Running head: PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN

Prevention of Catheter Associated Urinary Tract Infections

Liya Sarkisyan University of California, Los Angeles Spring 2013

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN Phase 1: Validation Phase Urinary tract infections (UTI) associated with indwelling catheters are the second most common cause of nosocomial infections worldwide (Pickard et al., 2012). UTIs are specifically defined as a threshold of bacteria being greater than 100,000 ml -1 (Peng et al.,

2010). When careful monitoring of urine output is needed, such as in intensive care units and in patients undergoing or recovering from complex surgeries, indwelling catheters are frequently used. However, caution must be taken to ensure that the benefits of using urinary catheters outweigh the many risks that may follow. If an infection ensues, these risks include prolonged hospital stays, bacteremia, sepsis, prosthetic join infections, and even death (Wald et al., 2008). Several studies have shown that the most effective intervention in preventing catheter-associated urinary tract infections (CAUTIs) is removing them as soon as they are no longer necessary or avoiding their use altogether (Elpern et al., 2009). However if their use is mandatory, nurses must be knowledgeable about various interventions that may help reduce CAUTIs. The information presented on the pilot study in this paper is based on the following research articles: 1) Cardenas, D.D. & Hoffman, J.M. (2009). Hydrophilic catheters versus non-coated catheters for reducing the incidence of urinary tract infections: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 90, 1668-1671. doi: 10.1016/j.apmr.2009.04.010 2) Chung, Y.C., Chen, H.H., & Yeh, M.L. (2012). Vinegar for decreasing catheter-associated bacteriuria in long term catheterized patients: A randomized controlled trial. Biological Research for Nursing, 14(3), 294-301. doi: 10.1177/1099800411412767 3) Elpern, E.H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., & Lateef, O. (2009).

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN Reducing use of indwelling urinary catheters and associated urinary tract infections. American Journal of Critical Care, 18(6), 535-541. doi: 10.4037/ajcc2009938 Cardenas & Hoffman (2009) conducted a randomized control trial to investigate whether using a hydrophilic catheter versus a non-coated catheter would result in fewer symptomatic UITs treated with antibiotics. Subjects (n=56) all had spinal cord injuries and were recruited through local newspaper advertisements, notices in Seattle-area clinics, and through the newsletter of the Northwest Regional Spinal Cord Injury System. Subjects completed a sociodemographic, equipment, and usual catheterization procedure

questionnaire, provided a 40-50 mL urinal sample for urinalysis and culture (collected once a month for the first 3 months then at months 6, 9, and 12), and completed an inventory of UTI symptoms on a monthly basis. The control group used a new, non-coated catheter with each catheterization throughout the study and was instructed on proper clean technique by a nurse. Only 45 participants (22 in the treatment group and 23 in the control group) completed the study. Mean comparisons by t tests and a chi-square comparison were done, as well as a Poisson regression using the number of symptomatic UTIs as the dependent variable. Results revealed that there was no difference in the number of symptomatic UTIs between groups (p = .61) but the number of UTIs that was associated with antibiotic treatment was significantly lower for the experimental group than for the control group (p < .02). Results also showed that UTIs occur more frequently in women when all other variables have been controlled. Limitations in the study included a small sample size and including a small number of women in the study (16 versus 29 men), suggesting that the finding that women are more at risk of catheter associated UTI might not be true. Finally, subjects were asked to self-report their symptoms, which always presents the possibility of false or inaccurate reporting.

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN Chung et al (2012) designed a single-blinded randomized controlled trial study to

evaluate the potential that rice vinegar administered via a nasogastric (NG) tube may have on decreasing CAUTI rates. In comparison to pharmaceutical drugs, vinegar is affordable, easy to preserve, readily accessible, and has been shown to suppress bacterial growth on lettuce and on animal feces. The experimental group received 100 mL of diluted vinegar while the control group received the same amount of water, both through an NG tube. The convenience sample (n = 60) was recruited from a long-term care facility in Taiwan and was equally divided in half into each group. However, only 44 patients completed the study with 25 in the experimental group and 19 in the control group due to the emergence of pneumonia, wound infection and UTIs in both groups. Urinalysis was performed before the study (pretest) and every week for 4 weeks (posttest 1, 2, 3, 4) and urine was cultured 1 week before the study (pretest) as well as on day 28 (posttest 4). A new catheter was used for all patients at the beginning of the study and CAUTIs were tracked by pH, bacterial titer, and turbidity. Data analysis was done using SAS 8.02 and SPSS 15.0 and results were determined using the Students t- test, Chi square test and generalized estimating equations (GEE). The study found that urine pH differed significantly between groups (p < 0.1) at pretest and after controlling for group-time interaction (every 4 weeks at each post test). No significant between-group difference in bacterial titer (p = .50) at pretest and no time-dependent effect was found. Significant between-group difference in bacterial titer was found at posttest 2 (p < .001) and 4 (p < .05) but not at posttests 1 (p = .63) and 3 (p = 40). For urine turbidity, there was a significant difference between groups (p < .001) at pretest and after controlling pretest and group-time interaction in the GEE model. There was no significant change in the number of bacterial strains from pretest to posttest 4 in the experimental group (X2(df = 4) = 1.93; p = .75) or in the

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN

control group (X2(df = 4) = 6.74; p = .15). This study provided healthcare providers and patients with an effective, non-pharmaceutical alternative to reducing bacterial growth in long-term catheterized patients. However, limitations included the small sample size, lack of investigation into the actual mechanism by which vinegar prevents UTIs, and the need for further research to explore the relationship between catheterization and other nosocomial infections. Elpern et al (2009) were interested in decreasing CAUTIs by restricting their use and removing urinary catheters as soon as their functional purpose was no longer warranted. After reviewing the literature, a team of clinicians developed and then taught their fellow healthcare partners criteria that described appropriate and inappropriate uses for indwelling catheters. Some examples of inappropriate indications included diuresis, frequent but nonessential determination of urinary output, and patient preference for catheterization when it was clinically unnecessary. Their quasi-experimental study consisted of 337 intensive care unit (ICU) patients over a 6-month period at the Rush University Medical Center in Chicago, Illinois. Each patient with a urinary catheter at the time of morning identification was counted as 1 device day and CAUTI rates were calculated by dividing the number of CAUTIs by the number of urinary catheter devices, multiplied by a1000. The data collected during the intervention phase, which included duration and appropriateness of catheterization, was analyzed alongside monitoring for CAUTIs. Using unpaired t tests to compare CAUTI rates before and after the intervention, it was found that 0 CAUTIs occurred during the 1432 device days as opposed to the 15 CAUTIs during the 3429 device days (4.7 per 1000 days). Results also showed that after the intervention, mean catheter days declined to 238.6 days per month from 311.7 days per month in the 11 months before the intervention. In all, 32% of device days were considered to be inappropriate. These differences were

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN statistically significant (p < .001) and supported the researchers hypothesis. Limitations included use of a single unit in a single institution, use of only indwelling urinary catheters, no control group, and the inability to calculate mean duration of catheterization before the intervention.

Overall, the rates of CAUTIs can be reduced if more time is spent on appropriate and mindful interventions. In all three studies, uses of non-pharmacological measures were the primary means of preventing CAUTIs. Although there are studies that investigate antibiotic prophylaxis in CAUTIs (Petronella et al., 2011), empirical use may contribute to the growing concern of drug resistant bacteria. The structure of the Elpern et al (2009) and Cardenas & Hoffman (2009) study underlined the vital role that nurses have in prevention of this prevalent nosocomial infection. In the Elpern et al (2009) study, nurses were the ones consulted by co-investigators about the primary reason for placement or continuation of the catheters. In fact, physicians are often unaware that their patients have been catheterized or do not know why they have been catheterized (Saint et al., 2000). In the Cardenas & Hoffman study (2009), it was the nurse that provided education to patients on sterile catheter use. Phase II: Comparative Evaluation Phase Fit of setting The findings from the articles described above are very applicable to my clinical setting. All three took place in long-term facilities, where nurses are familiar with placing and removing urinary catheters. Most healthcare organizations are also very concerned about UTI rates due to patient safety and insurance reimbursement. Substantiating Evaluation

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN Although the three studies varied in their interventions, their desired goal towards reducing CAUTIs was the same. The studies acknowledged that the best way to prevent infection was to decrease amount of catheter use but if that was not possible, nonpharmaceutical approaches should be considered. The study conducted by Cardenas and Hoffman (2009) used intermittent catheterization on spinal cord injury patients specifically. Basis for Practice My intervention would be centered around using clinical nurse leaders (CNL), who are trained to make fundamental systemic changes at the point of care that are driven by patient outcomes, to educate staff members about inappropriate catheter use and then

evaluate each patient using this criteria. The Evidence-Based Practice (EBP) Model that will be used is Stetlers model outlined by the National Collaborating Centre for Methods and Tools (2011). During the preparation phase, the clinical problem will be identified and search of the literature on prevention of CAUTIs will also be done. A large amount of research supports the importance of preventing and managing CAUTIs. The validation phase would consist of evaluating the credibility and reliability of the studies found in the literature. The comparative evaluation/decision-making phase would entail organizing and summarizing all validated sources and determining whether to use or reject the findings to move forward in the study. The clinical problem was narrowed down to three articles whose basis for the intervention was the same. Data on the rate of UTIs for specific institutions will be obtained from the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention. Implementation will take place during the translation/application phase. In phase IV, type of research use, method, level of use, and change strategies will be discussed. This will include various educational sessions offered to nursing staff by CNLs as well as a checklist of what to evaluate before inserting a catheter. In phase V, outcomes will be stated

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN and clarified. This will be defined as the number of CAUTIs each month over a 1 year period. Feasibility Benefits of using the intervention described above would be an increase in the

awareness of nurses of the important role they play in preventing CAUTIs. This, in turn, will improve patient outcomes, reduce cost, prevent complications in patient care, promote earlier discharge, and improve quality of life. Disadvantages might include going against patient preference for catheterization, resistance from staff members for change, and dissatisfaction from nurses to have an extra task added to their already busy schedules. Phase III: Decision-Making Phase Pilot Study The goal would be to determine a standardized, evidence-based approach to routinely evaluate the necessity of catheter use in ICU patients. Nurses are the most important decision makers when it comes to assessing whether catheter use is necessary and must take a more active role in eliminating use if possible. The pilot study will take place for 1 year in 2 different long-term care facilities that participate in the NHSN. Participants will be approximately 200 nurses in each hospital who have at least 5 years of experience. Final sample size will be determined by a power analysis. The patient population will be patients on all ICU units who have an indwelling urinary catheter. Nurses will be randomly assigned to either the experimental group, in which they will have formal educational sessions provided by CNLs on how to evaluate for unnecessary catheter use, or to the control group, in which they will have educational sessions on CAUTIs but not be given specific instructions on how to evaluate for unnecessary catheter use. Both information sessions will

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN include statistics about the prevalence and importance of reducing UTIs as a nosocomial

infection as well as information about various non-pharmaceutical approaches, including the use of vinegar described in the study done by Chung et al (2012). The experimental and control groups will be randomly assigned on each floor and in the two hospitals to control for any confounding variables that might have to do with the units or institutions. I hypothesize that by providing nurses with education about the difference between appropriate and inappropriate uses of indwelling catheters and how to educate patients about them, rates of CAUTIs will dramatically decline. There will be a set of prepared standards of what is an appropriate indication of urinary catheter use and what isnt as well as criteria that a patient must meet to be classified as having an UTI (See table 1 and 2 in Elpern et al., 2009). Both educational sessions will be provided by CNLs once a week for four weeks before implementation. When the study begins, each patient with a catheter at the time they are assessed will be counted as 1 device day. CAUTI rates will be calculated by the number of CAUTIs divided by the number of urinary catheter devices days multiplied by 1000. CAUTIs will be determined by obtaining a urinalysis at month 1, 3, 6, 9, and 12 by pH, bacterial titer, and turbidity. The number of CAUTIs per month on each floor in each institution will be obtained and graphed. Data collection will also include duration of catheterization and reasons for inappropriate use. Nurses in the experimental group will be asked to evaluate if the use of the catheter is necessary using the criteria twice during each shift. In order for this study to work, CNLs, doctors, unit managers, and nurses must accept the changes that may be brought forth. Each of these healthcare providers should already have the inner motivation to do all that it takes to improve patient safety, reduce mortality, and improve outcomes. However, an incentive will also be provided to externally help motivate the nurses. If the number of CAUTIs are kept below 10 each month for each unit,

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN the nurses participating in the study will each receive a $10 American Express gift card for each month that they meet this goal. Motivational flyers for lowering CAUTI rates will be posted in the staff lounge and mentioned in morning report.

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Barriers to change that this study will introduce is a resistance from nurses to have an additional task added to their already busy workload as well as fear of low satisfaction scores if they go against a patients preference for catheterization when its not actually necessary. One method to overcome these barriers is inviting all nurses to submit anonymous questions about their concerns to the CNLs, which will then answer them all during the educational sessions or address them in morning huddles. Giving the nurses a sense that they are not alone in their fears and providing evidence-based reasons for why what they are doing is so important will help decrease their resistance and improve compliance. Another method is to give nurses friendly reminders about the evaluation so that they dont forget about its importance. This can include pop-up messages on the computer screen the first time that the nurse scans the patients identification band to give morning medications. Communication of Findings For the administration of the organization, findings can be communicated using a PowerPoint presentation that explains the studys plan, implantation measures, cost, adherence, barriers, and statistical results. The PowerPoint presentation can be presented by all CNLs that were involved in the study. For staff nurses and ancillary health care personnel, findings can be presented on professional poster presentation boards and placed in both in the staff lounge and right next to where the supplies for a catheterization procedure are located. Finally, findings can be communicated to the public through the hospitals website, newsletters, and brochures can be placed near all entrances to the hospital.

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN

CITATION Cardenas, D.D. & Hoffman, J.M. (2009). Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 90, 1668-1671. doi: 10.1016/j.apmr.2009 .04.010 PURPOSE Prospective study to test whether use of a hydrophilic versus noncoated catheter would result in less symptomatic UTIs treated with antibiotics SAMPLE/SETTIN G n=56; 45 participants (22 in treatment group and 23 in control group) completed the study. Participants all had spinal cord injury and were recruited through local newspaper ads, notices in Seattlearea clinics, and through the newsletter of the Northwest Regional Spinal Cord Injury System. METHODS Randomized controlled trial. Intervention was use of hydrophilic catheter for intermittent catheterization. Control group were instructed about proper clean technique and used a new catheter with each catheterization throughout the study. Subjects completed a sociodemographic, equipment, and usual catheterization procedure questionnaire, provided a 40-50 mL urinal sample for urinalysis and culture and completed an inventory of UTI symptoms on a monthly basis. RESULTS

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DISCUSSION & LIMITATIONS No difference in the number of subjects who had at least 1 UTI found across groups. Results showed that UTIs occur more frequently in women when all other variables have been controlled.

Mean comparisons by t test, chi-square comparison, and Poisson regression was used. No difference in the number of symptomatic UTIs between groups (p = .61) but number of UTIs associated with antibiotic treatment was significantly lower for the experimental group (p < .02). Limitations included small sample size and self-reporting of symptoms.

Chung, Y.C., Chen, H.H., & Yeh, M.L. (2012). Vinegar for decreasing catheterassociated bacteriuria in long term catheterized patients: A randomized controlled trial. Biological Research for Nursing, 14(3), 294-301. doi: 10.1177/109980041 1412767

Prospective study to evaluate the effect of administering rice vinegar via a nasogastric feeding tube on catheterassociated bacteriuria in patients with long-term urinary catheterization.

n= 60; 44 participants (25 in the experimental group and 19 in the control group) completed the study. Participants who were catheterized for more than 30 days were recruited in a long-term care facility in Taiwan.

Single-blinded randomized controlled trial design was used. Experimental group received 100ml of diluted rice vinegar through and NG tube and the control group received an equal amount of water via the same route. Urinalysis was done at pretest and every 4 weeks afterwards for 4 posttests. CAUTI was tracked by pH, bacterial titer, and turbidity. Data analysis was done using SAS 8.02 and SPSS 15.0. Results were determined using the Students t- test, Chi square test and generalized estimating equations (GEE).

Urine pH differed significantly between groups (p < 0.1) at pretest and after controlling for grouptime interaction. No significant betweengroup difference in bacterial titer (p = .50). Significant betweengroup difference in bacterial titer at posttest 2 (p < .001) and 4 (p < .05) For urine turbidity, there was a significant difference between groups (p < .001) at pretest and after controlling pretest and group-time interaction in the GEE model. No significant change in the number of bacterial strains from pretest to posttest 4 in the experimental group (X2(df = 4) = 1.93; p = .75) or in the control group (X2(df = 4) = 6.74; p = .15)

All 3 measures improved over time in the group that received vinegar administration compared to the control group. Vinegar ingestion may acidify urine and acidified urine may inhibit bacterial growth. Over time, urine turbidity also decreased. Limitations included small sample size, unclear mechanism by which vinegar prevents CAUTI.

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Elpern, E.H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., & Lateef, O. (2009). Reducing use of indwelling urinary catheters and associated urinary tract infections. American Journal of Critical Care, 18(6), 535-541. doi: 10.4037/ajcc200993 8 Quasiexperimental study that aimed to reduce the number of UTIs by limiting the use of indwelling urinary catheters n=337; Participants were patients who were admitted to the ICU of the Rush University Medical Center in Chicago, Illinois between December 1, 2007 and May 31, 2008. 58% were women and the age range was 18-99, with a mean of 61 years. Informed consent was not required. A set of appropriate and inappropriate indications for use of urinary catheters were defined and taught to staff members. Patients with urinary catheters were evaluated every day using these criteria until the catheter was removed. Each patient that was identified with a catheter in the morning counted as 1 device day. CAUTI rates were defined as the number of CAUTIs divided by the number of urinary catheter device days multiplied by 1000. Unpaired t test used.

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456 of the 1432 device days (32%) were considered inappropriate. 108 inappropriate days of which urinary catheters were placed in the emergency department or outside facility and had to be removed. 119 or 1095 device days (11%) inappropriate days for catheters in place for 24 hours or more. Reduction of 73.1 catheter days after the intervention. There were 0 CAUTIs after intervention compared to 15 prior to intervention (p < .001). CAUTIs are a quality of care measure and reasonable goals to avoid catheter overuse can help lower their occurrence. Nurses play a central role in judging whether catheters should be placed and removed. Limitations included use of a single unit in a single institution, use of only indwelling urinary catheters, no control group, and the inability to calculate mean duration of catheterization before the intervention.

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN References Cardenas, D.D. & Hoffman, J.M. (2009). Hydrophilic catheters versus noncoated catheters

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for reducing the incidence of urinary tract infections: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 90, 1668-1671. doi: 10.1016/j.apmr.2009.04.010 Chung, Y.C., Chen, H.H., & Yeh, M.L. (2012). Vinegar for decreasing catheter-associated bacteriuria in long term catheterized patients: A randomized controlled trial. Biological Research for Nursing, 14(3), 294-301. doi: 10.1177/1099800411412767 Elpern, E.H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., & Lateef, O. (2009). Reducing use of indwelling urinary catheters and associated urinary tract infections. American Journal of Critical Care, 18(6), 535-541. doi: 10.4037/ajcc2009938 National Collaborating Centre for Methods and Tools (2011). Stretler model of evidencebased practice. Hamilton, ON: McMaster University. Retrieved from http://www.nccmt.ca/registry/view/eng/83.html Petronella, P., Scorzelli, M., Fiore, A., Corbisiero, M.C., Agresti, E., Esposito, S., & Freda, F. (2011). Antibiotic prophylaxis in catheter-associated urinary infections. New Microbiologica, 35, 191-198. Peng, M., Fang, Y., Hu, W., & Huang, Q. (2010). The pharmacological activities of compound salvia plebeian granules on treating urinary tract infection. Journal of Ethnopharmacology, 129, 5963. doi: doi:10.1016/j.jep.2010.02.029 Pickard, R., Lam, T., MacLennan, G., Starr, K., Kilonzo, M., McPherson, G.,NDow, J. (2012). Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterization in hospital: A multicenter randomized controlled trial. The Lancet, 380, 1927-1935.

PREVENTION OF CATHETER ASSOCIATED URINARY TRACT IN Saint S., Wiese, J., Amory, J.K., Bernstein, M.L., Patel, U.D., Zemencuk, J.K, Bernstein, B.A.,Hofer, T.P. (2000). Are physicians aware of which of their patients have indwelling urinary catheters? The American Journal of Medicine, 109(6), 476-480

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Wald, H.L., Ma, A., Bratzler, D.W., & Kramer, A.M. (2008). Indwelling urinary catheter use in the postoperative period. Archives of Surgery, 143(6), 551-557.