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Professional nurses can and must prevent urinary tract infections.

Ugh! Have you ever had a bladder infection? Almost every one of us have had the horrible sensation that you need to urinate. The burning when you do urinate. It feels like needles are passing through your urethra. Then there can be fever, back pain, the general aches, and overall sense of malaise. Well, just imagine going to the hospital and being "given" a urinary infection? As a patient, you might already be in pain and generally feeling like road kill, adding to that a urinary infection just seems like insult to injury.

Professional nurses have the opportunity to help patients and families heal. Professional nurses also have both the responsibility and the ability to prevent further damage and angst. Whether in a hospital, a home health agency, or a long term care organization, nurses are the caregivers that spend the most time with patients and can have the greatest immediate impact on their health. Health care acquired infections are devastating to patients and to their families. In 2002, it was estimated that 1.7 million infections were acquired in the health care setting. Of these infections, nearly 99,000 patients died (Klevens et al, 2002). Out of these 1.7 million infections, about 40% were urinary tract infections.

Urinary catheters are often seen as benign and a routine part of patient care. However, there are many reasons why urinary catheter care should not be considered as "business as usual," including the following potential complications. 1. Prolonged hospital stay, 2. Urinary sepsis, 3. Increased mortality, 4. Formations of encrustations or obstructive flow, 5. Reservoir for multi drug resistant organisms, and 6. Urethral strictures, orchitis, or prostatitis. The aforementioned complications can be devastating and there is an economic impact that must be considered as well.

According to a well known health economist, R. Douglas Scott, there are three factors that must be considered when evaluating the fiscal impact of any infection (March 2009). First, the direct cost to the facility and consumer, for example, antibiotics, increased length of stay, and potential procedures. Second, the costs related to productivity and nonmedical costs. Examples of this second component can include increase of cost for nursing wages or pharmacy wages to deal with the complication of increased care. Finally, the cost related to diminished quality of life, such as the financial and emotional burden on patients when they can no longer do the things they want to do. Imagine having to lose time at your job or stop going to personal hobby activities because you have to manage your catheter and receive home antibiotics every 12 hours. According to the Centers for Disease Control, the average cost per CAUTI (Catheter Associated Urinary Tract Infection) in a health care setting ranges from $1000 - $1300 dollars (CDC, 2009). This doesn't seem like a large figure but due to the volume of CAUTI's in the United States today, it is a billion dollar business.

So, what can we as nurses do to prevent catheter associated urinary tract infections? The primary action we can take is to follow the CDC's 2009 (CAUTI) Prevention Bundle (CDC 2009). The first action of the CAUTI bundle is to develop a trigger tool. A trigger tool prompts the nurse to ask the questions: "Why" is this catheter in place. Is it appropriate? As a vital part of the health care team, professional nurses (RNs) have a duty and an obligation to advocate for the health of our patients. So initiating a routine dialogue during provider rounds should include the date of catheter insertion and the discussion of whether or not the patient continues to need the catheter. Reasons for indwelling catheters include the following:

* Providing palliative care for incontinent persons who are terminally ill or severely impaired, for whom bed and clothing changes are uncomfortable.

* Managing skin ulceration caused or exacerbated by incontinence (Stage III or IV).

* Maintaining a continuous outflow of urine for persons undergoing surgical procedures that cause a delay in bladder sensation, or for individuals with chronic neurological disorders that cause paralysis or loss of sensation in the perineal area.

* Keeping with standard preoperative preparation for urologic surgical and procedures for bladder outlet obstruction.

* Providing relief for persons with an initial episode of acute urinary retention, allowing the bladder to regain its normal muscle tone.

* Need for accurate measurement of urinary output in intensive care settings. (CDC 2009).

When developing a CAUTI program, the RN should consider the following factors: 1. Alternatives to urinary catheters, 2. Proper techniques for insertion, 3. Proper urinary catheter maintenance, and 4. Quality improvement programs. The first action to review is considering alternatives to indwelling urinary catheters whenever possible. Examples would include external catheters for men, intermittent catheterization (or straight cath), special absorbent bed padding to urinary accidents such as hydrocolloid padding. In addition, the use of bladder scanners helps RNs to keep an eye on urinary retention and can aide in the use of intermittent catheterization.

A secondary action is that of proper technique for insertion. Insertion interventions would include programs in education, aseptic technique, hand hygiene, and early removal of catheters. A training program should be reviewed and implemented whereby clean hands and sterile technique of insertion and maintenance are key. Third, urinary bag maintenance is crucial; Education for bag maintenance plays an important role for nurses. Urinary bags should be emptied when 2/3 full. Changing the bag or catheter at routine intervals is not recommended. Rather the CDC recommends that catheters be evaluated based of indication (CDC 2009). Remember that the urinary catheter should be a closed system, meaning you should not break the seal. Often times as nurses we put in catheters and then decide we might need an urometer, for frequent monitoring. If at all possible utilize the appropriate catheter and bag system leaving the seal intact on the urinary device. If breaks or leakage occur and the patient still meets indicator criteria then replace the entire system, not just the bag. In addition, Hand Hygiene before manipulating the bag prevents infection (CDC, 2009). It is important for all health care providers who access the bag for urinary samples to use the appropriate ports and use aseptic technique. Cleanse the area with chlorhexadine gluconate and/or alcohol product prior to accessing the urinary drainage system for samples.

Finally, quality improvement programs focusing on prevention for urinary infection is a way to keep an ongoing focus on this issue. If your facility doesn't have a CAUTI program, start that dialogue. Protocols, algorithms, policies and procedures that allow for trigger tools and indication of catheter use can prevent CAUTI's. Education and performance feedback to nurses, nurse assistants, and other health care providers can reduce the incident of infection. Remember, radiology technicians, physical therapist, and other departments transport patients with urinary catheters and should be included in the education process.

Bottom line, nurses can prevent catheter associated urinary tract infections. Let's not keep these urinary catheters in for convenience sake. For more information and help in developing your program visit the Oklahoma Foundation for Medical Quality website at www.ofmq. com / hai.

References

Centers for Disease Control (2009). Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009. Centers for Disease Control --Health Infection Control Practices Advisory Committee. http://www.cdc.gov/hicpac/pdf/CAUTI/ CAUTIguideline2009final.pdf

R. Monina Klevens; Jonathan R. Edwards; Chesley L. Richards Jr.; Teresa C. Horan; Robert P. Gaynes; Daniel A. Pollock; Denise M., C. (n.d). Estimating health care-associated infections and deaths in U.S. Hospitals, 2002.(Report). Public Health Reports, 122(2), 160. Retrieved from Gale: Academic OneFile (PowerSearch) database

Scott, R. Douglas. (March 2009The Direct Cost of Medical Costs of Healthcare Associated Infections in US Hospitals and the Benefits of Prevention). Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention. http:// www.cdc.gov/ncidod/dhqp/pdf/Scott CostPaper.pdf

Disclaimer: This material is provided by the Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with The Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. HAI1015-OK-1010

Author: Toby Butler RN, CCRN, MSN Affiliation: HAI Quality Improvement Specialist Oklahoma Foundation for Medical Quality ONA Status: Member (Toby Butler)
PNEU 11%
SSI 20%
Other 22%
BSI 11%
UTI 36%

Note: Table made from pie chart.
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Author:Butler, Toby
Publication:Oklahoma Nurse
Date:Dec 1, 2010
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