Running Head: INDWELLING CATHETERS 1

Reducing Urinary Tract Infections Associated with Indwelling Catheters Rachel Hodges Ferris State University

INDWELLING CATHETERS Reducing Urinary Tract Infections Associated with Indwelling Catheters A catheter that is placed in the bladder and remains in place is known as an

indwelling urethral catheter (IUC), also called a retention or Foley catheter. Catheters are used to empty the bladder when it cannot be done naturally. They are a useful tool and have been used for many years in health care facilities. However, there is one major issue associated with indwelling catheters. The Centers for Disease Control (CDC), attributes catheter associated urinary tract infections (CAUTIs) to 30% of the infections in acute care hospitals (Roser, Altpeter, Anderson, Dougherty, Walton, & Merritt, 2012). This is the largest proportion of hospital acquired infections. These infections can lead to longer hospital stays, higher costs, and mortality. It is in everyones best interest to reduce the amount of CAUTIs, and it takes help from everyone to do so. A lot of research has been done to find ways to make indwelling catheters less of a risk for patients and health care facilities. Many facilities have put into place protocols that define when a catheter may be inserted, how it should be maintained, and when it should be discontinued. These protocols have proven to be very effective when enforced properly. In one study, in 2011, [a] hospital infection prevention team implemented an evidence based nurse driven urinary catheter removal protocol that identified indicators for urinary catheter insertion, maintenance, and discontinuation. The protocol empowered nurses to communicate with physicians to determine the medical necessity for the catheter, and remove the urinary catheter within 24 hours unless contraindicated (Roser, Altpeter, Anderson, Dougherty, Walton, & Merritt, 2012). Extensive education was provided to the physicians and nursing staff about the protocol and the Infection

INDWELLING CATHETERS Prevention Team conducted surveillance rounds to evaluate medical necessity and appropriate catheter care (Roser, Altpeter, Anderson, Dougherty, Walton, & Merritt, 2012). The results of this study uncovered data showing that physicians inappropriately

ordered Foley catheters quite frequently. (Roser, Altpeter, Anderson, Dougherty, Walton, & Merritt, 2012). The education of the hospital staff and new protocol proved to be an effective way to decrease patient cases of CAUTI. After implementation of the protocol, the facility found a decrease in catheter utilization in the intensive care units (ICUs) and the medical/surgical units. Catheter utilization rates and number of CAUTIs show a significant decrease from 2010 to 2011 (Roser, Altpeter, Anderson, Dougherty, Walton, & Merritt, 2012). There were a few lessons learned in this study. Physicians now look at the use of indwelling catheters more seriously and encourage the use of bedpans, urinals, bedside commodes, adult briefs, and intermittent urethral catheters, all of which have less of a risk of infection. Also, nurses exhibit empowerment to remove the catheter when no longer needed (Roser, Altpeter, Anderson, Dougherty, Walton, & Merritt, 2012). Protocols, like the one put into place in this study, should be used in all health care facilities to reduce CAUTIs. Another factor that can lead to infections related to indwelling catheters is improper insertion and maintenance. There are nurse-directed interventions, like using proper technique, which can reduce the number of CAUTIs. The patients genital area should be cleansed with antiseptic cleanser from the cleanest area to the most contaminated area prior to insertion and daily cleansing should be continued. (Oman, Makic, Fink, Schraeder, Hulett, Keech, & Wald, 2012). This removes any existing bacteria so it is not introduced into the urinary tract along with the catheter. Clean gloves

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should be used by the nurse while cleansing the area and sterile gloves while inserting the catheter. (Oman, Makic, Fink, Schraeder, Hulett, Keech, & Wald, 2012). The urinary tract is a sterile environment so anything that will be introduced into it must be kept sterile. To prevent irritation, inflammation, and infection, the catheter should be secured to the patients thigh. (Oman, Makic, Fink, Schraeder, Hulett, Keech, & Wald, 2012). The drainage bag should remain below the bladder at all times to prevent backflow. (Oman, Makic, Fink, Schraeder, Hulett, Keech, & Wald, 2012). Any backflow could lead to infection. The drainage should be emptied every eight hours, when it is two thirds full, or when the patient is to be transferred. (Oman, Makic, Fink, Schraeder, Hulett, Keech, & Wald, 2012). This also helps to prevent backflow and infection. These techniques should be second nature to nurses and should be used with every catheter. Another intervention that has been researched that would reduce the amount of nosocomial infections related to indwelling catheters is applying a substance to the surface of the catheter to prevent colonizing of bacteria. Hydrophilic substances, antibiotics, heparin, silver oxide and silver alloy have all been applied to the catheter surface as a preventative measure (Davenport & Keeley, 2005). Silver-coated hydrogel catheters seem to be the most promising. The use of two types of silver-coated urethral catheters has been reported in the literature: silver oxide and silver alloy with hydrogel. The silver coating can be applied to either the internal or external catheter surface or to both. Silver alloy with hydrogel appears to be more effective at reducing CAUTIs than does silver oxide (Davenport & Keeley, 2005). Several studies have been done showing a statistically significant benefit in all patients with silver-coated catheters (Davenport & Keeley, 2005). Since the study, due to lack of evidence, silver-oxide-

INDWELLING CATHETERS coated catheters have since been withdrawn from the market. The predominant silveralloy-coated catheter with hydrogel is known as the Bardex IC catheter manufactured by C.R. Bard (Davenport & Keeley, 2005). The Bardex IC catheters should be used by health care facilities to prevent bacteria colonizing and creating a biofilm along the interior and exterior surfaces of catheters. Silver-coated catheters [are] used to varying degrees in 59% of hospitals (Fink, Gilmartin, Richard, Capezuti, Boltz, & Wald, 2012).

Although it is the hospital staffs primary responsibility to prevent infections with indwelling urethral catheters, educat[ing] patients and families on IUC self-care, signs and symptoms of infections, and discharge instructions (Fink, Gilmartin, Richard, Capezuti, Boltz, & Wald, 2012) can help to reduce CAUTIs. Nurses and other hospital staff have many patients to care for and sometimes signs of infections are not caught. If a patient is able to identify a possible infection and report it, the infection can be treated before it gets worse. Also, patients and their family members often provide bathing for the patient. If they are not taught how to properly care for their catheter, it may not be cleansed and an infection could develop. Hospitals that do not currently provide IUC care and maintenance education to patients and families should be encouraged to incorporate this into daily practice, partnering with patients to improve care. However, hospital administration must be aware that this strategy should not be a substitute for staff adherence to core infection control practices (Fink, Gilmartin, Richard, Capezuti, Boltz, & Wald, 2012). When multiple evidence-based practiced are used in combination, the amount of CAUTIs should decrease drastically. Education should be provided to all staff and

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protocols should be put into place that dictate when indwelling urethral catheters are to be used and when they should be removed. Surveillance should be used to determine if catheters are being used properly. Alternatives to catheters should be used whenever appropriate. These would include devices like bedpans, commodes, adult briefs, and urinals. If an indwelling catheter is needed, equipment like silver-alloy-coated catheters should be used to prevent colonization of bacteria. Proper insertion techniques should be used in order to keep the urinary tract sterile. While a catheter is in place, it needs to be maintained by frequently emptying the drainage bag, keeping the drainage bag properly placed, and cleansing the genital area. Finally, patients and their families should be educated on how to help with care. It has been proven that all of these techniques alone help to reduce CAUTIs, and if they are combined, should nearly eliminate the infections.

INDWELLING CATHETERS References Davenport, K., & Keeley, F. (2005). Evidence for the use of silver-alloy-coated urethral catheters. Journal of Hospital Infection, 60(4), 298-303. Fink, R., Gilmartin, H., Richard, A., Capezuti, E., Boltz, M., & Wald, H. (2012). Indwelling urinary catheter management and catheter-associated urinary tract infection prevention practices in nurses improving care for healthsystem elders hospitals. American Journal of Infection Control, 40(8), 715-720. doi:10.1016/j.ajic.2011.09.017 Oman, S., Makic, M., Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2012).

Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal of Infection Control, 40(6), 548-553. doi: 10.1016/j.ajic.2011.07.018 Roser, L., Altpeter, T., Anderson, D., Dougherty, M., Walton, J., & Merritt, S. (2012). A Nurse driven Foley catheter removal protocol proves clinically effective to reduce The incidents of catheter related urinary tract infections. American Journal of Infection Control, 40(5), e92-3. doi: 10.1016/j.ajic.2012.04.161

INDWELLING CATHETERS NURS 240 EBP In Health Care Paper Grading Rubric with Presentation (150 points possible)
Criteria Typeface Running head & page numbers Title page Abstract Margins, Indents, & Spacing Headings Body of Paper Citations Quotes & Abbreviations References (minimum of 3 appropriate APA scholarly resources; at least one must be a scholarly journal article) Total Criteria Presentation Gives 5 minute summary on EBP paper topic Uses a Clear, logical format Audio/Speech is clear Visual/Presence is clear Total Comments: Not Submitted 0 0 0 0 0 0 0 0 0 0 More Than 2 Areas Incomplete or Inaccurate 5 5 5 5 5 5 5 5 5 5 1 or 2 Areas Incomplete or Inaccurate 8 8 8 8 8 8 8 8 8 8 Complete & Accurate 10 10 10 10 10 10 10 10 10 10

100 Not completed 0 0 0 0 0 With Presentation More Than 2 Areas Incomplete or Inaccurate 5 5 5 5 5 1 or 2 Areas Incomplete or Inaccurate 8 8 8 8 8 Complete & Accurate 10 10 10 10 10 50