Hi, welcome everyone. My name is Pat Posa and I'm the quality and patient safety program manager at Michigan Medicine. And I'm here today to talk to you about controlling the flood of CAUTIs in your high acuity ICUs. You're in or you're out. My disclosures include, I'm a subject matter expert on CAUTI and CLABSI for the Michigan Hospital Association, as well as a subject matter expert for cohorts of a collaborative with the AHA and HRQ. The objectives for this presentation are to discuss effective strategies for determining appropriateness of placing indwelling urinary catheters, identifying alternatives to indwelling urinary catheters and to reestablish the path to improve CAUTI rates in your high acuity ICUs. Why should we worry about CAUTI? Well, UTIs in general represent the fourth most common hospital acquired infection. And along with other device associated infections like CLABSI and ventilator associated pneumonia, they account for 30% of all the HAIs. There are about 93,000 UTIs in acute care hospitals, 70 to 80% of those UTIs are inpatients with urinary catheters. It can lead to increased morbidity, mortality, length of stay and costs. This is really a patient safety issue, not just a CAUTI. Urinary catheters are not harmless devices. They may lead to urinary tract infections, but they can also lead to trauma in the bladder. They can lead to immobility, pressure ulcers, patient discomfort, falls, venal thromboembolisms. We have many challenges to reducing our catheter associated urinary tract infection rates. As shared by Kathleen, the pandemic has significantly impacted our CAUTI rates. We've seen an increase in urinary catheter utilization both during the pandemic and it still exists. Also significant challenges in staff turnover, shortages and onboarding. So it's time to reset. Let's get back to the basics. We need to go back to the basics. In this article by Dr. Mettings, tiered approach to CAUTI prevention is outlined. I'm gonna focus today on the first tier, placing appropriate indwelling urinary catheters and encouraging the use of alternatives as well as optimizing prompt removal and urine culture stewardship. Preventing urinary catheter associated infections is all about disrupting the life cycle of a urinary catheter. Today, I'm just gonna focus on step zero and step three. So avoiding catheters if possible and prompt removal. And then we'll talk a little bit about culturing stewardship as key interventions to prevent CAUTI. Indications for placement of indwelling catheter have been outlined by many of our national associations, including the CDC, SHEA, IDSA and NHS. They include perioperative use for selected surgical procedures, urinary output in critically ill patients, management of urinary retention and urinary obstruction, assistance in pressure ulcer healing for incontinent patients and requests for improved comfort at the end of life. One of the most challenging indications is urine output in critically ill patients. There are a number of the guidelines that talk specifically about the appropriate use in critically ill patients. In the HIPAA guidelines, it's not as specific, but if you look at the American Nurses Association, as well as the Ann Arbor criteria for appropriate use, they provide clarification to the 2009 guidelines on the use for specific clinical scenarios. And indwelling catheters are appropriate for measuring and collecting urine output only when fluid status or urine cannot be assessed by other means. Just having a location of the patient being in the ICU is not an appropriate indication. Monitoring urinary output in critically ill patients is a true indication for having a urinary catheter. What are some of the types of treatments that require that close urine output monitoring? If the person is actively being resuscitated and getting fluid boluses, are they on vasopressors, inotropes, do they have high dose diuretics infusing, or are they on a vasopressor? And if so, what are the types of treatments that require diuretics infusing? Or are we doing hourly urine studies to measure life-threatening lab abnormalities? If you're not really responding to the patient's urine output hourly, I challenge you and your organization and your team to consider is that urinary catheter really necessary, or can you use other means to monitor the urine output? So how can we use alternatives to reduce urinary catheter utilization? The standard condom cath has been used for a long time in males to be able to have an alternative to having a urinary catheter in place. Over recent years, we've seen new both male and female devices for urinary collection that can allow us to be able to take accurate INOs in our critically ill patients. These collection devices prevent backflow and capture forward flow using continuous suction, and they'll divert urine away from the skin, addressing some of those risk factors of IAD. There have been a number of quality improvement projects that have shown the benefits of the using different alternatives. Here is one that was presented at a national meeting. This was in a surgical ICU. It was a pre-post QI study utilizing the external collection device for females. It also included daily rounds talking about the need for the urinary catheter, and they measured both CAUTI and SIR rates. And so they saw their CAUTI rate significantly decrease from 2.55% to 0.7, and their SIR from 1.395 to 0.38. What are some of the barriers to using alternatives? Time in general to place them, but it is minimal. The perception that the patient has to have a urinary catheter for accurate INO, and hopefully I've dispelled some of that. The unit culture issues and switching to alternatives just if that's not part of the culture. Nursing reluctance. It might take a little more work than a urinary catheter. Lack of physician support. Physicians not having the knowledge that alternatives are available and that they can provide accurate INOs. And it's important to have the right amount of supplies and the appropriate supplies for different indications and for different patient populations. So what are some of the strategies to overcome the barriers? Related to the need for accurate INO, in males we have both the external catheter as well as using just urinals or having patients get up to the bathroom. Same with females. And we now have female external devices that work very well. For the female or male incontinent patients, consider absorbent pads that can be weighed or other external devices. And having the right supplies available that have been tested and trialed with your unit to make sure that they have ease of use, have some stain power and are good for the patients. Another key strategy is to have a nurse-driven protocol. And so what's a nurse-driven protocol? When the order gets placed for a urinary catheter based on a certain indication, once that indication is no longer there, the nurse can remove that catheter without getting a different physician order. There are a number of studies that have been published pre and post the benefits of a nurse-driven protocol. Here's an example of one. This was a 19-month pre and a 15-month post intervention in a surgical trauma ICU. It was a multimodal. They included in their CAUTI prevention bundle was unit ownership of CAUTI's need to be reduced. And so unit leaders did twice daily rounds. Also auditing of the nurse-driven protocol, twice daily catheter care. And then they provided education, decreased the number of urinary cultures. And they changed also the method to collect urine to prevent bacterial overgrowth. So as a result of implementing that CAUTI prevention bundle, they saw a statistically significant decrease in both their CAUTI rate and their catheter utilization. They also saw a decrease in the number of urine cultures ordered per 1,000 patient days. And I'll talk more about urine culture stewardship in a few minutes. There are a number of factors that can affect the success of reminder orders, stop orders, and nurse-driven protocols, including communication pattern and unit culture relative to urinary catheter use, the nurse's comfort with urinary catheter removal protocols, the right urine collection alternatives, staff knowledge and skills, respect among the nurse and physicians, ownership by the frontline staff and local leadership to really support removing the urinary catheters, as well as understanding when CAUTIs do happen, why they happen. And then providing feedback and data on catheter use and infections to the team. Often when catheters are removed, there's variation in determining the post-catheter removal care. And it's really important to standardize that and educate on that. And it should be part of your nurse catheter removal protocol. The WOCN got a group of experts together and define interventions post-catheter removal, and they have various algorithms. And one of them being when indwelling catheter has been removed, what are your next steps? And looking for that patient voiding within six hours post-removal, and if not, what do you do? So very important to have this as part of your nurse-driven protocol. To decrease utilization, having conversations and assessing daily the necessity for the urinary catheter. And the conversation on rounds is not just, do we have a catheter, but why do we have it still in? And is that indication still relevant for this patient? There are other points in the care process for patients that are in the ICUs that might be a great time to reassess the need for different lines and tubes, and one of them being urinary catheters. So upon transfer, asking the question, what devices can be removed before we move this patient to a different level of care? The next key component to decrease CAUTIs in critically ill patients is really talking about the culture of care. Talking about the culture of culturing. Understanding that asymptomatic bacteria is a condition where you have a specified count of bacteria in an appropriately collected urine sample obtained from a person without clinical signs and symptoms of urinary tract infection. And ASB can lead to overuse of antibiotics because these patients have colonization or they have asymptomatic bacteria. They have bacteria in their urine, but they don't have an infection. It can result in overuse of antibiotics, increased resistance pathogens, and falsely inflate your organization's CAUTI rate. 23 to 50% of antibiotic days for UTIs are from asymptomatic bacteria. We need to remove some of our old practices or thoughts about when a urinary culture is necessary. In this previous survey of doctors and nurses related to indications to culture the urine, a lot was just on appearance or odor or dysuria and the standard practice of pan-culturing. When you spike to fever, just get blood urine and sputum. Or a UA that had just greater than 100 WBCs. So it's important to understand that we have to dispel some old myths or thoughts about when a urinary culture is indicated. Some of the ways to hardwire appropriate use of urinary catheters as well as appropriate ordering of urinary cultures is putting things in your EMR. So for example, to decrease inappropriate urinary cultures, incorporate a mandatory selection of standardized indications for ordering a urinary culture in a catheterized patient. And you can see here the list of recommended standardized indications. So some recommendations for urine culture management is to measure the percent of your patients treated with antibiotics for urinary tract infections with catheter and no documented signs or symptoms of clinical infection that asymptomatic bacteria. And then ensure proper collection and handling of urine specimens. Often it's important to replace catheters that have been in a long time in symptomatic patients before collecting a specimen. Delineate policies and procedures and educate personnel on proper methods to collect urinary cultures and standardize the use of refrigeration or preservative tubes to collect urine for culture. So standardizing those collection procedures to ensure that you're reducing contamination as that urine culture is being collected and transported. So here's a flyer that we provide our clinicians to as a reminder of indications, as well as if a Foley has been in longer than, and we use seven days, that we need to replace it before we collect the urinary culture and that the urinary culture should be collected in a tube that has preservative. In summary, we need to get that urinary catheter out and how do we do that? We use urinary catheters when appropriate indications are met and getting accurate I and O can be appropriately achieved through using alternatives. It's important to review necessity daily. Why do I have, do I have a catheter in and are the indications still valid? If not, let's get that catheter out. Increase the use of alternatives to both avoid putting catheters in and to getting them out in a timely fashion. Standardize your approach to getting urine cultures. And then it's so important to educate and reeducate staff and include at that education in onboarding. And both, we know that educational programs have been associated with mark reduction and in rates of CAUTI. And we know care processes need to be refreshed regularly and supported with feedback on performance to be effective. We need engaged leadership that will support this culture of safety. So when in doubt, take it out. Thank you very much. Thank you so much for listening to the presentation today and for allowing me to be here to present to you.

CAUTIs

catheter-associated urinary tract infections

urine collection

catheter removal

urine culture stewardship