Preventing Catheter-Associated Urinary Tract Infections
8 February 2016 Last updated:
26 February 2016
Preventing Catheter-Associated Urinary Tract Infections
This project developed nurse-led protocols for the insertion, removal and management of indwelling urinary catheters (IUCs) at John Hunter Hospital.
This project was the recipient of the Infection Prevention and Harry Collins Award categories in the 2015 NSW Health Awards.
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To reduce the use of IUCs and the rate of catheter-associated urinary tract infections (CAUTIs).
- Reduces the use of IUCs and the risk of CAUTI among hospital inpatients.
- Reduces the average number of days where the IUC is in situ, a key risk factor for CAUTI.
- Empowers nurses by providing them with knowledge and tools to better manage IUC usage.
- Educates patients on consent, best practice management and risks of IUCs.
- Standardises clinical practices and supports informed decision making.
- Enhances collaboration across services, specialties and professions.
- Improves quality of patient care, outcomes and experience.
In Australia, over 25% of patients have an IUC during hospital admission. Patients who have an IUC in place are five times more likely to acquire a urinary tract infection (UTI) than patients without an IUC. Urinary tract infection, the most common nosocomial infection worldwide, comprises 40% of all healthcare-associated infections and CAUTI represents 80% of this group. A recent study which included HNELHD data indicated that 1.7% of inpatients hospitalised for more than 48 hours contract a UTI, adding additional days (mean=4) to their length of stay. Research also suggests that up to 50% of IUCs are unnecessary and that the duration of catheterisation is a key risk factor for CAUTI.
From April 2014 to March 2015, there were 217,228 hospital admissions across HNELHD and potentially 53,057 patients (25%) who may have received an IUC. It was determined that reducing this number by 50% could prevent up to 26,000 patients from having an IUC inserted. This would result in a saving of $442,000 in equipment and prevent 4085 (7.7%) cases of CAUTI.
A ‘care bundle’ is defined as a collection of a small number of evidence-based practices or steps which are vital to achieving improvement in clinical outcomes. Although the concept of bundled interventions in healthcare infection prevention is not new, studies that aimed to reduce CAUTIs have had limited success. Following a literature review, it was decided that a nurse-led approach to IUC management was an obvious path, as nurses influence bedside decisions if provided with appropriate information and tools. At the time, no standardised protocols existed for IUC management in HNELHD.
- Data was collected on catheter usage and CAUTI rates in two pilot wards at John Hunter Hospital.
- Nurse-led protocols were developed through extensive consultations with stakeholders across HNELHD and implemented in the pilot wards.
- Patient and staff educational resources were developed and implemented by nurse educators, including staff surveys and catheter competency assessments.
- Evidence-based care bundles called ‘No CAUTI’ were developed to equip clinicians with the tools to make better decisions about catheter insertion and removal. These included badges, educational DVDs, posters, flowcharts and audit tools to increase awareness of CAUTI risks and help staff make informed decisions.
- Generic catheterisation packs were distributed across obstetrics, occupational therapy, emergency and other departments. Each pack contained all equipment needed to implement the nurse-led protocols, including documentation stickers and securing devices.
- An alert on urine microbiology reports was added to the electronic pathology reporting system to help identify and treat CAUTI.
- Regular audits were undertaken during the pilot project and post-implementation, with continued surveillance of CAUTI rates and bundle compliance.
- The project team provided consultation on the development of statewide guidelines to reduce CAUTIs in NSW.
- Sustained - the initiative has been implemented and is sustained in standard business.
- Project start: May 2014.
- Project finish: July 2015.
- Maitland Hospital
- Belmont Hospital
- John Hunter Hospital
This project was initially funded through a HNELHD Innovation Support Scholarship. The project team were supported internally by the New England Nursing and Midwifery Research Centre and two of the project team completed the Healthcare Redesign Diploma program through the ACI. An interprofessional consultative approach across departments and sectors contributed to successful outcomes.
- Evaluation occurred six months post-implementation.
- IUC usage rates in ward A reduced from 31% (n=121) of all admissions to 14.6% (n=42) (p<0.001). There were no reductions in ward B.
- The length of time the catheter was left in situ was reduced from a mean of 4.6 days to 3.9 days in ward A (not significant) and from 4.9 days to 2.9 days in ward B (p=0.038).
- Days in situ were influenced by operating theatre delays in ward A, however most catheters were removed within 24-48 post surgery.
- There was a significant reduction in number of patients being treated for CAUTI in both wards, from 8.4% to 0.7% (p<0.001).
- Staff awareness of CAUTI prevention increased as a result of the project, with standardised guidelines, decision tools, generic catheterisation packs, educational resources and audit tools available for all staff.
- Data collection methods and alert systems have resulted in a more timely diagnosis and treatment of CAUTI and clinicians are no longer treating asymptomatic bacteriuria unnecessarily.
- Reduced antibiotic use (not measured) as a result of this project may reduce potential side-effects in patients and improve outcomes.
- 2015 NSW Health Award, Harry Collins Award - Recipient
- 2015 NSW Health Award, Infection Prevention - Recipient
- 2015 HNELHD Quality Awards, Infection Prevention - Winner
- 2015 Australian Council on Healthcare Standards Quality Improvement Awards, Clinical Excellence and Patient Safety - Winner
- Prevention is essential to keep people healthy.
- This project’s outcomes reinforce the importance of integrated and collaborative approaches in developing and implementing high-quality, evidence-based strategies.
- The project team formed partnerships across all levels of HNELHD, from clinicians and nursing unit managers in wards, to senior clinicians in specialties such as emergency care, urology, orthopaedics, obstetrics and community health. The partnership included educators who will now be ready to assist with implementation in other facilities. These partnerships have provided a platform to share information and knowledge, achieve goals in reducing CAUTI rates and add value to organisational outcomes in the form of patient and resource efficiency and improved staff knowledge.
- Association for Professionals in Infection Control and Epidemiology (APIC). Guide to the elimination of catheter-associated urinary tract infections (CAUTIs): developing and applying facility-based prevention interventions in acute and long-term care settings. Washington; 2008.
- Gould CV, Umscheid CA, Agarwal RK et al. Healthcare Infection Control Practices Advisory Committee: Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control & Hospital Epidemiology 2010; 31(4): 319-26. doi:10.1086/651091.
- Institute of Healthcare Improvement. Bundle up for safety. Cambridge; 2011 [cited June 2015].
- Mitchell B, Ferguson J, Anderson M et al. Length of stay and mortality associated with healthcare-associated urinary tract infections: a multistate model. Under review.
- Oman KS, Makic MBF, Fink R et al. Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal of Infection Control 2012; 40(6): 548-53. doi:10.1016/j.ajic.2011.07.018.
- Saint S, Kowalski C, Kaufman S et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clinical Infection Disorders 2008; 46: 243-50.
- Saint S, Olmsted RN, Fakih MG et al. Translating healthcare-associated urinary tract infection prevention research into practice via the bladder bundle. The Joint Commission Journal on Quality and Patient Safety 2009; 35(9): 449-55.
Urology Clinical Nurse Consultant
Hunter New England Local Health District
Phone: 02 4922 3957
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