Reducing CAUTI: How to Approach it and Pi9alls to Avoid

Transcription

1 Reducing CAUTI: How to Approach it and Pi9alls to Avoid Mohamad Fakih, MD, MPH Associate Professor of Medicine Wayne State University School of Medicine St John Hospital and Medical Center, Detroit, MI

2 Goals UlNmate: Reducing the number of CAUTIs Intermediate: reduce the unnecessary placement and connnued use of catheters, comply with proper insernon and maintenance

3 Reducing Risk of CAUTI Limit catheter use to indicanons (Avoid placing the catheter unless appropriately indicated) Limit catheter use to indicanons (promptly remove those that are no longer necessary) Appropriate Care of the Catheter Proper InserNon Technique Reduce urinary catheter days leading to a reducnon in days at risk for CAUTI Reduce risk of introducing organisms to the bladder leading to a reducnon of risk of CAUTI when catheter in place 3

4 From the IDSA Guidelines (Hooton, Clin Infect Dis 2010; 50: ) the greatest impact of an intervennon may be to reduce the frequent occurrence of CA- ASB, rather than to directly reduce the number of episodes of CA- UTI, which occur much less o\en. CA- ASB: catheter associated asymptomanc bacteriuria

5 2009 PrevenNon of CAUTI HICPAC Guidelines (Gould et al, Infect Control Hosp Epidemiol 2010; 31: ) 5

6 Limit Use to IndicaNons Avoid use unless appropriate indicanon Promptly remove of catheter when no longer indicated ReducNon in Inappropriate Urinary Catheter Use Clear IdenNficaNon of what is considered an appropriate indicanon 6

7 How to Reduce Inappropriate Urinary Catheter Use PACU Remove promptly a\er surgery before transfer out ICU DisconNnue no longer needed before transfer out Non- ICU Evaluate for connnued need ED Avoid ininal placement Reevaluate for connnued need a\er panent stabilizes

8 How do we reduce CAUTI when the catheter is in place? Proper insernon technique Proper maintenance

9 Proper InserNon Technique Perform hand hygiene before and a\er placement. Maintain asepnc technique and use of sterile equipment. Use sterile gloves, drape, an annsepnc solunon for periurethral cleaning, and a single packet of lubricant for insernon. Use the appropriate catheter size. 9

10 Example of a Simplified InserNon Technique Checklist Components of checklist Hand hygiene before and after procedure Compliant Yes Yes, with correction Sterile gloves, drapes, sponges, aseptic sterile solution for cleaning, and single use packet lubricant used Aseptic insertion technique (no contamination during placement) Proper securement of urinary catheter post-procedure Closed drainage system and bag below patient postprocedure 10

11 Proper InserNon Technique To facilitate doing the procedure correctly, have all the elements of the procedure available in the urinary catheter placement kit Make sure the urinary catheter is secure to reduce risk of trauma.

12 Maintenance of Urinary Catheters Keep a closed system for the urinary drainage system. Make sure urinary flow is not obstructed: 1. No kinks of the catheter 2. Urinary bag should always be lower than the bladder 3. Regular emptying of urinary bag 12

13 Maintenance of Urinary Catheters (Gould et al, Infect Control Hosp Epidemiol 2010; 31: ) If break in closed system or leak, change urinary catheter and collecnng system Regular emptying of the collecnng bag Only change catheters and bags based on a clinical indicanon (obstrucnon, infecnon, or compromise of the closed system) RouNne hygiene of the periurethral area (no annsepnc use)

14 Maintenance of Urinary Catheters (Gould et al, Infect Control Hosp Epidemiol 2010; 31: ) No bladder irriganon unless obstrucnon (if irriganon indicated, then closed connnuous irriganon to be done)

15 Obtaining the Urine Specimen (Hooton, Clin Infect Dis 2010; 50: ) From sampling port (more likely to reflect what may be colonizing the bladder) Never use the drainage bag for specimen collecnon

16 How to Comply with Proper InserNon and Maintenance Update your policy to include the appropriate steps for insernon and maintenance Educate healthcare workers that place urinary catheters to provide the appropriate steps for placement and maintenance Consider periodic audits on placement and maintenance

17 What is CAUTI? MulNple defininons Clinical (IDSA) Surveillance (NHSN) Clinician (the physician s impression)

18 Clinical Diagnosis of CAUTI: not so Simple Symptoms: local (lower abdominal discomfort or flank pain), or systemic (nausea, vominng, and fever) Nursing home panents (fever and confusion) Spinal cord injury panents (fever, diaphoresis, abdominal discomfort, or increased muscle spasncity ) The signs and symptoms are not specific for CAUTI!!

19 IDSA Guidelines for Diagnosis of CAUTI (Hooton, Clin Infect Dis 2010; 50: ) Presence of symptoms or signs companble with UTI and urine culture with at least one organism Signs and symptoms: new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other idennfied cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort

20 IDSA Guidelines for Diagnosis of CAUTI (Hooton, Clin Infect Dis 2010; 50: ) If catheter removed: dysuria, urgent or frequent urinanon, or suprapubic pain or tenderness Spinal cord injury: increased spasncity, autonomic dysreflexia, or sense of unease

21 What is not DiagnosNc of CAUTI? (Hooton, Clin Infect Dis 2010; 50: ) Pyuria: does not help differennanng asymptomanc bacteriuria from CAUTI Presence of pyuria and bacteria in the urine is not equal to CAUTI If no pyuria is present in a symptomanc panent, then evaluate for an alternanve diagnosis other than CAUTI

22 NHSN SymptomaNc CAUTI ( Surveillance defininon: depends on having a posinve urine culture and clinical/ laboratory findings. Heavily dependent on the presence of fever May help evaluate improvement for the same hospital over Nme for those that are catheterized

23 NHSN SymptomaNc CAUTI ( CauNon: if pracnce of obtaining urine cultures changes, the NHSN rate may be influenced without a change in true CAUTI

24 What May Increase NHSN CAUTI Rate Despite Improvements in Process? An increase in obtaining urine cultures An intervennon that leads to significant reducnon in urinary catheter use, selecnng a higher risk populanon (Fakih, Am J Infect Control Aug 24; Wright, Infect Control Hosp Epidemiol 2011;32: ) The populanon based measure (with panent- days as a denominator) would help idennfy if there was improvement in CAUTI related to a reducnon in urinary catheter use

25 Inappropriate Treatment of AsymptomaNc Bacteriuria (Cope, Clin Infect Dis 2009; 48: ) The study evaluated those with asymptomanc bacteriuria and the factors associated with inappropriate annbionc use Advanced age, type of predominant organism (gram neganve), and an elevated urine white blood cells count were significantly associated with inappropriate treatment

26 The Clinician Clinician s pracnce does not mirror the diagnosis of CAUTI based on NHSN defininon Clinicians tend to treat asymptomanc bacteriuria Avoid obtaining urine cultures unless clinically indicated Promptly disconnnue annbioncs empirically started for a possible urinary source of infecnon if a definite non- urinary source is idennfied

27 Proper Use of Urine Cultures Bacteriuria or candiduria are common in panents with an indwelling urinary catheter The longer the duranon of catheter use, the higher the chances of having organisms in the urine By 1 week, about a quarter of those with a urinary catheter have organisms in urine, and all by 1 month

28 Proper Use of Urine Cultures It is important to only do urine cultures when suspecnng CAUTI or if it is part of sepsis workup Do not over- diagnose: obtaining urine cultures without an indicanon may result in inappropriate annbionc use and mislabeling a panent for having CAUTI Avoid having standing orders or reflex orders for urine cultures based on urinalysis results

29 What not to Do (Hooton, Clin Infect Dis 2010; 50: ) Screening for bacteriuria is NOT recommended except in special circumstances (pregnancy) Cloudy or odorous urine is NOT and indicanon to obtain a urine culture

30 Risk of Doing Cultures with no Symptoms Urinary catheter present in an asymptomanc panent Cloudy, odorous urine, sediments Inappropriate use of urine culture Inappropriate annmicrobial use More resistant organisms, Clostridium difficile, increased cost, PaNent harm

31 In summary Reducing CAUTI: 1. Most significant impact with reducing urinary catheter use 2. Proper insernon and maintenance of catheter system CAUTI rates: 1. Appropriate Use of urine cultures 2. Appropriate use of annmicrobials