Catheter-associated Urinary Tract Infection Prevention Research Articles

Bacteriology and Antibiotic Sensitivity Patterns of Urine in Urology Patients with Indwelling Urinary Catheters at the University Teaching Hospital in Lusaka, Zambia

Introduction: Catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection in hospitals worldwide, and the incidence has been reported to be up to 35%. The growing antibiotic resistance amongst the uropathogens isolated from CAUTI makes it challenging to manage. In Zambia, prolonged catheter use is a burden, particularly in patients awaiting definitive surgery, the elderly and the socioeconomically challenged. Bacterial colonisation following catheterisation is inevitable, with reports estimating the risk to be around 5-10% per day. By day 10, virtually all patients with urinary tract instrumentation have healthcare-associated UTI, with the duration of catheterisation the most important factor. Methodology: The study was a descriptive cross-sectional study conducted at UTH over a period of 10 months from July 2015 to May 2016. The cases were inpatients and outpatients with indwelling catheters in situ for not less than three calendar days. Simple random sampling was used to select candidates who were inpatients awaiting definitive surgery and outpatients in the same category as they attended clinics. Data collection and collection of specimens were done by the principal investigator, which was analysed by the microbiologist based at the UTH microbiology laboratory. The patients were recruited at one point, and the data collection exercise employed a questionnaire to collect socioeconomic demography and clinical information. The variables were collected using the data collection sheet for each participant. The data was then entered into SPSS software to clean and analyse data. The categorical variables were presented as proportions. The main concerns arising during specimen collection were the duration between the time of specimen collection and transfer to and processing at the main laboratory, which was kept within one hour. Specimens received within two hours of the collection were accepted. Results: A total of 228 patients were enrolled from both outpatient and inpatient departments. Approximately 75% yielded growth of bacteria, and 25.0% were negative. The pure growth yielded Klebsiella Pneumoniae 28.0% and E. coli 25.2%, as the most isolated pathogens. The antibiotic susceptibility testing revealed the highest resistance of the above isolates to ampicillin, nalidixic acid, norfloxacin, ciprofloxacin, levofloxacin, and borderline with cotrimoxazole. The organisms were least resistant to amikacin, imipenem, nitrofurantoin, and gentamycin. Acetinobacter and Citrobacter species were also highly resistant to the above drugs with nitrofurantoin in addition but least resistant to ampicillin. Conclusion: The study revealed a high prevalence of CAUTI in the urology section of the UTH, and practices such as poor hand hygiene, open catheter drainage, non-aseptic methods of catheter insertion and poor catheter care are possible contributing factors. There is an association between the insertion of indwelling catheters and subsequent development of CAUTI, and the strongest factors noted are the size of the catheters used and the patient's level of education. High resistance to antibiotics to many organisms of concern was noted.

Knowledge, attitude and practice in relation to catheter-associated urinary tract infection (CAUTI) prevention: A cross-sectional study.

Healthcare-associated infection (HAI) is one of the major threats to patients' safety besides being among the principal causes of patient morbidity and mortality. Catheter-associated urinary tract infection (CAUTI) is reported to be the most common HAI worldwide. CAUTI can be prevented with appropriate practice and care by healthcare personnel, especially nurses, who play the main role in urinary catheter care. Nurses' knowledge and attitude are considered to be important factors that influence their practice. To assess nurses' level of knowledge, attitude and perceived practice regarding CAUTI and its preventive measures. A cross-sectional design was adopted, and a self-administered questionnaire was used to collect data. Nurses from the medical and surgical inpatient wards of a tertiary teaching hospital in Malaysia were recruited in two stages using the stratified and simple random sampling methods. A total of 301 nurses participated. Descriptive analysis, an independent t test, ANOVA and hierarchical multiple regression were employed to analyse the data using SPSS software version 25. In addition, a STROBE checklist was used to report the results of this study. Nurses were found to have good knowledge, a positive attitude and good perceived practice regarding CAUTI prevention. Nurses aged above 30 and who had more than ten years of experience reported higher knowledge levels. Knowledge was found to be positively correlated with attitude and perceived practice; however, attitude explained a higher variance in perceived practice of CAUTI prevention compared with knowledge. Attitude was found to have a higher significant influence on perceived practice in this study. Educators need to emphasise the inculcation of a positive attitude among nurses rather than just knowledge for CAUTI prevention. Since this study assessed perceived practice, examining nurses' actual practice and its impact on patient outcomes is recommended in future studies.

Effectiveness of meatal cleaning in the prevention of catheter-associated urinary tract infections and bacteriuria: an updated systematic review and meta-analysis

ObjectiveA systematic review on meatal cleaning prior to urinary catheterisation and post catheterisation and reduces the risk catheter-associated urinary tract infections (CAUTIs) and bacteriuria was published in 2017, with further...

Risk Factors and Outcomes of Postoperative Catheter-Associated Urinary Tract Infection in Colorectal Surgery Patients: A Retrospective Cohort Study.

IntroductionCatheter-associated urinary tract infection (CAUTI) is a relatively common cause of postoperative morbidity in colorectal surgery patients. It has been associated with increased length of stay and mortality.MethodsWe performed a retrospective cohort study of 620 colorectal surgeries to assess the prevalence of CAUTI and its relationship with preoperative and operative factors. We also sought to identify its association with postoperative outcomes.ResultsWe found that CAUTI occurred in 20.6% of colorectal procedures. We found that CAUTI was associated with older patient age, female gender, higher BMI, higher American Society of Anesthesiologists (ASA) classification, lower hemoglobin, higher creatinine, lower albumin, urgent procedures, bilateral ureteric stent placement, usage of double-J (DJ) stents, postoperative abdominal sepsis, and perioperative steroid usage. CAUTI was also associated with the presence of underlying medical conditions such as hypertension, ischemic heart disease, chronic kidney disease, cerebrovascular disease, and diabetes. With regards to postoperative outcomes, it was associated with postoperative stroke, myocardial infarction, prolonged length of stay, Intensive care unit stay, and mortality.ConclusionCAUTI remains a significant cause of morbidity in colorectal patients. Our patient population had a significantly higher risk of CAUTI compared to other series. Though sometimes labelled a minor postoperative complication, its occurrence is associated with other more significant postoperative complications, including death.

Knowledge, Attitude and Practice on Prevention of Catheter-associated UTI among Nurses of a Tertiary Care Hospital

Introduction: Urinary tract infection (UTI) is among the common bacterial infections worldwide and approximately 80% are associated with a urinary catheter. Catheter-associated UTI (CAUTI) has been associated with increased mortality, morbidity, length of hospital stay and the best way of CAUTI prevention is to adhere to recommended guidelines on infection control in the use of a urinary catheter.
 Methods: A cross-sectional analytical study was conducted among the nurses of college of medical sciences. A total of 160 staff nurses were selected using a probability simple random sampling technique. Data was collected using a self-administered questionnaire for knowledge, Likert scale for attitude, and checklist for practice regarding the prevention of CAUTI. The data gathered was analyzed using both descriptive and inferential statistics in SPSS software.
 Results: Among the total of 160 participants, most of the nurses 59.37% had moderate knowledge and 16.25% had adequate knowledge towards the prevention of CAUTI. The positive attitude of nurses was 41.88% and the majority of nurses 64.38% had a good level of practice. Also, age (p=0.022), professional qualification (p=0.001), designation (p=0.001), current area of practice (p=0.030) and previous information towards CAUTI prevention (p=0.003) among all the socio-demographic variables were statistically significant with the level of knowledge regarding the prevention of CAUTI.
 Conclusion: Majority of nurses level of knowledge was not satisfactory and had a negative attitude regarding CAUTI prevention. This indicates that the implementation of an educational program is needed to enhance nurses' knowledge regarding catheter management to improve quality care.
 Keywords: attitude; catheter-associated urinary tract infections; CAUTI; practice; UTI

Build upon basics: An intervention utilizing safety huddles to achieve near-zero incidence of catheter associated urinary tract infection at a department of Veterans Affairs long-term care facility

BackgroundWhen traditional interventions are used in long term care for catheter associated urinary tract infection (CAUTI) prevention, residual rates are still high despite a decrease. We conducted a quality improvement study focusing our interventions on patient and staff behavioral patterns identified through a structured huddle process to improve upon the basics for CAUTI prevention. MethodsBaseline was from January 2016 to March 2017; the intervention period was from April 2017 to June 2020. We implemented a systematic huddle to determine root cause of each CAUTI and applied lessons throughout the facility. We measured the monthly CAUTI incidence per 1000 urinary catheter days and analyzed the reduction in CAUTI during the intervention period. ResultsCAUTI decreased by 73% during the intervention period compared to the baseline period, with an IRR of 0.27 (95% confidence interval [CI]: 0.11-0.66; P = .004). The number of catheter days per month increased by 4% in the intervention period (17,407 in 39 months) compared to the baseline period (6,440 in 15 months) with IRR of 1.04 (95% confidence interval [CI]: 1.01-1.07; P = .008). No patterns were noted in organisms responsible for CAUTI. ConclusionsOur findings stress the importance of looking beyond the traditional interventions for CAUTI prevention in long term care population. By doing this, interventions can be customized for this special population to achieve optimal outcomes.

The Compliance of Hospital Nurse in the Prevention of Urinary Tract Infection in Surabaya, Indonesia

Background: Catheter-Associated Urinary Tract Infection (CAUTI) is one of the most common infections in the hospital. In order to prevent and control CAUTI incidence, nurses are required to implement bundles of prevention. However, the lack of nurses’ compliance behavior in implementing the CAUTI bundle prevention was found. Objective: This study analyzes the nurse’s compliance behavior in implementing CAUTI prevention using the Theory of Planned Behavior (TPB) approach. Methods: This study was an analytical descriptive study with a cross-sectional design. Nurses who work in ICU, ICCU, HCU, and in-patient unit of the hospital were set as study population and taken as samples using simple random sampling. Background factors (age, education, knowledge, employment duration, career levels), attitudes, subjective norms, Perceived Behavior Control (PBC), and intention were determined as independent variables. In contrast, nurses’ compliance behavior in CAUTI prevention bundle implementation was determined as the dependent variable. Data were collected using a questionnaire and analyzed using logistic regression with a significance level of α < 0.05. Results: Among 111 nurses, most of them are in the age of 26-45 years (80.1%), has worked as a nurse for 8-13 years (29.7%), reach career level at Clinical Nurse 3 (51.4%), and have good knowledge about CAUTI prevention bundle (83.8%). The employment duration and career levels are background factors that correlate the most to the TPB factors. The nurses’ compliance behavior is influenced by attitude, subjective norm, PBC, and intention (P Value= 0.000). Multivariate analysis shows that intention is associated with nurses’ compliance behavior and increases nurses’ commitment to implement CAUTI prevention bundle (P Value= 0.033, OR= 6.46). Conclusion: The intention simultaneously influences the nurses’ compliance behavior.

Assessment of Knowledge, Attitude and Practice on Prevention of Catheter-associated Urinary Tract Infection (CAUTI) among Health Care Professionals Working in a Tertiary Care Teaching Hospital

Catheter-associated Urinary Tract Infection (CAUTI) is a common healthcare-related infection occurring in patients admitted for various ailments. Approximately 80% of hospital acquired Urinary Tract Infections (UTIs) are catheter associated. The purpose of the current research was to find out the level of knowledge, attitude and practice on prevention of CAUTI among healthcare professionals working in tertiary care hospital. A descriptive study was done among 95 health care working in tertiary care hospital in Chennai. The researchers administered standard questionnaire and statistically explored the knowledge, attitude, and practice levels about prevention of CAUTI among the participants. Among 95 participants, 28.4% and 71.6% of the individuals had moderately adequate knowledge and adequate knowledge about CAUTI. About 4.2% of the participants had unfavourable, 88.4% had moderately favourable and 7.4% had favourable attitude towards prevention of CAUTI. About 4.2% of the individuals had moderately adequate and 95.8% had adequate practice towards the prevention of CAUTI. There was significant correlation between attitude and practice. The professional experience of the participants showed statistically significant association with the level of practice among the demographic variables. In our present study, we found out that health care professionals had adequate knowledge, attitude, and practice on prevention of CAUTI. Medical education programs, frequent auditing with a checklist about catheter care must be conducted to maintain the achieved knowledge and practice levels.

Synergistic activity of weak organic acids against uropathogens

Urinary tract infections (UTIs) are among the most common hospital-acquired infections, with an estimated 75% of UTIs caused by urinary catheters. In addition to the significant healthcare costs and patient morbidity, the escalating antimicrobial resistance reported among common uropathogens make the investigation of efficacious new antimicrobial strategies of urgent importance. To examine the antibacterial activity of a suite of weak organic acids (WOAs) (citric acid, malic acid, propionic acid, mandelic acid, lactic acid, benzoic acid, pyruvic acid and hippuric acid), alone and in combination, against common nosocomial uropathogens (Proteus mirabilis, Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa). Minimum inhibitory concentration (MIC), minimum bactericidal concentration (MBC), minimum biofilm eradication concentration (MBEC), fractional inhibitory concentration index (FICI) values and kinetics of bactericidal activity of WOAs were determined by microdilution and time-kill assays. All tested WOAs displayed bactericidal activities against uropathogens in their planktonic and biofilm modes of growth when used individually. Moreover, WOAs in combination displayed synergistic activity against P.mirabilis, S. aureus and E.coli, with reductions in MIC values of up to 250-fold and significant reductions in biofilm formation. The synergistic multi-mechanistic combinations identified herein are anticipated to play an important role in the treatment and prevention of catheter-associated UTIs.

Knowledge of Nurses toward Prevention for Catheter-Associated Urinary Tract Infection in Public Hospitals at Amran City, Yemen

Background of the study: Catheter-associated urinary tract infection (CAUTI) is the most prevalent healthcare-associated infection worldwide, according to reports. Nurses are also accountable to acquire appropriate knowledge and practices of catheter care that will prevent UTI. Nurses’ knowledge is seen to be one of the most important factors in their practice. Aim of the study: To assess the nurse’s knowledge toward the prevention of catheter-associated urinary tract infection in public hospitals at Amran City. Methods: A descriptive cross-sectional study was conducted among nurses at public hospitals in Amran City, Yemen. A convenience sampling technique was of the study consisted of 93 nurses from different public hospitals that were participated in this study. Self-administered questionnaire was used to collect data from March 2021 to April 2021. Results: The distribution of nurses’ ware female 65.6%, belonged to age group between (25 to <30 years) 43.0%. The Diploma degree was the most available qualification 88.2%, 81.7% between 1 - 5 years’ experience as nurses. Knowledge regarding prevention of catheter-associated urinary tract infection was fair 72%, while 18.3% had a good. There is a significant statistical difference between knowledge level regarding prevention of CAUTI, and sex (P-value = 0.042). Conclusion: Most of nurses had fair knowledge level regarding prevention of catheter-associated urinary tract infection. Recommendations: We recommended increasing the knowledge of nursing staff through the courses training, workshop, and curriculums.

Educating nursing staff regarding infection control practices and assessing its impact on the incidence of hospital-acquired infections.

CONTEXT:Hospital-acquired infections (HAIs) are a global problem. One of the common causes of HAI is through the health-care workers, mainly because of failure to comply with the recommended infection control guidelines.AIMS:The aim of our study was to educate and train the nurses regarding infection control practices and assess the impact of training and assess whether this training actually made any change in the incidence of catheter-associated urinary tract infection (CAUTI) and intravenous (IV) line-related infections.MATERIALS AND METHODS:Baseline knowledge, attitude, and practices study of willingly participating 105 nurses regarding infection control was done. The incidence of CAUTI and IV line-related infection was calculated in the areas of their postings. They were trained via an educational module regarding infection control practices. We again assessed the incidence of CAUTI and IV line-related infections in the same areas 2 months after training. Data analysis was done using SPSS version 20.0. Student's t-test was used to analyze the difference in the prevalence of CAUTI and IV line-associated HAIs pre intervention and post intervention.RESULTS:There was reduction in the incidence of IV line-related infection, though it was not significant (P 0.15) and no change in the incidence of CAUTI after intervention.CONCLUSION:Single educational module though improved nurses' knowledge and attitude regarding infection control but failed to result in significant improvement in practices and incidence of HAIs.

809. Modified Laboratory Reporting to Prevent Catheter-Associated Urinary Tract Infections (CAUTIs)

BackgroundCatheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections. Many patients at our institution with a CAUTI do not have signs or symptoms of infection and bacterial growth likely represents asymptomatic bacteriuria (ASB). As a result, we implemented a Modified Lab Workflow (MLW) focused on diagnostic stewardship to improve urine culture (UCx) reporting and prevent misclassification and unnecessary treatment of CAUTIs.MethodsOn Sep. 1, 2019, laboratory reporting of Foley UCx was modified according to the protocol in Figure 1. UCx results were divided into 3 groups: (1) no growth, (2) mixed bacterial flora (≥3 organisms) not consistent with infection or (3) growth of ≤2 organisms with at least 1 organism ≥105 cfu/ml per National Healthcare Safety Network (NSHN) CAUTI definition. Group 3 UCx were resulted with instructions to the clinician (see Figure 1.). When requested, group 3 results were reviewed by Infection Prevention and released with organism identification and antibiotic susceptibility if it met Infectious Diseases Society of America (IDSA) CAUTI criteria. Otherwise they were resulted as: “Bacterial growth indicative of contamination or colonization.”Figure 1. Modified Laboratory Workflow for Reporting Urine Cultures from Foley Catheters ResultsBetween Sep. 1, 2019 to Mar. 1, 2020, a total of 134 UCx from catheterized patients were reviewed. Forty-two (31%) of UCx were from patients with a Foley in-situ ≥48 hours and processed through MLW; 92 UCx were from a Foley in place < 48 hours and excluded from the study. Of the 42 UCx processed via MLW, 16 (38%) were no growth and 7 (17%) had bacterial growth suggestive of contamination. For group 3, 19/42 (45%) had growth of significant bacteria but only 1(5%) met IDSA criteria for reporting. During the study, 6 additional CAUTIs were reported due to incorrect specimen labeling causing Foley urine specimens to subvert MLW.ConclusionDuring our study, we identified 1 CAUTI through apt MLW use. Seven total CAUTIs occurred (SIR=0.66); a majority due to incorrect UCx source labeling, resulting in missed MLW screening. Ten CAUTIs (SIR=0.97) were reported in the preceding 6 months. As part of a comprehensive CAUTI prevention program, a MLW can help reduce classification of ASB as a CAUTI. Education to providers on precise labeling of UCx source is a key component of a successful MLW.Disclosures All Authors: No reported disclosures

Prevention of catheter associated urinary tract infections: Assessment of knowledge and practices among nurses in a tertiary care centre in Nigeria

Background: Catheter-associated urinary tract infections (CAUTI) are responsible for up to 80% of healthcare associated infections. Recommended strategies to prevent CAUTI are based on implementation of a ‘care bundle’. Nurses are responsible for catheter care, yet few studies have been conducted in developing countries to assess their understanding of CAUTI and the care bundle. The study aimed to assess the knowledge and practices toward prevention of CAUTI among nurses. Methods and materials: A cross-sectional study was carried out in a tertiary hospital in Edo state, Nigeria between January and July 2019 among 200 consenting nurses recruited through a systematic sampling process. Data was collected using pretested questionnaires. A checklist was used for observation of patients with an indwelling catheter to assess compliance with CAUTI maintenance bundle. Analysis was done using the Statistical package for social sciences. Ethical approval was obtained. Results: One hundred and eighty nurses completed the study giving a response rate of 90%. Majority, 138 (76.7%) had fair knowledge of CAUTI and its prevention, 42 (23.3%) had poor knowledge. Gaps in knowledge were observed in the areas of appropriate indications for urinary catheterization, catheter care including removal, and risk factors for CAUTI. One hundred and forty-nine (82,8%) respondents had positive attitude although slightly above half erroneously believed that catheter removal should be at the convenience of nurses. Neither knowledge nor attitude was associated with any demographic characteristic. One hundred and three (71.0%) respondents had good practice and 42 (29.0%) poor practice of the CAUTI bundle. Practice was not associated with any demographic variable, but significantly associated with knowledge (χ2 8.62, df = 1, p < 0.001). One hundred and fifty-eight (87.8%) respondents had received training on catheter care as part of their nursing education, however there was no association between previous training and knowledge or practice of CAUTI prevention. Findings from the check list showed meatal hygiene not performed daily (23.8%) and urine bag and tubing on the floor (38.1%). Conclusion: There is an urgent need for education intervention to improve the knowledge and practices of CAUTI prevention bundle among nurses in the study area.

Implementation of evidence-based strategies to reduce catheter-associated urinary tract infections among hospitalized, post-surgical adults

Several catheter-associated urinary tract infection (CAUTI) prevention interventions were successfully implemented and evaluated on a surgical unit in a community-based hospital. Sustainability of CAUTI prevention efforts requires daily communication between multidisciplinary staff. In our hospital, daily report on CAUTI events and indwelling catheters at a hospital-wide, multidisciplinary safety huddle contributed to an enhanced focus on CAUTI-prevention strategies and unit-level reduction in device use days and CAUTI rates.

External Female Urinary Catheter: Implementation in the Emergency Department

The emergency department is a care environment in which indwelling urinary catheters are placed frequently; however, the significance of the role of the emergency department in catheter-associated urinary tract infection prevention has been overlooked. The use of an external female urinary catheter is an alternative to placing an indwelling urinary catheter for female patients in the emergency department who are incontinent of urine or are immobile. The purpose was to describe the implementation of an initiative to decrease the number of indwelling urinary catheters and increase the use of external urinary female catheters in non–critically ill women who visited the emergency department at a 451-bed Magnet-designated community hospital in the Southeast. For this clinical implementation project, the Plan, Do, Check, Act framework was used to develop the initiative, and outcome data were collected retrospectively and included an indirect calculation of the number of indwelling urinary catheters placed in the emergency department. A total of 187 external catheters were used in place of indwelling catheters in female patients over a 3-month period. No skin irritation or breakdown was observed. This project demonstrated the initial staff acceptability and feasibility of external female urinary catheter use in the ED setting.

Successfully Sustaining Infection Reductions: A Catheter–Associated Urinary Tract Infection (CAUTI) Prevention Initiative Five Years In

Background: Infection prevention efforts are complex, and sustaining reductions is even more challenging. At the UNC Medical Center, multidisciplinary hospital-wide work groups implement quality improvement initiatives to prevent healthcare-associated infections. The first and most successful initiative has been our catheter-associated urinary tract infection (CAUTI) prevention effort, which started in 2014. The program led to initial dramatic reductions, with continued reductions in CAUTI rates each year since then. Methods: A multidisciplinary workgroup formed in 2014 developed an evidence-based CAUTI prevention bundle and partnered with the nursing staff in 2015–2016 to implement practice changes as part of our hospital’s quality improvement “Spread of Innovations” model. These changes included (1) creation of a 2-person catheter-insertion checklist; (2) insertion skills validation for all nursing staff and nursing assistants; (3) standardization of a maintenance protocol and subsequent education and skills validation with nurses and nurse assistants; and (4) peer audits of urinary catheter maintenance. Additional initiatives implemented over the past 5 years include (1) routine resident education on CAUTI prevention; (2) annual nurse competencies to reinforce skills around CAUTI prevention; (3) introduction of products (eg, PureWick) as alternatives to indwelling catheters; (4) diagnostic stewardship efforts; (5) revisions to the electronic medical record; and (6) efforts to encourage removal of unnecessary catheters such as the “nurse-driven conversation” and Trial of Void. Results: Our CAUTI rates decreased 65% from 2.94 per 1,000 catheter days in the baseline period of 2014 to 1.02 in 2018. In our ICUs (excluding the neonatal ICU), the rate dropped 75% from 4.30 in 2014 to 1.08 per 1,000 catheter days in 2018. Conclusions: We attribute our continued reductions and successful sustainment of low CAUTI rates to several factors. First, the use of a multidisciplinary team was critical to obtaining buy-in from key stakeholders including nursing, nurse assistants, physicians, pharmacists, performance improvement specialists, and administration. Second, continuation of the maintenance peer audits outside the initial project year has provided an important framework for this project, giving regular opportunities for frontline staff to evaluate patients’ catheter condition and to give feedback to colleagues or “just in time education.” These activities potentially prevent infections in real time. Third, with the many competing priorities demanding clinicians’ attention, it has been important for the CAUTI workgroup to continue to evaluate the problem, to determine where opportunities for improvement remain, and to tailor initiatives to meet those needs. In this way, new work can focus on priorities identified by staff, and CAUTI prevention initiatives remain relevant.Funding: NoneDisclosures: None

Piloting a Quality Improvement Intervention for Urinary Catheter Removal to Reduce Catheter-Associated Urinary Tract Infection in a Medical Intensive Care Unit

Background: Catheter-associated urinary tract infections (CAUTIs) are among the most prevalent healthcare-associated infections (HAIs) globally, contributing to increased morbidity, prolonged hospital stays, and increased healthcare costs. Interventions that support prompt removal of the urinary catheter are evidence-based actions to effectively reduce CAUTI rates.1Objective: At the National Hospital of Tropical Disease (NHTD), catheter removal interventions in the intensive care unit (ICU) were implemented using quality improvement (QI) methodology to reduce CAUTI incidence and urinary catheter device utilization. Methods: Training was performed for ICU clinical staff with knowledge checks before and after the program. A bedside visual reminder of CAUTI risk and checklist to assess catheter need were implemented. Weekly compliance of provided visual reminders and checklists were measured using a simple audit tool. Device utilization ratios (DURs, ratios of device days to patient days), and CAUTI incidence rates (per 1,000 device days) were collected at baseline (July–September 2018) and quarterly thereafter until June 2019. Statistical significance was determined by an independent t test. Results: In the first quarter (October–December 2018), the CAUTI incidence rate decreased from 8.9 to 1.3 per 1,000 device days (P = .036). The ICU staff trained in CAUTI prevention, mean knowledge scores before and after training increased from 68% to 87%. The DUR decreased slightly from 0.59 to 0.55 after the first-quarter training then steadily increased in the following quarter (0.60; January–March 2019) and after the intervention (0.54; April–June 2019). CAUTI incidence rates also increased but were still lower than at baseline: 4.8 and 6.3 per 1,000 days of device use. Compliance of reminders was 51% during the first quarter, increased slightly in the second quarter 62%, then decreased to 40% during the last quarter. The nurses’ adherence to the daily checklist remained stable (&gt;75%). Conclusions: This CAUTI prevention project was the first use of quality improvement methodology to implement change at NHTD. A trend decrease in CAUTI was observed, though a greater decrease occurred at the beginning of the intervention. Limited compliance of daily reminders is likely reflected in no statistically significant decrease in DUR. Possibly, this quality improvement project raised awareness among clinicians to improve general CAUTI prevention practices in the ICU without decreasing DUR. Given limited compliance with reminder and checklists, the intervention will be revised during the next PDSA cycle to improve adherence.1Meddings J, Rogers MA, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 2014;23:277–289.Funding: NoneDisclosures: None

CAUTI: A Journey of Micturition at MICU Since 2014

Background: Catheter-associated urinary tract infections (CAUTIs) have gained popularity in recent years for increasing morbidity and mortality in multiple healthcare settings. In fact, they are the most common type of healthcare-associated infection (HAI) in US hospitals, and they account for ~35% of HAIs. Objectives: At our institution, CAUTI rates were higher than the national average; therefore, various preventative protocols were implemented. Southeast Health’s Medical ICU (MICU) has taken many measures to decrease the CAUTI incidence. Methods: We conducted an observational study with a retrospective analysis of the data beginning in 2014 after a poor performance at prevention of CAUTIs as noted in the Leapfrog Hospital Survey. As part of improving prevention measures in MICU, we started a lean project in 2015 that primarily focused on systems-based practices and improvements in the existing nurse protocols. Results: We were successful in this endeavor and in August 2018 the Alabama Department of Public Health (ADPH) reported that we still lower than the national average in prevention of CAUTIs. This finding led us to tighten the protocols and to appoint 2 infection preventionists in the MICU. With the assistance of the infection preventionists, we were able to actively decrease indwelling catheter and device days with daily multidisciplinary rounds to access the necessity for catheter use. We also set monthly attainable targets and reinforced nurse driven protocols with educational in-service programs. One of the most significant additions was the introduction of female external catheters (Purewick) in December 2019 and male external catheters (Liberty) in May, 2019. Our results showed a significant reduction in the number of CAUTIs divided by number of Foley catheter days in the MICU from 32 of 7,435 in 2014 to 1 of 5,934 in 2019. We are excited to see reduction in the CAUTIs with our above measures. We will continue our measures to reach our target of 0 CAUTIs, and we plan to remain above the national average.Funding: NoneDisclosures: None

Targeted Assessment for Prevention Facility Assessments: The Most Common CAUTI and CLABSI Infection Prevention Gaps

Background: The Targeted Assessment for Prevention (TAP) strategy is a quality improvement framework created by the Centers for Disease Control and Prevention (CDC) to facilitate the reduction of healthcare-associated infections (HAIs). TAP facility assessments are a component of the TAP strategy and are completed by staff across the facility to help identify perceptions of and target infection prevention gaps. We have described the gaps most commonly reported by facilities completing TAP facility assessments for catheter-associated urinary tract infections (CAUTIs) and central-line–associated bloodstream infections (CLABSIs). Methods: TAP CAUTI and CLABSI assessments were completed by acute-care facilities across the nation, with CDC technical assistance, from December 2014 to August 2019. Similar questions across 2 versions of CAUTI assessments and 3 versions of CLABSI assessments were combined. Analysis was limited to facilities with ≥10 assessments. Infection prevention gaps were defined as ≥33% respondents answering Unknown, ≥33% respondents answering “no,” or ≥50% of respondents answering “no” and “unknown” or “never” and “rarely” “sometimes” “unknown.” The analysis was completed at the facility level, and the gaps most commonly reported across facilities were identified. Results: In total, 1,942 CAUTI assessments from 42 facilities in 12 states and 1,623 CLABSI assessments from 29 facilities in 11 states were included for analysis. The mean numbers of assessments per facility were 46.2 for CAUTIs and 56.0 for CLABSIs. Across both CAUTIs and CLABSIs, commonly reported perceptions about infection prevention gaps included lack of physician and nurse champions for prevention activities, failure to conduct competency assessments, and inconsistency in select device insertion practices (Fig. 1). For CAUTIs, lack of practices to facilitate timely removal of urinary catheters were also commonly reported, with one-third of facilities reporting inconsistency in use of alerts for catheter removal, 78.6% reporting lack of physician response to these alerts, and 90.5% reporting deficiencies in removing unnecessary catheters in the postanesthesia care unit. For CLABSIs, 79.3% of facilities reported failure to replace central lines within 48 hours after emergent insertion, and 62.1% reported that feedback was not provided to staff on central-line device utilization ratios. Conclusion: For both assessments, absence of CAUTI and CLABSI prevention champions, failure to conduct competency assessments, and inconsistency in performing device insertion practices were commonly reported across facilities. These common gaps have and will continue to inform the development of tools and resources to improve infection prevention practices as well as help to better target the implementation of interventions.Funding: NoneDisclosures: None

Catheter-Associated Urinary Tract Infection Reduction in the Solutions for Patient Safety Pediatric Safety Engagement Network

Background: Catheter-associated urinary tract infections (CAUTIs) are a leading cause of healthcare-associated infection. Catheter insertion and maintenance bundles have been developed to prevent CAUTIs, but they have not been extensively validated for use in pediatric populations. We report the CAUTI prevention efforts of a large network of children’s hospitals. Methods: Children’s hospitals joined the Solution for Patient Safety (SPS) safety engagement network from 2011 through 2017 and elected to participate in CAUTI prevention efforts, with 26 hospitals submitting data initially and 128 participating by the end. CAUTI prevention recommendations were first released in May 2012, and insertion and maintenance bundles were released in May 2014 (Table 1). Hospitals reported on CAUTIs, patient days, urinary catheter line days (CLD), and they tracked reliability to each bundle. For the network, control charts were used to plot CAUTI rates, urinary catheter utilization, and reliability to each bundle component. Results: Following the introduction of the pediatric CAUTI insertion and maintenance bundles, CAUTI rates across the network decreased 61.6%, from 2.55 to 0.98 infections per 1,000 CLD (Fig. 1). Centerline shifts occurred both before and after the 2015 CDC CAUTI definition change, which may also have contributed to a centerline shift. Urinary catheter utilization rates did not decline during the intervention period. Network reliability to the insertion and maintenance bundles increased to 95.4% and 86.9%, respectively. Conclusions: Insertion and maintenance bundles aimed at preventing CAUTIs were introduced across a large network of children’s hospitals. Across the network, the rate of urinary tract infections among hospitalized children with indwelling urinary catheters decreased 61.6%.Funding: NoneDisclosures: None