Urinary tract infections are the most common type of nosocomial infection by far, accounting for up to 40 percent of infections reported by hospitals. Up to 80 percent of hospital-acquired UTIs are correlated with the use of an indwelling urinary catheter. Due to this high incidence, the overall costs to the health care system are staggering, with an estimated $451 million spent annually in the United States to manage these infections. In some cases, particularly in immunosuppressed patients, a CAUTI can progress to sepsis.
Concerns about costs, lengths of stay, and patient safety would be good enough reasons to establish protocols to reduce the incidence of CAUTIs, but now there’s a financial concern as well – as of October 1, 2008, Medicare has deemed these events to be “preventable” and will no longer pay for the cost of care associated with them. Instead, the tab will be picked up by the hospital itself, since the rules don’t allow the costs to be passed on to the patient. (Since then, several large insurers have followed suit with their own announcements that they will no longer reimburse for CAUTIs.)
Nurses are responsible for managing indwelling urinary catheters, and can effectively employ core strategies recommended by the CDC to help prevent CAUTIs. The goal is to minimize use in all patients, and to avoid use for the convenience of nursing staff (i.e. management of incontinence). If you believe a catheter is not indicated for a particular patient, talk to a nursing supervisor.
Some hospitals have implemented protocols for nurse-directed removal of unnecessary catheters – these allow for nursing assessment and intervention without a physician’s order. Some hospitals are instead using prewritten stop orders to ensure that post-op catheters are removed within a specified time period, or are implementing a system of alerts or reminders to remove catheters that are no longer necessary. A PowerPoint presentation from the University of Colorado explains protocols for Nurse-Driven Urinary Catheter Removal (PPT).
Patient Risk Factors for CAUTIs
According to the CDC, between 15 and 25 percent of hospitalized patients receive urinary catheters during their hospital stay. Other surveys place this figure higher, suggesting that up to 90 percent of ICU patients end up with a catheter. And many studies have found that catheters are frequently used unnecessarily, placing patients at risk for complications.
Female patients, the elderly, and those with compromised immune systems may be at increased risk for CAUTIs. However, the duration of catheterization is the most important risk factor for infection. Limiting the use of catheters to begin with, and then limiting the number of days the catheter remains in place are the primary strategies for minimizing risk.
CAUTI Prevention Strategies for Nurses
- If your hospital has devices and supplies available that allow you to use the most commonly used alternatives to indwelling catheters, make sure you are trained in their use.
- Always use aseptic technique for the placement, manipulation, and maintenance of indwelling catheters – and remember that handwashing is the first and most important preventive measure, followed by the use of barrier precautions such as sterile gloves, drape, sponges, antiseptic solution, and single-use packets of sterile lubricant.
- Following aseptic insertion of the catheter by properly trained staff, maintain a closed drainage and unobstructed urine flow (be sure there are no kinks in the tubing, etc.)
- In post-operative patients, remove catheters as soon as possible. The CDC recommends removal within 24 hours, unless there are appropriate indications for continued use.
- Every day, conduct a review of all patients with catheters, and advocate for the removal of those that are no longer necessary. Research shows that “forgotten catheters” are often inappropriate catheters – so don’t assume that physicians are always aware of a patient’s catheter status; it’s your job to speak up.
- If your hospital has implemented protocols for nurse-directed removal of unnecessary catheters, become familiar with them and follow them – these allow for nursing assessment and intervention without a physician’s order. Some hospitals are instead using prewritten stop orders to ensure that post-op catheters are removed within a specified time period, or are implementing a system of alerts or reminders to remove catheters that are no longer necessary.
- Participate fully in all process improvement measures, like those designed to measure compliance with indications for catheter placement. The CDC recommends the use of metrics, like number of CAUTIs per 1000 catheter-days, to keep track of improvements in CAUTI rates.
The CDC’s latest recommendations are compiled in the 2009 Guideline for Prevention of CAUTIs (PDF).
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