Pennsylvania Patient Safety Advisory Barriers to Urinary Catheter Insertion and Management Practices Despite evidence that catheter-associated urinary tract Epidemiology (APIC), and the Institute for Health- infections (CAUTIs) and accompanying adverse out- care Improvement (IHI). Limitations of the survey comes can often be prevented, these infections remain include that results represent about 26% of reporting among the most predominant healthcare-acquired hospitals in Pennsylvania at the time of the survey, infections in the United States. In May 2009, hospi- and the results may not reflect statewide adoption tal infection preventionists (IPs) across Pennsylvania practices. participated in a detailed survey of implementation Results of urinary catheter insertion and management prac- tices. The survey was designed to measure the level The majority of IPs indicated that their hospitals have of adoption of practices and tools useful to overcome fully implemented the requirement that a Foley cath- obstacles to uniform implementation of CAUTI-pre- eter securement device be used on all patients, have vention practices. The following discussion highlights a CAUTI prevention program in place with a desig- the survey results, which were also presented during nated physician champion, have a written plan that the June 2009 Pennsylvania Patient Safety Authority is communicated to clinical staff, and have adopted Webinar “Getting Past the Policy: Overcoming Barri- criteria for Foley catheter use. About 40% of the IPs ers to CAUTI Prevention Practices.” indicated that their hospitals have fully implemented assessment of annual competency for clinical staff on Clinical and Economic Consequences of CAUTIs CAUTI prevention practices and use of silver-coated Foley catheters on all catheterized patients. Forty-five Between 12% and 25% of all hospitalized patients are percent of the IPs indicated that their hospitals have catheterized during their hospital stay, and as many as formally discussed and considered a hospital policy 80% of all hospital-acquired urinary tract infections on standing orders allowing nurses to discontinue or can be attributed to indwelling urinary catheters.1 remove catheters that no longer meet criteria. Use of an indwelling urethral catheter is an invasive intervention that carries a significant risk for patient Prevention practices that the majority of IPs indi- harm leading to prolonged length of stay, second- cated their hospitals have not implemented include ary bacteremia, sepsis, and increased mortality.1 In a changing of chronic Foley catheters on admission, catheter awareness survey, 288 physicians and medical a hospital policy to prohibit catheter insertion if students from 4 university-affiliated U.S. hospitals criteria are not met, automatic reminders to nurs- were asked whether patients under their care had a ing for routine maintenance activities, and use of a Foley catheter. The physicians surveyed were unaware catheter-insertion checklist. IPs from these hospitals of Foley catheterization in 28% of 117 patients, and also indicated that there was no activity to implement subsequent patient observations indicated that 31% the following practices: incorporate catheter criteria of catheter use was inappropriate.2 Among the non- into the physician’s order form, provide written Foley reimbursable hospital-acquired conditions selected catheter education materials for patients, require by the U.S. Centers for Medicare & Medicaid Ser- physicians to document catheter necessity on a daily vices, CAUTIs received a high priority due to the basis, and periodically educate physicians about high cost and high volume and because prevention is CAUTI prevention strategies. reasonable through application of accepted evidence- Responses on implementation of a monitoring sys- based prevention guidelines.3 A systematic review of tem for documentation of Foley criteria on physician evidence published between January 2001 and June orders are spread across the categories of fully imple- 2004 found that the average cost of treating a CAUTI mented, formally discussed but not yet implemented, is $1,006 in 2002 U.S. dollars.4 A cost study from the and no activity to implement this item. University of Michigan Health System found the min- imum cost of treating a patient with catheter-related System Failures and Barriers bacteremia is at least $2,836 in 1998 U.S. dollars.5 Many organizations have adopted the practices Authority Survey of CAUTI Prevention Practices advocated in evidence-based guidelines but still Methods and Limitations struggle with implementation and lack methods for efficient and reliable performance of prevention The Authority surveyed IPs from Pennsylvania practices. The Authority polled attendees of its June hospitals about obstacles to implementing CAUTI 2009 Webinar about the most significant barriers to prevention guidelines. Sixty-five IPs completed the implementation of CAUTI prevention practices (see survey. The IPs were surveyed about implementa- Figure). Poll results indicate that the predominant tion of 16 practice elements (see Table), which were barriers among the attendees are lack of account- defined according to guidelines from the Centers for ability by members of the healthcare team for Diseases Control and Prevention (CDC), the Society appropriate and safe practice and active resistance for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and (continued on page 100) Page 98 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 3—September 2009 Table. Pennsylvania Patient Safety Authority Hospital Foley Catheter Practice Survey (N = 65) FULLY FULLY IMPLE- PARTIALLY FORMALLY THERE HAS BEEN NUMBER OF IMPLEMENTED MENTED IN SOME IMPLEMENTED DISCUSSED AND NO ACTIVITY TO RESPONDENTS THROUGHOUT THE AREAS OF THE IN SOME OR ALL CONSIDERED BUT IMPLEMENT THIS SURVEY QUESTION ORGANIZATION ORGANIZATION AREAS NOT IMPLEMENTED ITEM Hospital policy requires that a Foley 63.1% 10.8% 4.6% 9.2% 12.3% 65 catheter (FC) securement device be used on all catheterized patients. A catheter-associated urinary tract 51.6% 3.1% 17.2% 21.9% 6.3% 64 Vol. 6, No. 3—September 2009 infection (CAUTI) prevention program is in place with a designated physician champion. A written CAUTI prevention plan is in 49.2% 9.2% 10.8% 24.6% 6.2% 65 place that is communicated to clinical staff. The hospital has adopted written FC 49.2% 9.2% 13.8% 18.5% 9.2% 65 criteria. Clinical staff receives at least annual 42.2% 7.8% 20.3% 17.2% 12.5% 64 competency on CAUTI prevention strategies. Silver-coated FCs are used on 39.1% 4.7% 1.6% 21.9% 32.8% 64 catheterized patients. Hospital policy includes standing orders 13.8% 6.2% 3.1% 44.6% 32.3% 65 allowing nurses to discontinue/remove FCs that no longer meet criteria. Chronic FCs are changed on admission. 10.9% 4.7% 3.1% 15.6% 65.6% 64 Hospital policy prohibits FC insertion if 4.7% 3.1% 7.8% 29.7% 54.7% 64 criteria are not met. Routine maintenance activities 16.9% 6.2% 7.7% 24.6% 44.6% 65 (catheter securement, collection bag below bladder, emptying protocol) are prompted by automatic alerts or reminders to nursing staff. An FC insertion checklist is used to 10.8% 3.1% 10.8% 33.8% 41.5% 65 verify aseptic techniques and insertion criteria. FC-insertion criteria are incorporated 13.8% 6.2% 9.2% 27.7% 43.1% 65 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority into the physician’s order form. Catheterized patients receive written 13.8% 4.6% 15.4% 29.2% 36.9% 65 education materials on FC and infection prevention. Physicians are required to document FC 20% 6.2% 6.2% 32.3% 35.4% 65 necessity on a daily basis. The CAUTI prevention program includes 20% 6.2% 7.7% 30.8% 35.4% 65 periodic physician education on CAUTI prevention strategies, including FC- insertion criteria. A monitoring system is in place for 24.6% 7.7% 10.8% 26.2% 30.8% 65 documentation of FC criteria on physician’s orders. Page 99 Pennsylvania Patient Safety Advisory Pennsylvania Patient Safety Advisory (continued from page 98) “Getting Started Kit: Prevent Catheter-Associated Urinary Tract Infections: How-to Guide.” This guide Figure. Barriers to Prevention Practices from IHI focuses on four components of patient care (N = 48) recommended for all patients and outlines specific methods to translate research into practice change at BARRIERS the bedside.8 The guide is available online at http:// No monitoring/measuring 4% www.ihi.org/IHI/Programs/ImprovementMap/ system in place PreventCatheterAssociatedUrinaryTractInfections.htm. Active resistance to prevention “Guideline for Prevention of Catheter-Associated strategy implementation from 23% Urinary Tract Infections 2008.” CDC revised its staff and/or physicians 1981 guideline on preventing CAUTIs and released a Lack of accountability for draft guideline for public comment in June 2009.The appropriate and safe practice 42% guideline emphasizes specific recommendations for all aspects of CAUTI prevention and implementation ini- Inadequate education/ 6% tiatives, updates surveillance definitions, and lists clear competency program indications for Foley catheter use.9 The draft guideline is available online at http://www.cdc.gov/ncidod/ Difficulty enlisting champions 15% dhqp/pdf/pc/cauti_GuidelineApx_June09.pdf. Additional Resources Available through Unclear policies and procedures 10% the Authority The Authority conducted its June 2009 Webinar to 0 10 20 30 40 50 help hospital IPs identify practical strategies to over- PERCENTAGE come barriers, recall methods to enlist the support of physician and nursing champions, and recognize to prevention strategy implementation from staff how to encourage and monitor staff compliance with and/or physicians. Less common barriers included CAUTI prevention practices at the bedside. The unclear policies and protocols, difficulty enlisting phy- Webinar included discussion about results of the sician and nursing champions, inadequate education hospital survey and successful prevention efforts in and competency programs, and inadequate process or Pennsylvania. outcome monitoring/measuring systems. Presenters included representatives from hospitals in Pennsylvania that have successfully reduced CAUTI Risk Reduction Strategies rates through implementation of specific strategies. Several evidence-based guidelines summarize the most For example, at Doylestown Hospital, the 2005 inten- up-to-date, significant prevention and implementation sive care unit (ICU) CAUTI rate averaged 6.6 per strategies and provide a road map for development of 1,000 catheter days. A campaign initiated in 2006 institutional policy and practices to address CAUTIs. helped reduce the rate to 0 by first quarter 2009. (A The guidelines include the following: 22% decline in catheter utilization from 2006 to 2009 resulted in an accompanying decline in the housewide “Compendium of Strategies to Prevent Catheter- CAUTI rate from 9.5 in third quarter 2006 to 1.5 in Associated Urinary Tract Infections in Acute Care first quarter 2009.) The initiative addressed approved Hospitals.” The intent of this 2008 compendium, criteria for removal of Foley catheters by a registered published by SHEA and the Infectious Disease Soci- nurse without a physician order if criteria for use were ety of America, is to assist hospitals to prioritize and not met. Analysis of hospitalwide catheter practices implement practical strategies for CAUTI prevention. indicated that most ICU Foleys were inserted in The compendium summarizes specific expert imple- the emergency department (ED). A Foley insertion mentation and monitoring methods and addresses checklist and bundle were initiated in the ED, straight accountability as well as detailed process and outcome catheters were used for emergency specimens, and measures.6 The compendium is available online at Foleys were inserted only in controlled situations with http://www.shea-online.org/compendium.cfm. time for proper preparation (i.e., not during a code “Guide to the Elimination of Cather-Associated or a rapid response). The ED coordinator monitors Urinary Tract Infections (CAUTIs).” This 2008 guide, the checklists for orders, criteria, size of the catheters, published by APIC, outlines evidence-based prac- pericare, and the use of an assistant during insertion. tice guidance to CAUTI prevention in acute and Physicians document the reason for continued Foley long-term care facilities, including antimicrobial stew- use on a Foley utilization chart sticker. ardship, surveillance, and data dissemination, as well At Paoli Hospital, the IP identified 62 CAUTI cases as how to perform a CAUTI risk assessment.7 The in 2006, a rate of 5.39 CAUTIs per 1,000 catheter guide is available online at http://www.apic.org/ days. Failure modes and effects analysis helped Content/NavigationMenu/PracticeGuidance/ identify opportunities for improvement and standard- APICEliminationGuides/CAUTI_Guide1.htm. ization, including a nurse-driven catheter-removal Page 100 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 3—September 2009 Pennsylvania Patient Safety Advisory protocol, daily assessment of catheter care, and cri- 2. Saint S, Wise J, Amory JK, et al. Are physicians aware teria on the nursing flowsheet and daily rounds. A of which of their patients have indwelling urinary cath- Foley catheter bag label identifying the insertion date, eters? Am J Med 2000 Oct 15; 109(6):476-80. time, location, inserter, and a hand hygiene reminder 3. U.S. Department of Health and Human Services (HHS). was developed. Voiding trials and bedside commode HHS action plan to prevent healthcare-associated use increased, and bladder scanning was initiated. infections [online]. [cited 2009 May 8]. Available from Unit and physician champions were identified, and Internet: http://www.hhs.gov/ophs/initiatives/hai/ infection.html. registered nurses were reeducated about insertion, care, and catheter alternatives. Orders are required for 4. Stone PW, Braccia D, Larson E. Systematic review of Foley insertion, and daily physician reminders were economic analysis of health care-associated infections. Am J Infect Control 2005 Nov;33(9):501-9. instituted. Application of these strategies reduced the number of CAUTIs to 33 in 2008, a 47% reduction, 5. Saint S. Clinical and economic consequences of nosoco- or a rate of 3.59 infections per 1,000 catheter days, as mial catheter-related bacteruria. Am J Infect Control 2000 well as a consistent decline in unnecessary catheter Feb;28(1):68-75. usage from 11,489 to 9,180 catheter days. 6. Lo E, Nicolle L, Classen D, et al. Strategies to prevent catheter-associated urinary tract infections in acute care The Authority hosts an online collection of CAUTI hospitals. Infect Control Hosp Epidemiology 2008 Oct;29 resources, including the full Webinar presentations Suppl 1:S41-50. discussing efforts at Pennsylvania hospitals and 7. Association for Professionals in Infection Control and additional patient safety tools from the Webinar Epidemiology. Guide to the elimination of catheter-asso- presenters (a detailed nurse-driven Foley catheter- ciated urinary tract infections (CAUTIs) [online]. 2008 removal protocol; sample physician reminders; [cited 2009 Jul 17]. Available from Internet: http://www. insertion, performance, and tracking checklists; and apic.org/Content/NavigationMenu/PracticeGuidance/ APICEliminationGuides/CAUTI_Guide1.htm. an infection prevention tip sheet). The collection is available online at http://www.patientsafetyauthority. 8. Institute for Healthcare Improvement. Getting started org/EducationalTools/PatientSafetyTools/Pages/ kit: prevent catheter-associated urinary tract infections: how-to guide [online]. 2009 Feb [cited 2009 Jul 14]. home.aspx. Available from Internet: http://www.ihi.org/ Notes IHI/Programs/ImprovementMap/ PreventCatheterAssociatedUrinaryTractInfections.htm. 1. Saint S, Chenoweth CE. Biofilms and catheter-associ- 9. Centers for Disease Control and Prevention (CDC). ated urinary tract infections. Infect Dis Clin North Am Guideline for prevention of catheter-associated urinary 2003 Jun;17(2):411-32. tract infections 2008 [draft online]. [cited 2009 Jul 22]. Vol. 6, No. 3—September 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 101 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 3—September 2009. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2009 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.