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Prevention of Catheter Associated Urinary Tract Infection ( CAUTI ) [compatibility mode]


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Infection Control Guidelines for Prevention of Catheter Associated Urinary Tract Infection …

Infection Control Guidelines for Prevention of Catheter Associated Urinary Tract Infection
Infection Control Director, KKH.

Published in: Health & Medicine, Business
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  • 1. ١
  • 2. Healthcare Associated Urinary Tract Infections It is the most common type (± 40%) of NI involving both LTC and acute hospital settings Instrumentation is almost always associated with all cases Being the most common it is the most preventable Adults and children are equally affected ٢
  • 3. Main Types of Infections Main Types of HAIs 17% 44% 18% 10% 11% UTI SSI BSI Pneumo Others ٣
  • 4. Epidemiology of Catheter Associated Urinary Tract Infection  Magnitude of the problem  Incidence and cost     15 – 20 % of total hospital admission have FC Nearly 900,000 nosocomial UTI in the US 900, It cost $600 million if LOS increased by 1 day $600 In reality LOS increased by average of 3.8 days costing $3 billion $3 ٤
  • 5. Epidemiology of CAUTI cont….  Mortality  Related to bacteremia which accounts for 0.3 – 3.9% of total UTIs  Out of which fatality exceed 30% (4500 30% (4500 death/year)  Morbidity  Spread of infection through out urinary tract causing; absesses, epididymitis, orchitis…etc. orchitis…  Other complications like stones and polyps ٥
  • 6. Epidemiology of CAUTI cont….  Consequences of antibiotic use  Emergence of resistant strains  Epidemics of HA UTI   Urinary drainage bag act as a reservoir for the organisms to colonize and to transfer the resistant plasmid With poor hand hygiene cross-infection lead to crosshospital wide organisms ٦
  • 7. Epidemiology of CAUTI cont…. Catheter use It is an instrumentation that is almost used in all hospitals Endemics occurs throughout the hospital The daily IR is 2-16% for the first 10 days in the close system drainage Universal infection by 30 days in the close system drainage ٧
  • 8.  Role of catheter  Transurethral catheter break the normal defense mechanism  The retention balloon prevents complete emptying  Open channel to the bladder  Foreign body ٨
  • 9.  Bacterial factors  Pili  Hemolysin  Urease  Pathways of infection  Intraluminal (exogenous organism)  Extraluminal (endogenous organism) ٩
  • 10. Source Healthcare Associated Urinary Tract Infections Patient’s Own Flora CAUTI Medical Equipment Staff Member ١٠
  • 11. Etiological Agents Etiologic Agents 15% 25% 7% 8% 11% 16% ١١ E.Coli Enterococcus P.aeruginosa C.albican K.Pneumoniae Others
  • 12.  Host        factors Duration of use Female gender Absence of systemic antibiotics DM Renal insufficiency Advanced age Severe underlying illnesses ١٢
  • 14. Diagnosis OF CAUTI CDC Definition Exclude infections that acquired prior to admission Asymptomatic bacteriuia should have > 100,000 cfu/cc Culturing the catheter tip is of NO VALUE Uses of symptoms; only fever ١٤
  • 15. Preliminary Recommendations For Prevention Of CAUTI Appropriate Catheter Use Aseptic Insertion Proper Maintenance Systems Intervention Administrative Infrastructure ١٥
  • 16. Appropriate Urinary Catheter Use Insert catheters only for appropriate indications and leave in place only as long as needed. Do not use catheters in patients for management of incontinence. Use catheters in operative patients only as necessary, rather than routinely. For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible, preferably within 24 hours, unless there are appropriate indications for continued use. ١٦
  • 17. Preliminary Recommendations For Prevention Of CAUTI Catheter Use Appropriate Insertion Aseptic Maintenance Proper ١٧
  • 18. Appropriate Urinary Catheter Use, cont Use alternatives to indwelling urethral catheters in selected patients when appropriate. Condom catheter drainage is preferable to indwelling urethral catheters in cooperative male patients without retention or bladder outlet obstruction. Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in those with bladder emptying dysfunction. An ultrasound to assess urine volume may be used for those undergoing intermittent catheterization to reduce unnecessary catheter insertions. Clean technique for intermittent catheterization is an acceptable alternative to sterile technique for those requiring chronic intermittent catheterization. In the acute setting, use sterile technique and equipment for intermittent catheterization. ١٨
  • 19. Catheter Insertion Perform hand hygiene immediately before and after insertion or any manipulation of the catheter or site. Ensure that only properly trained persons who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility.  Insert catheters using aseptic technique and sterile equipment. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. Use the smallest bore catheter possible to minimize urethral trauma. Catheter Maintenance Maintain a sterile, continuously closed drainage system. Do not disconnect the catheter and drainage system unless the catheter must be irrigated. Maintain unobstructed urine flow. Do not use complex urinary drainage systems as a routine infection prevention measure. Do not change indwelling catheters or bags at arbitrary fixed intervals. Do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization. ١٩
  • 20. ٢٠
  • 21. Systems Interventions Implement quality improvement (QI) programs to enhance appropriate use of catheters and to reduce the risk of CAUTI. The purposes of QI programs should be: to assure appropriate utilization of catheters to identify and remove unnecessary catheters to ensure hand hygiene and proper catheter care CAUTI PREVENTION BUNDLE ٢١
  • 22. Administrative Infrastructure Provision of Guidelines Education & Training Supplies System of Documentation Surveillance Resources ٢٢
  • 23. WHAT IS A BUNDLE? A bundle is a structured way of improving processes of care and patient outcomes. It is a small straightforward set of practices – generally three to five that when performed collectively, reliably and continuously, have been proven to improve patient outcome. ٢٣
  • 24. CAUTI Insertion Bundle Documenting Optimal Care The Bundle 1. All patients with urinary catheters on OUR ward/clinical area will have a CAUTI insertion checklist. 2. The CAUTI insertion checklist will be complete and show that the care at catheter insertion was optimal. ٢٤
  • 25. CAUTI Maintenance Bundle Remove catheters as soon as possible, care for catheters individually The Bundle 1. Perform a daily review of the need for the urinary catheter. 2.Check the catheter has been continuously connected to the drainage system. 3. Ensure patients are aware of their role in preventing urinary tract infection. (Alternative bundle criterion if the patient is unable to be made aware: Perform routine daily meatal hygiene). 4. Regularly empty urinary drainage bags as separate procedures, each into a clean container. 5.Perform hand hygiene and don gloves and apron prior to each catheter care procedure; on procedure completion, remove gloves and apron and perform hand hygiene again. ٢٥
  • 26. CAUTI Insertion Bundle Standard Operating Procedure Statement UCs are used frequently in healthcare, however, the use of UCs can lead to serious life-threatening complications. UCs cause urinary tract infections and are the second leading cause of blood stream infections. To minimise the risk of complications, the insertion procedure must be optimal. We have a duty to our patients to optimise UC insertion care and to ensure that our UC care does not cause the patients harm. Monitoring our UC insertion care will assist us to optimise procedures, reduce the risk to patients and demonstrate the quality of care we provide. Objectives Objectives: 1.To optimise Urinary Catheter insertion procedures in OUR ward/clinical area and thereby minimise the risk of catheter associated urinary tract infections and secondary bacteraemias. 2.To be able to demonstrate quality urinary catheter insertion care in OUR ward/clinical area. Requirements Before the CAUTI Insertion Bundle Procedure can be considered: Signed commitment from the clinical team: consultants; junior doctors, ward manager and nurse team to optimising UC care. Procedure Perform hand hygiene..١ 2.Collect a bundle form and complete the top boxes: name, location, etc. 3.Identify all patients in the ward/clinical area who have a urinary catheter. 4.Review the medical/nursing notes of all patients with a urinary catheter and identify whether a CAUTI Insertion Checklist is present. 5.Note the presence/absence of the CAUTI Insertion Checklist on the CAUTI bundle form. 6.Review the CAUTI Insertion Checklist; if complete and the catheter insertion procedure was recorded as optimal Record as appropriate on the CAUTI Insertion Bundle form. Optimal is all the actions recorded as Yes and catheter size, balloon size, sterile water amount and reason for catheterisation being completed. 7.For each patient with a urinary catheter, repeat steps 4-6 until all notes and CAUTI Insertion Checklists have been identified and reviewed. 8.Complete the remaining CAUTI Insertion bundle form sections. After care ٢٦ Complete form. Give it to: Discuss and display the data when it has been returned. Keep Bundle forms for _____(time)
  • 27. Patient Name Hospital Number Date the catheter was inserted Resident Ward Before the procedure Alternatives to indwelling catheterisation have been considered and the need for urinary catheterisation in this patient outweighs possible complications. Yes No The clinical reason for insertion is specified and documented (see box below). Yes No The operator has been deemed competent in performing this procedure, or the role is being performed with supervision from a competent person. Yes No The operator has explained the need for a urinary catheter, and the potential complications to the patient, and gained the patient’s consent. Yes No The operator, and supervisor, removed jewellery, put on a clean plastic apron and performed a hygienic hand hygiene procedure and donned sterile gloves. Yes No The smallest gauge for effective drainage has been selected: state size; _______ Yes No The balloon is <10mls in size: state size of balloon; ____mls, and amount of sterile water inserted into balloon ____mls. Yes No Prior to starting the procedure: the procedure process was explained to the patient and the patient was reassured. Yes No During the procedure did the operator Clean the urethral meatus with sterile saline Yes No Lubricate the catheter with sterile lubricant Yes No Insert the catheter a little further once urine starts to drain before inflating the balloon (to ensure catheter is inserted in the bladder and not urethra). Yes No Aseptically connect the catheter to a sterile approved drainage bag. Yes No After the procedure did the operator Check drained urine for cloudiness and send a specimen to the laboratory if the urine was cloudy or offensive or if the patient had symptoms suggestive of a urinary tract infection. Yes No Position the catheter below the level of the bladder on a clean stand that prevents any part of the catheter drainage system coming into contact with the floor. Yes No Name of Operator: Name of Observer (if present): Valid clinical reasons for indwelling urinary catheterisation The clinical team need to closely monitor urinary output (haemodynamic monitoring) The patient cannot sufficiently empty his/her bladder (bladder outlet obstruction) The patient has a lack of bladder control and signs that the kidneys are not working well The patient has open wounds or pressure sores around the buttocks that are frequently soiled/contaminated with urine. ٢٧ The patient is severely ill, or has a disability that makes moving or changing very painful. State the reason for catheterisation if not one of the above: Tick
  • 28. Ward Named individual performing bundle Date Signature Patient Observation Was the urinary catheter inserted in this clinical area? Is there a Urinary Catheter Insertion Checklist for this patient? If present, does the Urinary Catheter Insertion Checklist indicate optimal insertion care? 1. Yes No Don’t know Yes No Yes No What, if anything, was missing or incorrect: 2. Yes No Don’t know Yes No Yes No What, if anything, was missing or incorrect: 3. Yes No Don’t know Yes No Yes No What, if anything, was missing or incorrect: 4. Yes No Don’t know Yes No Yes No What, if anything, was missing or incorrect: 5. Yes No Don’t know Yes No Yes No What, if anything, was missing or incorrect: 6. Yes No Don’t know Yes No Yes No What, if anything, was missing or incorrect: ٢٨7. Yes No Don’t know Yes No Yes No What, if anything, was missing or incorrect:
  • 29. Total Comment (if required) Summary Table of UC Maintenance Bundle Findings Total number of UCs in situ at start of the Bundle Total number of UCs inserted in our clinical area Total number of UCs inserted in our clinical area with insertion checklists Total number of UCs with optimal care documented on insertion checklist All or None Table – Was UC insertion care optimal Tick if achieved 100% 100% of UCs inserted in our clinical area had an insertion checklist 100% 100% of UCs inserted in our clinical area had an insertion checklist showing optimal care Insertion care was optimal if there was a complete and optimal insertion catheter checklist for each urinary catheter inserted in this clinical area. If insertion care was not optimal for urinary catheters inserted in other clinical areas, consider what can be done to communicate this to the clinical leaders responsible. responsible. ٢٩
  • 30. What date should be recorded as the “Date of CAUTI onset”? ٣٠
  • 31. The day the first positive urine specimen is taken OR The day the physician diagnoses the CAUTI and institutes antibiotics ٣١
  • 32. A patient is admitted to the hospital and has a catheter inserted on admission (Day 1).The following day (Day 2) this patient presents with a fever, loin tenderness and the physician diagnoses a UTI and prescribes antibiotics Does the patient meet the criteria for a CAUTI? ٣٢
  • 33. NO The first positive urine specimen must be taken or physician diagnosis of UTI must be more than 48 hours after the catheter was inserted ٣٣
  • 34. A patient is admitted to the hospital with a catheter in situ Are they included in CAUTI surveillance? ٣٤
  • 35. NO With the exception of patients who have a catheter inserted in ER or theatre prior to being admitted to the specialty ٣٥
  • 36. A patient is undergoing treatment for a UTI and has a urinary catheter inserted Are they included in the CAUTI surveillance? ٣٦
  • 37. NO Patients are excluded from CAUTI surveillance if they are undergoing treatment for a UTI at the time the catheter is inserted ٣٧
  • 38. A patient had a catheter removed and 2 days later they develop signs and symptoms for UTI Do they have a CAUTI? ٣٨
  • 39. YES A UTI is considered to be catheter associated if the patient had a catheter removed within the three days prior to the onset of the UTI ٣٩
  • 40. A patient has a catheter inserted in theatre before transfer to the ward Are they included in the CAUTI surveillance? ٤٠
  • 41. YES Patients who have a catheter inserted in ER or theatre prior to being admitted to the specialty are included ٤١
  • 42. A patient has a catheter inserted. 5 days later the catheter is removed and immediately replaced Is this considered to be a “new” or “continuous” catheterisation? ٤٢
  • 43. Continuous catheterisation Any catheter replaced within 24 hours of removal of the previous catheter is a continuous catheterisation If the interval between catheter removal and catheter replacement is more than 24 hours, a new period of catheterisation should be started ٤٣
  • 44. Following catheter removal, for how many days should the patient be followed up? ٤٤
  • 45. 3 Days Unless they are discharged, transferred or die, develop a CAUTI or the 30 day surveillance period ends before the end of the 3 day follow up period ٤٥
  • 46. A patient has intermittent catheterisation Are they included in surveillance? ٤٦
  • 47. NO Patients are excluded if the catheter is intermittent ٤٧
  • 48. A patient is transferred to the surveillance specialty where a catheter is inserted. Transfer notes state that the patient had a catheter in situ previously and it was removed 5 days prior to transfer. Does the patient meet the criteria for a “Previous Period of Catheterisation” ٤٨
  • 49. YES A patient who has has a previous catheter removed more than 24 hours but less than 7 days before the insertion of the present catheter meets the criteria for “Previous Period of Catheterisation” ٤٩
  • 50. ٥٠
  • 51. ٥١