Catheter-associated urinary

tract infection prevention

in the continuum of acute care
An initiative of the
NSW CLINICAL EXCELLENCE COMMISSION

Jan Gralton
BSc, PhD

Hosted by Jane Barnett

[email protected]

www.webbertraining.com March 29, 2017

Disclosure
No longer with the CEC
Direct questions: [email protected]

Acknowledgements
Dr Paul Curtis, Director of Clinical Governance (CEC)
2013/14 and 2014/2015 CAUTI project reference groups
NSW pilot sites
NSW Pathology
Health Education Training Institute
eHealth
State Forms Committee

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The NSW situation
NSW
Population: 7.64 million
Capital: Sydney
Land size: 809,444 km
(3x UK)
19 Local Health Districts/
Networks
220 facilities
1.84M admissions/year

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The NSW situation
Pre 2014
8/220 hospitals with dedicated acute care CAUTIs projects

Documented indication

CAUTI care bundle + education

Routine maintenance audits

Routine maintenance audits + infection surveillance

Organisational and process modification + education

Documented indication

Maxi audits in ED

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But is CAUTIs even a problem in acute care?
Mitchell et al, 2016:
Prevalence of HAUTIs in Australia is 1.73%
Increased LOS by 4 days
Reduced rate of discharge

0.9% of all acute admissions are affected by a CAUTI

66.7% of HAUTIs are CAUTIs
Types of HAUTIs Prevalence
Asymptomatic bacteriuria 29%
Cystitis 26%
Pyelonephritis 21%
Urosepsis 12%

References:
Mitchell BG, Ferguson JK, Anderson M, Sear J, Barnett A. Length of stay and mortality associated with healthcare-
associated urinary tract infections: a multi-state model. Journal of Hospital Infection. 2016;93(1):92-9.
Bjerklund Johansen, T. E., M. Cek, K. Naber, L. Stratchounski, M. V. Svendsen and P. Tenke. "Prevalence of Hospital-
Acquired Urinary Tract Infections in Urology Departments." European Urology 51(4).(2007): 1100-1112.
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What does that mean in terms of patient numbers?

Breakdown % Number
Number of acute admissions in NSW 2014/15 1, 840, 632
Estimated number of HAUTIs 1.73 31, 843
Estimated number of HAUTIs that are CAUTIs 66.7 21, 239
Estimated number of CAUTIs progressing to urosepsis 12 2,549

2, 549 NSW patients get a CAUTI that leads to urosepsis

=
49 patients a week
=
7 patients per day

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The NSW situation
Unknown burden
- Not a clinical indicator
- Clinical coding unreliable
- IMS data, not reported

Impetus to improve
- National Safety and Quality Health Service Standards:
3.9: Implement protocols for invasive device procedures regularly
performed with the organisation
3.10: Developing and implementing protocols for aseptic technique

- Anecdotal evidence from scoping visits

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What the literature says .
Unnecessary catheterisation

Extraluminal contamination -
breaches in asepsis
Insertion
Maintenance
Specimen collection

Intraluminal contamination -
unnecessary dwell time
Catheter biofilm 48 hrs
Photo: Janice Carr, CDC (Public Health Image Library)
post insertion
Reference: Jacobsen, S. M., D. J. Stickler, H. L. T. Mobley, et al. (2008). "Complicated Catheter-
Associated Urinary Tract Infections Due to Escherichia coli and Proteus mirabilis." Clinical
Microbiology Reviews 21(1): 26-59.
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What we were told .
If a patient has incontinence, you catheterise.
- convenience
- unsure of appropriate indications for catheterisation and alternatives -
bladder scanning is not undertaken to confirm retention

We only have Foleys in stock.

- unsure of catheterisation alternatives
- systemic lack of support for best practice

I didnt know how long it had been in for.

- not prioritised in clinical communication
- lack of awareness of insertion date and indication for insertion
- medical orders direct removal

Do I take off my gloves first ?

- sequencing of aseptic technique
- inappropriate specimen collection and poor collection technique
- placement of drainage device

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 Why do patients get CAUTIs in acute care?
Asepsis/infection control is Asepsis/infection control is Inappropriate urine
breached during insertion breached post-insertion specimen collection

Insertion competency varies Catheter is not secured to Dont know the appropriate indications
between clinicians body for urine specimen collection

Inappropriate catheter choice

Catheter is not routinely Catheters are inserted for
checked for breaches specimen collection
Aseptic technique is
not used
Patient contaminates Reliance on bag and dipstick
catheter or bag observations
Inadequate cleaning pre-insertion

Catheters are inserted for Catheters are forgotten until Catheter is not covered during ED No investigation of
wrong indications discharge or shift handover previous events

No catheter removal/review Catheter information is not Surveillance of CAUTIs is

Catheters are inserted for
plan is in place documented in one place not undertaken
nursing convenience

Poor understanding of No removal order is documented in Catheter insertion is not documented in Not a mandatory HAI
catheterisation risks the healthcare record the healthcare record clinical indicator

Lessons are not learnt

Catheters are used for Catheters are left Clinician awareness of
from previous CAUTIs
inappropriate reasons in situ for too long catheter is limited
events

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Is catheterisation actually indicated?

Up to 56% of catheterisations are not indicated

Inappropriate urinary catheterisations cause a CAUTI, longer
catheter dwell times and longer and more costly hospitalisation
Appropriate and Inappropriate varies between individual
clinicians, clinical teams, units and facilities

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What are the right indications for catheterisation?

Until recently, no universal list of indications

CDC and EAUN guidelines lack widespread adoption
Other guidelines also available inconsistent recommendations

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Appropriate indications for insertion

Pilot testing @ 7 sites

Finding 1: Inappropriate catheter insertions are occurring less frequently
Catheter use significantly decreased (2 sites)
Number of catheterised patients did not increase, despite significant increases in
patient numbers (2 sites)

Finding 2: Documentation of catheter insertion is getting better

Catheter use significantly increased (2 sites)
Number of catheterised patients increased significantly (1 site)

Finding 3: Nothing changed

2 sites
Validated that catheter insertion was not a problem
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Formal reliability testing

3 emergency departments, n= 50
Staff who used the tool made more appropriate catheter
selections
Staff who used the tool made more appropriate catheter choices
in scenarios that required more complex, multi-step decision
making processes (Cohens d = 0.88)
Less variation in the catheter selections if using the tool.

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 The Ann Arbor Criteria
Meddings J, Saint S, Fowler KE, Gaies
E, Hickner A, Krein SL, et al. The Ann
Arbor Criteria for Appropriate Urinary
Catheter Use in Hospitalized Medical
Patients: Results Obtained by Using
the RAND/UCLA Appropriateness
Method. 162. 2015;9 Suppl(S1-S34).
https://www.ncbi.nlm.nih.gov/pubme
d/25938928

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Source: Rachel Bowes, Solutions for Patient Safety http://www.solutionsforpatientsafety.org/wp-content/uploads/CA-
UTI_PediatricWebinar_Public.pdf

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Source: Rachel Bowes, Solutions for Patient Safety http://www.solutionsforpatientsafety.org/wp-
content/uploads/CA-UTI_PediatricWebinar_Public.pdf

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Arabic Traditional Chinese Simplified Chinese Greek

Hindi Italian Korean Vietnamese

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Implications of unnecessary specimen collection/culture
Patient level:
o Detection of asymptomatic bacteriuria antimicrobial treatment.
o Manipulation of closed system extraluminal contamination CAUTI

System level:
o Unnecessary pathology waste.

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 Advice on unnecessary laboratory testing

Source: http://www.choosingwisely.org.au/getmedia/aa012d60-e6d2-4246-a897-e762370578ad/RCPA-Choosing-Wisely-
recommendations.pdf.aspx
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 Advice on unnecessary laboratory testing

Source: http://www.choosingwisely.org/
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 In 1993, only 24% of CSUs collected were because of
UTI signs and symptoms!

Source: Rao, G.G. et al. Journal of Hospital Infection, 1993. 25: p. 219-22.
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 Appropriate urine specimen collection

Pilot testing @ 4 sites

Finding 1: Nothing changed

3 sites (ICU, ED, Ortho)
Validated that existing approach to specimen collection was good

Finding 2: Significant reduction in CSU and total urine specimen collection

1 site (Geriatric)

Finding 3: Significant reduction in catheter days and catheter use

1 site (Geriatric)
Gralton, J., Boston, B., Cook, C. Thomas, K., Taylor, P., Kizny Gordon, A., Smerdely, P., Hughes, G., Louey, M. Curtis, P.
Improving the appropriateness of urine specimen collection. Infection, Disease and Health. In Press

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 2
1 Attending MO
recognises
Attending MO that catheter
recognises that a is no longer
needed.
catheter is in
place.
3
Attending MO
writes order
to remove
catheter.

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Nurse
Source Meddings, J., et al., Reducing unnecessary urinary removes
catheter use and other strategies to prevent catheter- catheter
associated urinary tract infections: an integrative review.
BMJ Quality & Safety, 2013. 0: p. 1-13. 39
 Unaware catheter is in place Unaware of indication for catheterisation
Not documented Incomplete documentation/handover
Not handed over Reluctance

Attending MO is not available to order removal

Unpredictable rounding No removal order
Timing for TOV Incomplete documentation

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 Criteria led urinary catheter removal protocol
Evidence based - nurse led removal protocols
Alexaitis et al, 2014: Catheterisation length 2.5 days
CAUTI rate 20.5%
Cost of CAUTIs 40.7%

Parry et al, 2013: Catheter use 50%

CAUTI incidence 70%

Gotelli et al, 2008: Catheter use 7%

References:
Alexaitis, I. and B. Broome (2014). Implementation of a nurse-driven protocol to prevent catheter-associated
urinary tract infections. Journal of Nursing Care Quality 29(3): 245-252.
Parry, M. F., B. Grant and M. Sestovic (2013). Successful reduction in catheter-associated urinary tract
infections: Focus on nurse-directed catheter removal. American Journal of Infection Control 41: 1178-1181.
Gotelli, J. M., P. Merryman, C. Carr, et al. (2008). A quality improvement project to reduce the complications
associated with indwelling urinary catheters. Urology Nursing 28(6): 465-467.
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 Criteria led urinary catheter removal protocol

Overall aim is to reduce duration of unnecessary

catheterisation
Reduce number of catheters days
Reduce incidence of CAUTIs

Advantages
No reliance on documented removal order
Respects existing orders
Links into trial of void
Provides escalation pathways
Reduces burden on attending medical officer
Can be driven by other MOs or nursing staff (e.g. JMO removal round)

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Appropriate indications for insertion

Pilot testing @ 8 sites (1 lost to follow up)

Finding 1: Significant reduction in catheter days

Catheter use significantly decreased, implying reduced dwell times (4 sites)

Finding 2: Number of CAUTIs reduced

1 site

Finding 3: Nothing changed

3 sites
Validated that timely catheter removal was not a problem

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NSW Health Guidelines

Available from
http://www0.health.nsw.gov.au/policies/gl/2015/GL2015_016.html

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Where to find CEC resources

http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/cauti-prevention

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Thank you For further information:
Jan Gralton
National HAI Prevention Program, ACSQHC
P: + 61 2 9126 3655
E: [email protected]

CEC HAI Program

P: +61 2 9269 5582
E: [email protected]
www.cec.health.nsw.gov.au

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