1. Running head: CLINCAL PROJECT 1
Clinical Project for Synthesis 4502
Stephanie Dachno
North Park University
2. CLINICAL PROJECT 2
Abstract
The purpose of this paper is to review practices regarding the management of indwelling urinary
catheters, and prevention of catheter-associated urinary tract infections at Lutheran General
Hospital. Research on patients with catheters on the medical cardiac intensive care unit MCICU
was conducted along with an examination of catheter systems in the emergency department
compared to those used in the MCICU. Articles reviewed include guidelines of urinary
catheterization and their indications, catheter-associated complications, and assessment and
management strategies to ensure the best patient outcomes and minimize complications. The
research findings will possibly implement change within the hospital if the emergency
department is willing to use catheters with urine meters. After reviewing the data the risks
associated with changing catheter tubing are significant and therefore should not be changed.
Rather the emergency department needs to use urinary catheters with urine meters to avoid
compromising the closed system.
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Clinical Audit CAUTI at Lutheran General Hospital MCICU
A urinary tract infection, or “UTI,” is an infection that can occur in your kidneys, the
tubes or in the bladder (Dugdale, 2012). According to the Centers for Disease Control and
Prevention (2009) catheter-associated urinary tract infections (CAUTI) is the single most
common nosocomial infection. They account for more than 30 percent of hospital-acquired
infections with an estimated 13,000 attributable deaths annually. These staggering numbers have
increased cost to approximately 0.5 billion dollars per year nationally (CDC, 2009). With
significant increases in costs Centers for Medicare and Medicaid services have reformed
reimbursement policies that no longer cover hospital-acquired CAUTI. Due to the clinical and
economic consequences of CAUTI several institutions such as Healthcare Infection Control
Practices Advisory Committee HICPAC and the CDC have released recommendations for
insertion, maintenance and removal of indwelling urinary catheters aimed at prevention of
CAUTI.
As hospitals implement catheter protocols much of the responsibility falls to the nurse
although this should be an interdisciplinary team approach for better outcomes as evidenced in
other institutions (Institute for Healthcare Improvement, 2010). This includes but is not limited
to ensuring catheter placement is limited to patients who meet indications, following standards
for catheter insertion and maintenance, assessment of the necessity of catheter continuation on a
daily basis, ensuring prompt removal of catheters when no longer indicated, assessing for
possible infection and developing improvement plans. Three specific areas nurses should focus
on are education about appropriate indications for catheter use, proper insertion techniques and
alternatives to catheterization (Agency for Healthcare Research and Quality, 2012). After
consulting with the MCICU manager the increase in CAUTI rate on the unit in the past year has
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given cause for review of current practices and examination of CAUTI prevention measures.
This required the need to reeducate and reintroduce the CAUTI prevention measures to the staff
in addition to researching what changes could be made to reduce the CAUTI rate. At Lutheran
General Hospital approximately 78 percent of patients in the Medical Cardiac Intensive Care
Unit MCICU have indwelling urinary catheters. Almost 89 percent of the MCICU catheterized
patients obtain them in the emergency department. When this patient population is transferred to
the MCICU the collecting system is changed because the emergency department does not use
catheters with urine meters. Urine meters are essential for the nurses to accurately measure
hourly output for critically ill patients. In order to add the urine meter the nurse must change the
collecting system which in turn breaks the sealed tubing. This disconnection compromises the
sterile field and serves as a possible site for infection. Since this occurs so frequently on the unit
the question that should be researched is would changing the catheters used in the emergency
department to pre-connected sealed catheters with urine meters decrease the risk of CAUTI?
The purpose of this research is to identify the risk factors for CAUTI in Lutheran General
Hospital and recommend interventions to reduce these risks. In order to accomplish this goal this
paper will use gathered audit information on patients with indwelling urinary catheters on the
MCICU. Over the course of two months information was gathered on patients with catheters
including what department inserted them, if the tubing collection system was still intact, how
often the perineal area and catheter were assessed, compliance of nurses with appropriate
catheter care and review of catheter necessity. The paper will examine current nursing catheter
practices, hospital policies, evidence based risk factors and healthcare guidelines and prevention
strategies. This paper also aims to promote compliance between departments to further research
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the benefits of changing emergency department catheters and implementing those necessary
changes.
Review of Literature
Indwelling urinary catheters can be an invaluable instrument in the heath care setting
especially with critically ill patients. However, catheter associated urinary tract infections
represent an increasing challenge in nursing care. It is apparent when researching the evidence-
based literature that CAUTI’s are a major concern and the best way to stop them is through
prevention measures. The CDC and HICPAC in collaboration with other organizations have
developed a set of guidelines for the prevention of CAUTI (CDC, 2009).
It is important to consider why CAUTI guidelines are necessary. Accounting for more
than 30 percent of nosocomial infections they have been associated with increased morbidity and
mortality rates. CAUTI’s also increase the length of a patient’s hospital stay and consequently
increase cost to hospitals. In response to the detrimental effect CAUTI’s have had the CDC and
HICPAC revised guidelines for prevention of CAUTI’s in 2009.
The collaborative efforts had recommended core prevention strategies with considerable
focus on the placement, management and removal of indwelling urinary catheters. One of the
primary goals is placement of indwelling urinary catheters based on appropriate indications
(HICPAC, 2009). When considering catheterizing a patient health care staff must first address if
they meet the qualifications, and if catheterizing that patient outweigh the risks. Catheterizing a
patient can traumatize or perforate the urethra, it can dislodge or become blocked, renal
inflammation can occur and most important there is the possibility of introduction of bacteria
that can result in infection or death (Herter, 2010). Catheters may only be inserted for
appropriate indications. These include acute urinary retention or bladder outlet obstruction or the
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need for accurate measurement of urinary output in critically ill patients (Gould, 2009). These
situations often occur in the emergency department or in an ICU setting. Patients undergoing
perioperative or surgical procedures may be catheterized, or when assisting in healing an open
sacral or perineal wound. Indications for catheterization also include if the patient requires
prolonged immobilization or to improve comfort and ease during end of life care (Gould, 2009).
An example of an inappropriate use of catheters would be management of incontinent patients
for convenience of health care staff. If an alternative catheter can be as effective it should be
used since the risk of bacterial introduction in reduced (Godfrey, 20120).
Before interacting with any patient proper hand hygiene is essential especially when
introducing a foreign object into the body. In order to decrease the risk of trauma to the urethra
operators should use the smallest catheter possible (Agency for Healthcare Research and Quality,
2012). When inserting a catheter health care staff must use aseptic technique and sterile
equipment, then following aseptic insertion, maintain a closed drainage system. These actions
are to reduce the possibility of bacterial introduction into the tubing system and should only be
performed by properly trained personnel. If there is a break in aseptic technique, disconnection
or leakage the operator should replace the catheter and collecting system using the aseptic
technique and sterile equipment. It is also beneficial to use pre-connected, sealed catheter-tubing
systems. After the catheter is in place it should be secured to the patient decrease movement and
tension on the urethra (Gould, 2009).
While managing catheters the staff must be aware and diligent about the length of time
the catheter is in place. Catheters should be in only as long as required and assessed every shift
to check necessity and document an appropriate explanation (CDC, 2009). Aside from not
catheterizing a patient removing the catheter as soon as possible is the most effective way to
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prevent CAUTI (Godfrey, 2005). For removal much of the same guidelines as insertion apply,
only properly trained persons should remove patient catheters.
Tubing and collection bag care is simple but vital to reducing risk of infection. The
collection bag should remain below level of bladder at all times including during transfer to
prevent reintroduction of passed urine back into the bladder as well as avoiding twisting or
kinking the tubing. Urine needs to be able to flow freely without backing up into the bladder.
Changing the drainage bag and collecting system however, is an aspect of catheter maintenance
that seems to lack clear guidance (Godfrey, 2005). Whether this should be a clean or aseptic
procedure varies among institutions as well as how often it should be changed. The CDC
recommends changing the catheter and bags based on clinical indications rather than a fixed
schedule, which include possible infection, obstruction or if there is a break in the closed system
(CDC, 2009).
Finally performing proper peri-care once daily, when visibly soiled or after bowel
movements is crucial to reducing the risk of infection and should be documented accurately.
Antiseptics should not be used to clean the catheter but rather a routine hygiene system such as
soap and water (Gould, 2009). During the catheter assessment nurses should be aware of some of
the clinical manifestations of CAUTI. They include urgency, frequency, dysuria or suprapubic
tenderness, febrile temperature above 38 degrees Celsius, color or character changes in urine or
positive cultures (Herter, 2010).
Since the length of time a catheter is in place is one of the leading causes for CAUTI,
prompt removal is vital (Bernard, Hunter, Moore, 2012). To better enhance the appropriate use
of catheters, catheter removal alerts and reminders should be utilized in the computer charting
system. These should include stop orders and proper protocols for removal of unnecessary
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catheters. After removal follow-up surveillance has been shortened from 7 days to 48 hours to
align with other device-associated infections (Gould, 2009).
Project Design and Methods
Design
In order to conduct my research daily audits were completed to assess the catheterized
patients on the MCICU and the risks for CAUTI on this unit. This assessment reviewed the
number of patients on the unit with indwelling urinary catheters, length of time the catheters had
been in place and where they were inserted. The different catheters used in various departments,
specifically the emergency department, were compared to assess if current practices where
beneficial or need further evaluation to prevent CAUTI’s. One of the key elements focused on
whether or not the red seal, indicating a closed system, had been broken and for what reason. A
review of the catheter care of these patients was completed to determine if there were any
inconsistencies throughout the unit. Finally the catheter care practices being implemented on the
floor where compared to the CDC/HICPAC national guidelines to see if improvements could be
made.
Sample
The patient population specifically researched was patients who received their catheters in
the emergency department and were transferred to the MCICU. When these patients are admitted
to the MCICU the collecting system is changed in order to use urine meters. The urine meters on
the intensive care unit are essential to accurately measure hourly output of critically ill patients.
Therefore when the nurses change the collecting system they break the red seal. When the pre-
connected sealed tubing system is broken the sterile field becomes compromised and serves as a
possible site for infection. Other considerations was catheter care on the MCICU to make sure
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nurses were following protocols since inconsistent care can increase risk for CAUTI. Also
inconstant care may distort measurements of future research when comparing the risk of
infection from breaking the red seal.
Data Collection and Analysis
After collecting the data I found inconsistencies between departments with regards to the
type of catheter used. The emergency department uses a closed tubing system but does not
employ catheters with urine meters. Therefore the collecting system must be changed when
patients arrive on an intensive care unit in order to place a new collecting bag with a urine meter.
Approximately 89 percent of patients with indwelling urinary catheters on the MCICU have the
red seal broken indicating a break in the closed system. This issue that these two departments
utilize different catheters increases the patients risk for developing CAUTI. In order to remedy
this situation the emergency department and the MCICU need to discuss solutions including the
emergency department using the same catheters as the intensive care units. In order to implement
this change cost would need to be considered. The cost of the catheters with the urine meters
compared to the ones used in the emergency department. If the urine meters cost more that
would have to be compared to the cost to the hospital for extended length of stay for a patient
who acquires a CAUTI. If the benefits outweigh the costs the second dilemma would be to
educate and inform staff members of the emergency department and get compliance to
implement this change. Another issue may be deciding what to do with the old catheters once
change has be executed so that the hospital is not losing money or wasting valuable resources.
Evaluation
After completing my synthesis rotation at Lutheran General and conducting this research
study I felt like I really contributed to unit. During my time on the MCICU I have learned so
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much including the power one nurse has to make a difference and the responsibility of each
nurse to contribute to better their institution. In addition to improving my research skills this
process has mad me more diligent in my work and has significantly improved my situational
awareness. I have realized a nurses job is not confined to the patient, but rather it is our duty to
be a leader, an innovator, a patient and hospital advocate and we are capable of making the
workplace and the world a better place. My agency has taught me so much and they have said
they have seen great improvement in me and have confidence in my future as a great nurse.
Conclusion
Urinary catheterization is a common intervention used in the emergency department and the
intensive care unit to manage urinary problems and assess renal function in critically ill patients.
The common use of this intervention, however beneficial, is not always used or cared for
properly and inconsistencies between departments may compromise the system. Since urine
meters are necessary in the MCICU and the catheters placed in the emergency department do not
use them the ICU nurse must disconnect and change the collecting system. In doing so aseptic
technique should be required or sterile equipment should be used to replace the entire catheter
and collecting system. Rather than disconnect or replace the catheter however, it would be
beneficial for the emergency department to use catheters with the urine meters required in the
ICU. By implementing this change Lutheran General would significantly reduce the risk of
CAUTI’s because nurses in the MCICU would not have to compromise the system by breaking
the red seal or introducing an entirely new catheter, both of which have the possibility of
introducing bacteria. In addition to changing the catheters used in the emergency department the
MCICU should review proper catheter care protocols and perform catheter care only when
necessary and accurately document the amount and frequency of care. By adhering to the
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recommendations outline above, Lutheran General can provide effective catheter care and
prevent catheter-associated urinary tract infections.
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References
Agency for Healthcare Research and Quality. (2012). Appropriate urinary catheter placement in
the emergency department. Retrieved from <http://www.catheterout.org>
Bernard, M. S., Hunter, K. F., & Moore, K. N. (2012). A Review of Strategies to Decrease the
Duration of Indwelling Urethral Catheters and Potentially Reduce the Incidence of
Catheter- Associated Urinary Tract Infections. Urologic Nursing, 32(1), 29-37.
Centers for Disease Control and Prevention. (2009). Guideline for prevention of catheter
associated urinary tract infections. Retrieved from
<http://www.cdc.gov/hicpac/cauti/002_cauti_sumORecom.html>
Godfrey, H., & Fraczyk, L. (2005). Preventing and managing catheter-associated urinary tract
infections. British Journal Of Community Nursing, 10(5), 205. Retrieved from
<http://ehis.ebscohost.com.database.northpark.edu>
Gould, C. (2009). Guideline for prevention of catheter-associated urinary tract infections.
Retrieved from <http://www.cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf>
Healthcare Infection Control Practices Advisory Committee. (2009). Engaging the emergency
department to improve indwelling urinary catheter use: a detailed protocol. Retrieved
from <http://www.catheterout.org/?q=book/export/html/49>
Herter, R., Wallace, M. (2010). Best practices in urinary catheter care. Lippincott’s Nursing
Center, vol. 28, 342-349. Retrieved from
<http://www.nursingcenter.com/prodev/ce_article.asp?tid=1027118>
Institute for Healthcare Improvement. (2010). Catheter-associated urinary tract infection.
Retrieved from
<http://www.ihi.org/offerings/MembershipsNetworks/MentorHospitalRegistry/Pages/C
UTI.aspx>
