Implementation of a Quality Improvement Project to Document & Decrease the Rate of Contaminated Urine Cultures in our Neonatal Population

Abstract

ISSUE: Lo et al. (2008) found that urinary tract infections (UTI) are the most common hospital acquired infection. They identified that 80% of UTI’s are attributable to an indwelling urinary catheter. The two guiding documents infection preventionist reference when seeking guidance on Catheter Associated Urinary Tract Infection (CAUTI) prevention are the Healthcare Infection Control Practices Advisory Committee (2010) and the SHEA/IDSA Practice Recommendations (2008). Neither document addresses the neonatal population, nor does the National Healthcare Safety Network (NHSN) (2010) have a CAUTI benchmark for NICU’s. Furthermore, we were unable to identify expected rates of urine contamination specific for the neonatal population. The following abstract outlines our response to this literature gap. Project aim: To decrease the rate of contaminated urine cultures by 20% by the end of 2013. PROJECT: Our NICU is a Level III, 54 bed unit in an urban teaching facility. Using the Plan-Do-Study-Act methodology we analyzed all urine cultures collected from January through mid October, 2012. We conducted a literature review, created and delivered education on appropriate urine specimen collection using LippincottWilliams &Wilkins (2012) and implemented an audit process on every urine culture ordered. RESULTS: January through October, 2012 we had 26 incidences of symptomatic UTI, Criterion 3 & 4, using the NHSN (2012) surveillance definitions. In two incidences the patients involved had a foley in place. Over the same time period we collected an average of 24 urine specimens a month, 17 of which, on average, were negative. Ninety percent were collected by straight catheterization and 78% of the positive cultures were collected from male patients. Approximately 9% of positive cultures yielded mixed flora with no predominant organism, while 41.3% had colony counts 10,000 or less. Specimen collection education occurred in November, 2012. Preliminary results indicate a reduction in the number of contaminated urine cultures in NICU. Process measure results are pending. LESSON LEARNED: The Division of Health Care Quality Promotion (2009) estimated that CAUTI cost w$1000 per incidence. Costs associated with UTI treatment include antimicrobial therapy, central access required to deliver therapy, follow-up urine cultures and renal ultrasounds. Non-fiscal costs include adverse effects of antimicrobial therapy on bowel flora, increased risk of necrotizing enterocolitis, multidrug-resistant-organism development, pain and discomfort to the neonate, and emotional toll on the family members and care providers. The bottom line is, just because these infections are not benchmarked, doesn’t mean they shouldn’t be measured.