Catheter-associated urinary tract infections

Education, product and teamwork help Mercy Medical Center reduce CAUTIs

Editor’s Note: In the United States, 75 percent of all healthcare-acquired infections are either urinary tract infections, surgical site infections, bloodstream infections or pneumonia, according to The Joint Commission. Experts believe that many of these infections are largely preventable when evidence-based practices are followed consistently over time. Recently a joint “call to action” to move toward the elimination of healthcare-acquired infections was set forth by a number of organizations, including the Centers for Disease Control and Prevention, the Association for Professionals in Infection Control and Epidemiology, the Society for Healthcare Epidemiology of America, and the Infectious Diseases Society of America. Understanding and tackling healthcare-acquired infections is a complex process. Although contracting executives won’t be clinical experts on the topic, they can play an important role in the fight against infections. In Part 1 of a multipart series on infection control topics, the Journal of Healthcare Contracting focuses on central-line-associated bloodstream infections.

Striving for a 50 percent reduction in catheter-associated urinary tract infections is not an unrealistic goal, says Rich Lyon, BA, MA, JD, RN, CIC, infection control coordinator for Mercy Medical Center in Canton, Ohio. But for Lyon and the team at Mercy, it’s only the beginning.

“We’ve nearly reached that goal [of 50 percent reduction], and have set our targets on ‘zero tolerance,’” says Lyon. In the meantime, he and the Mercy team are watching with pride the steady downward curve of the incidence of CAUTIs in their facility.

A catheter-associated urinary tract infection is caused by germs that enter the urinary system through a catheter that has been inserted into the bladder to drain urine, according to Partnership for Patients, a public-private entity created in April 2011 by the Department of Health and Human Services in an attempt to make hospital care safer and less costly. These infections affect the bladder, and may also affect the kidneys. Urinary catheters are used in almost all hospital patients receiving major surgery and in many other situations. In recent years, up to 560,000 healthcare-associated urinary tract infections have occurred annually, 40 percent of which are preventable, according to Partnership for Patients.

“Patient safety concern alone is a good enough reason to establish protocols to reduce the incidence of CAUTIs, but now there is definitely a financial incentive as well,” says Michelle Christiansen, MS, PA, clinical resource team, urology, Medline Industries Inc. “CAUTI can have a significant impact on a health system’s bottom line and, given the frequency of these infections, costs add up quickly.

“Research shows that CAUTI increases hospital costs and length of stay,” continues Christiansen, whose company offers the ERASE CAUTI program, which encompasses education, a new tray design, and implementation process. “Research also shows that these infections can, in some cases, be deadly.”
CAUTIs are patient-safety indicators and are publicly reported, says Christiansen. What’s more, as of 2008, these preventable infections are no longer reimbursable by the Centers for Medicare & Medicaid Services, as a result of the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005. “Hospitals and patient care providers are under more pressure than ever to prevent CAUTIs, and their rates need to be trending towards zero,” she says.

CAUTI reduction program
Mercy’s efforts to eradicate catheter-associated urinary tract infections began in late fall 2011, explains Lyon. “We were dissatisfied with our own performance compared with the [National Healthcare Safety Network] measures,” he says. (The NHSN is a Centers for Disease Control and Prevention reporting program, which allows healthcare facilities to electronically share information regarding the safety of patient and healthcare personnel.)

The hospital established a CAUTI reduction team, which included infection control, nursing and urology. Step 1 was to review where Mercy stood with UTI events during the previous 12-month period, says Lyon. Step 2 was to talk with Mercy’s prime vendor, Medline Industries, about potential solutions, including the company’s one-layer Foley catheter kit.

Older kits stack their components, so that the nurse must take them out, stack them somewhere on the sterile field, and retrieve them as needed, explains Lyon. “That’s inconvenient for the nurse, and nurses have so much more to do now than they did in the past.” In contrast, Medline’s kit is in one layer, so nurses don’t have to stack or unstack anything.

Choosing a catheter wasn’t difficult, he says. “We wanted to go latex-free, which we had prior to this. And we wanted silver-coated catheters because of their antimicrobial action.” Medline offered both, and Mercy proceeded to trial the kit in three patient care units.

After a successful trial, the new product (and mandatory training program) was rolled out to the rest of the hospital. A baseline of CAUTI occurrence data had already been collected prior to the changes, so patient care managers and directors could see their performance on a unit-by-unit basis.

Lyon was especially attracted to the ERASE CAUTI online training program. All staff involved in inserting Foley catheters or in Foley catheter care were instructed to view the online training modules and take tests on the material presented. They were able to access the modules via terminals at the hospital (including those in the medical library) and on their home computers.

After three or four days, each additional day that a Foley catheter is in, the risk of infection increases by 5 to 8 percent, says Lyon, citing studies. So Mercy stressed education on insertion technique, particularly in the emergency department and the OR. In the ICU, where many catheter-associated urinary tract infections occur, the emphasis was on post-insertion catheter care. That means cleaning of the insertion site at least daily, and more if the patient’s condition necessitates it; and discontinuing catheterization as soon as possible.

“With any major change in products, you will often encounter misgivings or resistance by the end-user staff,” says Lyon. “It is crucial that they be provided adequate product change rationale and support training to help ease the transition.” In fact, when asked to identify the single most important factor in Mercy’s success in reducing CAUTIs, he answers, “Education, education, education, reinforcement and continual performance feedback to the nursing staff and physicians.”

Physicians and patients
Nurses and OR techs aren’t the only ones involved in Mercy’s CAUTI reduction program. Physicians and patients are part of the program as well.

“Studies have shown that often physicians don’t know a Foley has been placed in a patient, or that its use has been continued beyond necessity,” says Lyon. That’s why, after 48 hours of catheterization, Mercy places a reorder sheet, which reminds the doctor that a catheter’s additional usage time must be ordered.

Patients themselves can play a role in reducing catheter-associated urinary tract infections, he continues. “It is important that the patient understand why the Foley is being used, how it must be cared for, and that it needs to be removed as soon as circumstances will allow,” he says. The ERASE CAUTI kits include a patient education card which explains, in English and Spanish, why the Foley has been used and if it’s still needed.

“This education card encourages a patient to become an advocate in their own care,” says Christiansen. The card reviews information such as, “What is a urinary catheter?” and “What you should know about your catheter.” It also reviews ways the patient can reduce the risk of acquiring a catheter-associated urinary tract infection, including washing their hands and asking their doctor daily if the catheter is still clinically needed. “If the catheter can be removed from the patient when it is no longer needed, their risk of getting an infection is dramatically decreased.

“One of the biggest misconceptions regarding catheterization is that nothing can be done to prevent CAUTI, because the colonization of bacteria is inevitable,” she says. “Going up against that mindset is quite the obstacle.”

But with training, teamwork and the right products, hospitals and patients can overcome it.

Sidebar 1:
New CAUTI patient safety goal

The Joint Commission’s newest National Patient Safety Goal addresses catheter-associated urinary tract infections

The Joint Commission established its National Patient Safety Goals (NPSGs) in 2002 to help accredited organizations address specific areas of concern in regard to patient safety. The first set of NPSGs was effective Jan. 1, 2003.
The organization approved one new National Patient Safety Goal (07.06.01) for 2012, addressing catheter-associated urinary tract infection for the hospital and critical access hospital accreditation programs.
The NPSG calls on providers to implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections, and refers providers to guidelines established by the Society for Healthcare Epidemiology of America and the Centers for Disease Control and Prevention. Following is from the goal.

Elements of performance for NPSG.07.06.01

  1. During 2012, providers should plan for the full implementation of the NPSG by Jan. 1, 2013, says The Joint Commission. Planning may include a number of different activities, such as assigning responsibility for implementation activities, creating time lines, identifying resources, and pilot testing.
  2. Insert indwelling urinary catheters according to established evidence-based guidelines that address the following:
    • Limiting use and duration to situations necessary for patient care.
    • Using aseptic techniques for site preparation, equipment and supplies.
  3. Manage indwelling urinary catheters according to established evidence-based guidelines that address the following:
    • Securing catheters for unobstructed urine flow and drainage.
    • Maintaining the sterility of the urine collection system.
    • Replacing the urine collection system when required.
    • Collecting urine samples.
  4. Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-volume areas by doing the following:
    • Selecting measures using evidence-based guidelines or best practices.
    • Monitoring compliance with evidence-based guidelines or best practices.
    • Evaluating the effectiveness of prevention efforts.

Note: Surveillance may be targeted to areas with a high volume of patients using in-dwelling catheters. High-volume areas are identified through the hospital’s risk assessment as required in IC.01.03.01, EP 2.

A panel of patient safety experts advise The Joint Commission on the development and updating of NPSGs. This panel, called the Patient Safety Advisory Group, is composed of nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of health care settings.

Source: The Joint Commission,

Sidebar 2:
On the CUSP

The Centers for Disease Control and Prevention estimates that roughly 2 million healthcare-associated infections occur each year in U.S. hospitals. These infections are said to result in approximately $40 billion in excess healthcare costs and as many as 99,000 deaths.

In 2009, the Department of Health and Human Services launched the HHS Action Plan to Prevent Healthcare-Associated Infections. As part of this plan, the Agency for Healthcare Research and Quality increased support for and scope of a project funded in 2008 to reduce central line-associated bloodstream infections, and funded a second initiative to reduce catheter-associated urinary tract infections. Both of these projects, “On the CUSP: Stop BSI” and “On the CUSP: Stop CAUTI,” apply the Comprehensive Unit-based Safety Program (CUSP) to improve the culture of patient safety and implement evidence-based best practices to reduce the risk of infections.

On the CUSP: Stop CAUTI
In 2007, the Michigan Health and Hospital Association Keystone Center for Patient Safety & Quality implemented a project to reduce CAUTI, the most common of all healthcare-associated infections, in 163 inpatient units in 71 Michigan hospitals. The project implemented two separate bundles, one of which emphasized the timely removal of nonessential catheters and the proper care of necessary catheters, while the second bundle addressed the insertion of catheters, that is, appropriate indications and proper insertion technique. Participating hospitals achieved a reduction in indwelling catheters from 19 percent to 14 percent between January 2007 and December 2010, resulting in an estimated 26 percent reduction of patients with urinary catheters and a 30 percent improvement in appropriate catheter use.

The national “On the CUSP: Stop CAUTI” effort began in 2009 with support from the Agency for Healthcare Research and Quality. Its goal was to reduce mean rates of catheter-associated urinary tract infections in participating clinical units by 25 percent. “Stop CAUTI” looks to the work of the MHA Keystone Center as a model and uses the CUSP framework developed at Johns Hopkins to address culture change. Since the nationwide launch in late 2010 of “On the CUSP: Stop CAUTI,” more than 20 states have joined the initiative.
The Partnership for Patients, a public-private partnership led by the Department of Health and Human Services, has identified CLABSI and CAUTI as two of ten hospital-acquired conditions to be reduced by 40 percent by 2013. The 26 Hospital Engagement Networks (HENs), established by the Partnership for Patients and supported by the Centers for Medicare & Medicaid Services, will lead learning collaboratives and provide technical assistance for hospitals, and will develop mechanisms for monitoring hospitals’ progress toward providing safer care for their patients.

Source: National Implementation of the Comprehensive Unit-based Safety Program to Eliminate Healthcare-Associated Infections,