How national and local initiatives, as well as established best practice, can help nurses to reduce catheter- associated urinary tract infections in hospitalised patients
In this article…
- Indications for urinary catheterisation
- How to reduce risks of catheter associated urinary tract infections
- Details of Energise for Excellence and Safety Express
Susan Foxley is consultant nurse, continence care, Kings College Hospital NHS Foundation Trust, London.
Foxley S (2011) Driving down CAUTI rates. Nursing Times; 107, 29, early online publication.
Caring for patients who have an indwelling urinary catheter is a common feature of nursing practice, which for some patients is essential to their medical management. But evidence suggests in many cases catheterisation may be unjustified, exposing patients to a significant risk of acquiring a urinary tract infection, extending their length of stay and imposing an extra burden of care and cost to the healthcare provider. Improving nursing care for these patients depends on good education, robust research and audit pathways, evidenced best-practice, adequate resources, and effective devices and treatment. This article discusses national and local initiatives which have been developed to enable health professionals to drive down catheter associated urinary tract infections (CAUTI) rates.
Keywords: Indwelling urinary catheter, Catheter associated urinary tract infections (CAUTI), Closed drainage system
- This article has been double-blind peer reviewed
5 key points
- Catheter associated urinary tract infections (CAUTI account for 80% of hospital acquired infections
- For patients with an indwelling urinary catheter it is important to maintain a closed drainage system to reduce the risk of infection
- Nurses can reduce risks by washing their hands and wearing gloves and aprons before and after contact with a urinary catheter and drainage system
- Energise for Excellence is a quality framework for nurses, midwives and health visitors that aims to support the delivery of safe and effective care, concentrating on areas such as CAUTI
- The Safety Express programme aims to achieve reductions in four avoidable harms, including CAUTI
There is a longstanding and ongoing debate within the nursing profession about best practice in managing urinary catheters (Dougherty and Lister, 2004; Getliffe and Dolman, 2003).
This debate is fuelled by the fact urinary catheterisation is associated with a high incidence of catheter associated urinary tract infections (CAUTIs), which account for 80% of hospital acquired infections (Pellowe 2009).
CAUTIs are often seen as the acceptable side effect of urinary catheterisation carried out for a variety of reasons including: drainage, investigations, instillation of drugs and intractable incontinence (Foxley and Addison, 2008). Yet urinary catheter use is associated with a range of adverse outcomes, including death (Pellowe 2009).
The need to define a CAUTI is also a cause for debate within individual healthcare organisations, with each determining their own guidelines for catheterisation in collaboration with national guidance (RCN, 2008; DH, 2007). Defining the meaning of the words CAUTI at local levels will ensure collaboration of infection control teams when undertaking research and audit into the actual extent of the problem .
For patients with an indwelling urinary catheter it is important to maintain a closed drainage system by connecting the urinary catheter to the drainage bag and maintaining this as a sterile, continuously closed system. This method is regarded by health professionals as the “corner stone” of infection prevention and control in all care settings. Pellowe (2009)advised the connection between the catheter and the drainage system should not be broken unless absolutely necessary as this reduces the risk of urinary tract infection
A substantial amount of evidence suggests health professionals can reduce infection risks by washing their hands and wearing gloves and aprons before and after contact with a urinary catheter and drainage system - an approach endorsed by Turner and Dickens (2011). This is supported by Pratt et al (2007) who produced national evidence-based guidelines for the prevention of healthcare associated infections (Table 1).
Energise for Excellence (E4E)
E4E is a quality framework for nurses, midwives and health visitors that aims to support the delivery of safe and effective care, while creating positive patient and staff experiences that encourage momentum and sustainability (Fig. 1).
Over the next few years, the E4E project will concentrate initially on falls, pressure damage and CAUTI. These are closely tied into the Commissioning for Quality and Innovation (CQUIN) targets for local trusts. These targets need to be realistic, achievable and sustainable.
The chief nursing officer’s high impact action on urinary catheters requires trusts to “demonstrate a dramatic reduction in the rate of UTIs for patients in NHS-provided care” (NHS Institute for Innovation and Improvement, 2009). The best way to avoid infection is to not catheterise.
At King’s a specially adapted electronic database enables all nurses to enter data about patients they are looking after who have a urinary catheter. Data collection fields include the patient’s age, date of catheter insertion, whether fever is present, whether the patient is taking antibiotics and the date of catheter removal. Predetermined exclusion criteria eliminates patients with a suprapubic catheter, those undertaking self-catheterisation and children under one year of age.
At the end of each month, all data is analysed and forwarded to the strategic health authority. Data measured is broken down into two categories: those who have a urinary catheter in situ for 28 days and under and those with a urinary catheter in situ for 29 days or more. Further analysis groups the patients by three age ranges – 0-16 years, 17-69 years and over 70.
The in-house electronic database system allows each ward to print graphs to monitor their progress on a monthly basis. Monthly dashboard graphs linking performance can be produced for all wards and these results can be publicly displayed to share successes and offer complete transparency about performance details to staff and patients.
The Safety Express campaign is an additional programme being carried out in acute care, and run with strategic health authorities (Patient Safety First, 2011).
This national improvement programme will be delivered by the Quality, Innovation, Productivity and Prevention safe care team. Its aim is to reduce the incidence of four avoidable harms: pressure ulcers; serious harm from falls; CAUTI; and venous thromboembolism. It is different from E4E in that it concentrates initially on four pilot wards, and measures the four harms in relation to specific patients, rather than occurrences on the wards. It also looks to bridge the gap between organisations and involves a “host” organisation in acute care and a partnership organisation – usually a community provider. The programme focuses on preventing avoidable harm to patients throughout their inpatient hospital journey and discharge into the community, as well as vice versa.
Data is collected on the same date every month by one named person and measured against the trust’s “safety thermometer” to provide a snapshot of inpatient harms. An additional feature is the ability to collate all the urinary catheter data to give a snapshot of the trust’s CAUTI rate.
There is a wealth of supporting strategies designed to ensure compliance with best evidence-based practice and monitor progress that each NHS trust needs to make. These include a safety culture and reliable clinical care, with an appropriate supporting infrastructure. Educational and training opportunities have a high priority and are indispensable, as are active risk management and appropriate equipment to deliver safe care.
Tried and locally tested suggestions to reach E4E and Safety Express targets in relation to urinary catheter insertion and CAUTI rates are outlined in Table 2.
Table 2. Tried and locally tested suggestions to reach E4E and Safety Express targets for urinary catheter insertions and CAUTI rates
- Strong leadership and dynamic implementation group
- Trust-wide CAUTI definition, in line with national guidelines
- Robust urinary catheterisation policy
- Standardisation of urinary catheter-related equipment
- Robust audit trails: Saving Lives, Essence of Care Continence Benchmark, E4E, and Safety Express in conjunction with constructive pathways for the provision of feedback
- Collaborative work with infection control teams to determine trust-wide CAUTI rate twice yearly
- Urinary catheter care plan for inclusion in the nursing notes
- Patient urinary catheter usage checklist – to be used on discharge
- Full continence assessment for all patients presenting with bladder dysfunction
- Education programme at ward level – adapted to each ward’s needs
- Continence nurse of the year award
- Additional continence work around bladder and bowel care for all ages
- Web page that contains relevant catheter-related tools
- RCN (2008) and Skills for Health catheter care competency guidelines
- Productive regular meetings with all parties concerned in achieving organisation targets
Reducing the number of urinary catheters used across a trust depends on many factors, including bed days, type of organisation and the time of year.
Strict protocols are required for urinary catheter insertion, monitoring and early removal if appropriate. More importantly, this programme of care is a whole-team approach involving acute and primary care and, more importantly, the patients themselves.
Department of Health (2007) Saving Lives – High Impact Intervention No 6, Urinary Catheter Care Bundle. London: Department of Health.
Dougherty L, Lister S (2004) The Royal Marsden Manual of Clinical Nursing Procedures. London: Blackwell Publishing.
Foxley S, Addison R (2008) Your role in urinary catheter management. British Journal of Healthcare Assistants; 2: 2, 6-9.
Getliffe K, Dolman M (2003) Promoting Continence: a Clinical and Research Resource. London: Baillière Tindall.
NHS Institute for Innovation and Improvement (2009) High Impact Actions for Nursing and Midwifery. Coventry: NHSIII.
Patient Safety First (2011) “Safety Express” Guide to Programme Delivery. London: Patient Safety First.
Pellowe C (2009) EPIC 2 infection prevention guidelines – best practice. Continence UK; 3: 3, 28–33.
Pratt RJ et al (2007) National evidence-based guidelines for preventing healthcare associated infections in NHS hospitals in England (EPIC 2). Journal of Hospital Infection; 65S: S1–S64.
Royal College of Nursing (2008) Catheter Care. London: RCN. tinyurl.com/RCN-catheter
Turner B, Dickens N (2011) Long-term urethral catheterisation. Nursing Standard; 25: 24, 49-56.