Have trouble with CAUTI? Better get a handle on it soon

Joint Commission outlines new patient safety goal for 2012

Catheter-associated urinary tract infections (CAUTIs) are the most common form of hospital-acquired infections, accounting for as many as 80% of HAIs in acute care settings. According to the Wound Ostomy and Continence Nurses Society, the daily risk for patients in acute care settings is between 3% and 7%. It is enough of a problem that the Centers for Medicare & Medicaid Services (CMS) isn't going to reimburse for it in the future, and other payers generally follow the CMS lead. Now, the Joint Commission has made reducing CAUTIs a new patient safety goal for 2012, and accredited acute care and critical access hospitals will have to prove they are attacking it by 2013.

This isn't the first hospital-acquired infection (HAI) that the commission has directed facilities to address, says Kelly Podgorny, RN, MS, CPHQ, DNP, a project director at the Joint Commission. In 2006, several organizations created an HAI task force to see what evidence-based medicine was out there. They created a compendium to address five of them (See the entire compendium at http://www.shea-online.org/GuidelinesResources/CompendiumofStrategiestoPreventHAIs.aspx). Three — surgical-site infections, MRSA, and central line-associated bloodstream infections — were announced previously by the Joint Commission as areas of concern. Now, the CAUTI goal is the focus. Ventilator-associated pneumonia is on hold until the Centers for Disease Control and Prevention can finalize some issues of definition.

While the work is all of a kind, Podgorny says that you can't say that implementing the new goal will be "easy" because facilities have gone through this before with other HAIs. "Obviously there is experience with the three previous goals, but I do not know if you can say that it makes it easier to do the work for this one. Some of the implementation steps are similar — educating families, etc. — but the content is different and the mechanisms may differ, too."

As for what the goal is, it isn't a number, she says. While some organizations "are chasing zero, the goal is just to get better."

The compendium's section on CAUTI (http://www.jstor.org/stable/pdfplus/10.1086/591066.pdf) is a good place to start, but Podgorny says that isn't an end point. You should keep on top of professional literature because things change. She says that while it isn't required by the Joint Commission, it is a good idea to have multidisciplinary teams working on the issue. "Then do gap analyses and find out where you need work."

It is been nearly a year since Spencer (IA) Hospital started to look at CAUTI, says DeeAnn Vaage, RN, BSN, CIC, infection control preventionist at the 100-bed facility. As suggested by Podgorny, they put together a team to go over the evidence-based research. After determining where there were lapses, the team decided to update the electronic medical record to create prompts for every patient getting a urinary catheter. Now, the possible reasons for insertion pop up, and the patient has to meet one of them.

Further, nursing documents now require a nurse to determine if the requirements for the catheter continue to be met at every shift. If not, then a nurse has to notify a physician and get an order to remove the catheter, or obtain physician documentation of the reason to keep it in place.

"It was not that we had too many people getting catheters who did not need them," says Vaage, "but that we were keeping them in longer than necessary." The CDC recommends daily monitoring; Spencer requires at least twice-daily monitoring.

They also changed urinary catheter kits to one that included a device to better secure the catheter. That meant that there was no searching for a separate item or getting by without it, Vaage notes.

Spencer Hospital also embarked on an education program, using its annual skills fair to publicize the new records protocols, what the indications are for a catheter, and how to document them. They showed off the new catheter kit and an updated insertion protocol, too.

The results might not seem spectacular — the CAUTI rate was already remarkably low, she says, and it has gone down just a tad since the project began last summer.

However, catheters are being removed sooner and are being used less often. Given the similar infection rates, that means that the number of infections is decreasing.

Vaage thinks it would be great to get to zero, but that is unlikely. There are so many patient variables, she says. "If you have a trauma patient with a hip fracture who is immobile, it would be hard to get the catheter out, and the patient would be susceptible."

That said, the hospital continues to look for more ways to improve, including more automated prompts for nurses and physicians so that they can be more aware of it, and looking for other strategies and bundles that are working in other facilities.

For more information on this topic, contact:

  • Kelly Podgorny, RN, MS, CPHQ, DNP, project director, Joint Commission, Oakbrook Terrace, IL. Email: kpodgorny@jointcommission.org.
  • DeeAnn Vaage, RN, BSN, CIC, Infection Control Preventionist, Spencer Hospital, Spencer, IA. Telephone: (712) 264-6143.