Catheter-Associated Urinary Tract Infection Road

Catheter-associated Urinary Tract Infection (CAUTI) Road Map

MHA’s road maps provide hospitals and health systems with evidence-based recommendations and standards for the development of topic-specific prevention and quality improvement programs, and are intended to align process improvements with outcome data. Road maps reflect published literature and guidance from relevant professional organizations and regulatory agencies, as well as identified proven practices. MHA quality and patient safety committees provide expert guidance and oversight to the various road maps.

Each road map is tiered into fundamental and advanced strategies: -- Fundamental strategies should be prioritized for implementation, and generally have a strong evidence base in published literature in addition to being supported by multiple professional bodies and regulatory agencies. -- Advanced strategies should be considered in addition to fundamental strategies when there is evidence the fundamental strategies are being implemented and adhered to consistently and there is evidence that rates are not decreasing and/or the pathogenesis (morbidity/mortality among patients) has changed.

Operational definitions are included to assist facility teams with road map auditing and identifying whether current work meets the intention behind each road map element.

Resources linked within the road map include journal articles, expert recommendations, electronic order sets and other pertinent tools which organizations need to assist in implementation of best practices.

Road map Road map questions (if not present at your hospital or If specific road map element is missing, consider sections answering no, please see next column for suggested resources) the following resources:

FUNDAMENTAL Consider the following examples of patient education when (check each box if “yes”) developing teaching materials: • Centers for Disease Control FAQs about CAUTI The facility has a process in place to educate the patient about their urinary catheter [1]. Consider the following examples when developing discharge -- Education includes topics such as: symptoms of a urinary tract education for patients: infection, catheter care, and what the patient can do to help prevent Intermountain Healthcare Foley Catheter: Home an infection. • instructions The facility has a process in place to educate patients being discharged The Ohio State University Home Care for Your Foley with an indwelling catheter in place. • Catheter (Female) -- The patient has been educated on how to care for the catheter and The Ohio State University Home Care for Your Foley symptoms of infection using teach back method to ensure patient’s • Catheter (Male)

Patient & family education understanding. • The Ohio State University Home Care for Your Leg Bag

© 2019 Minnesota Hospital Association | 1 Road map Road map questions (if not present at your hospital or If specific road map element is missing, consider sections answering no, please see next column for suggested resources) the following resources:

FUNDAMENTAL Consider the following resources when developing or (check each box if “yes”) updating facility policies regarding urinary catheter use: Healthcare Infection Control Practices Advisory Committee The facility has a policy/process for urinary catheter use. • Guideline for Prevention of Catheter-Associated Urinary -- Follow CDC/HICPAC indications for urinary catheter insertion and Tract Infections (2009) use. • AHRQ Toolkit for Reducing CAUTI in Hospital -- Minimize perioperative urinary catheter use [Meddings et al. 2018]. Units: Implementation Guide, Appendix B. Urinary -- Use urinary catheters only when necessary and consider the use of Catheterization – Sample Policy alternatives to urinary catheter placement (e.g., condom catheters, AHRQ Toolkit for Reducing Catheter-Associated Urinary straight catheterization) [1,2,4] • Tract Infections in Hospital Units: Implementation Guide, -- Use a portable ultrasound device to assess the patient’s urine Appendix C. Bladder Scan Policy volume to reduce unnecessary catheter insertions prior to making a University of Wisconsin Policy for Insertion, Care and decision regarding catheter placement [1,3,4]. • Removal of an Indwelling Urinary Catheter -- Facility sets clear expectations that indwelling catheter placement Meddings J, Saint S, Fowler KE, et al. The Ann is not appropriate for the following reasons [1,3,4]: incontinence, • Arbor criteria for appropriate urinary catheter use in specimen collection [4], diagnostic testing when the patient is able hospitalized medical patients: results obtained by using to void [4]. the RAND/UCLA appropriateness method. Ann Intern The facility includes insertion criteria in the urinary catheter order Med 2015;162:S1-34. Available at http://annals.org/aim/ process [2]. Appropriate catheter use fullarticle/2280677/ann-arbor-criteria-appropriate-urinary- -- Utilize the electronic health record to hard wire insertion criteria into catheter-use-hospitalized-medical-patients order.

Consider the following resources for incorporating insertion criteria into the urinary catheter order process: • Mayo CAUTI reduction presentation, 2016 CHAIN Fall Conference – EMR example • Mayo Clinic CAUTI reduction using bundled approach

FUNDAMENTAL Consider the following examples when developing a (check each box if “yes”) standardized urinary catheter insertion checklist: Pennsylvania Patient Safety Authority Foley Insertion The facility utilizes a two-person “buddy” system for urinary catheter • Checklist insertions where the second person completes the insertion checklist, Catheter insertion practices observes for proper technique, and assists when needed [1].

© 2019 Minnesota Hospital Association | 2 Road map Road map questions (if not present at your hospital or If specific road map element is missing, consider sections answering no, please see next column for suggested resources) the following resources:

The facility utilizes a standardized insertion checklist [1]. • IPRO Foley Insertion Checklist -- Completed by a second person -- Checklist includes: ○○ Patient education prior to procedures. ○○ Review for catheter appropriateness, catheter alternatives and catheter order prior to insertion ○○ Use of as small of a catheter as possible to minimize bladder neck and urethral trauma [2,4]. ○○ Step-by-step aseptic insertion technique including hand hygiene and the use of sterile equipment. ○○ Securing indwelling catheters to prevent movement and urethral traction. ○○ Documentation of whether buddy system was used. The facility utilizes a standardized insertion kit that supports insertion process [1].

ADVANCED Antimicrobial/antiseptic-impregnated catheters have been (check each box if “yes”) studied as a potential means to prevent bacteriuria: • Cochrane Database Systematic Review – Types Consider implementation of antimicrobial/antiseptic-impregnated of Indwelling Urethral Catheters for Short-Term catheters [4]. Catheter insertion practices, continued Catheterisation in Hospitalised Adults • Systematic Review: Antimicrobial Urinary Catheters to Prevent Catheter-Associated Urinary Tract Infection in Hospitalized Patients

FUNDAMENTAL Catheter care and maintenance is a critical component of (check each box if “yes”) CAUTI prevention. Consider the following resources when developing your catheter care and maintenance processes: The facility has a standardized process in place for catheter care and • AHRQ Toolkit for Reducing CAUTI in Hospital maintenance. Units: Implementation Guide, Appendix B. Urinary -- Daily review of catheter necessity [1,2,4]; consider incorporating Catheterization – Sample Policy into already established rounds. • University of Wisconsin Policy for Insertion, Care and -- Practicing hand hygiene immediately before and after any Removal of an Indwelling Urinary Catheter practices manipulation of the catheter site or apparatus [1,2,4]. • Vanderbilt University Medical Center Guidelines for -- Using Standard Precautions, including the use of gloves and gown Management of Indwelling Urinary Catheters as appropriate, during manipulation of the catheter or collecting

Catheter maintenance system [1,2,4]. -- Maintaining a sterile continuously closed drainage system [1-4].

© 2019 Minnesota Hospital Association | 3 Road map Road map questions (if not present at your hospital or If specific road map element is missing, consider sections answering no, please see next column for suggested resources) the following resources:

-- Maintaining unobstructed urine flow keeping the catheter and tubing free of kinking [1-4]. -- Positioning the collecting bag below the level of the bladder and above the floor at all times [1-4]. -- Emptying the collecting bag regularly using a clean, collecting container for each patient; avoid splashing, and preventing contact of the drainage spigot with the non-sterile collecting container [1,2,4]. -- Securing indwelling catheters to prevent movement and urethral traction [1,2,4] -- Disconnecting the catheter from the drainage tube only if the catheter must be irrigated. -- Using aseptic technique if the collecting system needs replacement [1,2,4]. The facility has a standardized process in place for the provision of periurethral care. -- Standard processes follow routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) [1,2,4]. The facility has a process to ensure appropriate urine sampling practices. -- Collect through the sampling port with a sterile syringe using

Catheter maintenance practices, continued disinfectant to clean the port prior to obtaining the sample [2-4]. -- For larger samples, use aseptic technique to remove sample from drainage bag [1,2].

FUNDAMENTAL Facilities should review the following clinical guidelines when (check each box if “yes”) establishing standardized practice and indications for obtaining urine cultures: The facility has standardized practices and indications for obtaining • Healthcare Infection Control Practices Advisory Committee urine cultures based on clinical guidelines. Guideline for Prevention of Catheter-Associated Urinary Tract -- Guidelines include American College of Critical Care Medicine [5]; Infections (2009) Centers for Disease Control and Prevention [4]; Infectious Diseases • Diagnosis, Prevention, and Treatment of Catheter- Associated Society of America [3]. Urinary Tract Infection in Adults: 2009 International Clinical The facility has a process in place to evaluate practices and indications Practice Guidelines from the Infectious Diseases Society of for appropriate ordering of urine cultures. America -- Supports the following practices/rationale [3]: • Guidelines for evaluation of new fever in critically ill adult ○○ Based on patient signs/symptoms compatible with CAUTI

Urine culturing practices patients: 2008 update from the American College of Critical ○○ Part of an evaluation of sepsis without a clear source Care Medicine and the Infectious Diseases Society of America

© 2019 Minnesota Hospital Association | 4 Road map Road map questions (if not present at your hospital or If specific road map element is missing, consider sections answering no, please see next column for suggested resources) the following resources:

○○ Prior to urologic surgeries where mucosal bleeding anticipated Consider the following resources when developing processes or transurethral resection of prostate to evaluate practices and indications regarding the -- Early pregnancy (avoid urinary catheters if possible) appropriateness of urine culture orders: -- Discourages the following practices [3]: • CAUTI Pocket Card for CAUTI Evaluation, Hartley ○○ Urine cultures to screen patients on admission (in the absence • Hennepin Healthcare “The CAUTI Can-Can” webinar of CAUTI symptoms) • Hennepin Healthcare Urine Culture Algorithm ○○ Standing orders for urine cultures in the absence of an • Mayo CAUTI reduction presentation, 2016 CHAIN Fall appropriate indication Conference ○○ Urine quality (pyuria, odor, color, turbidity) to trigger urine • Mayo Clinic CAUTI reduction using bundled approach online culture • Sample Pocket Cards to Remove Urinary Catheters for ○○ Ordering urine cultures without a clinical assessment of the Physicians and Nurses patient’s condition; ensure that the signs and symptoms are • Nebraska Medical Center Urinary Tract Infection and compatible with CAUTI per IDSA Recommendations [3] Pan Asymptomatic Bacteriuria Guidance culturing (i.e., requesting multiple specimens and tests at once • Fakih MG, Khatib R. Improving the Culture of Culturing: in an attempt to identify a possible infection) Critical Asset to Antimicrobial Stewardship. Infection Control & ○○ Reflex orders for urine cultures based on urinalysis results Hospital Epidemiology. 2017;38(3):377-379. Available online. for catheterized patients; each urinalysis result should be • Maryland Campaign for Appropriate Antibiotic Use (CAAUSE) evaluated prior to urine culture order Asymptomatic Bacteriuria Algorithm ○○ Repeat urine cultures to document clearing of bacteriuria • Infectious Diseases Society of America guidelines for the The facility has a process in place that addresses screening of diagnosis and treatment of asymptomatic bacteriuria in adults catheter-associated asymptomatic bacteriuria. • Maryland Campaign for Appropriate Antibiotic Use (CAAUSE) -- Specifically, avoid screening patients for asymptomatic bacteriuria Asymptomatic Bacteriuria Practice Treatment Guidelines except for patients with selected conditions (e.g., undergoing • CDC Clinician Guide for Collecting Cultures urologic procedures, pregnancy) [2,3,6,7] and patients at high risk • Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship— for urinary tract infection [5]. Leveraging the Laboratory to Improve Antimicrobial Use. The facility has a process in place that addresses treatment of JAMA. 2017;318(7):607-608. https://jamanetwork.com/ Urine culturing practices, continued catheter-associated asymptomatic bacteriuria (presence of bacteria in journals/jama/article-abstract/2647071 urine culture without signs/symptoms of CAUTI). • Madden G, Weinstein R, Sifri C. Diagnostic Stewardship -- Specifically, avoid the use of antimicrobials for asymptomatic for Healthcare-Associated Infections: Opportunities bacteriuria except for patients with selected conditions (e.g., and Challenges to Safely Reduce Test Use. Infect undergoing urologic procedures, pregnancy) [2,3,6,7]. Control Hosp Epidemiol. 2018;39(2):214-218. Available The facility has a process in place to evaluate uncommunicative, febrile at https://www.cambridge.org/core/journals/infection- patients whereby an alternative explanation of fever is assessed prior control-and-hospital-epidemiology/article/diagnostic- to urine evaluation [5,8]. stewardship-for-healthcareassociated-infections- The facility has a process in place to conduct periodic audits on urine opportunities-and-challenges-to-safely-reduce-test-use/ culturing practice patterns to determine trends (e.g., among provider E2E185BF9CF7D0C9CAB0A8395ED5FEC9 groups, specialties, units) [1].

© 2019 Minnesota Hospital Association | 5 Road map Road map questions (if not present at your hospital or If specific road map element is missing, consider sections answering no, please see next column for suggested resources) the following resources:

FUNDAMENTAL Conducting a daily review of catheter necessity is an important (check each box if “yes”) strategy to help prevent CAUTI, as prolonged catheterization is the strongest risk factor for infection. Consider the following The facility conducts a daily review of catheter necessity [1,2,4]. resources to support this practice: -- Consider incorporating into already established rounds • Example Policy: Automatic Discontinuance Order for Foley -- Utilizing electronic or other reminders such as an automatic stop Catheter Use order that requires review of catheter indications and renewal of • IPRO Foley Catheter Daily Tracking Sheet indwelling catheter order [1-4]. Practice hand hygiene immediately prior to the removal of the catheter Nurse-driven urinary catheter removal protocols help minimize [2]. prolonged catheterization. Several resources and sample Evaluate the need for reinsertion post catheter removal e.g., bladder protocols are included below: scanner to assess urinary retention. • AHRQ Toolkit for Reducing Catheter-Associated Urinary Tract The facility has implemented a nurse-driven protocol to empower Infections in Hospital Units: Implementation Guide Appendix Indwelling catheter removal nurses to evaluate and discontinue unnecessary urinary catheters [1-3]. M. Example of a Nurse-Driven Protocol for Catheter Removal

FUNDAMENTAL The National Healthcare Safety Network (NHSN) provides (check each box if “yes”) standardized definitions for CAUTI through their Urinary Tract Infection Events Protocol. The facility’s medical record is designed to capture sufficient detail to allow for review of adherence to appropriate practices for catheter use, Consider use of the NHSN Standardized Utilization Ratio insertion, maintenance, and removal. (SUR) to further support internal improvement activities with an -- Includes: alternatives attempted, indications for catheter insertion external comparison relative to catheter removal in addition to [2,4], date and time of insertion/removal [2,4], daily review of tracking number of device days. continued need for catheter use [2], ongoing catheter maintenance [2], names of all health care personnel (HCP) and prescribers Consider the following example audit tools to support regular providing catheter care. review of best practice implementation: The facility conducts audits of insertion criteria selected with available • CDC Targeted Assessment for Prevention (TAP) Strategy: clinical information [1-4]. framework for quality improvement The facility conducts CAUTI surveillance using standardized definitions • Helen DeVos K-card: CAUTI and reviews metrics on a regular basis. [1,2,4]. • Abbott Northwestern Hospital Foley Maintenance and -- Utilize National Healthcare Safety Network (NHSN) definitions Indication Rounding Forms -- Metrics include: CAUTI rates, days since last CAUTI, urinary catheter utilization rates

Performance improvement monitoring The facility has a process in place to review and summarize learnings from every CAUTI with clinical team [1].

© 2019 Minnesota Hospital Association | 6 Road map Road map questions (if not present at your hospital or If specific road map element is missing, consider sections answering no, please see next column for suggested resources) the following resources:

A process is in place to provide feedback to patient care staff regarding Regular review of urinary catheter practices and use of adherence to appropriate catheter use, insertion, maintenance, and the root cause analysis (RCA) process can be useful in removal practices. examining the root cause of each CAUTI that occurs and -- Process measures (e.g., catheter appropriateness, compliance with identify key learning opportunities to prevent future events. catheter insertion practices, compliance with catheter maintenance • AHRQ Toolkit for Reducing Catheter-Associated Urinary practices, catheter insertion by units/areas [such as the emergency Tract Infections in Hospital Units: Implementation Guide, department]) are evaluated on a regular basis. Appendix O. CAUTI Event Report Template • AHRQ Learn from Defects tool • CUSP CAUTI SBAR (Situation, Background, Assessment, Recommendation) Template • Hennepin Healthcare Unit Based CAUTI Review monitoring, continued • CAUTI Inpatient Rounding Tool Performance improvement • CAUTI Pocket Card for CAUTI Evaluation, Hartley

FUNDAMENTAL Engaging a multidisciplinary team in CAUTI prevention efforts (check each box if “yes”) is a critical component of infection prevention. • AHRQ Toolkit for Reducing Catheter-Associated Urinary The facility has a multidisciplinary team to engage staff and guide Tract Infections in Hospital Units: Implementation Guide, CAUTI prevention efforts that includes leadership, physicians, and Appendix A. Checklists for Assessing Executive and nursing. Physician Champion Potential The facility has identified a CAUTI champion that reports to an interdisciplinary performance improvement structure supported by

Infrastructure leadership, physicians, and nursing [1,2]. The facility involves front-line staff as local champions of CAUTI prevention efforts [1,2].

FUNDAMENTAL Provider skill in insertion and removal of urinary catheters is (check each box if “yes”) an important component of safety and prevention of CAUTI. It is important to regularly educate and assess competency. The facility has education in place for providers, residents, and all • Bard Medical Insertion and Removal Skills Training health care personnel who insert/remove urinary catheters [1-4] Checklist incorporated into training on hire and at least annually. • Pennsylvania Patient Safety Authority Foley -- Includes: CAUTI education, appropriate adherence to aseptic Catheterization: Female Performance Checklist technique for insertion, appropriate use of catheters (including • Pennsylvania Patient Safety Authority Foley appropriate indications for insertion and maintenance), proper Catheterization: Male Performance Checklist

Staff education maintenance of catheters, practices and indications for obtaining • Vanderbilt Urinary Catheter Insertion Skills Competency urine cultures, potential adverse effects of inappropriate urine

© 2019 Minnesota Hospital Association | 7 Road map Road map questions (if not present at your hospital or If specific road map element is missing, consider sections answering no, please see next column for suggested resources) the following resources:

cultures such as increased utilization due to testing/antimicrobials/ • APIC/HRET Stop catheter-associated urinary tract consults, identification and removal of catheters that are no longer infections (CAUTI) in critically ill patients needed, and adherence to hand hygiene. • Hennepin Healthcare Myths and Truths About UTIs The facility provides hands-on training with competency evaluation for providers, residents, and all health care personnel allowed to insert/ remove urinary catheters [1-4] incorporated into training on hire and at least annually. -- Includes appropriate indications for catheter use and proper aseptic insertion/removal practices. The facility has a process to ensure that providers, residents, and all health care personnel providing catheter care/maintenance are qualified and trained in urinary catheter care/maintenance. The facility provides hands-on training with competency evaluation for providers, residents, and all health care personnel allowed to provide

Staff education, continued catheter care/maintenance incorporated into training on hire and at least annually.

REFERENCES

1. Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide. October 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/index.html

2. Lo E, Nicolle LE, Coffin SE, et al. Strategies to Prevent Catheter-Associated UrinaryTract Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology. 2014;35:464-479. Available at: http://www.jstor.org/stable/10.1086/675718

3. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625-663. Available at: http://www.idsociety.org/ uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Comp%20UTI.pdf

4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter- associated urinary tract infections 2009. Infection Control and Hospital Epidemiology. 2010;31(4):319-26. Available at: www.cdc.gov/hicpac/cauti/001_cauti.html

5. O’Grady NP, Barie PS, Bartlett JG, et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med 2008; 36:1330–1349.

6. U.S. Preventive Services Task Force. Screening for asymptomatic bacteriuria in adults: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2008;149:43-7. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/asymptomatic- bacteriuria-in-adults-screening

© 2019 Minnesota Hospital Association | 8 7. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54. Available at: http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_ Library/Asymptomatic%20Bacteriuria.pdf

8. Tedja R, Wentink J, O’Horo J, et al. Catheter-Associated Urinary Tract Infections in Intensive Care Unit Patients. Infect Control Hosp Epidemiol 2015;36(11):1330–1334.