CAUTI Quality Improvement Plan: Reducing Catheter Infections

Introduction

Catheter-associated urinary tract infection (CAUTI) is the most prevalent hospital-acquired infection (HAI), responsible for up to 34% of all hospital-acquired infections. Over half a million cases of CAUTI are reported every year in the United States, leading to higher rates of mortality and morbidity and overuse of hospital resources. The condition is of special concern particularly among older patients, based on revelations of inappropriate use of indwelling urinary catheters (IUCs) among this vulnerable population. Despite being the most common HAI, CAUTI has rarely been the focus of HAI control programs (Fink et al., 2012). A nationwide survey of infection control professionals reported poor implementation of CAUTI prevention measures — such as early removal of catheters and avoidance of indwelling urinary catheters — intended to reduce the number of catheter days. These findings are concerning, particularly when considered alongside studies recommending several evidence-based prevention practices, such as those outlined in the CDC's 2010 evidence-based guidelines, which make over sixty recommendations specific to CAUTI. It must be noted, however, that the majority of those recommendations are supported by limited evidence.

The 2009 guidelines released by the Infectious Diseases Society of America (IDSA) define catheter-associated urinary tract infections as infections contracted by patients currently fitted with urinary catheters or who had a catheter in place within the preceding forty-eight hours. According to the IDSA guideline, the term urinary tract infection (UTI) by itself refers to a significant concentration of bacteria in a patient with signs or symptoms attributable to the urinary tract and no other source. UTIs are the most prevalent hospital-acquired infections, accounting for nearly forty percent of all adult nosocomial infections. Notably, an overwhelming majority of UTIs — approximately eighty percent — are caused by IUCs (Leithhauser, 2004).

According to Gorman (2011), between 15% and 25% of all hospitalized patients are fitted with short-term indwelling catheters. The day-to-day risk of contracting CAUTI is three to seven percent in an acute care environment. IUCs are often placed for inappropriate reasons, and patients are frequently unaware of the presence of these devices. As a result, IUCs remain in place for extended durations. There is, however, significant variation in the reported rates of urinary tract infections among patients fitted with IUCs (Gorman, 2011).

Data from the CDC through the National Healthcare Safety Network (NHSN) revealed that acute care settings reported rates of between 3 and 7.5 infections per 1,000 catheter days. The Centers for Medicare and Medicaid Services (CMS) listed hospital-associated UTIs among the eight conditions for which health facilities will not receive additional funds (Gorman, 2011). The CMS guidelines also identified complications and risks associated with CAUTIs, including gram-negative bacteremia, chronic or acute pyelonephritis, epididymitis, prostatitis, periurethral abscess, and cystitis — conditions that can cause death in up to 60% of cases. CMS also lists CAUTI as the second most prevalent cause of nosocomial bloodstream infection.

Budgetary considerations are well within the means of the hospital and should present no difficulty for plan implementation. It is estimated that total cost savings from reduced CAUTI cases will be approximately $150,000 per year, while the "go-live" stage of implementation will require sufficient funding to meet supply needs (alternative types of catheters, bedding, waste removal) and a one-time purchase of a bladder scanner (approximately $10,000). These costs should be absorbable by the hospital. If upper management disagrees, a state grant could be applied for, or an appeal to local donors could be made, consistent with the hospital's longstanding mission.

Risk considerations include patient safety, staff fatigue, proper education, oversight of implementation, and maintenance of supply levels. These concerns will be mitigated through the application of Six Sigma and appropriate leadership theories such as Knowledge Leadership and Transformational Leadership, including effective use of emotional intelligence (EI) and transparency.

The strategic plan includes educating both staff and patients on the positive impact of reducing catheter exposure as a means of controlling and reducing infection rates. Training and monitoring will be implemented to guide the project, and Six Sigma will employ a top-down approach encompassing all levels of staff working together to fulfill the four E's of implementation: engage, educate, execute, and evaluate.

Definition of the Problem

The stakeholders involved include physicians, nurses, the hospital, and the patient. As noted above, the CMS has listed CAUTIs among the eight conditions for which health facilities will not receive additional payment (Gorman, 2011). A complication resulting from CAUTI can increase a patient's hospital stay by up to 0.4 days if asymptomatic and 48 hours if symptomatic (Leithauser, 2004). Although significant progress has been made in CAUTI prevention, unresolved issues remain. Efforts must focus on developing best practices in IUC use, and further research is needed to determine: which cases absolutely require catheter use; when reassessments should occur to determine continued need; what alternative methods are available; and best practices regarding catheter maintenance. Continuous reassessment of healthcare gaps and staff retraining are also necessary. All of these issues are addressed in this plan.

Currently, two sets of guidelines govern catheter use: those from the CDC and those from the IDSA. The CDC's 2009 guidelines recommend using catheters only for appropriate cases and keeping frequency and duration of use to a minimum, particularly among vulnerable populations such as the elderly, women, and individuals with impaired immunity. The CDC also recommends that indwelling catheters placed in patients undergoing surgery should be removed as soon as possible after the procedure is completed (Brusch, 2015). Use of IUCs for treatment of incontinence should be avoided. Importantly, the 2009 CDC guidelines recommend that nurses and physicians avoid routinely using systemic antimicrobials to prevent CAUTI in patients requiring either short- or long-term catheterization, as such routine use has been shown to promote resistant bacterial strains.

The 2009 IDSA guidelines for CAUTI recommend that indwelling catheters be used only with the patient's authorization in cases of imperative clinical need and when other alternatives for managing incontinence have been deemed ineffective. Long-term catheter use may increase patient satisfaction but also raises the risk of mechanical complications. It is not recommended in patients with morbid obesity, bleeding disorders, or prior abdominal irradiation or surgery. Intermittent catheterization is an alternative, though most individuals become bacteriuric within a few weeks; the rate of bacteriuria is one to three percent per catheter insertion (Brusch, 2015).

Systemic antimicrobial use has been reported to reduce the risk of UTI in catheterized patients, with the greatest benefit seen in individuals catheterized for three to fourteen days. However, many patients are already taking antibiotics for other conditions (Brusch, 2015). Repeated use of multiple antimicrobials may lead to resistant bacteria, which is why IDSA recommends against repeated antimicrobial use in patients already receiving antibiotics or antiseptics.

Considerable progress has also been made in reducing intravascular device infections. The economic motivation has been significant: catheter-linked bloodstream infections may generate more than $25,000 in additional hospital charges per case (Scott, 2009). Preventive approaches to reducing bloodstream infections are categorized by degree of supporting evidence into three tiers: what works, what probably works, and what might work. Approaches classified as "what works" incorporate foundational infection prevention principles and offer the strongest preventive effect against intravascular infections (Brusch, 2015).

Antimicrobial-impregnated catheters, for example, have demonstrated proven efficacy in infection control when used in appropriate patient populations. Approaches classified as "what probably works" — such as techniques for preventing thrombus infections and use of antimicrobial catheter flushes — have shown some efficacy but require further trials. Approaches classified as "what might work" are novel ideas tested in trials, including new catheter securement devices, active iontophoresis, and antimicrobial hubs.

Project Charter

The objective of this plan is to implement and assess the success of an intervention aimed at reducing CAUTIs in acute care settings by reducing the use of IUCs. The hypothesis is that catheter-days and CAUTI infection rates would decrease during the six-month intervention period compared to the eleven months preceding it. The total number of catheter-days and monthly CAUTI rates were calculated using unpaired t-tests before and during the intervention, with significance set at p < .05 (Elpern et al., 2009).

Unit clinicians were assigned the task of developing criteria for continuing the use of indwelling urinary catheters. During the intervention period, patients in the medical ICU with IUCs were assessed daily using these clinician-developed criteria (Elpern et al., 2009). Recommendations regarding continuation or discontinuation of catheterization were made based on evaluation results, and CAUTI rates during the intervention period were compared to those in the preceding eleven months.

The sample population consisted of all patients admitted to the medical intensive care unit over a twelve-month period who at any point had an IUC inserted. During the sampling period, all ICU patients with an IUC were identified daily by clinical co-investigators on nursing shift reports. Patients were evaluated from the day of ICU admission and on a daily basis thereafter using the established criteria for assessing catheterization continuance (Elpern et al., 2009). Nurse co-investigators were recruited principally to advise on catheter continuation or discontinuation. Daily assessments continued until the IUC was removed or the patient was discharged. Results of these evaluations were presented by nurses during multidisciplinary morning roundtables, and recommendations were made to discontinue IUCs in patients who did not meet the set criteria.

Total elimination of catheter-associated UTIs is not considered a viable goal by many practitioners. IUCs remain important in certain clinical situations, and even with strict adherence to best practices, some CAUTIs will occur. A more realistic goal is to reduce the extensive use of IUCs and to decrease CAUTI infection rates (Elpern et al., 2009). Adopting this approach may represent a significant shift for most acute care nurses, as incontinence management is a persistent challenge — particularly among obese, female, or immobile patients. During the research period, many patients were hesitant to discontinue catheterization due to fears of incontinence-related risks. It is anticipated, however, that reductions in infection rates will make nurses less hesitant to remove catheters, as concerns about risks and the additional workload of discontinuance (such as linen changes and hygiene interventions) are lessened.

Resource needs are expected to increase as new practices — such as early catheter removal — are adopted. Supplies such as linens, washroom products, and external catheters will be needed in greater quantities during the intervention period. Frequent bladder scanning to check for urinary retention will also be required. Further research is needed in this area; the plan was specifically limited by the small body of literature on incontinence-related risks and complications (Elpern et al., 2009), and few studies have examined patient comfort or discomfort with catheters, or compared the advantages and disadvantages of indwelling versus condom catheters.

Generalizability of outcomes is limited by the use of a single medical unit in a single facility and by the study's restriction to IUCs only. CAUTI rates were also compared before and during the intervention period rather than against a control group, introducing the possibility that other factors influenced outcomes during the study period (Elpern et al., 2009). Additionally, the appropriateness of catheter use was not determined by evidence-based criteria alone; rather, stakeholder consensus was used, with nurses' opinions given the greatest weight given their direct patient contact. This qualitative assessment should therefore be supplemented by quantitative data in future studies.

Conclusion

Generally speaking, significant progress has been made in the prevention of intravascular-related infections. Current research has deepened understanding of the risk factors associated with intravascular catheter infections, clarified preventive infection control tactics, and introduced new technologies such as antimicrobial-impregnated vascular catheters. Whereas vascular catheters are relatively new to medicine, urinary catheters have been in use for more than a century (Trautner and Darouiche, 2004). Sadly, several aspects of CAUTI pathogenesis render preventive tactics that work well for vascular catheters ineffective in the bladder. These challenges should not discourage continued research in this field; rather, they should be viewed as opportunities for future innovation.

Nurse re-education regarding insertion, management, and early removal of IUCs, combined with focused, unit-specific interventions, was found to reduce catheter-days and had a meaningful impact on CAUTI rates. Improved care procedures and patient outcomes were achieved by applying best evidence to direct practice and by developing system supports that offered education and enhanced product accessibility for optimal care. Although electronic media for training healthcare providers can present challenges, developing an online educational program for CNAs and RNs and updating hospital policy provided consistent, accurate, and concise content and proved a useful medium for improving practice (Oman et al., 2011). Re-education regarding a common nursing intervention raised what was previously perceived as a straightforward skill to a higher level of clinical significance. Product modifications that streamlined IUC tools, catheter types, and collection bags also created significant opportunities for practice improvement and cost savings.

Focused unit interventions — particularly those providing thorough education on postoperative urinary retention, using a bladder scanner to assess urinary retention, supporting intermittent catheterization, and promoting early removal of the IUC — led to reductions in indwelling catheter-days. A dedicated bladder scanner provided nurses with an objective means of assessing urinary retention and directing appropriate interventions. Use of the bladder scanner also helped prevent reinsertion of an IUC following early removal (Oman et al., 2011). Nurses regarded the bladder scanner as a crucial component of the intervention, and the Quality Intervention Team confirmed that it was used appropriately to prevent unnecessary IUC reinsertion.

In this quality improvement project, several limitations were identified. Because this was an uncontrolled pre/post intervention study, it is not possible to rule out the influence of factors other than the intervention itself on changes in catheter duration and observed CAUTI rates. Additionally, the evaluation of focused interventions within two units may have offered only a partial view of the overall effectiveness of the educational, product, and policy changes implemented. The total number of CAUTIs on the intervention units during the study period was low, and confidence intervals around CAUTI rates were relatively wide, making it difficult to assess the effect of the intervention on the primary outcome of interest (Oman et al., 2011).

To effectively change practice, multifaceted efforts are needed to reduce CAUTI incidence in hospitalized patients. IUCs are frequently indicated in acute care hospital settings, and efforts that reassess practice and care management strategies based on best evidence are required and should be continually revisited. The findings of this research support the value of implementing a CAUTI program that incorporates nursing education, product improvements, skills training, and surveillance to positively influence patient outcomes. Reassessing a common nursing practice led to improved IUC care practices and better patient outcomes.

The implementation strategy will make effective use of appropriate management theory to guide the plan. Theory provides a comprehensive, coherent, and consistent conceptual framework that can be applied as a design for change management. Risk management will also be employed to mitigate risks associated with patient safety, staff wellbeing and training, and resource availability. Risk mitigation involves identifying potential problems before they arise and addressing them proactively using available tools. This directly supports quality management, which is driven by the ability to achieve the goals of the conceptual model through a clear vision and clear means of execution. In relation to this project, the principle that quality management and change management are "two sides of the same coin" is foundational (McGregor, 2004, p. 28).

The central approach of this implementation strategy is that quality below depends on quality above, and that positive relationships within management translate to a better workplace environment at every level. The nurse administrator bears responsibility for keeping staff united and positive during the transition, particularly as staff adapt to the "go-live" phase of the change management model. This requires that the administrator cultivate a sense of approachability and trust so that the workplace atmosphere remains upbeat during this challenging transition period.

The likeability factor is pivotal in maintaining a healthy and productive organizational culture. Quality management leadership should demonstrate a high level of EI as the implementation strategy goes live, in order to reduce the risk of employee fatigue and patient care lapses. This depends heavily on proper oversight and dedication from the top down. Luthans (1988) states that "successful managers ... are not engaged in the same day-to-day activities as effective managers" but rather are those who "find that the way to get ahead ... is to be friendly ... both inside and outside the firm ... find a common interest ... and interact with them on that level" (p. 130).

Successful management is concerned with progress — going beyond the status quo and doing more than is minimally required in order to boost numbers, morale, motivation, and overall growth. The successful manager is one whose efforts are consistently oriented toward advancement. Getting ahead can be understood in terms of pay incentive as well as through the lens of the Hawthorne Effect: in the former, pay is the vehicle for advancement, while in the latter, recognition through being noticed serves the same function. In reality, the most skilled transformational leaders and effective managers are those who can provide a framework and culture that offers flexibility to individual team members while unifying everyone around a common goal.

Improvement — in oneself and in one's organization — is the universal goal, making workplace behavior the starting point for more efficient operations at every level. Such a mindset will be essential to the overall success of this initiative, as the Six Sigma method is used to monitor and measure stages of developmental progress, with a 0–100 model of reward and assessment ensuring that pivotal developmental milestones are adequately reached at every level of the organization.

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