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Reducing catheter associated urinary tract infections (CAUTI)

Reducing catheter associated urinary tract infections (CAUTI)

What is a Catheter Associated Urinary Tract Infection (CAUTI)?

A urinary tract infection (UTI) is an infection involving any part of the urinary system, including the kidneys, urethra, bladder and ureters.  UTIs are the most common type of healthcare associated infection.

Approximately 75% of UTIs acquired in hospital are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine.  Between 15-25% of hospitalised patients receive urinary catheters during their hospital stay.  The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter.  Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed.


What are we trying to achieve?

In 2010 an audit at North Shore Hospital highlighted that 1/3 (33%) of urinary catheters were used inappropriately.  This leads to an increase in the number of catheter associated urinary tract infections (CAUTI). 

Value: Better, Best, BrilliantOur overall aim is to reduce the number of CAUTI by 50%.  For this project we selected 3 wards to trial potential interventions to determine the most effective ways of reducing the rate of CAUTI.  If successful we would roll the interventions out to all wards across both North Shore and Waitakere hospitals..


What did we find?

We audited 3 pilot wards and found:

  • 8 diagnosed CAUTIs
  • 306 catheter days
  • a current rate of infection of 26.1 CAUTI per 1000 catheter days

Ward

CAUTI rate/100 catheter days *

Total catheter days

Mean duration of catheter (days)

Medical (A)

71.4

42

4.2

Surgical (B)

11.2

178

4.7

Rehabilitation (C)

34.9

86

8.6

* Rate = number of infections / number of catheter days x 1000


We also identified :

  • there was no education focus on CAUTI
  • many staff were unaware of when a catheter should be used
  • indwelling catheters were left in longer than the recommended period[1]
  • there was no routine surveillance to determine whether catheters were appropriate
  1. Research has shown that leaving a catheter in for 7 days increases risk of CAUTI by 25% (Ref: APIC guidelines 2008)

 

What have we done?

Education and Awareness

Three types of education were implemented on the pilot wards:

CAUTI - Before You Go Poster1.  Face-to-face education

2.  Daily reminders:

  • Verbally to medical staff
  • A written order in a patient’s clinical notes

3.  Use of ‘stop orders’

  • Use of labels to remind staff when catheters should be removed
CAUTI - Yellow Stop Sticker
CAUTI - Red Stop Sticker

To determine their effectiveness each pilot ward trialled a different combination of education interventions.

Intervention

Ward A

Ward B

Ward C

Face-to-face

Yes

Yes

Yes

Daily reminders

X

X

Yes

Use of stop orders

Yes

X

X

Indwelling catheters left in for longer than recommended

  • Charge nurse managers and ward nurses review all patients with a catheter and the indication for use as part of their daily round.
  • Instil a sense of urgency to remove a catheter that is no longer required.
  • A verbal reminder to doctors that a patient has a catheter.

Routine surveillance for appropriateness of an IDC

  • Improved system for reporting catheters and documenting the indication for use in nursing handover sheet.
  • Random audits for CAUTI and appropriateness of catheters.

What can you do to help us?

Patients and families can help us by being involved in their care by asking the hospital staff questions such as:

Before the procedure

Why do I need a urine cathether?

A few days after insertion

Do I still need a urine cathether?


Did we make a difference?

Five months after the interventions there was a 55.9% reduction in the rate of CAUTI across the three pilot wards.

Ward

Baseline Audit

One month after Interventions

 Five months after Interventions

% Improvement

Medical ward (A)
education/ stop rule

71.4/1000

20.4/1000

17.0/1000

76.0%

Surgical ward (B)
education only

11.2/1000

17.6/1000

7.1/1000

36.5%

Rehabilitation ward (C)
education/daily verbal reminders

34.9/1000

25.0/1000

15.6/1000

55.3%


Conclusion:

  • Ward A – stop rule and education resulted in a significant (and greatest) reduction in overall CAUTI rate.
  • Ward B – education alone showed a reduction in CAUTI rate.
  • Ward C – education and daily reminders showed a reduction in CAUTI rate (but not as great as the stop rule and education combined).
  • Reduction in CAUTI rates requires multimodal interventions and cannot be achieved only by reducing the average time catheters are in place.
  • Compliance with safe and sterile catheter insertion and care and use of bladder scanners, is not routinely monitored (unlike vascular catheters) but should be included in CAUTI prevention education.
  • Appropriate selection of patients for catheterisation and use of alternatives such as condom catheters can reduce CAUTI rates.  However, excessively prolonged duration of catheter use markedly increases the incidence of CAUTI in remaining patients.
  • The ‘stop rule’ appears to be most effective but is difficult to implement. Ongoing reminders, both verbal and visual, used as ‘alternative’ are effective.

Where to from here?

Continue with CAUTI audits on selected wards – education and daily reminders to nursing and medical staff should be used as a strategy to reduce CAUTI.