Nurse Prevention of Urinary Tract Infections

How Registered Nurses can Help Prevent Urinary Tract Infections
Background and Context
Concepts, models and theories
Today, catheter-associated urinary tract infections (CAUTIs) remain one of the primary causes of nosocomial infections in the United States. Despite increasingly aggressive efforts to reduce the prevalence of CAUTIs, current estimates indicate that as many as half of all hospitalized patients receiving indwelling catheters do not have the corresponding documentation concerning the application of evidence-based criteria for this clinical decision (Weldon, 2013). The most recent guidelines from the Healthcare Infection Control Practices Advisory Committee stress the need to infection prevention by limiting both the use of catheters wherever possible as well as the duration of use in order to decrease the number of nosocomial urinary tract infections (UTIs) (Welden, 2013).
The U.S. Centers for Disease Control (CDC) likewise emphasizes the need for the improved use of indwelling catheters and estimates that acute care hospitals experienced 93,000 UTIs in 2011 alone (Catheter-associated urinary tract infection, 2018). In addition, UTIs have been found to be responsible for more than 12% of all types of infections at acute care hospitals, and almost all of these infections are the result of indwelling catheters (Catheter-associated urinary tract infection, 2018). These alarming rates are all the more troubling given the frequency of indwelling catheter use in various acute care settings today.
Moreover, an estimated 12% to 16% of adult inpatients will have an indwelling catheter used on them during their hospital stay, but every day these devices are used causes an increased risk of between 3% and 7% of developing a CAUTI (Catheter-associated urinary tract infection, 2018). In addition, long-term care facility residents likewise suffer from inordinately high rates of CAUTIs (Keeping nursing home residents safe, 2018). Since the American population is aging rapidly, it is reasonable to posit that these rates will continue to worsen unless steps are taken today to improve the manner in which registered nurses are educated concerning evidence-based guidelines for indwelling catheter insertion and maintenance.
Relevance to nursing practice
Catheter associated urinary tracts infections are relevant to nursing practice because the CDC emphasizes that CAUTIs can result in a wide array of complications for hospitalized patients, including: prostatitis, epididymitis, and orchitis in males, and cystitis, pyelonephritis, gram-negative bacteremia, endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and meningitis (Catheter-associated urinary tract infection, 2018). These complications translate into elevated patient discomfort, longer hospitalizations, as well as higher mortality rates. In fact, the CDC estimates that in excess of 13,000 deaths are related to UTIs each year (Catheter-associated urinary tract infection, 2018).
Taken together, it is clear that greater focus needs to be placed on identifying optimal approaches to educate registered acute care nurses concerning these issues as well as current evidence-based approaches to indwelling catheter use.
Local background and context
The focus of this study will be on an inpatient acute care setting in a tertiary heath care in the United States that has historically experienced CAUTI rates in line with the national averages.
Role of the DNP student
In their capacity as research-focused professionals, prospective DNP students are especially well situated to assume a leadership role in developing educational strategies to provide nursing staff members with the information and tools they need to reduce CAUTIs in their health care facilities (LaVeck, 2017).
Theoretical Framework
The conceptual framework to guide this project was Malcolm Knowles's (1970, 1980, 1982) adult learning theory and “Novice to Expert” by Patricia E. Benner. This theoretical framework is especially appropriate for the purposes of this study since it includes both the manner in which adults learn most effectively as well as the importance of gaining hands-on experience as part of the learning process. As originally propounded by Knowles (1970), andragogy, or the methods used for teaching adults, is based on several key assumptions concerning the characteristics of adult learners as they mature that differ from assumptions about traditional pedagogy and child learners as follows:
Their self-concept moves from one of being a dependant personality toward one of being a self-directing human being;
· They accumulate a growing reservoir of experience that becomes an increasing resource for learning;
· Their readiness to learn becomes oriented increasingly to the developmental tasks of their social roles; and,
· Their time perspective changes from one of postponed application of knowledge to immediacy of application, and accordingly his orientation toward learning shifts from one of subject-centeredness to one of problem-centeredness (Knowles, 1970, p. 55).
Knowles’ (1980) subsequently developed this theoretical model based on four fundamental assumptions concerning how adults tend to learn and how they develop as a result.
• Concept of learner: Their self-concept moves from one of being a dependant person to one who is self-directed;
• Role of learners' experience: As individuals grow, they accumulate a reservoir of experience that becomes an increasingly rich resource for learning;
• Readiness to learn: Learners see education as a process for developing increased competence to achieve their full potential in life; and,
• Orientation to learning: As real life problems occur some learning situations require immediate attention (pp. 43-44).
Besides inculcating an organizational culture that places a high priority of achieving optimal clinical outcomes using evidence-based strategies (Trevellini, 2015), nurse educators must also ensure that the manner in which they approach the staff education process is consistent with the basic tenets of andragogy described by Knowles (1970, 1980) and expanded upon by Brenner (1982).
Based on the four fundamental assumptions described in study’s theoretical framework, Knowles (1980) subsequently recommended that adult educators seek to achieve the following for optimal learning opportunities:
1. Set a cooperative climate for learning in the classroom;
2. Assess the learner’s specific needs and interests;
3. Develop learning objectives based on the learner’s needs, interests, and skill levels;
4. Design sequential activities to achieve the objectives;
5. Work collaboratively with the learner to select methods, materials, and resources for instruction; and,
6. Evaluate the quality of the learning experience and make adjustments, as needed, while assessing needs for further learning (Adult learning theories, 2011).
These recommendations are highly congruent with Benner’s (1982) views on adult education. From Benner’s perspective, experiential learning opportunities are an integral component of gaining the knowledge and expertise needs by registered nurses today. In this regard, Benner advises that, “Experience, in addition to formal education preparation, is required to develop this competency since it is impossible to learn ways of being and coping with an illness solely by concept or theorem” (p. 406). This observation does not mean, of course, that registered nurses practicing in acute care must personally experience every disease or illness condition they treat in order to fully understand its implications for others and how best to intervene, but it does mean that gaining hands-on experience and having opportunities for empirical observations concerning patient responses and clinical outcomes in an essential part of the adult learning process. As Benner concludes in this regard, “A deep understanding of the situation is required before one acquires a repertoire of ways of being and coping with a particular illness experience” (p. 406).
These assumptions are also highly consistent with the guidance provided by Benner (1982) concerning the manner in which most effectively adults learn which are discussed further in the staff education section that follows further below.
Definition of Terms Common in Critical Care Nurses on Preventing Catheter Associated Urinary Tract Infections
Unless otherwise indicated, the following definitions were taken from the CDC’s most recent guideline (2017, pp. 6-7) concerning the prevention of CAUTIs:
ANA: This acronym refers to the American Nurses Association (Gelinas, 2015).
APIC: This acronym means that Association for Professionals in Infection Control and Epidemiology (APIC), (Smith, 2015).
ASB: This acronym means asymptomatic bacteria.
CAUTI: This acronym means catheter-associated urinary tract infection.
CCU: This acronym means critical care unit.
CIC: This acronym refers to clean intermittent catheterization..
CDC: This acronym refers to the U.S. Centers for Disease Control.
CFU: This acronym means colony-forming units.
DNP: This acronym means doctorate of nursing practice (LaVeck, 2017).
HAI: This acronym means healthcare-associated infections (Keeping nursing home residents safe, 2018).
HICPAC This acronym refers to the Healthcare Infection Control Practices Advisory Committee.
LOS: This acronym means length of stay.
MDR: This acronym refers to multi-drug resistance.
PVR: This acronym means post-void residual (Streamlined evidence-based RN tool kit for catheter associated urinary tract infection prevention, 2015).
SUTI: This acronym means symptomatic urinary tract infection.
UTI: This acronym refers to a urinary tract infection.
Relevance to Critical Care Nurses on Preventing Catheter-Associated Urinary Tract Infections to Nursing Practice
Registered nurses practicing in acute care settings are on the front lines of preventing CAUTIs, but their effectiveness in achieving improved clinical outcomes is frequently hampered by limited organizational resources, a suboptimal organizational culture and a lack of knowledge concerning current evidence-based indications for urinary catheter insertion and maintenance (Smith, 2015). For example, according to one registered nurse, “Because RNs play a major role in reducing CAUTI rates to help prevent harm and save lives, it's crucial we focus on CAUTI reduction and prevention—now” (Gelinas, 2015, p. 6).
Indeed, given their high incidence rate and potential for causing increased lengths of stay, patient discomfort, associated complications and even death, it is clear that greater focus needs to be placed on helping acute care nurses become more proficient in preventing CAUTIs using evidence-based guidelines. In this regard, Smith (2015) emphasizes that, “Nurses at all levels can influence patient outcomes in a positive way. By focusing on evidence-based prevention strategies and promoting a culture of safety and accountability, (registered nurses can) reduce urinary-catheter device days” (p. 46). Fortunately, there are some current evidence-based guidelines available for this purpose, including the national initiatives discussed further below.
National Initiatives to Address and Prevent CAUTIs
Current national initiatives concerning indications for urinary catheter insertion and maintenance to reduce the incidence of CAUTIs include guidelines from the HICPAC as well as the Association for Professionals in Infection Control and Epidemiology (APIC) (Smith, 2015). A summary of the most recent recommendations from the HICPAC’s guidelines concerning appropriate indications for indwelling catheter use are set forth in Table 1 below.
Table 1
Summary of HCPAC guidelines concerning indwelling catheter use
Area of recommendation
Description
Appropriate indications for indwelling catheter use
• Patient has acute urinary retention or bladder outlet obstruction.
• Need for accurate measurements of urinary output in critically ill patients.
• Perioperative use for selected surgical procedures:
o Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract.
o Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU).
o Patients anticipated to receive large-volume infusions or diuretics during surgery.
• Need for intraoperative monitoring of urinary output.
• To assist in healing of open sacral or perineal wounds in incontinent patients.
• Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures).
To improve comfort for end of life care if needed.
Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate.
• Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction.
• Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients.
Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction.
• Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration.
Proper techniques for urinary catheter maintenance
• Following aseptic insertion of the urinary catheter, maintain a closed drainage system.
• Maintain unobstructed urine flow.
• Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system.
• Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use.
• Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.
• Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery), do not use systemic antimicrobials routinely to prevent CAUTI in patients requiring either short or long-term catheterization.
• Do not clean the periureteral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate.
• Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended.
• Routine irrigation of the bladder with antimicrobials is not recommended.
• Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended.
Clamping indwelling catheters prior to removal is not necessary.
Source: Gould, Umsheid, Agarwal et al. (2017), HICPAC Infection Control Practices Advisory Committee
In addition, the APIC guidelines also include recommendations for proper techniques for urinary catheter maintenance that can be used for nursing staff education purposes as described below.
Staff Education
At present, quality and performance improvement initiatives are driving significant changes in the United States healthcare system (Smith, 2015). In this regard, Ileno and Wideman (2013) emphasize that, “In our current health care environment of tightening fiscal demands, cost and efficiencies in patient care delivery highlights the importance of using the best evidence based on nursing to improve quality outcomes and the financial status of hospital-based organizations” (p. 194). These trends also highlight the importance of educating nursing staff members concerning the most recent evidence-based practice guidelines for indwelling catheter insertion and maintenance.
Consequently, critical care nursing educators are faced with the need to identify the most appropriate methods for helping their professional nursing staff gain the knowledge they need concerning best evidence-based practices in those areas where they can make the most difference,, including most especially the reduction in the rate of nosocomial infections in general and CAUTIs in particular. According to Brenner (1982), adult learners tend to experience five sequential levels of proficiency as they gain knowledge and empirical experiences as set forth in Table 2 below:
Table 2
Five sequential steps to skills acquisition by adult learners
Step
Description
Novice
Nurses at this stage have no experience with the situations in which they are expected to perform tasks. In order to give them entry to these situations, they are taught about them in terms of objective attributes. These attributes are features of the task that can be recognized.
Advanced beginner
Nurses at this stage of learning demonstrate marginally acceptable performance. This person is one who has coped with enough real situations to note (or to have them pointed out by a mentor) the recurrent meaningful situational components, called aspects.
Competent
Competency, typified by the nurse who has been on the job 2 to 3 years, develops when the nurse begins to see his or her actions in terms of long-range goals or plans. The nurse is consciously aware of these plans, and the goal or plan dictates which attributes and aspects of the current and contemplated future situation are to be considered
most important and which can be ignored. For the competent nurse, a plan establishes a perspective, and the plan is based on considerable conscious, abstract, analytic contemplation of the problem.
Proficient
With continued practice, the competent performer moves to the proficient stage. Characteristically, the proficient performer perceives situations as wholes, rather than in terms of aspects, and performance is guided by maxims. Experience teaches the proficient nurse what typical events to expect in a given situation and how to modify plans in response to these events.
Expert
Nurses at the expert level no longer rely on an analytical principle (rule, guideline, maxim) to connect their understanding of the situation to an appropriate action. Expert nurses, with their enormous background of experience, have an intuitive grasp of the situation and zeros
in on the accurate region of the problem without wasteful consideration of a large range of unfruitful possible problem situations.
Source: Adapted from Brenner, 1982, pp. 403-405
As can be readily discerned from the sequential learning phases set forth in Table 2 above, nurses tend to transition from a strict reliance on abstract theory to accepted concrete, evidence-based practices as they gain experience in various nursing applications. Moreover, these five progressive levels of learning correspond to two basic features of becoming expert at a given task or concept. The first feature concerns a fundamental shift from a dependence on abstract principles to a focus on using empirical observations and professional experiences as a framework for health care delivery (Brenner, 1982). The second feature represents a shift in understanding and perception from a view of the problem in terms of its disparate parts to a holistic understanding of the dynamics that are involved (Brenner, 1982).
In sum, then, educating nursing staff concerning best evidence-based practices concerning CAUTIs represents a timely and valuable enterprise for nursing educators in all acute care settings. One such evidence-based tool kit for preventing CAUTIs has been developed by the American Nurses Association (ANA). The CAUTI prevention tool kit was developed through a collaborative effort between representatives from the CDC, ANA, the American Geriatrics Society, the Association of periOperative Registered Nurses, the Centers for Disease Control and Prevention, the American Hospital Association and the Wound, Ostomy and Continence Nurses Society (Gelinas, 2015). The algorithm used by the CAUTI prevention tool kit has four overarching objectives as follows:
1. Prevention of CAUTI;
2. Placement of fewer indwelling urinary catheters;
3. More timely removal of IUCs per CDC Guidelines; and,
4. Consistent, timely evidence-based nursing assessments and interventions for adequate bladder emptying (Streamlined evidence-based RN tool: catheter associated urinary tract infection prevention, 2015, p. 1).
The tool kit begins with the diagnostic criteria set forth by the CDC’s HICPAC Infection Control Practices Advisory Committee for CAUTIs as follows:
· Acute urinary retention (sudden and painful inability to urinate or bladder outlet obstruction;
· To improve comfort for end-of-life care if needed;
· Critically ill and need for accurate measurements of input and output (e.g., hourly monitoring);
· Selected surgical procedures (GU surgery/colorectal surgery);
· To assist in healing open sacral or perineal wound in the incontinent patient;
· Need for intraoperative monitoring of urinary output during surgery or large volumes of fluid or diuretics anticipated; or,
· Prolonged immobilization (potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures) (Streamlined evidence-based RN tool: catheter associated urinary tract infection prevention, 2015, p. 1).
If patients satisfy any of the foregoing criteria, the ANA’s CAUTI prevention took kit’s algorithm depicted in Figure 1 below becomes applicable:
Figure 1. ANA’s CAUTI prevention tool kit algorithm for identify patients at risk of developing CAUTIs
Source: ANA, 2015 at https://www.nursingworld.org/~4aede8/globalassets/practiceand policy/innovation--evidence/clinical-practice-material/cauti-prevention-tool/ana cautipreventiontool-final-19dec2014.pdf
The assessment for the adequacy of bladder emptying pursuant to the above algorithm is set forth below:
A. If Patient HAS urinated (voided) within 4-6 hours follow these guidelines:
· If minimum urinated volume ? 180 ml in 4-6 hours or urinary incontinence present, confirm bladder emptying.
· Prompt patient to urinate/check for spontaneous urination within 2 hours if post-void residual (PVR) < 300-500 ml
· Recheck PVR within 2 hours.
· Perform straight catheterization for PVR per scan ? 300-500 ml.
· Repeat scan within 4-6 hours and determine need for straight catheterization.
· Report to provider if retention persists ? 300-500ml.
· Perform ongoing straight catheterization per facility protocol to prevent bladder overdistension and renal dysfunction, usually every 4-6 hours.
· If urinated >180 ml in 4-6 hours (adequate bladder emptying), use individual plan to promote/maintain normal urination pattern.
B. If Patient HAS NOT urinated within 4-6 hours and/or complains of bladder fullness, then determine presence of incomplete bladder emptying.
· Prompt patient to urinate. If urination volume ? 180 ml, perform bladder scan.
· Perform bladder scan to determine PVR. If no scanner available, perform straight catheterization (Streamlined evidence-based RN tool kit for catheter associated urinary tract infection prevention, 2015, p. 2).
The streamlined evidence-based RN tool kit for CAUTI prevention also includes a comprehensive checklist for inpatients which is depicted at Appendix A. While the ANA’s CAUTI prevention tool kit represents a valuable resource for RNs in general and those practicing in acute care settings in particular, there remains the need to identify optimal strategies to educating them concerning these protocols, a need that directly relates to goals of studies such as this one.
Summary
The research was consistent in showing that despite increasingly aggressive efforts to address the problem; CAUTIs remain a persistent source of nosocomial infections in the United States today. Although there are national initiatives underway that have developed evidence-based guidelines available concerning indwelling catheter use and maintenance, it is reasonable to conclude that far too many registered nurses remain uneducated concerning these protocols and there is an ongoing need to ensure that all staff members fully understand and appreciate the need for these strategies. A major part of the problem, it would seem, is the decision to use an indwelling catheter in the first place. In fact, the research also showed that a majority of patients receiving indwelling catheters lack documentation that reflects an evidence-based decision to place it in the first place, suggesting that the viable alternatives described in Table 1 and evidence-based practices set forth in Table 2 above are not being taken into consideration. These trends underscore the importance of studies such as this in improving nursing in acute care settings, and nurse educators are well situated to address this need head-on.?
References
Benner, P. (1982, Mar). From novice to expert. The American Journal of Nursing, 82(3), 402-407.
Catheter-associated urinary tract infection. (2018, January). U.S. Centers for Disease Control. Device associated module.
Gelinas, L. (2015, March). Enough already! Let's start using ANA's CAUTI tool- now. American Nurse Today, 10(3), 6.
Gould, C. V., Umscheid, C. A., Rajender, K. A. et al. (2017, February 15). Guideline for prevention of catheter-associated urinary tract infections. Healthcare Infection Control Practices Advisory Committee, 2-61.
Ileno, B. A. & Wideman, M. (2013, July/August). The financial and clinical benefits of a hospital-based PhD nurse researcher. Nursing Economics, 31(4), 194-197.
Keeping nursing home residents safe. (2018). PowerPoint presentation.
Knowles, M. S. (1970). Andragogy: An emerging technology for adult learning. The British Library.
Knowles, M. S. (1980). The modern practice of adult education: From andragogy to pedagogy. New York: Follett.
LaVeck, D. (2017). What is a DNP? Nurse.org. Retrieved from https://nurse.org/ articles/how-to-get-a-dnp-is-it-worth-it/.
Smith, C. V. (2015, January). On the road to zero CAUTIs: Reducing urinary-catheter device days: How a culture shift, a quality-improvement project, and electronic solutions reduced one hospital's CAUTI incidence. American Nurse Today, 10(1), 46-50.
Streamlined evidence-based RN tool: catheter associated urinary tract infection prevention. (2015). American Nurses Association. Retrieved from https://www.nursingworld.org/~4aede8/globalassets/practiceandpolicy/innovation--evidence/clinical-practice-material/cauti-prevention-tool/anacautipreventiontool-final-19dec2014.pdf.
Trevellini, C. (2015, September). Operationalizing the ANA CAUTI prevention tool in acute-care settings. American Nurse Today, 10(9), 5-9.
Welden, L. M. (2013, September). Electronic health record: Driving evidence-based catheter-associated urinary tract infections (CAUTI) care practices. Online Journal of Issues in Nursing, 18(3), 50-55.
Appendix A
Indwelling Urinary Catheter (IUC) Insertion Checklist to Prevent CAUTI in the
Adult Hospitalized Patient: Important Evidence-Based Steps
[Source: Streamlined evidence-based RN tool: catheter associated urinary tract infection prevention, 2015, p. 2]