Revised CAUTI guidelines include behavioral changes
Michigan leads the way on CAUTI prevention
Revised compendium guidelines to prevent catheter-associated urinary tract infections (CAUTIs) include some new socio-adaptive and technical strategies for infection preventionists to consider.1
"Much of the socio-adaptive recommendations came from the work performed by Michigan-based CAUTI researchers during the past decade," says Sanjay Saint, MD, MPH, George Dock professor of medicine at the University of Michigan Medical School and epidemiologist at the VA Ann Arbor (MI) Healthcare System.
"We have made more than 40 site visits and [done interviews] over the phone to hospitals from Maine to California," he says. "We’ve had interviews with chief executive officers, mid-level managers, infection preventionists, and front-line nurses and physicians."
Site visitors focused on CAUTI and learned how successful hospitals have implemented programs. And they assessed what wasn’t working in struggling hospitals. Practical issues involving implementation came from the Michigan program’s "four E’s" of engagement, education, execution, and evaluation, notes Lindsay Nicolle, MD, professor of internal medicine and medical microbiology at the University of Manitoba in Winnipeg, Canada.
"Dr. Saint has made valuable tools and examples from his program available and is willing to share them," she says.
In a recent publication in JAMA Internal Medicine, Saint and colleagues showed that hospitals in Michigan had a 25% reduction in CAUTIs while non-Michigan hospitals had only a 6% reduction.2
The CAUTI guidance paper contains key findings regarding socio-adaptive research, which is especially relevant when organizations are implementing programs, Saint notes.
For example, here are a few of the barriers and possible solutions cited by the CAUTI compendium team:
Lack of physician buy-in to CAUTI prevention practices: The possible solutions including finding a physician champion and providing physicians with feedback and data about urinary catheter use and monthly indwelling urinary catheter prevalence and CAUTI rates;
Difficult to do education for nurses because of their inflexible schedules regarding overtime and non-patient care time: Bring education to the bedside through unit competencies and talking with nurses one-to-one during the point prevalence assessments;
Physicians are resistant to having an automatic stop order for nurses to discontinue urinary catheter use: One solution could be to have nurses prompt physicians for DC order as an initial strategy to build rapport and to identify a physician champion who can serve as an advocate.
Immediate impact: Limit catheter use
Hospitals could make the biggest impact with an immediate change to limit catheter use, Nicolle says.
"Don’t use a catheter unless there is a clear indication for it, and make sure catheter use is based on clear, existing guidelines," she adds. "Once a catheter is in place, make sure it’s removed as soon as possible."
The key technical aspect of the revised guidance is that there is more evidence now to support early removal of the catheter, Saint says.
"This would include daily assessment of the catheter by the bedside nurse or computerized reminders that the patient has a urinary catheter," he says. "There have been approximately 30 studies that show catheter reminders, stop-orders, and nurse-initiated removal protocols working quite well," he explains.3
"There is now new research focusing on the emergency department, showing how that would be a good venue in which to intervene to reduce the use of urinary catheters," Saint adds. "In most hospitals, the number one place of insertion is in the ER."
Health systems can use stop orders, reminders, and nurse protocols with indications showing why the patient needs to have the catheter removed, he says.
"Some hospitals use a default method where the catheter is removed unless an order for continuation is given; others have it set up where after 48 hours, the nurse contacts the physician to ensure the catheter is removed it depends on the culture of the hospital," Saint explains. "The most important aspect is to ensure that daily assessment is occurring, and in these guidelines we have additional research to support that approach."
Another new part of the guidelines involves catheter use for women having C-sections and thoracic surgery patients, Nicolle says.
"Systematic review suggests that evidence does not support indwelling catheter use for C-section patients and thoracic surgery patients," she adds.
The revised guidance also reflects new research about the previously unresolved area of antimicrobial catheters. Based on a 2012 Lancet study, there is good evidence that antimicrobial catheters should not be used routinely, Saint says.4
"They found no benefit for using antimicrobial catheters," he says. "This means we cannot rely on a technological fix like antimicrobial coating; we have to rely primarily on behavior change."
Fortunately, it’s easier to encourage behavior change with automated cues and reminders as health systems increasingly move to electronic health records, he notes.
When a nurse inputs data about a patient’s use of a Foley catheter, the pull-down screen will show indications, and if there are no indications then the nurse will be instructed to call the physician or get an order for catheter removal, Saint says.
"Or, if the medical executive committee has approved nurse-initiated discontinuation then the nurse is empowered to remove the catheter," he adds.
The revised guidance continues to reinforce CAUTI prevention education and proper technique for catheter insertion.
Health systems could assess staff annually on their insertion technique.
Hospitals increasingly are requiring surveillance on units to collect data on the percentage of patients who have a catheter and CAUTI rates, Saint says.
"They want actionable information so that a quality improvement change can happen in real time," he says.
Early removal of urinary catheters also will address the important area of preventing non-infectious harms of the catheter, a topic that has recently been the focus on increased attention.5
- Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Cont Hosp Epi 2014;35(5):464-479.
- Saint S, Greene MT, Kowalski CP, et al. Preventing catheter-associated urinary tract infections in the United States: a national comparative study. JAMA Int Med 2013;173(10):874-879.
- Meddings J, Rogers MA, Krein SL, et al. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 2013. Sept. 27.
- Pickard R, Lam T, MacLennan G, et al. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: A multicentre randomised controlled trial. Lancet 2012;380:1927-1935
- Hollingsworth JM, Rogers MA, Krein SL, et al. Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis. Ann Intern Med 2013;159(6):401-410.