Evidence Based Practice: Assassination of Myths CAUTI (Catheter Associated Urinary Tract Infections) reviews some of the myths healthcare teams use to perpetuate the need for indwelling urinary catheters (aka foleys) and replaces these myths with Evidence Based Practices. Citations and hyperlinks are included for all recommendations and are current as of Spring 2013. This presentation was presented to the Emory Healthcare system-wide CAUTI prevention retreat both in 2013 and 2014 and has been the basis for both entity and unit-based education to healthcare professionals.

1. Assassination of Myths:
Evidence Based Practices in
CAUTI prevention
Monica N. Tennant, MSN, APRN, CCNS

2. What is Evidence Based Practice?

3. Trust the publication or the expert?

5. What’s the big deal?
• up to25% of hospitalized patients
– 5-10% NH residents
• Often placed for inappropriate indications
• Physicians frequently unaware pt has a catheter
• Initial insertion unjustified in 21% of patients
– Continued use unwarranted for >50% of days
catheter remained
Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med.
1995;155:1425.-9
Weinstein JW et al. ICHE 1999;20:543-8 Munasinghe RL et al. ICHE 2001;22:647-9 Warren JW et al. Arch Intern Med 1989;149:1535-7
Saint S et al. Am J Med 2000;109:476-80 Benoit SR et al. J Am Geriatr Soc 2008;56:2039-44 Jain P et al. Arch Intern Med 1995;155:1425-9
Rogers MA et al J Am Geriatr Soc 2008;56:854-61 Saint S. et al. Clin Infect Dis 2008;46:243-50

6. What’s the risk?
• Daily risk is up to 10%, approaching
–100% after 30 days
• Between 75% to 90% of patients with
asymptomatic bacteriuria do not develop
systemic inflammatory response or infectious
signs or symptoms
Garibaldi, Mooney, Epstein, & Britt, 1982; Saint, Lipsky, & Goold, 2002
http://www.cdc.gov/hicpac/cauti/005_background. html

7. EBP can be fun!
Quote from the article Indwelling Urinary Catheters: A One-Point Restraint?:
• “Beyond the health and financial burden of
inappropriate catheter use is the substantial patient
discomfort caused by catheters. In a recent
prospective study,
– 42% of catheterized patients reported that the indwelling
catheter was uncomfortable,
– 48% reported that it was painful, and
– 61% noted that it restricted their activities of daily living
– 2 respondents provided unsolicited comments that
their indwelling catheter “hurts like hell”

8. Evidence Based Risk Factors for CAUTI
http://www.cdc.gov/hicpac/cauti/001_cauti.html

9. What is your hospital monitoring?
• In a recent survey of U.S. hospitals:
– > 50% did not monitor which patients catheterized
– 75% did not monitor duration and/or
discontinuation
Jain P, Parada JP, David A, Smith LG. Overuse of the
indwelling urinary tract catheter in hospitalized medical
patients. Arch Intern Med. 1995;155:1425.-9
Saint S, Lipsky BA, Baker PD, McDonald LL, Ossenkop K. Uri
nary catheters: what type do men and their nurses prefer? J
Am Geriatr Soc. 1999;47:1453.-7

10. Core Prevention Strategies
• Insert catheters only for appropriate
indications
• Leave catheters in place only as long as
needed
• Ensure that only properly trained persons
insert and maintain catheters
• Insert catheters using aseptic technique
and sterile equipment (acute care setting)
• Following aseptic insertion, maintain a
closed drainage system
• Maintain unobstructed urine flow
• Hand hygiene and Standard (or
appropriate isolation) Precautions
• Right Reason
• Right precautions
• Right insertion
• Right maintenance
• Right flow
(all Category IB) http://www.cdc.gov/hicpac/cauti/001_cauti.html

11. When can I insert a foley?
• Inserting an Indwelling urinary catheter is an
invasive procedure requiring an MD order
http://www.cdc.gov/hicpac/cauti/001_cauti.html

12. “But my patient is different!”
We’re in the ICU/Critical Care
• 95% of UTIs occurring in the
ICU develop in patients with
indwelling urinary catheters
(70% outside ICU)
• 50% of these patients
qualify for condom
catheters
It’s more convenient
• Urinary catheter-related
infection leads to an almost
threefold increase in the risk for
death, independent of other
comorbid conditions
• Each CAUTI costs up to $2836
Platt R, Polk BF, Murdock B, Rosner B. Mortality associated with
nosocomial urinary-tract infection. N Engl J Med. 982;307:637.-42
Platt R, Polk BF, Murdock B, Rosner B. Reduction of mortality associated
with nosocomial urinary tract infection. Lancet 1983;1:893.-7

13. “But my patient is . . . “
Incontinent?
• Patients with indwelling
urinary catheters are less
mobile
– Considered a 1-point restraint
• Patients without indwelling
urinary catheters are more
frequently repositioned,
decreasing risk for pressure
ulcers
– Assist to bedpan, BSC, or
changing of linens
Going to Surgery?
• Procedures less than ___?
time do not require
indwelling urinary catheters
• Remove catheters ASAP
postoperatively, preferably
within 24 hours, unless
there are appropriate
indications for continued
use
Saint, S., Lipsky, BA., Goold, SD. (2002). Indwelling Urinary Catheters: A One-Point Restraint? Annals of Internal Medicine.
137(2):125-127.
Gotelli, JM et al. (2008). A Quality Improvement Project to Reduce the Compincations Associated with Indwelling Urinay
Catheters. Urol Nurs; 28(6); 465-467.

14. “But I didn’t break sterile technique!”
• Formation of biofilms on the surfaces of catheters
and collecting systems
• Bacteria within biofilms resistant to antimicrobials
and host defenses
• Some novel strategies have targeted biofilms
(silver)
Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp

15. Evidence on breaking the seal
Maintain a closed drainage
system
• If breaks in aseptic technique,
disconnection, or leakage
occur, replace catheter and
collecting system using aseptic
technique and sterile
equipment
• – Consider systems with
preconnected, sealed
catheter-tubing junctions (II)
• – Obtain urine samples
aseptically
CDC, IHI, and the procedure your hospital uses in Lotus Notes, Lippincott, that old binder . . .

16. No Dependant Loop: Go with the flow
• Maintain unobstructed urine flow
• Keep catheter and collecting tube free from kinking
• Keep collecting bag below level of bladder at all times
– do not rest bag on floor
• Empty collecting bag regularly using a separate, clean
container for each patient.
– Ensure drainage spigot does not contact nonsterile container.
http://www.cdc.gov/hicpac/cauti/001_cauti.html
The urine in this line will never overcome the pressure of
the air in this line to jump into the drainage bag.
This is called a “dependant loop.”
The bladder will expand with urine preventing drainage
into the bag as long as there’s a dependant loop in the
catheter tubing.

17. Core Recommendations from CDC to
prevent CAUTI
• Implement quality improvement programs to
enhance appropriate use of indwelling catheters
and reduce risk of CAUTI
Examples:
– Alerts or reminders
– Stop orders
– Protocols for nurse-directed removal of unnecessary
catheters
– Guidelines/algorithms for appropriate perioperative
catheter management
http://www.cdc.gov/hicpac/cauti/001_cauti.html

18. Supplemental Prevention Strategies:
Examples
• Consideration of alternatives to indwelling
urinary catheterization (II)
• Use of portable ultrasound devices for assessing
urine volume to reduce unnecessary
catheterizations (II)
• Use of antimicrobial/antiseptic-impregnated
catheters
(IB, after first implementing core recommendations for use, insertion, and
maintenance and ensuring compliance with core recommendations )
Newton et al. Infect Control Hosp Epidemiol 2002;23:217-8

19. • Intermittent Catheterization
– Patients with neurogenic bladder
• Condom catheters
– Males without obstruction or retention
• Bladder Ultrasound Scanners
– 2 research studies of Neurogenic bladder patients
with intermittent cath had fewer catheterizations
per day but no reported differences in UTI
Supplemental Prevention Strategies:
Examples
Polliak T et al. Spinal Cord 2005;43:615-19 Anton HA et al. Arch Phys Med Rehab 1998;79:172-5

20. All recommendations in HICPAC guidelines
http://www.cdc.gov/hicpac/cauti/001_cauti.html
• Healthcare Infection Control Practices Advisory Committee
(HICPAC)
– Federal committee provides advice and guidance
to CDC and Secretary of DHHS
– 14 external infection control experts
• Other non-voting members from professional societies,
consumer groups, public health organizations
– Expert opinion can and does change:
(With your help!)

21. What is NOT evidence based practice?
• Changing catheters or drainage bags at routine,
fixed intervals
• Irrigation of bladder with antimicrobials
• Routine antimicrobial prophylaxis
• Cleaning of periurethral area with antiseptics
while catheter is in place
• Routine screening for asymptomatic bacteriuria
• Instillation of antiseptic/antimicrobial solutions
into drainage bags
• Antiseptic releasing cartridges in drain ports of
catheters
http://www.cdc.gov/hicpac/cauti/001_cauti.html

22. Now is the time to
put EBP into practice and

23. Additional References/resources
• GouldCV, Umscheid CA, Agarwal RK, Kuntz G, Pegues
DA, and HICPAC. Guideline for Prevention of
Catheter‐associated Urinary Tract Infections
2009.http://www.cdc.gov/hicpac/cauti/001_cauti.html
• IHI Program to Prevent CAUTI http://www.ihi.org/
• APIC CAUTI Elimination Guide http://www.apic.org/
• IDSA Guidelines (Clin Infect Dis 2010;50:625‐63)
• SHEA/IDSA Compendium (ICHE 2008;29:S41‐S50)
• National Quality Forum (NQF) Safe Practices for Better
• Healthcare – Update April 2010 . CDC/Medscape
collaboration http://www.cdc.gov/hicpac/
• All references and slide are available from
Monica.tennant@emoryhealthcare.org

24. Where did Monica find all of that?

25. Click on the Ask a Librarian Link:

26. The Librarian will research it for you!

27. Or on the same Woodruff Library link:

28. Do we have time for CAUTI Rock?
• CAUTI Block Video
• http://www.youtube.com/embed/Ct1StTQHuYs
• And the winner is...
In honor of National Patient Safety Awareness Week Mar. 5-9, creative JPS
team members entered a video contest with submissions promoting The
Joint Commission National Patient Safety Goals. This year's winner...ICU and
the "CAUTI Block", the new patient safety goal for 2012. Published March 23,
2012
Credits:
Lisa Temple, RN - lyrics
Albert Trevino and Randy Valdez, MSTs - music video mixing and recording
Holly Hatchett, Laci Brown and Stacy Nicholson, RNs - props
Paula Bauman, Ann Wynne and Bryan McCurdy - backup singers
Extras:
Di Patterson, RN Carrie Grabruck, RN
Amir Haq, RN Laura Canright, RN
Jacob Jordan, RN Marie Moses, RN
Leslie Haas, RN Amanda Turton, RN
Trudy Sanders, RN, Patient Safety Officer