Prevention strategies for catheter-induced urinary tract infections

Reducing Catheter Induced UTIs

Reducing Catheter Induced Urinary Tract Infections

Catheter induced urinary tract infections are common occurrences in any hospital-like setting. Because of this, catheters should only be used when absolutely necessary and not because it is convenient for hospital staff. Although this type of infection is very common, it is also very preventable. Such things as the type of catheter used, proper hygiene, as well as frequent replacement of the catheter can go a long way in preventing any type of infection from occurring. The prevention and reduction of urinary tract infections due to indwelling catheters is of great benefit to the patient, not only medically, but for some monetarily also. This is because Medicare and Medicaid will no longer pay for any type of hospital acquired infections and urinary tract infections resulting from an indwelling catheter fall into this category.

IMPORTANCE OF TOPIC

This project is aimed at reducing catheter induced infections in patients. The reason for this is because it will reduce the morbidity rate of patients from this type of infection as well as reduce cost for the patient and the hospital. Catheter induced urinary tract infection is a universal problem and one way to combat it is the use of non-latex catheters since many patients have found to be allergic to latex. Instead, the recommended type of catheter is the all silicone, silver lined one. This catheter has been shown to reduce the rate of urinary tract infections in patients.

This issue is of great importance to nursing education because the nurses are generally the ones that insert the catheters and are responsible for the care of the patients with the catheters. Nurses must be educated on the necessity of the catheter and should determine if other, safer methods are available. They should also be aware of such things as proper hand hygiene in order to reduce the rate of infection because according to Deutsch, as many as 1.7 million hospital acquired infections occur in the United States annually resulting in at least 99,000 deaths (2008).

Jim Thorpe Rehab is affiliated with the Integris Southwest Medical Center. Southwest Medical Center has already implemented procedures regarding Foley catheters which have cut down on the number of days the patients need to keep the catheter in. Since certain information is classified and can only be viewed by hospital personnel, Jim Thorpe Rehab does not know of the policies. As a result, Jim Thorpe Rehab must come up with their own set of policies to implement. This is necessary because the facility has a large Medicare and Medicaid patient base and cannot afford an abundance of infections that they will ultimately be responsible for financially.

It should be mentioned that the rehabilitation facility does not have a high incident of catheter induced urinary tract infection patients, but procedures need to be documented for the benefit of the hospital and the patients. Also, beginning in 2008 Medicare and Medicaid will no longer pay for hospital acquired infections so the hospital staff must have written procedures on how to cut down on the rate of infection and the Medicaid and Medicare patients need to be informed of any financial obligations.

III. LITERATURE REVIEW

With regard to the type of Foley catheter used, much has been written about the all-silicone silver Foley catheter because of its ability to repel infections. The use of this type of catheter has been proven to reduce the incidence of catheter induced urinary tract infections as well as medical costs associated with these infections (Bystrom, 2005; Caudill, 2005; Davis, 2005; Foster, 2005; Hutchins, 2006; Mack, 2005; McArdle, 2005; and Sullivan, 2005). Many hospitals and healthcare facilities have switched over to the used of the silver coated Foley catheters, and although they are better than latex in the reduction of infections, there is still a chance that the patient will get an infection if other measures are not taken.

Drekonja notes that knowledge regarding the use of Foley catheters and ways to prevent infection has increased among nurses. An internet survey was administered to several nurses in Minnesota and the majority of them agreed that the use of the silver coated catheters as well as cleaning and replacement will cut down on the incident of the patient catching a urinary tract infection (2010). Graves did a study on the correlation between the length of the hospital stay and the incident of the patient getting a catheter induced urinary tract infection. He found that the greater the length of the hospital stay, the more likely the patient was to get the infection and that this coupled with older patients increased the likelihood of getting the infection even more (2007). For this reason, nurses and other staff should not assume that the silver plated Foley is a guarantee against infections. Proper care must still be taken for the patient involved.

Given that urinary tract infections account for approximately thirty percent of hospital acquired infections in health care settings, it makes sense to find ways to reduce this number. Rothfield states that of this thirty-percent, eighty percent of these infections are catheter related and those simple measures can be taken to greatly reduce this percentage. He says that in most health care settings catheters are overused and other methods for infection reduction are readily available such as using superabsorbent diapers instead. A study was conducted at a medical facility using the superabsorbent diapers and Rothfield reports that the rate of catheter induced urinary tract infections decreased from 48 patients to just 9 patients within a short amount of time (2010). The use of a diaper may seem an embarrassment to some, but a skilled nurse can explained tactfully how wearing the diaper gives the patient more freedom than the catheter would. They can also explain how the chance of getting the catheter reduced urinary tract infection has been eliminated because there is no catheter involved.

This issue is apparently prevalent in medical facilities worldwide. In Japan, a study was done by Tsuchida, et al., on the rate of catheter induced urinary tract infections and they discovered that many nurses in several medical facilities assumed that by using the all silicone silver plated catheters meant that they could provide less care and upkeep for the patient. As a result, the rate of infection increased which meant that the nurses should have been educated on this type of catheter before using them on patients (2008). Even though this type of catheter has been shown to reduce the rate of urinary tract infections, the same care and hygiene practices used for other types of Foleys should still be administered with the newer types of catheters. If not, the same situation that happened at the medical facilities in Japan is likely to happen elsewhere.

Although the type of Foley catheter used can help to prevent urinary tract infections, other steps and measures taken by hospital personnel can also be followed in order to reduce the risk of infection. Typically, when a patient is in the Intensive Care Unit (ICU) of a hospital or healthcare facility, he does not maintain the ability to use the bathroom facilities on his own. As a result, a catheter may be used. Allen found that a major cause of infection was due to cross contamination by hospital workers. He says that something as simple as washing hands in between patients can eliminate this, but may nurses and healthcare providers fail to do this simple step (2005).

Allen's example outlines why the need for a monitored hand washing system is necessary. A hand hygiene monitoring device was conducted at the Toronto Rehabilitation Institute in Ontario, Canada. Small monitoring devices were installed in patient rooms as well as restrooms and healthcare professionals wore a badge-like device which notified them to wash their hands upon leaving the room. The frequent washing of hands helped to reduce the spread of hospital acquired infections (Boscart, 2010).

It should be noted that washing hands with soap and water may not always be possible, so hospital should ensure that dispenser with anti-bacterial gel is easily accessible throughout the medical facility. This is due to the fact that in addition from spreading one patient's germs to another because of lack of hand washing, a healthcare professional my touch an object in the hospital that is not as clean as it should be. This is considered environmental contamination and this coupled with lack of hand washing can definitely increase the rate of infection (Carling, 2010). Education regarding the prevention of hospital acquired infections is crucial. The appropriate staff should be educated on issues such as proper care and cleaning of the catheter, hand washing hygiene and even when to determine whether or not a catheter should be used at all (Gokula, 2007).

The push to use the all silicon, silver coated Foley catheters as well as to eliminate hospital acquired infections is important because not only does it lower the morbidity rate, it also lowers costs. Although the silver coated catheters have a higher upfront cost than latex catheters, the cost balances out because of the reduced amount of urinary tract infections which leads to a reduced need for antibiotics and other methods to eliminate the infection (Dikon, 2006). This is important because the cost of hospital acquired infections run high. The cost to care for a patient with a hospital acquired infection is almost three times the amount to care for a patient without a hospital acquired infection (Hassan et al., 2010).

Since hospital acquired infections can be attributed to the hospital, Medicare and Medicaid will no longer cover payment of these infections beginning in 2008. Medicare and Medicaid reimbursements are designed to set payment rates that are consistent with hospital costs (Malatestinic et al., 2003). An acquired hospital infection is not considered a cost to Medicare or Medicaid since the patient contracted the infection through no fault of his own, but while under the care of the hospital staff. Deutsch does not agree with this decision and states that Medicare and Medicaid are doing more harm to the patients by withholding hospital payments and instead should invest more money into the Agency for Healthcare Research and Quality so that hospital staff can be trained properly on the procedures to take to avoid hospital acquired infections (2008).

It is reasonable for Medicare and Medicaid not to feel they should reimburse for hospital acquired infections because cases such as these can be seen as hospital neglect. In some cases, when patients acquire the infections it is due to negligence on the part of the caregiver by not performing proper hand hygiene or not caring for and cleaning the catheter sight properly. However, even with the most stringent set of hospital procedures in place to reduce infections, even a small percentage of patients may be prone to acquiring them. No matter how the patient acquired the infection, he is still left out in the cold if Medicare or Medicaid refuses payment. This is not fair to the patients and this is the point that Deutsch is making. Other means should be sought out, such as proper education instead of the complete withdrawal of the payments.

One thing to consider regarding this Medicare and Medicaid reimbursement issue is that both will reimburse in the case of self neglect (Franzini and Dyer, 2008). This is when the patient does not (for whatever) reasons take care of himself. Sometimes mental illness can be involved preventing the patient to properly care for himself, but sometimes the neglect is willful. A patient can be mentally sound but does not take the medications prescribed to him, yet Medicare will reimburse for this.

In essence, what should be done is what Deutsch suggests. More funding should to go into educating hospital staff on the proper procedures to prevent hospital acquired infections. Educating the staff seems to be a more effective measure than withholding payments. The withholding of payments for hospital acquired infections has the potential to put the patient at a disadvantage unless the hospital takes ownership and covers the costs associated with the infection.

Medicaid reimbursements have a direct impact on nurse staffing levels, in particular at nursing homes. Harrington et al. (2007), found that Medicaid only nursing homes had fewer nursing staff with fewer nursing hours than for profit nursing homes. This is important not because it is an indication of the quality of nurses at the Medicaid only facilities, but these facilities have a tendency to be short staff because of the reduction of reimbursements could mean more patient neglect and a higher chance for hospital acquired infections.

Lately, there has been a reduction in the Medicare and Medicaid patients that Advance Practice Nurses (APN) as well as physicians will treat (Cunningham and O'Malley, 2008; Frakes and Evans, 2006). The whole issue of what Medicare and Medicaid will reimburse can be detrimental to their business, especially if it is a private practice. The last thing these professionals need is to have payments withheld because they are being blamed as the cause of a patient getting an infection.

Stone (2009), states the following, "This is a radical change in reimbursement, which may result in a variety of practice changes. The first and most positive is that hospitals react as CMS hopes and find ways to improve processes and decrease health care-associated infections. The second is that there is no real change in the infection rate; in this case, hospitals may lose the incremental revenues or just change coding practices. The third and least positive response is that the policy results in perverse incentives for hospitals to engage in processes that are not in the patients' best interest but protect the hospital" (p. 17A).

V. EVALUATION OF OUTCOMES

The Jim Thorpe Rehab facility already has a low incidence of urinary tract infections due to Foley catheters. However, the facility does not have any documented procedures in place which give statistics on the duration of how long the catheter has been left in or the number of infections per year for the facility. The information is important and needs to be tracked for reporting purposes. A plan was developed to assist the facility with a plan that could be implemented immediately.

Since there was no documented information on the data that the facility needed, everything was measured from the day that the project was implemented and then reassessed over a six-month period. The reported outcomes are as follows:

Inputs -- the inputs for the project were the silver coated Foley catheters, superabsorbent diapers and the facility patient-care staff members.

Activities -- using silver coated Foley catheters on patients requiring the use of one for more than three days, frequent and thorough hand washing of the staff, proper cleaning and care of the Foley catheters, and mandatory training of staff on care and use of the catheters.

Outputs -- the patients actually needed to have the Foley catheters inserted (latex and silver coated).

Outcomes -- many patients were more than willing to wear the superabsorbent diapers as opposed to having the catheter inserted; the staff expressed appreciation over the hand washing reminders and did not feel that is was information overload; the staff were trained on the proper care and cleaning of the Foley catheters and willingly signed the consent for stating that they would adhere to the training they received.

Outcome targets -- The targets over the six-month period were recorded and favorable. They are as follows:

At the end of the six-month period, the number of patients wearing the superabsorbent diapers as opposed to the Foley's rose 10%.

At the end of the six-month period, the number of catheter induced infections was reduced from 23 patients to 14 patients.

After the end of the six-month period, all of the staff members reported remembering to wash their hands in between caring for patients.

After the end of the six-month period, all of the staff members had participated and completed the training successfully and the rehab center received a 100% return on the consent forms.

Based on the outcome targets, it appears that the program designed for the Jim Thorpe Rehab center is successful so far. These outcomes are considered short-term outcomes and the center needs to continue to follow the plan and evaluate it again in another six months. At this point, this will become a long-term outcomes evaluation with the expectation that there will be continued improvement.

This will be an ongoing project and will not terminate at the end of the one-year period. This is important because if on-going evaluation is not done, the climate or attitude of the staff might change and they could become lax on the procedures they have consented to perform. Also, any new staff members will need to be informed and trained and become a part of the evaluation project in order for the facility to run smoothly and improve on its process to cut down and even possibly eliminate catheter induced urinary tract infections.

VI. CONCLUSIONS AND RECOMMENDATION

The Jim Thorpe Rehab center is fortunate in that there is an abundance of information pertaining to the causes and reduction of catheter induced urinary tract infections. Although it is affiliated with the Southwest Medical Center which has been successful in its plan to reduce the urinary tract infections, the information cannot be shared between facilities because of hospital liability issues. As such, the Jim Thorpe Rehab center had to come up with its own plan to monitor and reduce the rate of urinary tract infections due to the Foley catheter. The facility already has a low rate of these types of infections and should be commended for wanting to further explore and implement policies that will further reduce the rate of infection.

As with any plan, there may be glitches and in this case, the glitches may be that there may still be a few patients that acquire infections. Since Medicare and Medicaid no longer reimburses for hospital acquired infections, documentation is key. The majority of patients at the Jim Thorpe are Medicare and Medicaid patients and the facility cannot afford a high rate of infections acquired at the facility because in the end, they will end up eating the cost. In order to have a leg to stand on, strong documentation of patient care is in order. The final recommendation for this one year project (which will be re-evaluated with the possibility of revisions) at the one-year period is as follows:

1. In addition to the steps outlined in the plan, patient charting is crucial. Patient care staff must chart when the Foley was inserted and whether or not it is a latex or silver coated.

2. Patient care staff must keep a detailed chart on each person with a Foley catheter and list the number of times per day the Foley was cleaned and monitored.

Another step that is recommended is to do anonymous patient surveys. Patients with Foley catheters could be asked, but not required, to fill out a survey that does not contain any personally identifiable information. The surveys could be placed in a boxed that is locked by an outside source that will evaluate the surveys. The information could be compiled into a report that is made available to the patient care staff so that they can judge how well they are performing by the people they are caring for. Should and incident arise where Medicare or Medicare refuses a claim, this information along with the other documentation the rehabilitation center has can help to build a strong case.

This is merely a suggestion and the patients in no way should be forced or coerced into completing the survey. Another recommendation is to have the patient care staff members fill out an anonymous survey on the plan that has been implemented. The survey would consist of Likert style questions as well as open-ended questions requiring a written response. The last part of the survey will be constructed to give the staff members an opportunity for suggestions or make comments on what they feel is working well, and what isn't working well. Much like the patient surveys, this survey would not be mandatory, but highly encouraged because the staff's input is important. Decisions should not be made, nor a plan implemented without their input.

Everyone must work together in order to make the plan successful. Evaluators must not jump in thinking they know everything, but they should get the input of the staff and even patients in order to ensure that the plan is carried through and is working. Catheter induced urinary tract infections are the highest type of hospital acquired infection, but it does not have to be so. This is an infection that is highly preventable, but only if certain basic steps are implemented before, during and after the catheter insertion. The procedures set forth in the plan developed for the Jim Thorpe Rehabilitation center are not only developed to assist the facility, but they have been developed to benefit the patients and staff in the hopes that the facility can reach a zero patient rate of infection.