Prevent catheter-associated urinary tract infections
Recognizing risk factors on admission
After reading this article, you will be able to:
- Explain the rationale for inserting, continuing, and removing indwelling urinary catheters in hospitalized patients
- Identify populations at risk of catheter-associated urinary tract infections (CAUTI)
Editor’s note: The following is adapted from HCPro’s new book Preventing Catheter-Associated Urinary Tract Infections: Build an Evidence-Based Program to Improve Patient Outcomes. For more information on this book or any other in our library, visit www.hcmarketplace.com.
CAUTIs are the most common of all hospital-acquired conditions (HAC). Eighty percent of UTIs result from indwelling urinary catheters, and 12%–16% of patients admitted to acute care hospitals may have indwelling urinary catheters at some point during their stay.
Significant changes in assessment, care, and documentation are needed in most facilities to prevent CAUTIs in inpatient populations. And to effectively reduce CAUTIs in hospital settings, nurses’ attitudes regarding catheter use must change.
The knowledge that as many as 15%–25% of patients will have a urinary catheter inserted during the course of their hospitalization should provide sufficient cause for clinicians to recognize the risk for patients to acquire CAUTIs (see “Identifying CAUTI risk factors” on p. 5) as a result of catheter use in hospital settings1.
With this proportion of patients having indwelling urinary catheters, coupled with the fact that CAUTI is the most common type of HAC, the decision to place indwelling urinary catheters should not be taken lightly. Catheter insertion, continuation, and care are in the hands of clinicians who have an opportunity to prevent patients from being exposed to this significant HAC. It is important to assess patients who already have catheters in place on arrival, as well as to monitor those who have catheters placed once they are admitted to hospital settings.
It is also essential to review documentation tools and ensure that assessment items related to catheter insertion and care are in place to allow staff members to document specifics with ease. In organizations with electronic documentation, reports can be provided by mining data that allow clinicians to monitor the number and types of catheters used, specific aspects of the care provided, and the number of catheter days.
As patients enter your facility, assessments and appropriate actions should be taken with patients who are symptomatic for UTIs. In cases in which the patient presents with a catheter in place or requires catheter placement shortly after admission, having the proper tests completed to be able to document that the patient’s UTI was present on admission (POA) saves the organization from being held accountable for CAUTIs.
Decisions regarding the process for initial and ongoing assessment and management of patients with asymptomatic UTIs documented with positive urine cultures will need to be led by your physician champions with the guidance of infectious disease specialists. Recommended courses of action for assessment, monitoring, and management of symptomatic and asymptomatic bacteriuria also need to be established and communicated to physicians and to the clinical staff.
Detailed assessments of patients by their nurses during the admission process must be carefully partnered with and supported by physician documentation to determine whether a patient’s UTI preceded placement of the urinary catheter and was POA, or whether the infection was acquired as a result of the hospital admission and is then considered a HAC according to the Centers for Medicare & Medicaid Services’ (CMS) definitions2. POA conditions are determined by using the following criteria:
- There must be clear differentiation in the presence of diagnosis/condition at time of admission or development of the problem after admission.
- Physician documentation of the condition must exist in the patient’s medical record. If POA, it must be documented concurrently with the physician’s admission orders.
- Primary responsibility for complete and accurate documentation lies with the physician/licensed independent practitioner.
- Any incomplete documentation requires provider clarification.
Physicians and nurses must work closely as a team to identify patients at high risk for CAUTI and carefully and accurately document findings in patients’ medical records. These intraprofessional team members must also share the opinion that the best means of preventing CAUTI is to reduce catheter use whenever possible.
Nurses must remember that not all patients with a UTI develop signs and symptoms and learn how to distinguish between symptomatic and asymptomatic bacteriuria in these hospitalized patients3. Starting with comprehensive patient histories on arrival is essential to identify patients’ risk factors for developing a CAUTI or to determine whether they already have a UTI on admission.
1. Fernandez, R.S.; and Griffiths, R.D. (2006). “Duration of Short-Term Indwelling Catheters: A Systematic Review of the Evidence.” Journal of Wound Ostomy and Continence Nursing 33:145–155.
2. CMS (2008). “Hospital-Acquired Conditions.” Available from www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage.
3. Tambyah, P.A.; and Maki, D.G. (2000). “Catheter-Associated Urinary Tract Infection is Rarely Symptomatic.” Archives of Internal Medicine 160:678–682.
Identifying CAUTI risk factors
Current literature findings and a record review of patients with catheter-associated urinary tract infections (CAUTI) suggest the following as risk factors1:
- Gender (e.g., women are more likely to have UTIs than men)
- Advanced age
- History of urinary tract problems (e.g., enlarged prostate or urologic surgery)
- Neurologic conditions (e.g., spinal cord injury) causing neurogenic bladder problems
- Previous UTIs
- Previous and/or current abnormal voiding patterns
- Current catheter history
- Comorbid conditions such as diabetes
Patient assessments must also include documentation of any signs and symptoms of UTIs, including:
- A frequent urge to urinate
- A painful, burning feeling in the area of the bladder or urethra while urinating
- A fullness in the rectum (in men)
- Suprapubic tenderness
- Passing only a small amount of urine
- Cloudy or reddish-colored urine
- Fever greater than 100.3ºF (38ºC), with or without chills
- Pain in the back or side
1. Lo, E.; Nicolle, L.; Classen, D.; Arias, K.M.; et al (2008). “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals.” Infection Control and Hospital Epidemiology 29:S41–S50.
Adapted from Preventing Catheter-Associated Urinary Tract Infections: Build an Evidence-Based Program to Improve Patient Outcomes.