On the CUSP: STOP CAUTI
Frequently Asked Questions
- Getting Started
- Data Collection
- Indications for Catheter Placement
- Care and Removal of Catheters
- Clinician Engagement
- Key Contacts
- How can I join On the CUSP: Stop CAUTI? — State level coordinators initiate and manage participation of hospital teams in On the CUSP: Stop CAUTI. If you are a member of a hospital team and have an interest in joining the initiative, contact the coordinator for your state. A list of state coordinators can be found here.
- Who is eligible to participate? — All adult and pediatric acute care, critical access, and long-term acute care hospitals are eligible to participate. A primary goal of the initiative is to improve safety culture, which is specific to individual units. Therefore, all participating teams should be unit-based, and cross-unit team formation is discouraged.
- Does the national On the CUSP: Stop CAUTI project team collect data, or does each participating state collect data and submit results? — Each participating hospital unit team is responsible for data collection on their unit. Data is then submitted to the MHA Care Counts database on a monthly basis.
- In what format are data collected? — Monthly data elements are entered into the web-based data portal, MHA Care Counts. At the start of the project, a readiness assessment is administered through SurveyMonkey. Data collection tools are available to help unit teams streamline and organize data collection and submission processes.
- How much time is required for participation? — Approximately 10 percent of a project team leader’s time should be committed to the initiative. Team leaders are usually nurse managers, but may also be frontline nurses, physician champions, or quality and safety improvement leaders. Two to four hours per month of a physician champion’s time and five percent of a data coordinator’s time should be committed to the project as well. All unit team members should participate in on-boarding calls, regular monthly content and coaching calls, and in three one-day learning sessions that occur at the beginning, middle, and end of the project.
- Who should be on our unit team? — At a minimum, all hospital unit teams should include: a physician champion, nurse champion (if the project leader is not a nurse), data coordinator, and hospital executive champion.
- How many people from each hospital team should travel to the state-hosted, face-to-face educational meetings? — A minimum of two or three members from each hospital unit team should attend the state-level, face-to-face learning sessions, as the learning sessions are intended to support team development and interaction. It is recommended that at least one physician, one nurse, and one infection control practitioner attend from each team.
- Which reason for having a catheter today should be recorded in Care Counts if a nurse documented “I&O Critical Illness” as reason for Foley continuation for a patient on a general surgical unit? — If you have a formally approved hospital policy that allows the continuation of catheters outside of the intensive care unit for intake and output monitoring, then the “hospital approved indication” would be appropriate. We still encourage you to assess the continued need for the catheter in these cases and explore alternatives such as measuring urine from a bedpan using a graduated cylinder, condom catheters for male patients, or daily weights.
- Do we include our swing bed, OB and hospice patients in patient and catheter day counts? — As long as 80 percent of the patients on any unit are of the type described for that location type (see chapter 15 of the NHSN manual http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf ) there is no need to exclude any patients from the patient count nor their catheter days from the catheter day count. This means that if there are a few swing beds on the unit, but these account for less than 20 percent of the patients on the unit, these patients will be included in the count. If hospice and OB patients are part of the unit that is participating in the project, then these patients should be included in the count.
- How should suprapubic catheters that are hooked to Foley bags and draining be counted? — Suprapubic and condom catheters are not counted in the study for catheter days or infections.
- Should patients with continuous bladder irrigation be counted? — Those with bladder irrigation have a urological problem that is being managed (usually hematuria, clots so possible conditions that may cause urinary obstruction). These catheters are counted like other indwelling urinary catheters (Foleys) for the study. Infections related to these catheters are also counted.
- If our hospital collects HSOPS data at a different time than the project requests it, can we use the data we submitted to our hospital? — Yes, you can, but it might delay the state level reports. The data must be survey level, unit specific, response rate >60% and have discipline identifiers.
- Why is it necessary to have two different methods for counting days? — The population based outcome measure, patient-days denominator, is a better measure for interventions to reduce inappropriate use whereas the NHSN measure is the best to evaluate the proper aseptic placement and maintenance of the device. Because of this, we have chosen to use both methods of counting days.
- Trauma Surgeons have said that the frequency of a condom catheter associated UTI is as high as a CAUTI. So why take out the urinary catheter only to apply a condom? — There are references that compare these two drainage systems. Please see:
Condom Versus Indwelling Urinary Catheters: A Randomized Trial
S Saint, SR Kaufman, MAM Rogers, PD Baker, K Ossenkop, and BA Lipsky
Journal of the American Geriatrics Society, July 2006, 54(7), pages 1055-1061.
Urinary Catheters: What Type Do Men and Their Nurses Prefer?
S Saint, BA Lipsky, PD Baker, LL McDonald, K Ossenkop
Journal of the American Geriatrics Society, December 1999, 47(12), pages 1453-1457
- What is the specific definition for strict I&O? Is there a time limit, i.e. 2-3 days? — Strict I&O refers to frequent monitoring (e.g., hourly) of fluid intake and output, typically among patients who are critically ill or who are experiencing acute illnesses associated with fluid retention or decreased urine output. I&O monitoring does not mandate the use of an indwelling urinary catheter and can be accomplished by collection of urine via a variety of non-invasive means, including commode, bedpan, urinal, or external urinary catheter, in the appropriate clinical situation. I&O monitoring is most often continued until the acute illness leading to fluid imbalance is improving or resolving rather than for some arbitrary interval.
- For a severe CHF patient, is a Foley not considered an appropriate intervention to record I and O? — We do not promote using the urinary catheter for those with CHF in the non-ICU setting. Work with the cardiologists on other ways to assess dieresis such as daily weights.
- Is catheter placement for chronic UTIs ever an appropriate indication? — Clarify what is meant by chronic UTIs on your unit. Sometimes the term “chronic UTI” is used for patients who have urinary structural abnormalities (either obstruction or leading to neurogenic bladder) that lead to persistent bacteriuria in a person with the same organism. In this situation, the reason for the “chronic UTI” is what should be entered as the indication.
- If a patient has a complicated urologic surgery and is in an intensive care unit postoperatively with a catheter needed beyond the immediate 24 hour post-op period because of the nature of the surgery, could the indicator “perioperative use in selected surgeries” apply?–It is part of the perioperative appropriate indications, and the limit of use is based on whether the catheter is still needed based on the urology team evaluation. However, if the urologist recommends that the catheter is no longer needed but in the ICU they required fluid monitoring, the indication will change to fluid monitoring in ICU.
- Should catheters be placed preoperatively for urine analysis/culture and sensitivity on total hip replacement patients? — Urine culture before orthopedic surgery is not evidence-based. The only two indications to test and treat asymptomatic bacteriuria prior to operation are urologic studies and pregnancy.
- A majority of our CAUTIs occur in critical care patients who need Foleys. We use condom catheters on male patients, but there are no alternatives for females. How can you tell the physicians to remove the Foley when the patient is on strict I&O? — Monitoring fluids in the ICU is an indication for urinary catheter use. I would suggest you discuss with the intensivist the reasons for close intake and output monitoring and their value in management. If they are necessary for management, then the use of the catheter is acceptable. Another option is use of bed weighing scales, but you will need to make sure these scales provide accurate measurements.
- In developing a nurse-driven protocol for catheter removal, we are having difficulty aligning the SCIP measures with the best practice/recent literature findings we think are relevant to the creation of a protocol for removal that will work for all specialties. What would you suggest? — Many hospitals are interested in implementing a nurse driven protocol to be compliant with SCIP measures or other measures that may affect their payments. There will be many pressures to put indications in that would be acceptable for CMS. However, fitting the SCIP requirements to all hospital patients may adversely affect your efforts. Use the CDC HICPAC guidelines and fit the SCIP recommendations to those guidelines. Look at the HICPAC indications related to the surgical population and address the SCIP indications and where they fit into the HICPAC guidelines. Having institutionally agreed-upon indications that would still comply with SCIP and do not lead to unnecessary use would be the best approach.
- We discontinue Foleys and place a condom catheter as soon as possible, even on our intubated patients who are unable to void on their own. But condom catheters retain urine, and we end up replacing the Foley. What is your suggestion for those patients? The specimen sent for culture after placement shows UTI. — Condom catheters are an alternative to indwelling urinary catheters primarily for male patients with urinary incontinence who have underlying cognitive impairment. They are not appropriate to use among patients who have urinary retention whatever the cause. The use of bladder scanners with intermittent straight catheterization may reduce the risk of catheter reinsertion, particularly in the post-operative setting. Urine specimens should be collected for culture only for appropriate clinical indications (i.e., suspected symptomatic urinary tract infection) and not routinely following catheter insertion or reinsertion.
- What are ICUs and Critical Care units doing to not use Foley catheters on patients who are vented? Are they really just having patients be incontinent and using pads? My Intensivists are struggling with pulling the Foleys. — Not all vented patients need accurate I&Os. For those who do not need accurate I&Os and are vented, it may be difficult to not use the urinary catheter, especially if these patients are sedated. This is one of the limitations of the HICPAC guidelines. One option is to focus on weaning and extubating the patients and removing the catheter at that point.
- What is the role of the executive team and physician team in catheter removal? — One key in On the CUSP: Stop CAUTI is to obtain physician staff support. Catheter removal should be ordered by a physician or nurse driven with physician support. The indications need to be agreed on by the medical and nursing staff. Usually urinary catheters placed or followed by urology are not included in the assessment for removal by nurses without physician order. It is easier if the hospital has bladder scanners to assess for retention post Foley removal if patient does not urinate after a period of time. Each hospital needs to have their own process established for removal without physician order.
- Is it preferred to change Foleys every 72 hours? — Routine change of urinary catheters should not be done. For the hospital setting, Foleys should not be changed unless there is a mechanical problem, a break in the closed system of the catheter, or clinical indications. It may also be considered when treating CAUTI per Category IIC of the HICPAC guidelines.
- What is best practice for catheters that require irrigation after GU surgery? — This is not easy to do without breaking the system especially if there are clots. There are three-way urinary catheters that can be used, and it should be done very infrequently.
- How should you accommodate intra-abdominal pressure monitoring if the process requires breaking the system to connect the pressure monitor? — You may need to change the Foley at the same time to prevent introducing organisms up to the bladder.
- Are silver-impregnated catheters appropriate for routine use or use greater than five days and do you consider them effective in CAUTI prevention? — Given the important clinical and economic consequences of catheter-associated urinary tract infection (CAUTI), researchers have tried novel approaches to prevent this common patient safety problem. Several clinical and economic studies have evaluated antimicrobial urinary catheters. While the studies to date appear to indicate that antimicrobial catheters reduce (or delay) bacteriuria, it remains unclear if these novel catheters will reduce clinically more important endpoints, such as symptomatic infection or urinary tract-related bacteremia. However, in patients at high-risk of CAUTI (e.g., neutropenic and severely immune-compromised patients) or of developing a complication after bacteriuria occurs, or in those hospitals that have unacceptably high CAUTI rates despite adherence to other preventive strategies, antimicrobial catheters may play an adjunctive role in preventing CAUTI. Additional information can be found on CatheterOut.org (http://www.catheterout.org/?q=antimicrobial-catheters).
- What should I do if the stabilization device is obstructing flow? — The issue may be that the device is positioned in a way that kinks the tubing. Check this and if it appears to be the device, contact the manufacturer about the issues.
- How do you prevent CAUTIs in patients who require a long indwelling urinary catheter, such as those with perirectal or sacral Stage 3-4 wounds? — Patients who require long-term indwelling catheters will eventually all be colonized with bacteria (100 percent of patients with urinary catheters have bacteria in their urine by 1 month, and the definition of a chronic Foley is >1 month). Reducing the risk of symptomatic CAUTI in this population may require ensuring that the urine flow is not impeded. So ensure the bag is below the patient, and the catheter is not obstructed. Also reduce the risk of urethral trauma (use securement devices). CDC HICPAC guidelines comments on obstructed catheters with “Further research is needed on the benefit of irrigating the catheter with acidifying solutions or use of oral urease inhibitors in long-term catheterized patients who have frequent catheter obstruction. (No recommendation/unresolved issue)” For obstructed catheters, change the entire catheter system unless there is an issue with placement (i.e., the catheter cannot be placed unless it is done by a urologist).
- How do you reduce CAUTI with yeast, especially in patients with wounds on long term antibiotics who require a Foley? — Yeast usually colonizes the urine. Increased yeast in the urine usually indicates antibiotic pressure (i.e. patient was prescribed antibiotics, which suppressed bacteria and now is colonized by yeast. Yeast is an unusual source of clinical CAUTI, although using the NHSN definition, if yeast and a fever are present, it will fit the definition. Minimizing antibiotic pressure will likely reduce colonization with yeast. Keeping the urinary catheter system closed and complying with insertion and maintenance will help delay colonization with either bacteria or candida.
- For patients with sepsis or other illnesses requiring multiple antibiotics and a need for Foley catheter how do you prevent CAUTI with candida species? — Antifungals are not the answer. Complying with proper insertion and maintenance and avoiding unnecessary antibiotic pressure can prevent CAUTI.
- Can you share a best practice for obtaining a specimen that is not contaminated? Is there any new product to protect the catheter port, or a way to effectively clean the port?
HICPAC Guideline, 2009:
- If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant. (Category IB)
- Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag. (Category IB)
SHEA/IDSA Compendium, 2008:
- For examination of fresh urine, collect a small sample by aspirating urine from the sampling port with a sterile needle and syringe after cleansing the port with disinfectant (A-III).
- Obtain larger volumes of urine for special analyses aseptically from the drainage bag (A-III).
- Appropriate disinfectants to use for cleaning the sampling port include isopropyl alcohol, povidone iodine, and chlorhexidene gluconate. No evidence supports the superiority of one disinfectant agent over another for this purpose.
- Do you recommend using antibacterial CHG wipes for Foley care? — No. Antiseptic wipes for periurethral care do not reduce the risk of symptomatic urinary tract infection in patients with indwelling urinary catheters.
HICPAC Guideline, 2009:
Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. (Category IB)
Evidence Summary: Low-quality evidence suggested no benefit of antiseptic meatal cleaning regimens before or during catheterization to prevent CAUTI. This was based on no difference in the risk of bacteriuria in patients receiving periurethral care regimens compared to those not receiving them. One study found a higher risk of bacteriuria with cleaning of the urethral meatus-catheter junction (either twice daily application of povidine-iodine or once daily cleaning with a non-antiseptic solution of green soap and water) in a subgroup of women with positive meatal cultures and in patients not receiving antimicrobials. Periurethral cleaning with chlorhexidine before catheter insertion did not have an effect in two studies.
- Is there any validity (for reducing infection rates) in changing out Foleys on a regular basis such as every 30 days for patients with chronic Foleys? — There is no benefit to changing indwelling urinary catheters at routine intervals.
HICPAC Guideline, 2009:
Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II)
Evidence Summary: Low-quality evidence suggested no benefit of routine catheter or drainage bag changes to prevent CAUTI. This was based on no difference or an increased risk of SUTI and no difference in bacteriuria with routine compared to as-needed changes or with more frequent changing intervals. One study in nursing home residents found no differences in SUTI with routine monthly catheter changes compared to changing only for obstruction or infection, but the study was underpowered to detect a difference. Another study in home care patients found an increased risk of SUTI when catheters were changed more frequently than monthly.
SHEA/IDSA Compendium, 2008:
Do not change catheters routinely. (A-III)
- How are nurses and nurse managers being held accountable for adhering to bundles? — The On the CUSP: Stop CAUTI project does not hold project participants accountable; it is dependent upon the management structure at each hospital. From our experience, this project should be owned by nursing. In general, nursing ownership has shown to have even more impact than physician ownership. The particular individuals in nursing who have been most valuable are the directors of nursing or nurse managers. Hopefully, they encourage bedside nurses to take ownership of assessing which patients have catheters, which patients don’t need them, and which patients should have catheters removed because they are no longer necessary.
- Can you share a little more about how you got medical staff to approve nurse-driven removal protocols? — There are four keys to successful implementation of nurse-driven protocols:
1. Early engagement from physician champion
2. Data first
3. Protocols must be first be approved by both physician and nursing leadership prior to implementation
4. Physicians and nurses must still discuss unusual cases
Having physician champions engaged in the protocol and process development early on is key, especially someone who has the respect of his/her physician colleagues. This individual can be an Epidemiologist, Infectious Disease Physician, Urologist, or CMO, or someone else in a physician leadership role. Show the data first! The nurse driven protocol data presented in executive committees often demonstrates that this approach can reduce infections by 50 percent. The person presenting should be a physician champion. It is also important to address the non-infectious harms of unnecessary urinary catheters (e.g. discomfort and immobility related to urinary catheter. The criteria for nurse driven removal should be approved by medical executive committee and nursing leadership, prior to implementation. This list does not preclude the need for nurses and physicians to discuss individual circumstances that may arise. For any questions that arise from the nursing staff about whether or not the catheter should be removed, the nurse manager or director should contact the responsible physician.
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