This article has been updated in June 2020.
Catheter-acquired urinary tract infections (UTIs) are one of the most common healthcare-acquired infections, accounting for 20 percent of healthcare acquired bacteremia in acute care facilities and over 50% in long-term care facilities. Approximately 70-80%of these infections are attributable to use of an indwelling urethral catheter.
Due to this high incidence, the overall costs to the health care system is estimated at a staggering $424 to $451 million annually in the United States. Some studies estimate the additional costs of a catheter-associated urinary tract infection (CAUTI) to range from $4,694 to $29,743 per patient. In some cases, particularly in immunosuppressed patients, a CAUTI can progress to sepsis.
What Are CAUTIs and What Causes Them?
A UTI is an infection involving the urinary system, including the urethra, bladder, ureters or kidney. UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN).
As mentioned above, 70-80% of these infections are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra. These are common, with 15-25% of hospitalized patients receiving urinary catheters when in the hospital. Generally, the longer the catheter is in, the higher the risk of a CAUTI.
Cost Concerns with CAUTIs
CAUTIs are costly and can lead to patients staying longer in the hospital, but there is an associated Medicare cost 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.)
How Can Nurses Help Prevent CAUTIs?
Nurses are responsible for managing indwelling urinary catheters, and can effectively employ core strategies recommended by the CDC to help prevent CAUTIs. In addition, nurses should minimize use in patients when possible, and avoid use for the convenience of nursing staff (i.e. management of incontinence).
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 to reduce the risk of a CAUTI. They are also implementing a system of alerts or reminders to remove catheters that are no longer necessary.
Common Patient Risk Factors
According to the Mayo Clinic, UTIs are common in women due to their shorter urethra, which shortens the distance that bacteria must travel to reach the bladder. 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
As a nurse, you can help prevent CAUTIs with your adherence to best practices and good hygiene. Here are a few tips:
- 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.
- 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.
Here are a few additional resources to help you learn more about CAUTIs and how to prevent them:
- Centers for Disease Control and Prevention: Catheter-associated Urinary Tract Infections
- Catheter-associated Urinary Tract Infection and the Medicare Rule Changes
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