A better approach

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Proper hand hygiene is the No. 1 infection control measure that can help prevent CAUTIs.
Proper hand hygiene is the No. 1 infection control measure that can help prevent CAUTIs.

It's a phrase most healthcare professionals know best as a five-letter acronym — CAUTI — and it's one of the most common, costly and preventable challenges long-term care providers face. 

Catheter-associated urinary tract infections account for nearly 30% of infections reported by long-term care facilities and the indwelling urinary catheter is the source of a majority of them. 

That's because putting any invasive device into the body that extends externally bypasses the first line of defense against infection: the skin. The issue can involve an indwelling Foley catheter, IV, cannula or PICC, notes Pennsylvania Infection Prevention Consultant Steven J. Schweon, RN, MPH, MSN, CIC, HEM, FSHEA.

 “Once that natural barrier has been disturbed, the invasive device becomes a portal of entry for microorganisms and infection,” he points out.

When nursing aides use the same container to empty catheter drainage bags from multiple residents (or even from the same resident multiple times), this also increases a resident's risk of an indwelling catheter infection. So does forgoing adequate hand washing, wearing gloves or changing gloves between residents. Among residents in long-term care, many of whom already have compromised health, a catheter infection may quickly spread to the renal system and bloodstream, exacerbating medical conditions such as heart disease and diabetes and often requiring hospitalization, Schweon explains.

“The onus, therefore, needs to be on infection prevention, not just infection control,” he says. 

So how can long-term care facilities best prevent — or at the very least minimize — CAUTIs? And what are some alternatives to indwelling catheters for those residents who need urinary voiding assistance? The answers are not always simple.

Limited indications

In 2009, the Centers for Disease Control and Prevention released guidelines for the prevention of CAUTIs in acute and non-acute healthcare settings, including long-term care facilities. The guidelines provide examples of indications for appropriate urinary catheter use, and proper techniques for catheter insertion and maintenance. They also mandate that healthcare providers must have a medically necessary reason for using an indwelling catheter, says Deb Burdsall, RN, MSN, RN-BC, CIC, an infection preventionist at the Lutheran Home, a senior living community in Arlington Heights, IL.

“Everyone at the facility — including the nursing staff, physicians, the dietician, even occupational and physical therapy — has to be on the same page: You don't put a catheter in and you don't leave a catheter in unless the person absolutely needs it,” says Burdsall, a Communications Committee member of the Association for Professionals in Infection Control and Epidemiology. 

One of the few times a chronic indwelling urinary catheter may be appropriately indicated for use in a long-term care setting is when a resident is experiencing acute urinary retention or a bladder outlet obstruction and the problem cannot be corrected medically, surgically or practically managed with intermittent catheterization. An indwelling catheter also may be medically necessary on a short-term basis to assist in healing perineal or sacral wounds, or for comfort care at the end of life, says Mary Crosby, RN, a clinical consultant with Briggs Healthcare.

It's also important for long-term care facilities to thoroughly evaluate residents coming from the hospital, where an indwelling catheter may have been inserted for a surgical procedure and then never removed. In fact, research shows that about half of all residents with indwelling catheters transferred from an acute-care facility can have them removed upon arrival at a long-term care facility, says Helene Cissell, RN, BSN, clinical resource manager with Medline's urology division.

“Inappropriate use of indwelling catheters really needs to be eliminated,” Cissell says. “Catheters are not a substitution for nursing care of an incontinent patient.”

New technologies

Rather than relying on long-term indwelling Foley catheters, infection control experts recommend several new technologies and catheter alternatives to help manage urinary incontinence. Depending on a resident's medical condition, intermittent urinary catheterization can be a quick and easy way for staff or even a high-functioning resident to empty the bladder.

When used in combination with frequent bladder scanning that employs a portable ultrasound device to assess urine volume, intermittent catheterization helps reduce the use of unnecessary indwelling catheters in many patients, Cissell says. External catheters, including condom catheters for men and urinary pouches for women, and suprapubic catheters, which are inserted into the bladder surgically through a small incision above the pubis, are other viable alternatives for incontinence management. Their use is associated with much lower rates of urinary infection, Crosby says. 

Scientists also continue to examine the benefits of catheters coated with silver, a pure substance that is said to be bacteria-static, says Margaret Willson, RN, MSN, CWOCN, manager of clinical and marketing education at Hollister Incorporated.

“Silver alloy catheters have been reported as successful in terms of diminishing harmful bacteria that can contaminate the catheters and tubing,” says Willson, chair of the Wound Ostomy and Continence Nurses Society continence committee. “But there's a concern that the constant use of silver may lead to the development of superbugs to which antibiotics will become resistant.”

Researchers from the University of Michigan are developing an “electromodulated smart catheter” that releases a bacteria-killing nitric oxide substance at the start of an infection, says Jacqueline Vance, RNC, CDONA/LTC, director of clinical affairs at the American Medical Directors Association. The technology works by chemically sensing changes in the pH around the catheter. Certain changes signal when bacteria have formed a sticky film on the catheter, and a health-jeopardizing infection is imminent. The catheter then “turns on” and releases nitrous oxide, disrupting the bacterial films and stopping the infection, Vance explains.

Infection prevention

When alternatives are unsuitable and the healthcare team decides an indwelling catheter is medically necessary, it's important for long-term care staff to follow proper infection control practices, says Cheryl Hutton, BSN, RN, CWON, a member of the McKesson Medical-Surgical Clinical Resource Team. That means properly training staff on the insertion and care of indwelling catheters, using strict sterile technique during catheter insertion and maintaining a closed sterile insertion and drainage system. It's also important to use the smallest catheter possible and properly secure it after insertion to prevent movement and urethral traction, says Schweon, who adds that keeping the collection bag below bladder level but off the floor at all times also is crucial.

Above all, however, hand hygiene has been recognized as the single most important measure for preventing the spread of infection. To that end, staff must be aware of when and how to perform hand hygiene and they should educate residents and their families about their role in infection prevention, says Megan DiGiorgio, MSN, RN, CIC, a clinical OR specialist with GOJO Industries. 

According to the CDC, all healthcare workers must perform hand hygiene immediately before and after catheter insertion or care by using either soap and water or an alcohol-based hand rub. Healthcare workers also should follow proper hand hygiene procedures before putting on clean or sterile gloves, DiGiorgio says.

“Gloves are never a substitution for proper hand hygiene,” she says.

It's also important that, whenever possible, electronic medical record systems be used for CAUTI prevention efforts. These systems can be used to document  the rationale for catheter placement and monitor dates and times of catheter insertions and removals, Hutton says.

“Long-term care staff can even use the reminder systems in the medical records to target opportunities to remove the catheter,” she says.

Finally, it's crucial that long-term care professionals don't pre-emptively prescribe antibiotics for a UTI just because a catheter becomes contaminated or a culture indicates that there are bacteria in a resident's urine, Schweon says.

“Bacteriuria is very common in catheterized residents, and does not, by itself, indicate infection,” he says. “Guidelines are available to assist with diagnosing infection, and criteria include a fever or an elevated temperature above baselines, costovertebral tenderness, rigors or new-onset of delirium.” n

Fast Facts

 - An estimated 13,000 deaths annually are attributed to urinary tract infections.

 - Up to 80% of urinary tract infections are associated with the presence of an indwelling urinary catheter.

 - Catheter-associated urinary tract infections cost between $400 million and $500 million nationally — per year.

Source: CDC, 2013