Take steps to protect patients from infection.
- Indwelling urinary catheters can be the source of both infectious and noninfectious complications.
- Nurse play a critically important role in preventing CAUTI.
- Proper maintenance including hygiene, securement and maintenance of a closed system is integral to prevention of CAUTI.
The indwelling urinary catheter (IUC) isn’t a harmless device. In fact, in 1982, Warren and colleagues reported that the risk of catheter-associated urinary tract infection (CAUTI) increases 3% to 7% each day that the IUC remains in place. More recent data from Lo and colleagues re-emphasize these important findings. All indwelling devices—including IUCs, central line catheters, and surgical implants—can form biofilm (a dense matrix of pathogenic microorganisms that adheres to an object’s surface), which can cause infection. This matrix also attracts more organisms and becomes impenetrable, protecting bacteria from antibiotics and limiting the immune response because white blood cells can’t get through.
Evidence-based guidelines suggest that the first line of defense against CAUTI is not inserting the IUC in the first place—or removing it as soon as possible. But what happens when a patient has a catheter in place and meets the criteria for continued use?
Is it necessary?
Nurses have an important role to play in discontinuing an IUC when it’s no longer needed. Start with a daily review of the Centers for Disease Control and Prevention (CDC) criteria for appropriate use of an IUC to see if it is still needed. (See IUC criteria from the CDC.) For example, a patient may have needed an IUC to monitor urine output or titrate medications, but is it still needed? Ask this question during interprofessional and nurse rounding.
Having a streamlined process in place for discontinuing an IUC also is important. Meddings and colleagues describe four phases in the life cycle of an IUC: insertion (step 1), care (step 2), removal (step 3), and reinsertion (step 4). Because avoiding catheter use is the most important CAUTI prevention strategy, the researchers performed an evidence review focused on steps 1 and 3. They found that most IUCs are left in place longer than necessary primarily because the system for removing them is complex when it requires a provider order.
IUC criteria from the CDC
The 2009 Centers for Disease Control and Prevention (CDC) guideline for catheter-associated urinary tract infection (CAUTI) prevention includes the following recommendations for appropriate indwelling urinary catheter (IUC) use:
- Patient with acute urinary retention or bladder outlet obstruction
- Accurate urinary output measurements in critically ill patients
- Perioperative use for selected surgical procedures:
- urologic surgery or other surgery on contiguous structures of the genitourinary tract
- anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in the postanesthesia care unit)
- patients anticipated to receive large-volume infusions or diuretics during surgery and need for intraoperative urinary output monitoring
- To assist in healing of open sacral or perineal wounds in incontinent patients
- Prolonged patient immobilization (for example, potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)
- To improve comfort for end-of-life care
The second item on this list—“need for accurate urinary output measurements in critically ill patients”—presents a challenge because the terms aren’t well-defined. As a follow-up to these guidelines, Meddings and colleagues developed “The Ann Arbor criteria for appropriate urinary catheter use in hospitalized medical patients: Results obtained by using the RAND/UCLA Appropriateness Method.” They assembled an interprofessional group of experts—including nurses, providers, infectious disease specialists, and infection preventionists—from all areas of acute care to rate IUC use scenarios. The group made two important clarifying recommendations. An IUC should remain in place if:
- hourly measurement of urine volume is required to provide treatment (for example, managing hemodynamic instability, hourly fluid titration, drip vasopressors, inotropes) or life-supportive therapy
- daily (not hourly) measurement of urine volume is required to provide treatment and can’t be assessed by other means (for example, acute renal failure workup, acute I.V. or oral diuretic management, I.V. fluid management in respiratory or heart failure).
Nurses can download an online program by the CDC and Health Research and Educational Trust that highlights use of these criteria at cdc.gov/infectioncontrol/pdf/strive/CAUTI102-508.pdf.
Many hospitals have nurse-driven protocols that allow nurses to discontinue an IUC without a provider order if the patient meets the criteria. Several studies highlighted by Lo and colleagues have demonstrated a significant decrease in CAUTIs when this approach is used.
In addition to nurse-driven protocols, reminders and checklists (which can be built into the electronic health record [EHR]) also are helpful. However, because these reminders can be ignored, some hospitals have developed an automatic stop order (a specific date or time) that requires the provider to either reorder the IUC or discontinue it.
No matter what mechanism is in place, nurses must be aware of organizational policies, mindful of how long an IUC has been place, and know whether it still meets criteria for continuation. Many EHRs can display which patients on a unit have an IUC and how many days the catheter has been in place.
Care and maintenance
When early IUC removal isn’t an option, nurses should follow evidence-based recommendations for ongoing catheter care. The American Nurses Association developed a CAUTI tool that incorporates actions related to preventing CAUTI in patients requiring an IUC, including:
- Secure the device and position the drainage bag below the bladder.
- Maintain unobstructed urine flow by keeping the catheter and tubing free from kinking.
- Maintain a closed drainage system. If any breaks in the closed system occur, the catheter and collecting system should be replaced.
You can download the complete tool at nursingworld.org/practice-policy/work-environment/health-safety/infection-prevention/ana-cauti-prevention-tool.
Here’s a closer look at key nursing activities related to care and maintenance: urine collection and drainage, hygiene, and proper securement.
Urine collection and drainage
Current CDC IUC urine collection guidelines recommend cleaning the port with disinfectant and then using a sterile syringe or adaptor to aspirate a small sample from the needleless sampling port.
Keep the urinary drainage bag below the level of the bladder, but don’t place it on the floor. Empty the bag regularly using a separate, clean collection container for each patient; avoid splashing the contents and touching other objects with the drainage spout. If a patient is being transported to a diagnostic or testing area, empty the drainage bag and ensure the transporter knows to keep it below the level of the bladder.
Nurses should specify and document the protocol for perineal and periurethral care and ensure that everyone knows, understands, and follows it. Perineal care should be performed at least once a day per your organization’s protocol and after each episode of incontinence. Perineal care is especially important when a patient becomes incontinent of stool. Jacobson and colleagues note that Escherichia coli, which is part of normal GI flora, is the most common pathogen associated with CAUTI. Containment devices may be needed to control fecal incontinence.
Variations in products and methods of performing perineal care can present challenges. The 2009 CDC guidelines recommend avoid cleaning the periurethral area with antiseptics while the IUC is in place. Instead, clean the area during regular bathing. Likewise, the 2014 Compendium of Strategies to prevent CAUTI, by Lo and colleagues, suggests that cleaning with antiseptics is unnecessary. However, many hospitals provide chlorohexidine (CHG) baths to certain patients or patient populations, including those who have a central line. CHG has a long-lasting effect on the skin and can help reduce the number of bacteria that may infect the central line. A 2018 abstract by Mueller and colleagues identified CHG bathing and catheter care as a bundle element that resulted in a statistically significant decrease in CAUTI in an intensive care unit.
Hand hygiene before and after manipulating the catheter and providing perineal care is imperative for infection prevention. Perform hand hygiene and don gloves immediately before and after accessing the drainage system, emptying the drainage bag, and collecting a urine sample.
Properly securing the IUC and tubing can help prevent pressure injuries, accidental dislodgement, and the patient pulling the catheter out. Traumatic removal can lead to pain and bleeding. In addition, catheters have the effect of restricting patients’ movement and ability to ambulate more freely, so securely a catheter correctly is key.
Translating theory into practice
Hardwiring IUC maintenance and care recommendations into daily practice can be challenging. For example, perineal care frequently is assigned to ancillary personnel, who may require education and training to understand its importance and develop proper skills.
Nurses also may face challenges with provider engagement. Some providers don’t view the IUC as an important risk for infection. Include them in planning and education, identify a provider champion, and ensure all providers receive regular feedback about CAUTIs.
Education should be provided to all staff, patients, and family members who may have a role in IUC maintenance. Education can help healthcare staff connect the dots between what may seem like a simple task and potential patient harm. Many organizations use storytelling (for example, short descriptive narratives shared at unit meetings and huddles) to link an adverse outcome to a real patient, while protecting the patient’s identity. Stories should focus on the patient and include a brief description of harm (or efforts to reduce harm) and outcomes. Focusing on real patients and circumstances helps engage staff and provides a deeper understanding of the importance of preventive practices. Some hospitals perform a debrief or root cause analysis to identify opportunities for improvement when a CAUTI occurs.
Multiple studies have provided insight into the effectiveness of care bundles to prevent CAUTI. However, a challenge to the bundle approach is deciding which elements to include and keeping the bundle short enough to be monitored easily. One tactic is to separate the insertion bundle from the maintenance bundle.
Some organizations use the maintenance bundle information as a checklist and an adherence monitoring (audit) tool to ensure improvements are made as needed.
Key components of the maintenance bundle should include observing for:
- daily documentation of need assessment
- an intact tamper-evident seal
- catheter securement with an appropriate device
- hand hygiene performed before and after contact with the patient and catheter components
- daily periuretheral care performed according to hospital policy
- unobstructed urine flow
- criteria met for catheter removal.
When designing a compliance audit, identify the specific population to be monitored, the number of observations, who will collect the data, and who will analyze and report it.
Reducing CAUTI rates
Approximately 560,000 patients develop CAUTI each year, leading to extended hospital stays, increased healthcare costs, and increased patient morbidity and mortality. Nurses can help reduce CAUTI rates—by ensuring appropriate IUC insertion and duration and proper care and maintenance—to save lives and prevent harm.
Linda R. Greene is manager of infection prevention at the University of Rochester, Highland Hospital in Rochester, New York.
Agency for Healthcare Research and Quality. AHRQ Safety Program for Reducing CAUTI in Hospitals: Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide. September 2015. ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
American Nurses Association. Streamlined Evidence-Based RN tool: Catheter Associated Urinary Tract Infection (CAUTI) Prevention. nursingworld.org/~4aede8/globalassets/practiceandpolicy/innovation–evidence/clinical-practice-material/cauti-prevention-tool/anacautipreventiontool-final-19dec2014.pdf
Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Healthcare Infection Control Practices Advisory Committee. June 6, 2019. cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf
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Warren JW, Tenney JH, Hoopes JM, Muncie HL, Anthony WC. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis. 1982;146(6):719-23.