Nursing Actions to Reduce Use of Urinary Catheters in Intensive Care Units
Introduction
Among infections acquired in the course of treatment in acute care hospitals, 32% are urinary tract infections (UTI) and 75% of these urinary infections are associated with an indwelling urinary catheter (Centers for Disease Control and Prevention, 2017). The problem is magnified in intensive-care units (ICUs), where over 50% of patients, many critically ill, have indwelling catheters. Of UTIs diagnosed in ICU patients, 95% are associated with catheters (Chenoweth & Saint, 2013). The national incidence of CAUTI is 2.5 per 1000 catheter days (Saint et al, 2016) however, this rate varies widely among hospitals. The CDC recommends judicious use and early removal of catheters. The CDC’s recommendations include the use of urinary catheters for critically ill patients only during the time when accurate output measurements are necessary, removal of catheters in most post-operative patients within 24 hours, and avoiding the use of catheters to manage incontinence (except in the case of serious incontinence-related pressure injuries or end of life care) (Gould, et al., 2017). Despite these recommendations, Saint and colleagues (2016) showed little change in the rates of indwelling catheter usage in ICUs. Catheter-associated urinary tract infections (CAUTI) are important because of its association with increase length of hospital stay (LOS), increase the cost of treatment, and increase the risk of sepsis and death.
When a patient develops a CAUTI, his/her length of hospital stay is frequently increased due to the need for additional treatment. Although the CDC does not precisely quantify the increase in LOS, any increase in hospital stay may be associated with the risk of complications related to prolonged reduced mobility (such as muscular deconditioning and deep vein thromboses), confusion and delirium (especially in older patients), and further adverse events such as infections or falls (CDC, 2017). Mitchel, Ferguson, Anderson, Sear, and Barnett (2016) found among over 160,000 admissions, 1.73 % acquired a hospital Associated UTI with an average length of stay of four days.
The Leapfrog Group (2017), noted a direct medical cost of $758 per CAUTI, with nearly 450,000 events per year. Scott (2009) noted, such costs do not include other medically-related costs (such as the hospital room and hospital staff), nor does it account for the measurable costs (lost work time, lost work time by family members) and immeasurable costs (pain and suffering, debility) incurred by the patient. In many cases, the Centers for Medicaid Services will not reimburse hospitals for the treatment of hospital acquired CAUTI. The cost is borne by the hospital and ultimately by the hospital’s staff and patients, all of whom may be affected by this redirection of financial resources. The CDC (2017) estimated over 340 million dollars spent in health care is attributed to CAUTI in the U. S. each year.
Urinary Tract Infections (UTI) in U.S. hospitals were found to account for the highest number of infections compared to other HAI (in 2002) and attributed to over 13,000 deaths with a mortality rate of 2.3% (Klevens et al., 2007). Saint (2013) noted that bacteremia occurs more frequent in certain types of patients (male, patients with malignancy, immunosuppressed; tobacco users) than others. Secondary to nosocomial bloodstream infections, about 17% of hospital-acquired bacteremias are from a urinary source, with an associated mortality of approximately 10% (CDC, 2017). Development of urosepsis following CAUTI is multifactorial, but nevertheless this iatrogenic event is an outcome that is preventable.
A CAUTI is an iatrogenic event with an incidence of 2.5 per 1000 catheter days (Saint, et al., 2016). Kennedy and colleagues (2013) found there was a 5% increase of acquiring a CAUTI for every day it was left in place over the standard practice of 28 days. The CDC’s recommendation suggests CAUTI are best reduced by minimizing the use of indwelling catheters and removing them as soon as possible (CDC, 2017). Although indwelling catheters are ordered by physicians, Chenoweth and Saint (2013) reported, physicians were often unaware that their patients had an indwelling catheter. Thus, nursing interventions to reduce the use of indwelling catheters could be a key force in reducing CAUTI. Given the related risk of CAUTI, it is essential to explore interventions to decrease incidence of such events. The purpose of this paper is to investigate whether a nurse-driven protocol for catheter removal is associated with a reduction in catheter days and a concomitant reduction in urinary tract infections among adult intensive care patients.
PICO
In adult intensive care patients (P), does a nurse-driven catheter removal protocol (I) compared with the standard practice of catheter removal per physician order (C) reduce rate of Catheter Associated Urinary Tract Infections (O)?
References
Centers for Disease Control and Prevention. (2017). Catheter-associated urinary tract infections (CAUTI). Retrieved 2/2/2018 from https://www.cdc.gov/hai/ca_uti/uti.html
Chenoweth, C., & Saint, S. (2013). Preventing Catheter-Associated Urinary Tract Infections in the Intensive Care Unit. Critical Care Clinics, 29(Enhancing the Quality of Care in the ICU), 19-32. doi:10.1016/j.ccc.2012.10.005
Gould, C.V., Umscheid, C. A., Agarwal, R.. K., Kuntz, G., Pegues, D. A., & the Healthcare Infection Control Practices Advisory Committee. (2017). Guideline for prevention of catheter-associated urinary tract infections 2009. Retrieved from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf
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The Leapfrog Group. (2017). National healthcare safety network (NHSN) catheter-associated urinary tract infection (CAUTI) outcome measure. Retrieved from http://www.hospitalsafetygrade.org/media/file/CAUTI.pdf
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Scott, R. D. (2009). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Retrieved from https://www.cdc.gov/hai/pdfs/hai/ scott_costpaper.pdf