Preventing Catheter- Associated Urinary Tract Infections in Indwelling Catheters. Study Guide

Transcription

1 4588 Preventing Catheter- Associated Urinary Tract Infections in Indwelling Catheters Study Guide

2 Video produced and distributed by: Envision, Inc. 644 West Iris Drive Nashville, TN Kimberly-Clark Health Care Education 3

3 ACKNOWLEDGEMENTS We would like to express our sincere appreciation to the following individuals CLINICAL ADVISORS Vicki L. Brinsko, RN, BA, CIC Infection Prevention & Control Vanderbilt University Medical Center Lorrie G. Ingram, RN, BSN Infection Prevention & Control Vanderbilt University Medical Center Barbara Gray, RN, BSN Quality Consultant Vanderbilt University Medical Center Dr. Lindsay Nicolle Professor, Dept. of Internal Medicine/Medical Microbiology Section of Infectious Diseases University of Manitoba/Health Sciences Centre FILMING LOCATION Vanderbilt University Medical Center Nashville, Tennessee Envision, Inc This program sponsored in part through an unrestricted educational grant provided by Rochester Medical Corporation 4

4 Table of Contents I. Introduction II. Objectives III. Indications for Use of Indwelling Urinary Catheters IV. Epidemiology and Pathogenesis V. Surveillance VI. Risk Factors A. Duration of Catheter Use B. Host Susceptibility C. Catheter and Collection System Management VII. Interventions A. Judicious Catheter and Collection System Selection B. Proper Insertion and Removal Techniques C. Infection Prevention Practices VIII. Complications of Catheter Use A. Infection B. Leakage or Bypassing C. Blockage D. Lack of Urine Flow E. Other Complications IX. Education X. Conclusion XI. References XII. Tools A. Foley Catheter Automatic Discontinuation Assessment/Documentation B. Best Practices for the Prevention of Catheter-Associated XIII. Post Test XIV. Continuing Education Application XV. Program Evaluation Form XVI. Post Test Answers Kimberly-Clark Health Care Education 5

5 Instructions for Continuing Education Credit This program has been approved by Envision, Inc. for 1.0 Contact Hour, Program Number 002UTI10. Envision, Inc. is an approved provider by the California State Board of Registered Nursing, Provider Number CEP To obtain continuing education credit: View video presentation Review study guide Complete CE application form, including applicant information, test answers and evaluation section Forward the application form and $10 processing fee to: Envision, Inc. 644 West Iris Drive Nashville, TN Certificates will be mailed within 4 weeks. 6

6 I. Introduction Invasive devices such as catheters are leading causes of infection in healthcare facilities. And there is one type of catheter that is responsible for more healthcare-associated infections (HAIs) in hospitals, long term care and home care than any other device the indwelling urinary catheter. More than 1 million cases of CA-UTI occur each year in U.S. hospitals and nursing homes, 1,2 and CA-UTIs account for up to 40% of HAIs. 1,2 It is estimated that 25% of patients in the acute care setting will have an indwelling urinary catheter at some point in their hospitalization, 3 and 69% of patients in medical ICUs hospitalized in NNIS hospitals from had urinary cathters. 4 Catheter-associated urinary tract infections or CA-UTIs are generally assumed to be benign. However, CA-UTIs may be associated with significant complications, such as cystitis, pyelonephritis, infection, prostatitis, epididymitis, orchitis in males, and encrustation; less commonly, bacteremia and complications of metastatic infection including endocarditis, septic arthritis, endophthalmitis, and meningitis may occur. 5,6 CA-UTIs are the second most common cause of healthcare associated bloodstream infection. 7-9 CA-UTIs increase length of stay by 1 to 3 days and add to overall patient costs, especially if bacteremia occurs. 10 In addition, urinary catheters often precipitate unnecessary antimicrobial therapy, and are a major reservoir for resistant pathogens. 7-9,11-13 One study has linked CA-UTIs and surgical site infections. 14 Not all catheter-associated urinary tract infections or CA-UTI are preventable. For example, there are certain factors that increase the risk of infection that may not be modifiable in a patient. However, there are many CA-UTI that are avoidable. This is why as of October 1, 2008, Medicare discontinues reimbursement for the extra cost of treating catheter-associated urinary tract infections that occur while the patient is in the hospital. 15 In addition, there is a national push to get to zero in the incidence of reportable healthcare-associated infection rates by the Agency for Healthcare Research and Quality (AHRQ), 16 The Joint Commission, 17 the Association for Professionals in Infection Control (APIC) 18 to name a few. As primary caretakers of patients with urinary catheters and as patient advocates, nurses must take an active role in the safe use, management and timely removal of indwelling urinary catheters in order to prevent CA-UTIs. If we are to reduce the numbers of infections, clinicians will need to first follow evidence-based practices such as those in the CDC Guideline for the Prevention of Catheter-Associated 2009, 19 the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals by Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), and The Joint Commission, 19A Diagnosis, Prevention and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America; 19B Clinical Fact Sheets by the Wound, Ostomy and Continence Nurses Society (WOCN) 20, and professional guidelines and get back to the fundamentals of nursing for the care and maintenance of the urinary catheter. II. Objectives After viewing this program and completing the Study Guide, the learner will be able to: Explain at least 3 interventions that will prevent the acquisition of UTI in catheterized patients Discuss risk factors for the acquisition of CA-UTI Discuss infection prevention practices for the care and management of the catheter and collection system Kimberly-Clark Health Care Education 7

7 III. Indications for Use of Indwelling Catheters An indwelling urinary catheter, also known as a Foley catheter, is a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a collection system. 21 There are various indications for an indwelling urinary catheter: 19,20,22,23 Short term catheters typically remain in place for up to 2 weeks, and may be used for: Management of acute urinary retention Post-op bladder decompression Monitoring urinary output in critically ill patients To aid in urological and pelvic surgery Sudden and complete inability to void Temporary relief of bladder outlet obstruction secondary to enlarged prostate gland, urethral stricture, or obstructing pelvic organ prolapse Long term use, usually for more than 30 days, may be used: To relieve urinary tract obstruction or urinary retention when surgery or intermittent catheterization is not feasible If urine leakage is preventing healing of Stage III or IV pressure ulcers In selected patients, the use of urinary catheters may also have a role for: Urinary incontinence Irreversible medical conditions, such as metastatic terminal disease, coma, and end stage diseases Examples of inappropriate uses of indwelling catheters include: 19 As a substitute for nursing care of the patient or resident with incontinence As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void For prolonged postoperative duration without appropriate indications (e.g. structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc.) IV. Epidemiology and Pathogenesis An indwelling catheter increases the risk for urinary tract infection by interfering with the body s local defense mechanisms against infection by irritating the urethral and bladder mucosa and by providing a surface for growth of bacterial biofilm A biofilm is defined by Morris as a collection of microorganisms and their extracellular products that adhere to and multiply on catheter surfaces. 27 A biofilm forms intraluminally and extraluminally and ascends the catheter in a retrograde fashion. 28 The longer a urinary catheter is kept in place, the higher the risk of biofilm formation which leads to infection. And, the more well developed the biofilm structures, the more resistant to antibiotics and the host immune system. 25,27 8

8 As of January 1, 2009, the Centers for Disease Control and Prevention (CDC) and the National Healthcare Safety Network (NHSN) 6a state a catheter- associated urinary tract infection or CA-UTI is a urinary tract infection that occurs in a patient who had an indwelling urethral urinary catheter in place at the time of or within 48 hours before the onset of the UTI. This means that CA-UTI may be identified even after a catheter is removed. There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated. 6 There are two types of catheter-associated UTI symptomatic infection, and asymptomatic infection. The majority of these infections are asymptomatic or without symptoms, and may resolve spontaneously with the removal of the catheter and without the need for antibiotics However, symptomatic infection may occur with the use of a urinary catheter, and will sometimes be severe. 32 (For criteria of Symptomatic Infection, see Section VIII, Complications of Catheter Use, pg 18.) The majority of infections occur by pathogens entering along the catheter walls extraluminally (outside the catheter) between the catheter and the urethra: 24,33-35 During insertion of the catheter due to contamination or inadequate hand hygiene Later when microorganisms ascend from the perineum and colonize the meatus Pathogens can also enter intraluminally (inside the catheter) through ascending colonization in biofilm: 24,33,35 From breaks in the closed drainage system, such as during irrigation From collection bags that become cross contaminated by the hands if they are not washed before changing bags or emptying urine When collection bags are raised, such as during transport, and the microorganisms flow into the bladder By capillary action even when the bag is below the bladder CA-UTI can also occur when larger sized catheters (>14 Fr) block or obstruct the drainage of periurethral glands. 20,36 The most common microorganisms that cause CA-UTI in hospitals include Escherichia coli, Staphylococci, Enterococci, Enterobacter, Proteus mirabilis, Pseudomonas aeruginosa and Klebsiella pneumoniae - many of which are drug-resistant pathogens. 32,35 In fact, patients with silent catheter-associated bacteriuria comprise a huge reservoir for highly resistant organisms, especially in critical care units Candida infection is also an increasingly common cause of CA-UTI, especially for patients in the ICU, on broad-spectrum antimicrobials or with underlying diabetes mellitus. 41,42 Many of these organisms are endogenous to the patient s own bowel flora. Other organisms may be acquired from the hands of healthcare personnel during insertion, care and maintenance of the catheter and collection system; by crosscontamination from other patients; or by exposure to non-sterile equipment or contaminated solutions. 35,43,44 Staphylococci and enterococci as well as yeasts are the most common organisms for CA-UTI caused by organisms ascending along the surface of the catheter; while water-borne gram-negative organisms such as Pseudonomas, Enterobacter and Acinetobacter are most common along the intraluminal route from the collection bag. 24 Outbreaks of these pathogens as well as Serratia from this route are well documented Kimberly-Clark Health Care Education 9

9 V. Surveillance Surveillance is recommended to monitor when urinary catheters are used, and how often symptomatic infection occurs. 6,19,19A An accurate means to identify patients with urinary catheters and track the duration of catheterization is necessary to optimize patient safety and prevent infection. 48 In addition, research shows that if feedback on infection rates is given to clinicians, there is often a decrease in the subsequent rates of CA-UTI. 49,50 Under The National Healthcare Safety Network (NHSN) Patient Safety Component Protocol, surveillance for CA-UTI should occur in ICUs, specialty care areas (such as inpatient dialysis units, hematology/oncology wards, bone marrow transplant units) and any other inpatient location in the institution where denominator data can be collected, such as surgical wards. 6 The revised NHSN 2009 Facility Survey Form is available at Beginning October 1, 2008, Medicare discontinues payment for the extra cost of treating catheter-associated urinary tract infections that occur while the patient is in the hospital. 15 While the Centers for Medicare and Medicaid s pay for performance requirements may make testing for UTI s upon admission tempting, there may be unintended consequences to unnecessary testing upon admission of asymptomatic patients who have catheters but do not have symptoms. Clinicians may feel pressured to treat UTI with antibiotics, which is usually not warranted when the patient has no symptoms of UTI or systemic infection. This may lead to superinfection, as well as the selection of antibiotic-resistant pathogens CMS discourages unnecessary testing upon admission of asymptomatic patients who have catheters but do not have symptoms and encourage testing only if symptoms suggesting urinary infection are present. 51 VI. Risk Factors There are several risk factors that increase the risk of CA-UTI: Duration of catheter use Host susceptibility Improper or inadequate catheter/collection system management A. Duration of Catheter Use Many studies point to duration of catheter use as the most important risk factor for the acquisition of catheterassociated UTI. 55,58-60 The daily risk of acquiring infection is 3 to 7% per day, and by day 30 of catheterization essentially all patients are infected. 61,62 Studies show that indwelling catheters are significantly overused, a factor acknowledged as long ago as ,64 For example, in a study by Jain et al, the main cause of unjustified placement of initial and prolonged use of indwelling urinary catheters was urinary incontinence. 65 In another study by Saint et al many physicians were unaware that their patients had urinary catheters. 66 In addition, urethral catheters have been referred to as a one point restraint, raising serious safety and even ethical concerns regarding their use. 67,68 Therefore, the research consensus is that catheterization should be avoided unless there are clear and established indications for urinary catheter use. 10

10 There are some situations when indwelling urinary catheters cannot be avoided. But indwelling urinary catheters should not be used as a substitute for nursing care of incontinent patients, or for the convenience of staff. And because of the risk of multiple complications, long term indwelling urinary catheters should only be used for patients who cannot be managed with less invasive options. 19,20,69,70 The use of indwelling urinary catheters should be limited to: 19A,69,70 Patients undergoing surgical repair of the genitourinary tract in order to facilitate healing Patients requiring relief of anatomic or physiologic outlet obstruction Postoperative or critically ill patients requiring accurate urinary output Comatose, paralyzed or debilitated patients in order to prevent infecting pressure ulcers or having skin breakdown As an exception, to improve comfort at patient or family request, particularily for end of life care. 19A Alternatives to indwelling urethral catheterization should be considered. 19 For example, consider bedside commode use and voiding trials for incontinent patients. A bladder scanner may be utilized to determine if a patient has urinary retention and needs a catheter For patients who have trouble voiding due to a neurogenic bladder or bladder outlet obstruction, consider intermittent catheterization for periodic bladder emptying. 20,71 An external condom catheter may sometimes be used for male patients without obstruction. 75 manipulation by patients has been associated with increased infection rates. 76 However, frequent Suprapubic catheterization may be more comfortable and acceptable to some patients but requires a surgical procedure and may not be associated with a lower incidence of CA-UTI. 77 The 2008 Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals states there is not enough evidence to support the routine use of suprapubic catheters for short-term catheterization to prevent symptomatic urinary infection. 19A If indwelling urinary catheters are used, they should be removed as soon as no longer necessary. 19,19A,45,66,78 Some facilities are finding successful results through the use printed or computer-based reminders with automatic stop orders mandating the removal of the catheter after 48 to 72 hours unless the patient has not met certain clinical criteria. Other facilities authorize nurses to remove catheters without doctors orders if clinical criteria are met. 71,79-82 At the Yale-New Haven Hospital a program was instituted to increase physician awareness of placement of an indwelling catheter in the Emergency Department and encourage temporary use via Computerized Physician Order Entry as part of admission orders. The physician would then be prompted to discontinue the device, maintain the catheter for 48 hours, or maintain the catheter chronically. As part of the same initiative, a nurse-driven protocol allowed nurses to discontinue a catheter independent of physician orders if certain criteria were met. Education was also provided to nurses on alternatives to indwelling urinary catheters, and bladder scanners were used to determine if there was urinary retention. At the end of a six month period, there was a 47% reduction in the incidence of CA-UTI and the criteria for inappropriate use decreased from 24% to 14.8%. 71 Kimberly-Clark Health Care Education 11

11 B. Host Susceptibility Another risk factor for acquiring CA-UTI is host susceptibility. The following individuals are more likely to acquire CA-UTI: 3,24,59,60,83,84 Females are at higher risk than males due to shorter urethras/shorter travel from the perineum and anus to the bladder Patients with advanced age Those with fecal incontinence and heavy periurethral cutaneous colonization, causing perineal and meatal colonization Major pre-existing conditions such as diabetes, elevated creatinine, malnutrition, and other infections Those who are debilitated Those on a urology service, such as those with a urinary tract abnormality Those who are catheterized outside of the sterile operating room environment or late in hospitalization Patients with uremia/azetemia, or urea and other nitrogenous waste in the blood Presence of a urethral stent Healthcare providers should recognize and identify factors that increase the risk for CA-UTI and implement best practice interventions that will prevent infection in susceptible patients. C. Catheter and Collection System Management The third risk factor for acquiring catheter-associated UTI is related to how the catheter is managed. Improper or inadequate infection prevention during insertion, care and management of the catheter and collection system can substantially increase the risk of infection. This is why aseptic technique and best practices during insertion, care and maintenance are so important to the prevention of infection. There are primarily three points of bacterial entry: Along the catheter walls - both interior and exterior 2. At the junction between the catheter and drainage bag if the system is opened 3. At the drainage outlet Proper care of the catheter and collection system is vital to preventing infection. If we follow the fundamentals of nursing and infection prevention practice, we can meet and even exceed facility and national goals for preventing catheter-associated UTI s during the hospital stay. 12

12 VII. Interventions As renowned infection prevention expert William Jarvis, MD of Jarvis and Associates notes, no single intervention prevents any HAI; rather, a bundle approach, using a package of multiple interventions based on evidence provided by the infection control community and implemented by a multidisciplinary team is the model for successful HAI prevention. 85 The following interventions may be considered by a facility in the implementation of practices to prevent catheter-associated urinary tract infection. A. Judicious Catheter and Collection System Selection Judicious catheter selection can help prevent CA-UTI in susceptible patients, and reduce other catheter-related complications. Catheter material and its influence on the onset of CA-UTI have resulted in many studies and sources of debate, and emerged as an important consideration for the individualized care of the patient. Indwelling catheters are most commonly made from latex or 100% silicone. Latex is soft, flexible and conformable, and was the material used to make the first Foley catheters. 86 However, latex has been associated with potentially fatal allergic reactions in both patients and clinicians. Latex also swells as it absorbs body fluids, increasing the outside diameter and decreasing the drainage lumen. 87 Coating the latex with polytetrafluoroethylene (PTFE) or coatings containing silicone reduces the swelling; however, latex is still associated with higher rates of encrustation and outflow blockage. 88,89 100% silicone catheters cause less irritation and eliminate the risk of reaction to latex, and the large diameter and thin walls may prevent the formation of biofilm, decreasing blockage. In addition, silicone catheters prevent the build-up of protein and mucous due to greater compatibility with the urethral lining. 90 However, silicone catheters may lose fluid due to osmosis; and because the elastic properties of silicone are different than latex, silicone Foley balloons are more likely to cuff when deflated. 91 This problem can be minimized by following the manufacturer recommended procedures for balloon deflation. Many of today s catheters incorporate surface coatings to reduce the risk of latex reaction, improve the surface smoothness of the catheter, and prevent the development of biofilm formation. 33 Options include hydrophilic coatings that absorb water to produce a slippery outside surface; as well as silicone elastomer and polytetrafluoroethylene (PTFE) which are intended to reduce the irritating effects of latex on the urethra. 88 Hydrophilic catheters may be preferable to standard catheters for patients requiring intermittent catheterization. 19 The newest technology in catheter manufacturing is in the development of catheters with anti-infective/antimicrobial properties designed to reduce colonization, bacterial attachment, and migration. 92 For example, in recent years, new technology has resulted in catheters that are coated with antimicrobials, or impregnated with a urinary antiseptic. 35, The CDC recommends that if the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI, consider using antimicrobial or antiseptic-impregnated catheters. 19 Always select catheters based on evidence-based research, professional guidelines and your facility s protocols. In addition to considering catheter materials, clinicians should choose a small catheter, preferably 14 to 16 French (FR), unless the patient is prone to blood clots, sediment or blockage that could occlude the lumen. Larger size catheters can lead to leakage, increase the risk of obstruction of urethral glands, create discomfort, and lead to UTI, erosion and irritation. 20,78,107 Select a small 5 ml size balloon inflated according to manufacturer guidelines. The balloon is designed to act as a retention device rather than an anti-leak device. Larger balloons may raise the risk of infection by increasing the volume of urine that pools below the level of the drainage eyes. The balloon should be inflated with 10 ml s of water to assure uniform and symmetrical inflation. 20 It is recommended that sterile water rather than saline be used, as saline can crystallize around the balloon and make removal and deflation difficult or even traumatic. 33 Kimberly-Clark Health Care Education 13

13 Straight-tipped catheters should be used for routine catheterization. Coude-tipped catheters may be considered for difficult insertions involving the male prostatic curve, with the tip pointed upward towards the patient s umbilicus. 92 Use and maintain a sterile, continuously closed drainage system. 19,20,108 An open system is a nearly universal guarantee of a catheter-associated UTI, 108 while a closed system has been shown to reduce CA-UTI in short-term indwelling catheters. 108,109 Consider kits with pre-connected catheters and sealed bag junctions to maintain a closed system, and kits and collection bags that include a feature designated to help prevent urine reflux back into the drainage tubing. 32,33 Never disconnect the catheter or drainage tube unless irrigation is necessary to relieve obstruction; and use strict aseptic technique for these circumstances. 32 Failure to maintain a closed system predisposes patients to infection. 19,108,110 If there is encrustation, obstruction, or signs or symptoms of infection, change the entire system. 20 Collection systems should have sturdy hangers and a secure bottom drain holder for the bottom drain tube to keep the system off the floor and to protect the emptying valve from contamination. 111 B. Proper Insertion and Removal Techniques To prevent infection, catheters must be inserted by trained professionals following strict adherence to aseptic technique. 32 In general the following aseptic practices must be followed whenever inserting an indwelling urinary catheter in the acute setting: 19,19A,35,70 Perform proper hand hygiene according to the CDC 112 and World Health Organization 113 guidelines using soap and water or alcohol based hand rub before and after insertion Don clean gloves and thoroughly clean the perineal area with soap and water Use aseptic technique and sterile materials, such as sterile gloves and fenestrated sterile drapes during the insertion process Clean the periurethral area with an appropriate antiseptic or sterile solution prior to insertion of the catheter The CDC states that in the non-acute setting, clean (i.e. non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization. 19 Securing the catheter with an adhesive anchoring system or a catheter strap will avoid movement or excessive tension on the catheter; as well as urethral traction or irritation, prevent accidental dislodgement, and increase comfort. 33,78 Do not use adhesive tape to secure the catheter as it may not stay on well, may be detrimental to the catheter material, and the sticky residue can accumulate microorganisms that can contaminate the catheter. 87 Gently perform perineal care as needed with soap and water using correct techniques, but avoid manipulating the catheter. 19 Always clean female patients from front to back (meatal to anus) so that bacteria from the rectum is not spread to the urethra and vagina. 78 The WOCN recommends cleaning daily and after each bowel movement. 20 Studies do not support the use of scheduled meatal care after insertion using antimicrobial ointments or solutions as this does not reduce the risk for CA-UTI Avoid the use of petrolatum-based creams or ointments as they can degrade latex catheters. 92 Remove the catheter according to manufacturer instructions. Some manufacturer s suggest allowing fluid from the balloon to return to the syringe by gravity, while others recommend fluid be aspirated prior to removal. 92 Some studies suggest that aspiration may encourage formation of creases or cuffing at the balloon area, collapse the inflation lumen and increase balloon diameter size, which can result in difficult removal and urethral trauma. 117,118 Always follow manufacturer instructions. 14

14 Step by Step Insertion Techniques The following techniques are based on nursing practice, research and guidelines; however, be sure to always follow your facility s protocols. 19A,20,33,35,70,78,92,107, Perform proper hand hygiene. 2. Explain to the patient the procedure and what they can expect. 3. Next, place the patient in the appropriate position. Females should be supine with knees bent, feet two feet apart, and with hips flexed. Inserting a catheter from the rear will introduce fecal bacteria into the bladder and is not recommended unless the patient has limited mobility. Males should lie down with legs extended and thighs slightly apart. 4. Don gloves and with a cleansing wipe or soap and water and cloth, cleanse the genital area and perineum. Then rinse and pat dry. 5. Place a moisture proof pad with the plastic barrier facing down under the patient s buttocks. 6. Remove your gloves, and perform hand hygiene. 7. Prepare the sterile field by placing the catheter tray on a bedside table and opening carefully using aseptic technique. 8. Don sterile gloves, and place the fenestrated drape over the perineal area. 9. Prepare or open an appropriate antiseptic or sterile solution such as povidone iodine or chlorhexidine wipes and set aside. 10. Next, generously lubricate the distal tip of the catheter to avoid urethral trauma, especially for male patients. The use of 2% lidocaine jelly prior to catheterization reduces discomfort and may prevent urethral spasms as well. 11. If manufacturer recommendations suggest pretesting the balloon, use a sterile water syringe, attach it to the balloon port and inflate the balloon to assure patency. Deflate the balloon by removing the plunger pressure do not draw back the plunger. 12a. If the patient is female, use your non-dominant hand to separate the labia, and keep this hand position until the catheter is fully inserted. Using the dominant hand, cleanse the skin with the antiseptic solution from anterior to posterior, using one swab for each side of the labia, and a separate swab for the urethral meatus. Dispose of each swab away from the sterile field after use. Using aseptic technique, insert the catheter into the urethral meatus and continue to advance the catheter until urine begins to flow. It may be beneficial to ask the patient to bear down in order to relax the sphincter muscles. If the catheter is accidentally inserted into the vagina, leave it there as a landmark and begin again with new supplies. 12b. If the patient is male, use your non-dominant hand to hold the penis. Then using the dominant hand, clean the glans with the antiseptic solution, beginning with the urinary meatus and working outward in a circular motion; then repeat using a new swab. Dispose of the swab away from the sterile area. With the penis perpendicular to the patient s body, apply light upward traction with the non-dominant hand, and insert the catheter using aseptic technique. 13. Continue to advance the catheter until urine begins to flow. Never use force to insert a catheter. If you encounter slight resistance, try twisting the catheter or ask the patient to take deep breaths. If you meet with continued resistance, discontinue the procedure and notify a physician. 14. Once you have established urine flow, the catheter should be inserted another inch or two to ensure that the balloon is in the bladder and not in the urethra. Make sure the catheter is inserted to the hub in males prior to inflating. Kimberly-Clark Health Care Education 15

15 15. Properly inflate the balloon after placement, following manufacturer recommendations. Generally, a 5ml balloon will require 10 ml s of liquid. Confirm placement by very gently tugging on the catheter and checking for urine output. 16. Place the urinary drainage bag below the level of the patient. 17. Secure the catheter in place with an adhesive anchoring system or a catheter strap - either at the tubing junction, as this allows for movement with activity, or above the Y port - according to facility policy. In women, catheters should be secured on the upper thigh, and in men the upper thigh or abdomen. 18. When you are done securing the catheter, pat the perineal area dry with the drapes, then reposition the patient to a more comfortable position. 19. Dispose of gloves and other materials and perform hand hygiene. 20. Be sure to document: Date and time of insertion Individual who inserted catheter The catheter size and type Balloon inflation size Ease of insertion and how the patient tolerated the procedure The reason for placement and the intended duration of catheter use. If appropriate, arrange for electronic or other reminders for removal at the specified time. The characteristics of the urine, such as time of capture, amount obtained, color and appearance Whether a specimen was obtained C. Infection Prevention Practices Consider having patients with indwelling catheters not share rooms (if possible) in order to decrease the likelihood of transmission between patients especially if one of the patients is infected or colonized with a highly resistant organism. While the CDC and the IDSA do not have a recommendation on this issue, catheterized patients, especially asymptomatic patients, frequently serve as reservoirs of infectious organisms. Cross transmission is likely to occur from the hands of healthcare professionals, and has been documented during outbreaks. 46,47 Consider spatial separation of catheterized patients, in conjunction with improved hand hygiene practices. 46,47 Strict adherence to aseptic technique during care and maintenance of the catheter site and collection system should keep the overall risk of CA-UTI below 25% for the first two weeks of catheterization. 125,126 Always observe basic infection control by using Standard Precautions, including performing proper hand hygiene before and after patient care, and donning the appropriate PPE during any manipulation of the catheter or collecting system. 19,70,112 Urine flow must not be obstructed, as bacteria moving backward from the outlet tube toward the catheter is a source of contamination. The tubing should continue in a straight line to the collection bag with no kinking or looping, and should always be above the level of the collection bag. 32 The collection bag itself should always remain below the level of the patient s bladder. Drainage tubes placed above the level of the bladder are a major risk factor for infection. 24,59 If there are other collection devices, place the urine collection bag on the opposite side of the bed. In semi-private rooms, drainage devices should be placed on opposite sides of the room

16 These Infection control principles also apply during patient transport in a stretcher or wheelchair: 78 Never place the collection bag on the stretcher. Instead, place it below the level of the patient s bladder Place the tubing above the level of the collection bag, and on the opposite side of the stretcher from other collection bags Never clamp the tubing during transport Empty the collection bag if possible prior to transport When collecting urine for either a specimen or volume measurement, use aseptic technique: 32,43,70,78 Perform hand hygiene before donning and after removing gloves Wear gloves as up to 15% of CA-UTIs occur in clusters from cross contamination 78 Manipulate the catheter and drainage system as little as possible, as the more often you access the port, the more likely the chance to introduce bacteria Obtain the urine sample from a newly inserted catheter whenever possible rather than an existing system Disinfect the sampling port with a disinfectant such as 70% alcohol and allow to air dry. Then aspirate the urine through the safety port with a sterile syringe Be sure to get the specimen to the lab as quickly as possible. Refrigerate the specimen if there will be a delay. If a patient is to receive antibiotics for symptomatic urinary infection and the existing catheter has been in place for over 7 days, it may be prudent to remove the existing catheter and place a new catheter before obtaining the specimen and before initiating the antimicrobial. 127 In long term care, this practice has been found to facilitate specimen collection by eliminating difficult to eradicate bacterial biofilm on the catheter, and speeding clinical improvement with reduced febrile days and decreased post treatment relapse. 32,92,127,128 Please note that the CDC recommendations do not support routine catheter changes. Instead, it is suggested to change catheters and drainage bags based on clinical indications, such as infection, obstruction, or when the closed system is compromised. 19 Each facility will need to consider the needs of their patient population to establish policy. For example, hospitals that routinely accept patients from long term care with chronic indwelling catheters may find that catheters are often encrusted, patients are admitted with organisms that may cause CA-UTIs, or there is a question as to how long the catheter has been in place. To avoid the risk of incurring infection, facilities may choose to replace existing catheters for these patients upon admission. Additionally, routinely changing the catheter before the culture is performed may not be necessary if infection is suspected but not yet confirmed. Always follow your facility s policy. Empty the collection bag regularly according to facility policy. Some recommendations suggest at least every 8 hours or with volumes greater than 400 ml s to avoid stasis and migration of bacteria. 78 In the acute setting, emptying the bag may occur more often to monitor fluid status and renal function. 129 When emptying the collection bag: 70,78,130,131 Do not allow the spigot or spout to touch the sides of the container. Be sure to completely empty the collection bag each time, using a separate urine graduate for each patient preferably single use. Wipe the drainage port with a disinfectant before closing it. When you are done, remove and dispose of your gloves and perform hand hygiene. Avoid irrigation unless medically indicated. Opening a closed system to irrigate can introduce bacteria. In addition, irrigation with antimicrobials to prevent or eradicate bacteria in not only ineffective, it can actually increase the percentage of CA-UTIs caused by organisms resistant to the drugs in the irrigating solution. 78,132,133 This is also why routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended. 19 Kimberly-Clark Health Care Education 17

17 Maintain adequate hydration with oral or intravenous fluids in order to continuously flush the system (30 ml/kg body weight/day). 20,78 Correct constipation and eliminate impaction, as these may cause pressure against the bladder and bladder neck, occlude catheter lumen and impair bladder emptying. 20 VIII. Complications of Catheter Use It s important to become familiar with the signs and symptoms of indwelling urinary catheter complications and learn how to respond to them. A. Infection Be sure to monitor the patient for signs of infection, and remember that a patient may develop a UTI even after the catheter has been removed. 6 In January 2009 NHSN modified the Catheter Associated Urinary Tract Infection (CAUTI) Protocol as well as the UTI definition. NHSN states the following: Catheter-associated urinary tract infections are defined using symptomatic urinary tract infections (SUTI) criteria. Report UTIs that are catheter-associated (patient had an indwelling urinary catheter at the time of or within 48 hours before the onset of the event). NOTE: There is no minimum period of time that the catheter must be in place for the UTI to be considered catheter-associated. These new definitions are effective January 1, a,6b The adult patient is considered to have Symptomatic UTI if they have: 6 Criterion #1a: Patient has an indwelling catheter in place at the time of or within 48 hours prior to specimen collection And At least one of the following signs or symptoms with no other recognized cause: Fever (>38 C), suprapubic tenderness, or costrovertebral angle pain or tenderness And A positive urine culture of 10 5 colony-forming units (CFU)/ml with no more than two species of microorganisms. Criterion #1b: Patient did not have an indwelling urinary catheter in place at the time of specimen collection nor within 48 hours prior to specimen collection And Has at least 1 of the following signs or symptoms with no other recognized cause: Urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness And A positive urine culture of 10 5 CFU/ml with no more than 2 species of microorganisms. 18

18 Criterion #2a: Patient has an indwelling catheter in place at the time of or within 48 hours prior to specimen collection And Has at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), suprapubic tenderness, or costovertebral angle pain or tenderness And A positive urinalysis demonstrated by at least 1 of the following findings: Positive dipstick for leukocyte esterase and/or nitrite Pyuria (urine specimen with 10wbc/mm 3 or 3wbc/high power field of unspun urine) Microorganisms seen on Gram stain of unspun urine And A positive urine culture of 10 3 and 10 5 CFU/ml with no more than 2 species of microorganisms. OR Patient had indwelling catheter removed within the 48 hours prior to specimen collection And Has at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness And A positive urinalysis demonstrated by at least 1 of the following findings: a. positive dipstick for leukocyte esterase and/or nitrite b. pyuria (urine specimen with 10 white blood cells [WBC]/mm3 or 3 WBC/high power field of unspun urine) c. microorganisms seen on Gram stain of unspun urine And A positive urine culture of 10 3 and >10 5 CFU/ml with no more than 2 species of microorganisms. Criterion #2b: Patient did not have an indwelling urinary catheter in place at the time of specimen collection nor within 48 hours prior to specimen collection And Has at least 1 of the following signs or symptoms with no other recognized cause: frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness And A positive urinalysis demonstrated by at least 1 of the following findings: Positive dipstick for leukocyte esterase and/or nitrite Pyuria (urine specimen with 10wbc/mm3 or 3wbc/high power field of unspun urine) Microorganisms seen on Gram stain of unspun urine And A positive urine culture of 103 and 105 CFU/ml with no more than 2 species of microorganisms. Symptoms alone are not always reliable in the diagnosis of symptomatic UTI. A large prospective study found that the catheter itself can be the source of symptoms. 134 In addition, while pyuria (presence of pus in urine) is commonly used to help diagnose urinary tract infections in non-catheterized patients, it should not be used alone as a criteria for obtaining a urine culture in catheterized patients. 24 This is especially true in the case of infections caused by gram-positive cocci and yeasts. 37 Kimberly-Clark Health Care Education 19

19 Please note that while a clean-voided specimen showing >10 5 CFU/ml is the criterion for true infection, it has been shown that once any microorganisms are identified in urine from an indwelling catheter, progress to concentrations >10 5 occurs rapidly and predictably. This is why concentrations of >10 2 or 10 3 CFU ml in urine collected with a needle from a sampling port may represent true CA-UTI. 125,135,136 A bacterial count of 10 3 CFU ml can also be significant if obtained in the presence of an antibiotic. 137 Patients with symptomatic infection will require immediate antibiotic therapy. 32 Asymptomatic Bacterimic Urinary Tract Infection (ABUTI) is defined as: 6 Patient with or without an indwelling urinary catheter has no signs or symptoms (i.e. no fever (>38 C), for patients 65 years of age*; and for any age patient no urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness, OR for a patient 1 year of age, no fever (>38 C core), hypothermia (>38 C core), apnea, bradycardia, dysuria, lethargy, or vomiting. And A positive urine culture of 10 5 CFU/ml with no more than 2 species of microorganisms** And A positive blood culture with at least 1 matching uropathogen microorganism to the urine culture. * Fever is not diagnostic for UTI in the elderly (>65 years of age) and therefore fever in this age ggroup does not disqualify from meeting the criteria of an ABUTI. ** Uropathogen microorganisms are : Gram-negative bacilli, Staphylococcus spp., yeasts, beta-hemolytic Streptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae, and Corynebacterium (urease positive). It is important to note that there are no benefits to antibiotic treatment of ABUTI. Bacteriuria does not by itself cause an increase in mortality, but appears to be a marker for poor health, especially in the elderly. 138 Thus, there is no clear clinical benefit to antimicrobial therapy for asymptomatic bacteriuria The exception is treatment of asymptomatic bacteruria immediately before an invasive urologic procedure. 19A B. Leakage or By-Passing Leakage or by-passing is the main cause of unnecessary catheter changes and affects as many as 65% of patients. 142 This can be caused by bladder spasms, infection, fecal impaction or constipation, luminal occlusion, catheter encrustation, loss of elasticity of the urethra in females, or traction on the bladder neck by an unstabilized catheter. 20,142 First, identify the cause of the leakage; then, plan interventions accordingly. Check the catheter for patency. 20 If the catheter is obstructed with clots or mucous, perform intermittent irrigation using saline and aseptic technique. If the obstruction can only be kept open with frequent irrigation, remove and replace the catheter. Do not replace the catheter with a larger sized catheter or balloon, as this will further irritate the bladder and urethra. 20 Assess the patient for signs and symptoms UTI. Consult a physician to obtain a urine culture if the urine appears to be infected. Remember to remove and replace the existing catheter with a new catheter prior to obtaining the culture

20 Assure the balloon is the proper size and correctly inflated. 20 Stabilize the catheter. 20 Check for fecal impaction and remove if present. Help the patient maintain regular elimination with a bowel program. 20 Consult a physician to treat severe bladder spasms. 20 C. Blockage A lack of urinary flow may be due to blockage from mucous, protein, crystals, blood clots or biofilm, and the risk of blockage increases with the duration of catheterization. Irrigation with saline is not effective in removing occlusions due to encrustation 143 and antiseptic solutions are not effective at eradicating biofilms. 144 Therefore, if the patient has a history of blockage, catheter changes will be needed. However, be aware that there are no recommended standard intervals for changing catheters. Catheter change schedules should be based on the individual needs of the patient rather than replaced at standard intervals. 19,145 If the catheter is changed, do not replace the catheter with a larger size catheter or balloon, as this will further irritate the bladder and urethra. 20 D. Lack of Urine Flow A lack of urinary flow may also indicate encrustation and is due to alkaline conditions in urine that increase the likelihood of minerals crystallizing on the interior lumen of the catheter. Because of its material composition, the use of silicone rather than latex catheters may delay the onset of encrustation. 90 E. Other Complications Inadvertent dislodgment, also known as unintentional catheter removal, may occur with the balloon inflated. This is often due to acute delirium or chronic dementia, when the patient may not be aware or remember the rationale for the use of the catheter and the consequences for its removal. Remember that CA-UTIs are the second most common cause of healthcare-associated bloodstream infection and clinicians should remain vigilant for symptoms. The longterm indwelling catheter may cause additional complications such as urethral damage, urethritis or inflammation of the urethral meatus, urethral stricture and urethral erosion or tearing, 33 cystitis, pyelonephritis, infection, prostatitis, epididymitis, orchitis in males; and less commonly, endocarditis, septic arthritis, endophthalmitis, and meningitis; 5,6 Always consult a physician to discuss complications and treatment options. Kimberly-Clark Health Care Education 21