be accessible in the patient record and recorded in a standard format for measurement purposes.
• Empower healthcare teams to review, identify, and remove catheters that are no longer indicated. A change in viewpoints could be: Trying to identify opportunities for catheter removal in patients with indwelling catheters.
• Provide regular feedback to staff on the process and outcomes of the program.
• Regularly monitor and measure the outcomes of the program.

In the event that you are trying to launch a new (or update an old) nursing driven CAUTI prevention program, it is crucial to have the buy-in (support) of a physician in a leadership role. This could be an Epidemiologist, Infectious Disease Physician, Urologist, or Chief Medical Officer. Early physician support will help in the presentation (the “pitch”) of your program. There are four crucial points to remember for launching a nursing driven program:

• Early support and engagement from a physician champion. “Champion” indicates a physician in a leadership role (and/or a senior nursing leader) who supports the initiative and can help steer the initiative through red tape and hospital leadership approval.
• Data is crucial. When launching a new initiative the data should clearly identify the problem and establish the baselines through which the program will be measured.
• Prior to implementation, the program must be approved by nursing leadership and appropriate physicians. Although it is exciting to just jump in and do it, having the support of the appropriate leadership will only help a program grow.
• Even though the program will be nursing driven, physicians and nurses should still discuss out of the ordinary cases. This helps establish a team atmosphere in which both physicians and nurses are working together to eliminate CAUTI.

Performance Metrics:
Measuring the outcomes of a CAUTI prevention program is crucial to determining the efficacy of the program and for identifying areas for improvement. Routine measurement and surveillance can help leadership teams identify whether CAUTI cases are increasing or decreasing in high risk or high use areas, specific departments, during specific shift times, or organization wide. Listed below are several metrics being used and compared by health care leaders nationwide in order to calculate the monthly rate of CAUTI in a specific area for a specific time period.

• Numerator: Number of new CAUTI cases in the area in the time period.
• Denominator: Number of Urinary Catheter days in the area in the time period. (We can think of Urinary Catheter days as each day that a patient has Urinary Catheter. To accurately produce this number, count the total number of patients with urinary catheters at the same time each day.)
• (# of new CAUTI cases in the area in a time period) / (# of Urinary Catheter days in the same area in the same time period) X 1,000.

The above listed rate is a NHSN rate that can be used for comparing the performance or organizations or units. Since Urinary Catheter Days is the denominator, patient safety interventions reducing the amount of total Urinary Catheter Days (Removal programs, stop orders, nursing driven catheter reviews) have the potential to increase the NHSN CAUTI rate.

Without question, reducing unnecessary catheter usage is the evidenced based practice. Recognizing this, the Agency for Health Care Research and Quality (AHRQ) has recommended also taking into account the population based CAUTI rate when reviewing the performance of specific programs. This would be calculated by:

• Numerator: # of CAUTI episodes occurring during a specific time period in a specific area.
• Denominator: # of patient-days during the same time period and in the same area.
• Multiply by 10,000
• Example: (# of CAUTI episodes occurring during a specific time period in a specific area) / (# of patient days during the same time period and in the same area) X 10,000

Compliance with educational programs is a crucial factor in reducing the amount of CAUTI occurrences.⁵ In order to calculate the percentage of personnel who have proper training:

• Numerator: Number of personnel who insert urinary catheters who have the proper training.
• Denominator: Number of personnel who insert urinary catheters.
• (# of personnel who insert urinary catheters who have the proper training) / (# of personnel who insert urinary catheters) X 100

The rate of bloodstream infections secondary to CAUTI is also a valid metric in that blood stream infections secondary to CAUTI are negative patient safety outcomes that lead to increased mortality and lengths of stay ⁵.

• Numerator: Number of episodes of blood stream infections secondary to CAUTI.
• Denominator: Total number of urinary catheter days for all patients that have an indwelling urinary catheter.
• (# of episodes of blood stream infections secondary to CAUTI) / ( Total # of urinary catheter days for all patients with an indwelling catheter) X 1,000

A standardization factor of 1,000 is used for the National Healthcare Safety network rates due to the desire the view the rates in cases per 1,000 catheter days. The National Healthcare Safety Network is a division of the Centers for Disease Control and Prevention and is the most widely used healthcare associated infection tracking system in the United States. Their system allows healthcare organizations to track and improve their internal processes by examining the national performance benchmarks.

Urinary tract infections are the most common healthcare associated infections in the United States. As such it is crucial for health care teams to implement, measure, and improve their internal processes and systems in order to create settings that continue to promote comprehensive patient safety. Nursing driven programs should be a vital part of the initiative within an organization to eliminate catheter associated urinary tract infections.

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