Presented by: Phenelle Segal, RN CIC President, Infection Control Consulting Services, LLC

Transcription

1 Catheter-associated Urinary Tract Infection (CAUTI) in Long-Term Care Settings Presented by: Phenelle Segal, RN CIC President, Infection Control Consulting Services, LLC Presenter has no financial disclosures Outline Act 52 of 2007 Reporting Requirements for Nursing Homes Definitions/Criteria for reporting CAUTI Case Studies Clinical Scenarios Summary of CAUTI Prevention Strategies

2 PA- Act 52 of 2007 Nursing Home Reporting Requirements Report to Authority and Department of Health (DOH) through a single interface: PA Patient Safety reporting System (PA- PSRS) Eliminated need for duplicate reporting Detailed requirements published in PA Bulletin September PA- Act 52 of 2007 Reporting Requirements Criteria based on nationally recognized standards in consultation with the HAI Advisory panel Developed using McGeer Criteria together with CDC definitions, adapted to the longterm care setting Does not replace mandatory notification to PA-DOH of reportable diseases PA- Act 52 of 2007 Reporting Requirements List of Reportable Infections 1. Symptomatic Urinary Tract Infection 1.1 Indwelling urinary catheter related 1.2 Non-urinary catheter related 2. Respiratory Tract Infection 2.1 Lower Respiratory Tract Infection (Pneumonia/Bronchitis/tracheobronchitis) 2.2 Influenza-like illness

3 PA- Act 52 of 2007 Reporting Requirements List of Reportable Infections 1. Symptomatic Urinary Tract Infection 1.1 Indwelling urinary catheter related 1.2 Non-urinary catheter related 2. Respiratory Tract Infection 2.1 Lower Respiratory Tract Infection (Pneumonia/Bronchitis/tracheobronchitis) 2.2 Influenza-like illness PA- Act 52 of 2007 Reporting Requirements List of Reportable Infections 4. Gastrointestinal Tract Infection 5. Other infections 5.1 Intra-abdominal infection (peritonitis/deep abscess) 5.2. Meningitis 5.3. Viral Hepatitis 5.4. Osteomyelitis 5.5. Primary Bloodstream Infection Definition of Healthcare-associated Infection (HAI) An HAI is a localized or systemic condition that was not present or incubating upon admission to a facility Each infection should be considered individually when assessing the incubation period If an infection resulting from an invasive device (such as a central or peripheral line or indwelling urinary catheter) occurs within 48 hours of transfer from a hospital to the nursing home, the HAI should be reported to the hospital and NOT reported as a nursing home related HAI

4 Definition of Healthcare-associated Infection (HAI) In the event that a resident is transferred from a hospital and an in-dwelling device is inserted in the nursing home upon admission (such as a peripheral IV or indwelling urinary catheter) and an infection occurs within 48 hours after insertion, in the absence of signs and symptoms and/or documentation of an infection upon transfer from the hospital, the infection should be reported as a nursing home HAI Confirmation of Infection Defined as: Surveillance completed and HAI confirmed according to the standardized criteria utilized by a staff member responsible for infection control Confirmation is NOT defined as the onset of signs and symptoms or suspicion of an infection Confirmation of Infection For purposes of meeting the 24-hour reporting requirement for Serious Events set forth by Act 13, nursing homes must submit reports of HAIs within 24 hours of their confirmation. If confirmation of an HAI occurs over a weekend or State government holiday, reports must be submitted by 5 p.m. on the next workday

5 Key points in defining Infections in the Elderly All signs and symptoms of an infection must be acute, new or rapidly worsening. Non-infectious causes should always be considered before defining an infection. A change in mental or functional status is often indicative of a developing infection. Antimicrobial treatment alone is not indicative of an HAI. Key points in defining Infections in the Elderly Physician Diagnosis Physician diagnosis plays a significant role in defining certain infections particularly where laboratory and radiology resources would be preferable but are limited Fever In the elderly population, a fever is defined as an oral or equivalent temperature* of F (38 C) or an increase of 2 F (1.1 C) over baseline Note: Tympanic thermometers are widely used in long-term care and manufacturer s recommendations together with baseline temperatures are utilized to determine a fever. If baseline temperatures are not obtained or available, refer to manufacturer s recommendations Criteria: Symptomatic Urinary Tract Infection Resident with Urinary Catheter: TWO or more of the following with no other recognized cause: > Fever and/or chills with no other source > Flank or suprapubic pain or tenderness (self described or identified upon examination) > Gross hematuria or change in character of urine > Change in mental and/or functional status from daily baseline

6 Criteria: Symptomatic Urinary Tract Infection Resident with Urinary Catheter Contd: Note: a. If a urinalysis is obtained, one or more of the following must be positive IN the presence of defined signs and symptoms. > Positive leukocyte esterase and/or nitrate > Pyuria (>= 10 white blood cells) b. If a urine culture is obtained, >= 100,000 microorganisms per cc of urine with no more than 2 species of microorganisms must be present together WITH defined signs and symptoms. c. According to CDC/NHSN a CAUTI is reported in patients who had an indwelling urinary catheter at the time of or within 48 hours before onset of the event. Case Studies/Scenarios A 69 year old male catheterized between March 20 April 13, developed a fever, acute mental status change and malodorous cloudy urine on April 16. A urinalysis was done and revealed the following: 10 white blood cells [WBC]/mm3 of unspun urine Positive dipstick for leukocyte esterase A culture was done and revealed the following >100,000 colonies of E. coli Would this reportable infection be entered as a CAUTI? Yes No Case Studies/Scenarios An 85 year old man with a chronic in-dwelling urinary catheter (>60 days) presents with a fever of 102 F and acute mental status changes. The physician suspects a UTI and orders the catheter removed and a new one inserted. The catheter tip is sent for culture and reveals a positive growth of Citrobacter Freundii. In addition, a urine culture reveals the following: > 3 species of microorganisms Would this event be entered as a CAUTI? Yes No

7 Case Studies/Scenarios A 74 year old female returned on July 13 from an acute care admission status post ventral hernia repair. While in the hospital she had an indwelling catheter between July 10 July 13. Upon readmission to the NH she had orders to be intermittently catheterized for acute urinary retention and this was discontinued on July 15. On July 17, she presented with dysuria, suprapubic tenderness and gross hematuria. A specimen was sent and it revealed the presence of an infection. Would the Infection Prevention Designee report this as a nursing home related HAI? Yes No If yes, would this be considered a CAUTI? Yes No CMS F-Tag 315 Urinary Incontinence addresses the following areas: Management of incontinence Catheterization Prevention of Urinary Tract Infections CMS F-Tag 441 The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection CAUTI Risk Assessment Consider conducting a baseline CAUTI risk assessment Steps to conducting assessment: Assess whether an effective organizational program exists Assess population at risk Assess baseline outcome data Determine financial impact of CAUTI Use all of the above information to complete the CAUTI portion of the overall organizational risk assessment

8 Management of Urinary Incontinence Assessment of bladder function and incontinence status (bladder scanner) Restoration of normal bladder function - important to prevent UTIs and decrease the risk of skin breakdown Treatment includes behavioral therapy, medications, medical devices, and surgery (last resort, uncommon practice) Intermittent catheterization depending on type of incontinence? Use of condom catheters for men and absorbent pads and products for men and women In-dwelling catheterization as a last resort and only if medically indicated with the goal of discontinuing the catheter as soon as medically possible Indwelling Catheter Use As per F-Tag 315 medical justification for catheter use is indicated and clinical condition must demonstrate a necessity Assessment of a resident admitted to the nursing home with an indwelling catheter for continued use of the device Certain medical conditions do justify the use of an indwelling catheter Indwelling Catheter Use Indicated for: Urinary Tract Obstruction Neurogenic bladder with retention Stage 3-4 Sacral decubiti with incontinence Hospice, Comfort or Palliative Care (if requested) Indwelling Catheter Not Indicated For: Resident or family request Immobility Specimen Collection Overall convenience Measuring output in a resident

9 Catheter related best Practices Daily assessment of catheter necessity Removal of catheter as soon as possible if not medically indicated Consider early removal of the catheter using a reminder or nurse-driven removal protocol i.e., automatic stop orders Prevent tension on the catheter by keeping it anchored at all times Monitor for obstruction of urine flow through the catheter. Secure the catheter to facilitate the flow of urine. Perform perineal care twice daily and after each bowel movement Catheter related best Practices Insert catheters using aseptic technique paying special attention to appropriate hand hygiene and wearing of gloves Maintain a sterile, closed drainage system Use aseptic technique when obtaining specimens from the port ONLY. Clean port with disinfectant Provide each resident with a urine emptying container and avoid touching the spigot against the sides DO NOT: Routinely replace catheters particularly if a doctor has not ordered it. Routinely change tubing or drainage bags Irrigate catheters unless a doctor has ordered if for catheter obstruction Disconnect the catheter from the drainage tubing

10 References PENNSYLVANIA BULLETIN. Volume 38 Saturday, September 20, Reporting Requirements for Nursing Homes under Chapter 4 of the Medical Care Availability and Reduction of Error (MCARE) Act. Barriers to Urinary Catheter Insertion and Management Practices Pa Patient Saf Advis 2009 Sep;6(3): Sep6(3)/Pages/98.aspx References CAUTI Prevention in Nursing Home/Long-Term Care Residents. PA Patient Safety Authority Educational tools. Published 10/1/ Pages/nhwebinar.aspx Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs). APIC Elimination Guidelines: nationguides/cauti_guide_0609.pdf The Newly Revised F-Tag 315 and Surveyor Guidance for Urinary Incontinence in Long-Term Care. Theodore M. Johnson, II, MD, MPH, CMD, and Joseph G. Ouslander, MD, CMD.JAMDA November pdf QUESTIONS??

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