Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide

Stop catheter-associated urinary tract infections (CAUTI) in critically ill patients.

1. RAISE AWARENESS AND UNDERSTAND THE RISKS OF INDWELLING URINARY CATHETERS

Possible misconceptions:

Note: Quotes below are show in cartoon quote balloons.

"It's just a Foley, so what's the big deal?"
"All immobile patients need a urinary catheter to prevent hospital-acquired pressure ulcers."
"CAUTI prevention isn't my responsibility."
"My team needs precise fluid intake and output details for our patients throughout their ICU stay."

What the science & evidence show:

CAUTI is a serious patient safety issue.¹

• Complications associated with CAUTI result in increased length of stay, patient discomfort, excess health care costs, and even death.
• It's about more than just the Foley. Unnecessary catheterization puts patients at risk for urinary tract infections and may cause other complications such as multidrug-resistant organisms, additional antibiotics leading to increased risk of Clostridium difficile infection, immobility (Foley is considered a "one-point restraint), hospital-acquired pressure ulcers, falls, and venous thromboembolism.^{2, 3}
• Not all critically ill, immobile patients need Foley catheters.
• All team members—from frontline staff to leaders—have a responsibility to help prevent CAUTI.
• CAUTI prevention is also tied to the “bottom line” with potential financial implications associated with Centers for Medicare & Medicaid Services and healthcare-acquired conditions, value based purchasing, and population health.
• CAUTI outcome measures are used to assess performance.

2. CONSIDER ALTERNATIVES FOR MEASURING FLUID INTAKE AND OUTPUT

• Daily weights (image of scale below text)
• Condom catheter (image of catheter below text)
• Female and male urinals (image of urinals below text)
• Straight intermittent catherization (image of catheter tube below text)
• Patient commodes (image of commode below text)
• Absorbent briefs or under pads that can be weighted to obtain urine output (image of under pad below text)

3. RETHINK THE “CULTURE OF CULTURING” URINE

• Reflex pan culturing may lead to C. difficile infection.
  
  Asymptomatic bacteriuria
  + exposure to unnecessary antibiotics
  possible C.difficile infection
• If a patient develops a new fever, "…(> 38.3 C), it is a reasonable trigger for a clinical assessment but not necessarily a laboratory or radiologic evaluation for infection." ⁴
• Don’t assume an ICU patient’s fever is due to a urinary tract infection...
• ...Other causes could include: ⁴
  • Respiratory tract infection
  • Gastrointestinal infection
  • Bloodstream infection
  • Neurological pathology that may result in altered thermoregulation
• "Critical care units could reduce the cost of fever evaluations by eliminating automatic laboratory and radiologic tests for patients with new temperature elevation (level 2). Instead, these tests should be ordered based on clinical assessment."⁴

4. TACKLE CAUTI

1. Pause and verify that the patient has an approved indication before inserting catheter.
2. Involve a second person during insertion to facilitate aseptic technique.
3. Evaluate continued need daily.
4. Empower nursing staff to discontinue catheter use as soon as possible.

Make a difference. Change the culture. Visit www.ahrq.gov/CAUTItools for more information.

1. Bell L. AACN Practice Alert: Catheter-Associated Urinary Tract Infections. November 2011.
2. Saint S, Savel RH, Matthay MA. Enhancing the Safety of Critically Ill Patients by Reducing Urinary and Central Venous Catheter-related Infections. Am J Resp Crit Care Med. 2002;165:1475-9. PMID: 12045119.
3. Fakih MG, Krein SL, Edson B, et.al. Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm. Am J Infect Control. 2014 Oct;42(10 Supple):S223-9. PMID: 25239714.
4. O’Grady NP, Barie PS, Bartlett JG, et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med. 2008 Apr; 36(4):1330-1349. PMID: 18379262.