Urinary tract infection (UTI) due to catheter usage is a common nosocomial infection that results to discomfort to the patient, activity restriction, and delay in hospital discharges. Added to these, it is an added medical expense to the patient’s own pocket because Medicare and other Medicaid Services have decided to stop reimbursing hospitals for the additional expense of caring for inpatients with catheter-associated urinary tract infection(CAUTI) (Sanjay et al, 2009).
Thus, I am proposing Michigan Health and Hospital Association (MHA) Keystone Center’s “ABCDE” approach on preventing CAUTI(Sanjay, et al, 2009):
A- adherence to strategies that help prevent infections such as proper education, hand washing and use of aseptic techniques
bladder ultrasound could be done first to ensure an indwelling catheter is really needed
condomand indwelling catheters (i.e. Foley catheters) should only be used if found suitable to the patient’s case
do not put Foley catheter unless it is really indicated
early removal of the catheter must have a protocol to remind the health staff involved.
Methods of Data Gathering and Evaluation
Methods will be computation of prevalence rate of CAUTI’s before and after implementation of the “ABCDE” approach. If no prevalence data exists before, at least 3 months of prevalence statistics should be obtained before implementation of the “ABCDE” approach in order to evaluate the effectiveness of the strategy. The number of hospitalization days will also be computed before and after the change. Survey of nurses’ method of care and attitudewith regard to CAUTI prevention will also be done before and after the change to see if their skills in preventing CAUTI have improved.
Subjects
Subjects will be composed of inpatientswho have Foley catheter for more than 24 hours. Patients who have an allergy to silver, nitrofurazone, or silicon will be excluded. Pregnant patients will also be excluded since UTI is one of the most common infections during pregnancy and thus including them in the study may show a false positive increase in the prevalence of CAUTI (Masinde, et al, 2009).
CAUTI Defined
For this study, we will consider nosocomial CAUTI as having a count of greater than 103 colony forming unit/mL (CFU/mL) of funguria or bacteriuria (Tambyah& Maki, 2000). Bacterial quantitative culture is still considered as the gold standard in diagnosing UTI (Manoni et al, 2009).
Data Gathering
The purpose for catheterization will be noted for every patient included in the study. This is in compliance of the “D” in the “ABCDE” approach—ensuring that Foley catheter is really indicated for the patient’s case. For each patient included in the study, the nurse must aspirate approximately about three milliliters of urine from the catheter’s sampling port every day. Note that the sampling port should first be disinfected (i.e. 10% povidone iodine) before aspiration is obtain via a sterile syringe. The specimen must immediately be brought to the laboratory and cultured. All of theseprecautions aredone in order toreduce false positive result of bacterial infection from other sources aside from CAUTI.
Aside from aspirating urine samples, the nurses involved in the study must question the patients daily if the latter have any discomfort, pelvic or urethral pain, dysuria, sense of urgency or other symptoms that can occur with catheter usage. Nurses should also review their patients’ records to see if fever and other clinical data pointing to infection exist.
Nurses’ Survey to Evaluate Method of Care
A survey to assess nurses’ method of care and attitude with regards to CAUTI prevention will be implemented before and after the program. This is to evaluate if there’s an improvement in nursing intervention with regards to CAUTI prevention. The survey will focus on CAUTI prevention practices such as hand washing, wearing of gloves, inserting the catheter without touching it, and keeping a sterile barrier. Other components of the “ABCDE” approach would also be asked such as using of bladder ultrasound to ensure the necessity of indwelling catheters and early removal of catheter once it is not needed. (See Appendix A for a survey sample).
The average number of hospital day will also be computed and compared pre and post the “ABCDE” approach to see if this CAUTI prevention practice can reduce hospitalization days.
Variables
Variables will be prevalence of CAUTI, average number of hospital days, and nurses’ method of care and attitude.
Tools and Actions to Educate Nursing Staff
The first step to implement the “ABCDE” approach is for the management to enlist one nurse who will serve as the leader in creating and organizing the CAUTI prevention team. This team will be composed of head nurses from different departments. The CAUTI prevention team must attend workshops from other hospitals that implement the “ABCDE” approach. Once the team has learned everything they can about preventing CAUTI interventions, they can now start teaching it to their own department.
Teaching methods would include a lecture with a power point presentation to refresh nurses’ theoretical knowledge about infections such as UTI, catheter usage and indication, and aseptic techniques. Application of knowledge with regards to catheter usage, insertion, and removal will also be supervised and evaluated by the head nurse. Data gathering methods, such as urine aspiration and daily patient rounds to question patients if they have UTI symptoms, will also be checked by the head nurse.
Each head nurse should ensure that their nursing staff knows what they are doing. If a nurse doesn’t know how to properly insert a catheter, the head nurse must teach the former. Teaching is not enough. The head nurse must also evaluate if his/her staff has the proper knowledge and skills to implement the “ABCDE” approach. The survey at the end of the implementation approach will also evaluate if there’s an improvement in the methods of care of the nursing staff.
The management should document all relevant data. If the “ABCDE” approach is found to be successful in the hospital, then the management can spread the news of this CAUTI prevention approach to its neighboring hospitals.
Appendix A
Source: Sanjay, S. et al. (2008). Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study. Clin Infect Dis. 46 (2): 243-250. doi:10.1086/524662
References
Masinde, A. et al. (2009). Prevalence of urinary tract infection among pregnant women at
Bugando Medical Centre, Mwanza, Tanzania. Tanzania Journal of Health Research.
11(3). Retrieved from: http://www.ajol.info/index.php/thrb/article/view/47704
Manoni, F. et al (2009).Cutoff values for bacteria and leukocytes for urine flow cytometer
Sysmex UF-1000i in urinary tract infections. Diagnostic Microbiology and Infectious Disease. 65(2): 103-107. doi:10.1016/j.diagmicrobio.2009.06.003
Meddlings, J. et al. (2012). Reducing unnecessary urinary catheter use and other strategies to
prevent catheter-associated urinary tract infection: An integrative review. BMJ Quality &
Safety.doi:10.1136/bmjqs-2012-001774
Sanjay, S. et al. (2008). Preventing hospital-acquired urinary tract infection in the United
States: A national study. Clin Infect Dis. 46 (2): 243-250. doi:10.1086/524662
Sanjay, S. et al. (2009). Translating health care–associated urinary tract infection prevention
research into practice via the bladder bundle. JtComm J Qual Patient Saf. 35(9): 449– 455. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791398/
Sanjay, S. et al. (2013). Preventing catheter-associated urinary tract infection in the
United States: A national comparative study. JMA Internal Medicine.173(10), 874-
879. doi:10.1001/jamainternmed.2013.101
Tambyah, P. & Maki, D. (2000). Catheter-associated urinary tract infection is rarely
symptomatic: A prospective study of 1497 catheterized patients. Arch Intern Med.
160(5):678-682. doi:10.1001/archinte.160.5.678.
