Catheter Associated

Urinary Tract
Infections - Prevention
& Interventions

Natalie Alwin, Misa Berndt, Samantha Helms, Nick Mar, Johnathan Mougin, Emma
Randall, Emily St. Germain, Lisa Siewert, Jaime Varner

Background/Description
Catheter Associated Urinary Tract Infection (CAUTI)
Occurs when germs, usually bacteria, enter the urinary tract via
urinary catheter and cause infection.
15-25% of hospitalized patients may receive indwelling urinary catheters.
30% of infections reported by acute care hospitals are urinary tract
infections, making it the most common type of healthcare-associated
infection.
CAUTIs have been associated with increased morbidity, mortality, hospital
cost, and length of stay.
(CDC, 2009)

Why Provide Direct Education to Nurses?

Nurses are
At the frontline of catheter care.
Directly responsible for catheter management, care and removal
Are able and amongst the first to recognize clinical change in patients
Since nurses directly interact with caring for the catheter, they are crucial for
identifying the signs of a CAUTIs.
Since nurses are at the frontline of care, providing education to these professionals
can aid in faster diagnosis of CAUTIs, and ultimately reduce the rate of
occurrence.
(Boon et. al, 2009)

PICOT
In adult patients, will mandated professional
development education for registered nurses on
catheter related infection prevention and catheter
care, compared to no supplemental education,
reduce the prevalence of CAUTI in a cost effective
manner in the acute care setting?

Statistics
450,000 catheter-associated tract infection occur annually in hospitals
in the United States.
CAUTIs account for 4 of 10 HAIs in the US.
Indwelling catheters are inserted in between 25-33% of patients
admitted to the hospital
If a patient contracts a CAUTI there is an addition $1000 of healthcare
costs that are not covered by insurance.
This all adds up to an expense of $450,000,000 per year nationwide!
Nationally, an estimated 13,000 deaths each year
attributed
to
(Fuchs,are
Sexton,
Thornlow &
CAUTI

Current Practice
Appropriate use of urinary catheters:

Acute urinary retention or bladder outlet obstruction

Accurate measurements of urinary output in critically ill patient

Surgical patients- removed in PACU if applicable

Assist in healing of open sacral or perineal wounds in incontinent patients

Improve comfort for end of life care if needed

Inappropriate use of urinary catheters:

Substitute for nursing care of the patient or resident with incontinence

Obtaining urine for culture or other diagnostic tests when the patient can voluntarily
void

Prolonged postoperative duration without appropriate indications

Consider using alternatives to indwelling urethral catheterization in selected patients when
appropriate
(CDC, 2009)

Current Practice
Primary CAUTI Prevention Measures
Insert catheters only for appropriate indications
Leave catheters in-place only as long as needed
Only properly trained persons insert and maintain catheters
Insert catheters using aseptic technique and sterile equipment
Maintain a closed drainage system
Maintain unobstructed urine flow
Hand hygiene and standard (or appropriate) isolation precautions

(CDC, 2009)

Arizona Current Practice

Statewide
The Standardized Infection Rate for CAUTI at Arizona hospitals is 11 percent higher than
the national baseline, according to data released by the CDC in March 2014
The Arizona Hospital and Healthcare Association (AzHHA) launched a collaborative effort
with member health organizations across the state to reduce CAUTIs in May 2014
Local
In an article from the Arizona Daily Star in 2015, according to the U.S. Centers for Medicare
& Medicaid Services (CMS) Banner-University Medical Center Tucson, Carondelet St.
Josephs Hospital and Tucson Medical Center were in the worst-performing 25 percent
of hospitals nationwide on a matrix of hospital-acquired conditions
(Azhha, 2014); (Innes, 2015)

Synopsis of Literature Results

The Keystone Bladder Bundle includes the following:
Alternatives to indwelling urinary catheterization
Urinary catheter reminders or removal prompts and nurse-initiated urinary catheter
discontinuation protocol
Portable bladder ultrasound monitoring
Insertion care and maintenance

Barriers to the Bladder Bundle

Difficulty with nurse and physician engagement
Patient and family request for indwelling catheters
Catheter insertion practices and customs in emergency department

Synopsis of Literature Results Cont.

Where are hospitals falling short?
Prevention methods for CAUTI:
Training was provided to 64% of hospitals on aseptic technique and CAUTI
prevention at time of initial nursing hire
Only 47% annually validated competency of indwelling catheter insertion
28% of respondents reported having no CAUTI prevention policy at all

Synopsis of Literature Results Cont.

How to decrease CAUTI rates?
Early engagement and targeted educational initiatives
Promoting Indwelling Urinary Catheter (IUC) tags: Tags use went from 46.2% to
84.6% as more education sessions occurred. Prevalence of CAUTIs went from
19% to 17% over one year
CAUTI continuation checklist: Use of computer algorithms in combination with
nurse collected patient data to determine whether or not a catheter should
be discontinued.
Clinical Nurse Specialist and physician on team to assess urinary catheter
utilization: It was found effective to address misinformation about use at
meetings and on the clinical units
CAUTI education fair: Reduced rates of CAUTI from 4.71 to 1.29 per 1000
patient device days. This fair increases the understanding and adherence to

Strengths of Articles
Many hospitals in the US do not have established systems that
routinely monitor the placement or duration of urinary catheters
CAUTI prevention educators were recruited from a variety of sources,
widening the knowledge base. This included nurse educators,
faculty from a local university, and the facilitys clinical nurse leader
The fair was flexible and accommodated varying schedules so that all
ICU and transplant staff members could receive EBP education
Peer-to-peer education provided a safe and non-threatening
environment to optimize learning

Limitations of Articles
Relationships between the use of various infection prevention
practices and CAUTI outcomes in the surveyed hospitals could not
be directly explored
Potential for response bias. To minimize bias, interviewees must
include a diverse set of organizational roles and perspectives about
the Bladder Bundle initiative
Hospital sample was not representative of many hospitals because it
was not-for-profit, making it hard to generalize
Small sample sizes, questions how universal the results may be
The approach averages hospital quality, instead of directly taking into
account the quality of care or variation in underlying infection risks

Evidence-Based Nursing Recommendations

Each study indicated a possibility of improvement of CAUTI rates
Providing education is a critical component of all interventions

Based on the findings from the studies, we suggest that the hospital
provides a supplemental nursing education event annually to
maintain competency of nurses in the management of urinary
catheters
This education event will include specific education on:
How to use the Bladder Bundle protocol, including improvement to the bundle
system
The purpose of indwelling catheters and consequences of inappropriate use

Implementation
When: Bi-annual education (January and July), Everyone attends one
hour before or after their shift
Where: conference room within the hospital
How: Nurse educators will organize prior to the education fair and
base education material off of best evidence based practice (CAUTI
bundle). Nurse educators will be present at each booth of fair and
present information to the nurses, a quiz will be implemented
directly after completion of the education session to evaluate
competency

Application
4 booths - 1 nurse educator per booth
Each nurse must attend a 10 minute educational session at each booth that discusses
various EB practices to implement into their care.
Topics to be discussed:
How to use bladder bundle protocol
Purpose of indwelling catheters, consequences of inappropriate use
The importance of protocol compliance
How to use tools and qualifications to determine when a catheter should be removed
Nurse Educators will use a variety of methods to appeal to all styles of learning:
Visual aids

Timeline
-

December (year prior): Have a team meeting with nurse educators

December (year prior): Train them on the specific interventions

January: Education fair #1

-

Quiz after fair

First week of March: Anonymous Post-Survey

-

compliance, effectiveness, relevance, satisfaction, ease of use

Second-Fourth week of March: Analyze answers to surveys

May: Nurse Educator Rounding

June: Have a team meeting with nurse educators

June: Plan educational points and how to integrate nurses feedback into next educational fair

Cost
Analysis
Average hourly wage per nurse X # of nurses employed X 1 hr = total cost per session
According to the Bureau of Labor Statistics (2012), the average nursing hourly wage in
Arizona is $34.78.
Hypothetically, if there were 342 acute care nurse being educated, the total hospital cost
would be:
$34.78 X 342 nurses X 1 hr = $11,894.76 per education session
($23,789.52 per year)
There is no data regarding what it has cost other facilities to implement this EBP because
no other facilities have implemented this exact EBP.
As previously stated, one CAUTI costs an extra $1,000 per patient. Therefore, in the
reduction of just 24 CAUTIs the hospital would have made their money back. (*the 24
is based on the hypothetical hospital cost per year*)

Risk vs benefit
Risks
The education requires the staff to set aside separate time to have urinary catheter education
reinforced, which can result in negative staff attitudes.
Staff does not comply with the education even after receiving it.
Staff fails the mandatory quiz after the education
Having too many qualifications for the use of a urinary catheter to reduce CAUTIs could prevent
patients who could benefit from the use of a urinary catheter from receiving proper care.
Benefits
The increased education would result in improved confidence of nurses when caring for patients
with indwelling catheters and making decisions related to indwelling catheters.
Reduces the long-term costs to the hospitals by preventing CAUTIs.
Reduces the length of time patients have an indwelling catheter which can be an uncomfortable
experience.

Evaluation of Intervention
1.Estimate CAUTI rates prior to implementation of education
intervention
2.Follow up staff education with a quiz on CAUTI prevention protocol.
After training sessions are complete, examine quiz scores for
competency
3.Six months following education intervention, administer a survey to
ascertain if nurses felt that they were more aware of following
catheter care protocols, as compared to before the education
intervention was implemented.
4. Compare statistics of how many CAUTIs occurred since educational
program (CAUTI fair)

Summary
Introduction: Catheter Associated Urinary Tract Infection (CAUTI)
Occurs when germs, usually bacteria, enter the urinary tract via urinary catheter and cause
infection.

Description of Issue:
CAUTIs account for 4 of 10 HAIs that occur in our hospitals
Indwelling catheters are inserted in between 25-33% of patients admitted to the hospital
These infections are costing us as a nation approximately $450,000,000 per year!
Nationally, an estimated 13,000 deaths each year are attributed to CAUTI

Supportive Studies:
Main points:

Summary Continued
Discussion of Best Practice: A supplemental nursing education event
annually to maintain competency of nurses in the management of
urinary catheters
Application to facilities: In-Service education sessions put on by
nursing educators.
Cost Analysis: $34.78 X 342 nurses X 1 hr = $11,894.76 per
education session
$23,789.52 per year

Summary Continued
Risk vs. Benefit:
Risk
Non-compliance
Staff satisfaction
Benefit
Reduce rates of CAUTI saving lives, complications, and money

?????

References
Arizona Hospital and Healthcare Association. (2014). Hospitals Seek Reduction in Catheter-Associated Urinary Tract Infections, 2014. Retrieved from http://www.azhha .org/wpcontent/ uploads/2014/11/
AzHHA _Announces _Statewide_Patient_Care_Initiative
Bureau of Labor Statistics (2012). Occupational employment and wages, May 2011. Occupational Employment Statistics. Retrieved from http://www.bls.gov/oes/2011/may/oes291111.htm
CDC. (2009). Guideline for prevention of catheter-associated urinary tract infections, 2009. Retrieved from http://www.cdc.gov/hicpac/cauti/005_background.html
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