Policies / Protocols Guidelines & Procedures Example

SERVICE ISSUED BY Infection Control Infection Control Coordinator SUBJECT APPROVED Prevention of Catheter Associated Urinary Tract Infection BY: CQO

I. POLICY

To provide the appropriate care for adult guests receiving urinary catheterization.

II. PURPOSE

Urinary catheterization is commonly performed as part of routine medical care. Urinary tract infections account for approximately 40% of all healthcare associated infections, and most of these infections follow instrumentation of the urinary tract, mainly urinary catheterization.

III. RESPONSIBILITY

All Registered Nurses

IV. ACTION DIRECTIVES

A. Inpatient Admission Catheter Care Guidelines: 1. On admission, assessment of indwelling catheter presence will be performed and documented in Entry to Care. 2. If indwelling catheter present, order will be obtained from physician for urine culture. 3. If lab results are positive, a PHIIP Query will be placed on the progress note requesting the ordering physician to address Urinary Tract Infection with indwelling catheter Present on Admission condition. 4. Every shift, the need for continued catheterization will be assessed. In electronic medical record document the appropriate “Cath Criteria” for continued need for indwelling catheter. 5. If no criteria met for continued catheterization, obtain order to remove catheter.

V. PROCEDURE

A. Considerations Prior to Catheterization Because of the infection risk associated with urinary catheterization, avoiding catheterization should be practiced whenever possible. The following are examples of indicators when urinary catheterization would be acceptable: 1. Patients with acute urinary retention or obstruction: Mechanical obstruction, urethral or bladder outlet obstruction related to benign prostatic hypertrophy, severe edema with penile swelling, urethral stricture or urinary blood clots. Also for acute urinary retention related to neurogenic bladder most often related to spinal cord injury or progressive neurological disease or to medications that reduce bladder muscle contractility or sensation. 2. Patients who require accurate measurement of urinary output in critically ill patients. 3. Patients who require perioperative use in selected surgeries: for prolonged surgical procedures, large volume infusions during surgery, intraoperative urinary output monitoring, urological surgeries, or other surgeries on contiguous structures of the genitourinary tract. 4. Patients who require assistance with healing of perineal and sacral wounds in incontinent patients. 5. Patients who are at the end of life care for hospice/comfort/palliative care. 6. Patients who require immobilization for trauma or surgery; includes instability in the thoracic or lumbar spine, multiple traumatic injuries, such as pelvic fractures, and acute hip fracture when there is a risk of displacement with movement.

B. Alternatives to Urinary Catheterization Other methods of urinary drainage such as condom catheters, suprapubic catheterization, and intermittent urinary catheterization may be suitable alternatives to indwelling catheters, and should be considered for appropriate patients.

C. Personnel All hospital personnel who insert urinary catheters will be trained and competent in sterile and aseptic technique. In addition all personnel who provide catheter care shall practice aseptic technique.

D. Catheter Use Urinary catheters should be inserted only when necessary, and left in place only for as long as necessary. UNDER NO CIRCUMSTANCES, MAY URINARY CATHETERS BE USED SOLELY FOR THE CONVENIENCE OF PATIENT CARE PERSONNEL OR PER FAMILY REQUEST.

E. Catheter Insertion, Care and Maintenance 1. Perform hand hygiene prior to catheter insertion, as well as before and after any manipulation of the catheter, catheter site, or apparatus. 2. Catheters are to be inserted using aseptic technique with equipment provided in sterile catheter insertion trays. 3. The smallest sized caliber catheter that provides adequate drainage should be used. Males: 16-18 French Females: 16-22 French 4. The catheter should be properly secured to the guest’s leg with a catheter stabilization device after insertion to prevent movement, disconnection, and/or trauma to the urethral area. 5. A sterile, single use continuous closed drainage system should be connected to the urinary catheter, and maintained. 6. The catheter and drainage tube should not be disconnected unless the catheter must be irrigated. 7. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. If the Foley catheter was a difficult insertion, then notify physician of possible contamination. Remove only with physician direction under these circumstances.(i.e. Coude, TURP, CBI, and enlarged prostate). If the catheter cannot be removed, the catheter-tubing junction must be disinfected with an alcohol sponge and a new drainage system must be connected to the catheter. 8. Silver alloy coated catheters have been shown effective in decreasing UTI infections related to long term use of indwelling Foley catheters. 9. In order to achieve a free flow of urine: a. The catheter and collecting tube should be kept from kinking or from becoming dependent. b. The collecting bag should be emptied regularly using a separate collecting container/graduate for each patient. c. When emptying the collecting bag, the drainage spigot, and the nonsterile collection container should never come in contact. d. Collection bags should always be kept below the level of the bladder, taking care not to allow the bag to touch the floor. 10. The meatal area should be cleansed with soap and water at least once daily, and as needed if the area becomes soiled with fecal matter, or other contaminants.

KEY NOTE: Aseptic technique is the effort taken to keep patients as free from hospital micro-organisms as possible (Crow 1989). It is a method used to prevent contamination of wounds and other susceptible sites by organisms that could cause infection. This can be achieved by ensuring that only sterile equipment and fluids are used during invasive medical and/or nursing procedures.

F. Irrigation 1. Irrigation should be avoided unless obstruction is anticipated (i.e., after prostatic or bladder surgery, or to relieve obstruction due to bleeding or other causes.) 2. When irrigation is necessary follow physician orders. 3. If the catheter becomes obstructed and can be kept open only by frequent irrigation, the catheter should be changed if it is likely that the catheter itself is contributing to the obstruction (i.e., formation of concretions).

G. Specimen Collection 1. The sampling/drainage port should be used for specimen collection via the following procedure. a. Perform hand hygiene. b. Gloves should be worn for specimen collection. c. Cleanse the sampling port with a hospital approved antiseptic prior to withdrawing a specimen. d. Using aseptic technique, withdraw urine using a luer-lock syringe. e. Specimen should be labeled with the appropriate identifiers and transported immediately to the laboratory in a biohazard specimen bag. f. Document in the medical record. g. Collecting specimens from the drainage bag should not be done, as organisms cultured directly from the drainage bag have a poor correlation with true urinary pathogens.

H. Catheter Change Interval Indwelling catheters should not be changed at routine fixed intervals. URINARY CATHETERS SHOULD BE REMOVED AS SOON AS THEY ARE NO LONGER NEEDED.

VI. REFERENCES

APIC Implementation guide: Guide to Preventing Catheter-Associated Urinary Tract Infections, 2014.

HICAPAC: Guidelines for Prevention of Catheter Associated Urinary Tract Infections, 2009

Institute for Healthcare Improvement (IHI) 5 Million Lives, Getting Started Kit: Prevent Catheter Associated Urinary Tract Infection: How-to Guide, 2008.

SHEA/IDSA PRACTICE RECOMMENDATION: Strategies to Prevent Catheter- Associcated Urinary Tract Infections in Acute Care Hospitals: 2014 Update, 2014.

The Joint Commission; 2013 Hospital National Patient Safety Goals. www.jointcommission.org