Preventing Catheter-Associated UTIs in Acute Care Hospitals

Section 4: Recommended Strategies for Cauti Prevention

Recommendations are categorized as either (1) basic practices that should be adopted by all acute care hospitals or (2) special approaches that can be considered for use in locations and/or populations within hospitals when HAIs are not controlled by use of basic practices. Basic practices include recommendations where the potential to impact HAI risk clearly outweighs the potential for undesirable effects. Special approaches include recommendations where the intervention is likely to reduce HAI risk but where there is concern about the risks for undesirable outcomes, where the quality of evidence is low, or where evidence supports the impact of the intervention in select settings (eg, during outbreaks) or for select patient populations. Hospitals can prioritize their efforts by initially focusing on implementing the prevention approaches listed as basic practices. If HAI surveillance or other risk assessments suggest that there are ongoing opportunities for improvement, hospitals should then consider adopting some or all of the prevention approaches listed as special approaches. These can be implemented in specific locations or patient populations or can be implemented hospital-wide, depending on outcome data, risk assessment, and/or local requirements. Each infection prevention recommendation is given a quality-of-evidence grade (see Table 2 ). Recommendations for preventing and monitoring CAUTI are summarized in the following section and Table 1 .

I. Basic practices for preventing CAUTI: recommended for all acute care hospitals

1. 
   Provide appropriate infrastructure for preventing CAUTI
   
   1. 
      Provide and implement written guidelines for catheter use, insertion, and maintenance (quality of evidence: III).
      
      1. 
         Develop and implement facility criteria for acceptable indications for indwelling urinary catheter use. While research assessing the appropriateness of indwelling catheter use is limited, expert consensus–derived catheter indications have been developed. Examples of appropriate indications for indwelling urethral catheter use are limited and include the following:
         
         1. 
            Perioperative use for selected surgical procedures, such as urologic surgery or surgery on contiguous structures of the genitourinary tract; prolonged surgery; large volume infusions or diuretics during surgery; intraoperative monitoring of urine output needed.
            
         2. 
            Hourly assessment of urine output in patients in an ICU.
            
         3. 
            Management of acute urinary retention and urinary obstruction.
            
         4. 
            Assistance in healing of open pressure ulcers or skin grafts for selected patients with urinary incontinence.
            
         5. 
            As an exception, at patient request to improve comfort (eg, end-of-life care).
            
         
         
         
      
      
      
   2. 
      Ensure that only trained, dedicated personnel insert urinary catheters (quality of evidence: III).
      
   3. 
      Ensure that supplies necessary for aseptic technique for catheter insertion are available and conveniently located (quality of evidence: III).
      
   4. 
      Implement a system for documenting the following in the patient record: physician order for catheter placement, indications for catheter insertion, date and time of catheter insertion, name of individual who inserted catheter, nursing documentation of placement, daily presence of a catheter and maintenance care tasks, and date and time of catheter removal. Record criteria for removal and justification for continued use (quality of evidence: III).
      
      1. 
         Record in a standard format for data collection and quality improvement purposes and keep accessible documentation of catheter placement (including indication) and removal.
         
      2. 
         Utilize electronic documentation that is searchable, if available.
         
      
      
      
   5. 
      Ensure that there are sufficient trained personnel and technology resources to support surveillance for catheter use and outcomes (quality of evidence: III).
      
   
   
   
2. 
   Perform surveillance for CAUTI if indicated on the basis of facility risk assessment or regulatory requirements
   
   1. 
      Identify the patient groups or units in which to conduct surveillance on the basis of risk assessment, considering frequency of catheter use and potential risk (eg, types of surgery, obstetrics, critical care; quality of evidence: III).
      
   2. 
      Use standardized criteria, such as NHSN definitions, to identify patients who have a CAUTI (numerator data; quality of evidence: III).
      
   3. 
      Collect information on catheter-days and patient-days (denominator data) and indications for catheter insertion for all patients in the patient groups or units being monitored (quality of evidence: III).
      
   4. 
      Calculate CAUTI rates and/or standardized infection ratio (SIR) for target populations (quality of evidence: III).
      
   5. 
      Use surveillance methods for case finding that are documented to be valid and appropriate for the institution (quality of evidence: III).
      
   6. 
      Consider providing unit-specific feedback (quality of evidence: III).
      
   
   
   
3. 
   Provide education and training
   
   1. 
      Educate healthcare personnel involved in the insertion, care, and maintenance of urinary catheters about CAUTI prevention, including alternatives to indwelling catheters, and procedures for catheter insertion, management, and removal (quality of evidence: III).
      
   2. 
      Assess healthcare professional competency in catheter use, catheter care, and maintenance (quality of evidence: III).
      
   
   
   
4. 
   Use appropriate technique for catheter insertion
   
   1. 
      Insert urinary catheters only when necessary for patient care and leave in place only as long as indications remain (quality of evidence: II).
      
   2. 
      Consider other methods for bladder management, such as intermittent catheterization, where appropriate (quality of evidence: II).
      
   3. 
      Practice hand hygiene (based on CDC or World Health Organization guidelines) immediately before insertion of the catheter and before and after any manipulation of the catheter site or apparatus (quality of evidence: III).
      
   4. 
      Insert catheters following aseptic technique and using sterile equipment (quality of evidence: III).
      
   5. 
      Use sterile gloves, drape, and sponges; a sterile or antiseptic solution for cleaning the urethral meatus; and a sterile single-use packet of lubricant jelly for insertion (quality of evidence: III).
      
   6. 
      Use as small a catheter as possible consistent with proper drainage, to minimize urethral trauma (quality of evidence: III).
      
   
   
   
5. 
   Ensure appropriate management of indwelling catheters
   
   1. 
      Properly secure indwelling catheters after insertion to prevent movement and urethral traction (quality of evidence: III).
      
   2. 
      Maintain a sterile, continuously closed drainage system (quality of evidence: III).
      
   3. 
      Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur (quality of evidence: III).
      
   4. 
      For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after cleansing the port with disinfectant (quality of evidence: III).
      
   5. 
      Obtain larger volumes of urine for special analyses aseptically from the drainage bag (quality of evidence: III).
      
   6. 
      Maintain unobstructed urine flow (quality of evidence: III).
      
      1. 
         Keep the collecting bag below the level of the bladder at all times; do not place the bag on the floor (quality of evidence: III).
         
      2. 
         Keep catheter and collecting tube free from kinking (quality of evidence: III).
         
      3. 
         Empty the collecting bag regularly using a separate collecting container for each patient. Avoid touching the draining spigot to the collecting container (quality of evidence: III).
         
      
      
      
   7. 
      Employ routine hygiene; cleaning the meatal area with antiseptic solutions is unnecessary (quality of evidence: III).
      
   
   
   

II. Special approaches for preventing CAUTI

Perform a CAUTI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital with unacceptably high CAUTI rates or SIRs despite implementation of the basic CAUTI prevention strategies listed previously.

1. 
   Implement an organization-wide program to identify and remove catheters that are no longer necessary using one or more methods documented to be effective (quality of evidence: II).
   
   1. 
      Develop and implement institutional policy requiring periodic (usually daily) review of the necessity of continued catheterization.
      
   2. 
      Consider utilizing electronic or other types of reminders (Figure 1) of the presence of a catheter and required criteria for continued use. Some examples include the following:
      
      1. 
         Automatic stop orders requiring review of current indications and renewal of order for continuation of the indwelling catheter.
         
      2. 
         Standardized electronic or paper reminders of persistent catheters together with current catheter indications (Figure 1) targeting either physicians or nurses.
         
      
      
      
   3. 
      Conduct daily review during rounds of all patients with urinary catheters by nursing and physician staff to ascertain the necessity of continuing catheter use.
      
   
   
   
2. 
   Develop a protocol for management of postoperative urinary retention, including nurse-directed use of intermittent catheterization and use of bladder scanners (quality of evidence: II).
   
   1. 
      If bladder scanners are used, clearly state indications, train nursing staff in their use, and disinfect between patients according to manufacturers' instructions.
      
   
   
   
3. 
   Establish a system for analyzing and reporting data on catheter use and adverse events from catheter use (quality of evidence: III).
   
   1. 
      Calculate device utilization ratio (device-days/patient-days) to supplement CAUTI rates.
      
   2. 
      Define and monitor adverse outcomes in addition to CAUTI, including catheter obstruction, unintended removal, catheter trauma, or reinsertion within 24 hours of removal.
      
   3. 
      For analysis, stratify measurements of catheter use and adverse outcomes by relevant risk factors (eg, sex, age, ward, duration). Review data in a timely fashion and report to appropriate stakeholders.
      
   
   
   

III. Approaches that should not be considered a routine part of CAUTI prevention

1. 
   Do not routinely use antimicrobial/antiseptic-impregnated catheters (quality of evidence: I).
   
2. 
   Do not screen for asymptomatic bacteriuria in catheterized patients (quality of evidence: II).
   
3. 
   Do not treat asymptomatic bacteriuria in catheterized patients except before invasive urologic procedures (quality of evidence: I).
   
4. 
   Avoid catheter irrigation (quality of evidence: II).
   
   1. 
      Do not perform continuous irrigation of the bladder with antimicrobials as a routine infection prevention measure.
      
   2. 
      If continuous irrigation is being used to prevent obstruction, maintain a closed system.
      
   
   
   
5. 
   Do not use systemic antimicrobials routinely as prophylaxis (quality of evidence: III).
   
6. 
   Do not change catheters routinely (quality of evidence: III).
   

IV. Unresolved issues

1. 
   Use of antiseptic solution versus sterile saline for meatal cleaning before catheter insertion.
   
2. 
   Use of urinary antiseptics (eg, methenamine) to prevent UTI.
   
3. 
   Use of catheters with valves.
   
4. 
   Spatial separation of patients with urinary catheters in place to prevent transmission of pathogens that could colonize urinary drainage systems.
   
5. 
   Antimicrobial prophylaxis at catheter removal to prevent symptomatic infection.
   

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Figure 1.



Urinary catheter reminder. From Saint et al.