Catheter-associated urinary tract infections (CAUTIs) are preventable complications of hospitalization. An interdisciplinary team developed a curriculum to increase awareness of the presence of indwelling urinary catheters (IUCs) in hospitalized patients, addressed practical, primarily nurse-controlled inpatient risk-reduction interventions, and promoted the use of the IUC labels (“tags”). Five thirty-minute educational sessions were cycled over three daily nursing shifts on two inpatient medical floors over a 1-year period; participants were surveyed (n = 152) to elicit feedback and provide real-time insight on the learning objectives. Nurse self-reported IUC tagging was early and sustained; after the IUC tag was introduced, there was a significant increase in tagging reported by the end of the block of educational sessions (from 46.2% to 84.6%, P = 0.001).
Early engagement combined with a targeted educational initiative led to increased knowledge, changes in behavior, and renewed CAUTI awareness in hospitalized patients with IUCs. The processes employed in this small-scale project can be applied to broader, hospitalwide initiatives and to large-scale initiatives for healthcare interventions. As first-line providers with responsibility for the placement and daily maintenance of IUCs, nurses are ideally positioned to implement efforts addressing CAUTIs in the hospital setting.
The presence of an indwelling urinary catheter (IUC) is the principal risk factor for catheter-associated urinary tract infection (CAUTI) development. Despite the risk of prolonged catheter placement, few hospitals actively track catheterized patients, and providers are often not aware of the presence of catheters in their patients.
Nurses are at the frontline of catheter care. As the providers most involved with IUCs in hospitalized patients, nurses are responsible for IUC placement, day-to-day catheter management, and the removal of IUCs. Responsible for specimen collection, nurses play a vital role in the diagnosis of CAUTIs. Among catheterized patients, they are often the first to notice a clinical change or technical problem.
Despite their central role in IUC care and management, only a handful of published reports have highlighted the role of nurses in the prevention of CAUTI. The majority of these publications have followed a quality improvement (QI) approach, at times bundled with hospital-wide policy changes.
An Internet survey demonstrated inconsistent catheter-related knowledge among nurses. However, reeducation of surgical nurses in urinary catheter management has shown to have a modest decrease in catheter days. Gaps in knowledge may potentially impair the effectiveness nurses may play in the prevention of catheter-related complications.
With a goal of increasing awareness about the presence of IUCs among medical inpatients, our team developed an educational curriculum. After eliciting staff engagement by cultivating champions and involving the staff in all stages of the process, we instituted a practical, catheter-care curriculum which introduced QI concepts and incorporated principles of basic microbiology and hand hygiene to mirror established infection-control practices. The curriculum targeted aspects of catheter care within the scope of practice of nursing providers and was built on published guidelines.
The purpose of the QI project was to improve compliance with documentation of indwelling urinary catheter insertion. As a tangible application of their education, we promoted the use of the catheter labels (“tags”) and monitored engagement over the course of the educational sessions.
Urinary catheterization and CAUTI prevention policy
Policy Purpose: To identify approved indications for urinary catheterization and describe proper insertion, catheter care and prompt removal of a urinary catheter to reduce patients’ risk for a catheter- associated urinary tract infection (CAUTI).
Policy Statement(s):
I. Insertion of a sterile catheter in to the urinary bladder may be completed by a licensed nurse after a physician’s order has been obtained.
II.It is the responsibility of registered nurses to evaluate the necessity for urethral catheterization, monitor urinary drainage each shift reporting changes, review catheter necessity daily, and remove urethral catheters as soon as possible.
Equipment:
I. Catheter tray with drainage bag
II. Catheter securement device
Procedure:
I. Insertion and removal – Refer to Lippincott Nurses guide to Clinical Procedures/Insertion Policy
II. Bundle to Prevent Catheter-Associated Urinary Tract Infections (CAUTI)
a. Catheterize only when necessary
i. To relieve acute or chronic urinary retention or bladder outlet obstruction;
ii. To obtain accurate measurements of urinary output in critically ill patients (i.e. ICU with I&O every 2 hours or urometer bag with I&O every 2-4 hours)
iii. For perioperative use in patients undergoing the following surgical procedures:
1. Urologic surgery or other surgery on contiguous structures of the genitourinary tract
2. Prolonged duration of surgery (remove catheter in PACU)
3. Large-volume infusions or diuretics during surgery
4. Intraoperative monitoring of urinary output
iv. To promote healing of sacral or perineal wounds in incontinent patients.
v. For patients who require prolonged immobilization
1. Unstable thoracic or lumbar spine injuries
2. Multiple traumatic injuries (e.g., pelvic fractures)
vi. Spinal and/or epidural anesthesia (removal within 48 hours)
vii. To improve comfort for end of life care if needed
b. Consider alternatives to indwelling catheters when appropriate
c. Emphasize good hand hygiene
d. Insert catheter using aseptic technique and sterile equipment
e. Use smallest bore catheter possible
i. Use catheter sizes of 14 FR and 16 Fr with 10cc balloon when appropriate
ii. Use a coude catheter in elderly male patients with known or suspec ted prostate enlargement
f. Use a generous amount of sterile lubricant for catheter insertion
i. MAY use urologic lidocaine jelly prior to catheter insertion (if no allergy) for male patients of an attending urologist or unless otherwise ordered.
g. Use portable ultrasound device to assess urine volumes in patients with intermittent catheterization to help reduce unnecessary catheter insertions
h. Maintain system properly
i. Secure catheter appropriately
ii. Keep drainage bag lower than patient’s bladder at all times, including during transport, avoiding contact with the floor
iii. Maintain a closed sterile drainage
iv. Empty the urinary drainage bag frequently enough to prevent reflux
v. Use a separate and clean container for each patient
vi. Avoid contact between the urinary drainage tap and the container when emptying the drainage bag
vii. Obtain urine samples from a sampling port using aseptic technique
i. Provide perineal care daily and after bowel movements, ensuring external catheter is also cleaned
j. Observe and document the clarity of urine every shift. Report changes immediately.
k. Review daily for catheter necessity and remove as soon as possible. (Refer to Algorithm for Removal of Foley Catheter).
Documentation:
I. Electronic Health Record (EHR) nursing documentation
a. Date and time
b. Type and size of catheter, cc’s used for filling balloon
c. Amount and color of urine
d. Patient tolerance
e. Daily catheter necessity
II. Record on Intake and Output record the amount of urine output every 8 hours or as indicated.
Algorithm for Removal of Foley Catheter
Assess patient upon admission/transfer and each shift for one of the following indicators for urinary catheterization:
□ Urinary Tract Obstruction (i.e., enlarged prostate, blood clots)
□ Neurogenic bladder dysfunction
□ Urinary retention not manageable by other means (i.e. intermittent catheterization)
□ Stage III or Stage IV decubitus ulcer in an incontinent patient
□ Urological or gynecological surgery or urinary catheter placed by urologist
□ Aggressive treatment with diuretics or fluids which requires accurate output measurement
□ Prolonged immobilization due to spine or traumatic injury
□ Immediate post-op (Day 1 or Day 2)
□ Patient is terminally ill
If none of the above indicators is selected, continue daily assessment.
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