A catheter-associated urinary tract infection (CAUTI) is an infection caused by bacteria introduced via an indwelling urinary catheter (IUC). Although IUCs are necessary for some patients, Dartmouth-Hitchcock (D-H) is over utilizing them in comparison to peer institutions, placing our patients at higher risk of infection.

We have seen a 24 percent increase in our FY2018 CAUTI cases compared to similar months in the prior two fiscal years. There were 25 cases by this time in both FY2016 and FY2017 (July – February). This is important, as patients who develop a CAUTI often have a longer length of stay, higher cost of care, and increased mortality.

Decreasing these preventable infections is a major focus of our FY18 hospital-acquired conditions reduction strategy. To achieve success, we are asking everyone to practice with a questioning attitude and approach the use of an IUC with CARE:

• Consider alternatives to IUCs,
• perform All maintenance bundle elements when IUCs are in place,
• Remove IUCs when indications are no longer met,
• and Examine the appropriateness of a urine culture in patients with an IUC).

“Patients sometimes require invasive devices, including central venous catheters and indwelling urinary catheters, that increase their risk of infection,” says Regional Hospital Epidemiologist Michael Calderwood, MD, MPH. “While state and national data show significant declines in the rates of central line-associated bloodstream infections (CLABSIs) following an enhanced focus on insertion and line maintenance bundles, these same data demonstrate less of an improvement in rates of catheter-associated urinary tract infections (CAUTIs). Still, it is possible to reduce CAUTIs. Hospitals that reduce catheter use have seen significant declines in their CAUTI rates.”

Guidelines from the Centers for Disease Control and Prevention help guide the use of IUCs, to reduce possible infections by limiting their use and removing them as soon as possible.

“Reducing CAUTI incidence requires changing the culture,” says Jessica Swain, MBA, MLT, CIC, infection preventionist. “That change is being driven by the use of a Best Practice Alert (BPA) that incorporates a Nurse-Driven Protocol for IUC Removal (NDP). Providers receive a BPA that requires selection of an evidence-based indication for maintaining the IUC, or the discontinuation of the IUC either in the moment or via the NDP. It is a team effort that supports nurses who are charged with assessing on-going need. When there is no longer an evidence-based need, the catheter should be removed,” Swain says. Also, nurses can also utilize the Nurse-Driven Protocol for IUC removal independently if there is no longer an evidence-based need.

“Practice area nurses provide catheter care and assessment at least once a shift, says Alyssa Olson, MSPH, BSN, RN, CIC infection preventionist. When infections do occur, local practice areas take a deep dive to figure out what happened, and to adopt changes aimed at preventing future CAUTIs.”

Nursing has been doing a lot of work to improve practice around assessment by:

• using a bladder scanner prior to placing an IUC for urinary retention,
• replacing IUCs inserted under unknown conditions at another health-care facility,
• optimizing compliance with all prevention bundle elements for the duration of time that an IUC is required,
• and changing long-term catheters prior to obtaining a urine culture to reduce the detection of asymptomatic catheter colonization.

However, “you can’t have a CAUTI if you don’t have a urinary catheter,” says Calderwood.

Therefore, it is critical that all providers understand the evidence-based indications for an IUC and discuss opportunities for catheter removal daily. This is a culture change that is critical to the safety of our patients, and one that will require engagement of all members of the care team.

In addition, the multi-disciplinary D-H CAUTI committee has identified the need to improve our practices around when to send a urine culture. It is quite common that a urine culture is sent (or reflexed) as part of a fever work-up, in the absence of UTI symptoms. This can lead to the detection of asymptomatic bacteriuria (bacteria in the urine, which poses little risk to the patient). Instead, providers should consider alternative sites of infection and not send urine cultures in the absence of symptoms.

The CAUTI Working Group, a multi-disciplinary team led by George Blike, MD, chief quality and value officer and Karen Clements, RN-BSN, MSB, FACHE, chief nursing officer, is tracking progress, removing barriers and moving D-H toward improvement goals. While the goal for all HACs is 0 events, D-H has been working toward a 15 percent reduction in CAUTIs from 2017 to 2018 via a 10 percent reduction in catheter utilization rates.

“Everyone at D-H, as part of our commitment to being a high-reliability organization, should practice with a questioning attitude. We can improve the safety of our patients and the quality of care we deliver by asking questions,” says Laurie Nolan-Kelley, DNP, RN, CNL. “Does this patient need an IUC? What is the indication? Is there an alternative? Are there urinary symptoms, and if not, is a urine culture appropriate? These are the questions we need to ask ourselves and each other if we are to provide the best possible CARE.”