'Dignity': IPs kick UTIs out of rehab

Program leads to a 89% drop in infections

UTIs have been termed the Rodney Dangerfield of infections, out of a skewed perception that they are easy to treat and have relatively little clinical consequence.

The conventional wisdom is that UTIs rarely lead to serious or fatal infections, but the Michigan Health & Hospital Association's Keystone Center for Patient Safety & Quality estimates that 5% of all deaths caused by health care-associated (HAI) infections are from cather-associated urinary tract infections (CAUTIs). That's 5,000 fatal infections if one uses the typical ballpark figure of 100,000 HAI deaths annually.

The most common infectious complication of care, urinary tract infections are well worth preventing. It can be done, even in non-acute facilities that must adapt the guidelines created for other settings. Exhibit A is a 300-bed Nebraska rehabilitation hospital, where nurses, occupational and physical therapists, case managers and education staff collaborated with patients and their family members to dramatically reduce CAUTIs.

The interdisciplinary team at Madonna Rehabilitation Hospital in Lincoln, one of the largest free-standing rehabilitation hospitals in the country, reduced catheter associated urinary tract infections (CAUTIs) by 89% over a 14-month period, Kristina Felix, BA, RN, CRRN, CIC, an infection preventionist at the facility, reported recently in Baltimore at the annual educational conference of the Association for Professionals in Infection Control and Epidemiology.

Primarily, the team worked to decrease the use of catheters — a known risk factor for UTIs — discontinuing their use unless medically necessary. In cases where urinary catheters were required, the team educated nursing, therapy staff, family members and patients on proper care to reduce the chance of infection. When the project was initiated in February 2010 the CAUTI prevalence rate was 36.6%, but dropped to a stunning 6.6% three months later. The original pilot concluded in April 2011.

Felix's team identified underlying reasons for catheter use when medical necessity was in question. Contributing factors included patients admitted to rehabilitation settings from acute care facilities with catheters in place, and patients whose families viewed catheters as a more convenient way to manage incontinence.

Adapting the guidelines

"Our facility cares for patients with some very complex medical and physical needs," she says. "Best practice guidelines that are published really didn't [address] the problems that we see in our facility with bladder management and the needs of many of our patients. So we put together a task force. We wanted to understand first of all why the patient had the catheter, but more importantly what were the obstacles to removing them. We found that the use of the catheter sometimes was a 'convenience' for staff and actually for patients as well."

The task force improved bladder management protocols and standards, balancing the medical requirements of the patient with the need for patients to be infection-free, continually re-assessing the appropriateness for each catheter. They utilized a "de-catheterization protocol," to safely remove medically unnecessary catheters and improve the health of the patient.

"We looked at every facet of bladder management, including better ways to assist patients to the bathroom in a timely manner, different types of commodes and engaging the entire care team in the bladder management processes," she said. "We implemented education with all members of the care team, including patients and family members, so that everyone understood the process and the benefit to the patient of reduced UTIs."

Education regarding proper care of catheters and tubing was reinforced to staff and patients. Felix estimated that their program prevented up to 30 UTIs per month and saved the facility about $1,000 per infection avoided. There were little additional costs associated with implementing these interventions. However, there was the rather difficult task of changing the perception of UTIs and catheters among staff and even patients.

"It was quite an issue," she said. "At the beginning we asked a lot of questions of our therapists and nurses to see why we were using [catheters]. What was the thought process? People did think it was convenient, but we found that if the catheter was out — and it was a learning process — the patients were able to move about freer without the bag and tube — the patients actually felt better without it."

An aspect of patient "dignity" was restored in that regard, though again they had to change some perception among patients and family members that the catheter eases care.

"Overall, we have seen such a change in the thought process," she said. "We really don't like to use them and we are focused on getting them out when we can. If the patient does need the catheter, the focus is how we can prevent the infection. Everybody's mindset has changed. It helps to have the key administrative people [involved]. With that kind of support we couldn't do anything but move forward and be successful."