Indwelling Catheters and Their Relation To Urinary Tract Infections - Essay Example

? Evidence Based Protocol Indwelling Catheters and their Relation To Urinary Tract Infections Nursing 500 Liberty Maxine Wardlow 03/29/11 Dr. Little Abstract Urinary tract infection (UTI) related to the use of catheter is very common in hospitals and nursing home settings. It is the most common type of nosocomial infection within nursing homes and its recurrence is a grave health issue, if healthcare providers do not take appropriate measures to contain and resolve this problem, which is a serious health hazard. UTI can lead to major health complications to human organs including ureters, bladder and kidney besides entailing complications like bacteremia. Catheter- associated urinary tract infections (CAUTIs) are caused by bacterial infections (e.g. Escherichia Coli), which is the common bacteria (Lindsay, E. 2001). In our place of practice, which is a nursing home facility, there have been significant increase in the amount of catheter and non-catheter related urinary tract infections in the patients undergoing treatment in the hospital. Research has shown that5% of patients that come to the hospital per day has urinary tract infection. Common endemic infection outbreaks as well as colonization and infection with antimicrobial drug resistant microorganisms have become a common feature within long term care facilities (Lindsay, E. 2001, pg. 205). Catheter associated urinary tract infections entail increased morbidity, mortality and financial costs. The nursing home facility has a protocol in place to reduce the number of UTIs, but it is rarely being utilized, and, therefore the system needs to be modified. CAUTIs can be reduced by removing the catheters upon arrival to the facility. Health care professional must assess the patients for the prevalence of UTIs, since this is a very common infection within nursing home facilities. Introduction and Preparation: The elderly population within the United States comes to approximately 40 million and by 2020 it is expected increase to 55 million. As the population grows, there exists a likelihood that most of the elderly will require assistance in long term care facilities. These sub-acute care facilities offer health related services for those persons who are in need of health care, for debilitated diseases which can no longer be treated in the hospital due to insurance or other financial constraints. Working in a nursing home and rehabilitation (NH/R) sub-acute environment has many challenges deriving from staffing problems, such as shortfall in nurse to patient ratio of 14 to 20 besides the chances of endemic infections. My main concern is the increased rate of urinary tract infections in patients with urinary catheters whether it is from the hospital or in-house (NH/R). In my facility, newly admitted patients from hospitals have or had indwelling catheters. Within 48 hours of admission, a few of the patients have showed signs and symptoms of urinary tract infection such as fever, abdominal tenderness and frequent need for urination with complaints of burning sensation. In such cases, the normal practice is to commence the administration of antibiotics prophylactically after collecting their urine specimens. The elderly are prone to a decrease in fluid intake due to a decline in the thirst mechanism and enhancing the chances of UTI. Urinary Tract Infections are caused by poor aseptic techniques and, therefore, catheters should not be used for convenience but for exclusive medical purposes only. According to the Center of Disease Control (CDC), the appropriate measures for indwelling urinary catheterization are: acute urinary retention, accurate measurement of urine output in critical patients and patients requiring prolonged immobilization, such as unstable spine or pelvic fractures. (Dumont, C. &Wakeman,J. 2010.Pg. 29). I, therefore, encourage charge nurses to discontinue the use of catheters. Studies have shown that infections in long-term care facilities are highly prevalent in the United States. The most frequent infections within nursing homes are respiratory tract, urinary tract, skin and soft tissue and gastrointestinal infections (diarrhea). Nosocomial infections are reported to affect one in ten hospital patients yearly and, approximately, it accounts for 23% of regular patients and 80% this relate to the use of indwelling urinary catheters. Urinary tract infections are the most common and it accounts for 0.46-4.4 frequency per 1,000 patient days. The National Healthcare Safety Networks (NHSN) define catheter associated urinary tract infection (CAUTI) as, “A urinary tract infection that occurs while the Foley catheter is in place or within 48 hours of its removal” (Wenger, J. 2010. pg.42). The use of urinary catheters is common hospitals and nursing homes.1 in 5 patients admitted within the acute care hospitals receives an indwelling catheter without a diagnosis or following the facility protocol. The rate increases with the amount of patients with Medicare. The longer the Foley catheter is in place, the greater is the risk of urinary infection, which frequently occurs after placement of urinary catheters. Each day of catheter use is associated with an approximately 5% increase in bacteriuria. (Saint, S. MD., Meddings, J.MD et al. 2009). Urinary tract infections can decline if we follow the guidelines strictly according to the facility protocol and minimize the usage of Foley catheter for the convenience of the nurses or patients. As a matter of policy, rampant use of catheter insertion as a convenient means must be stopped. We are the patients’ advocates and they are relying on us to help them achieve their ultimate health objectives. Validation and Literature Review The literature on CAUTIs was researched via the PubMed search, MEDLINE with full text, EBSOCO host and Ovid using subject headings “Urinary tract infections in nursing homes and with the Keyword “catheter” “Foley” and “bladder infection.” Other journals were used directly for PubMed search. The review on UTIs in long term care facility that are associated with the use of urinary catheters’ reveals facts about how the infection came about, what causes it and the ways suggested to prevent it from reoccurring. Bacteriura is associated with the length of time the catheter has been in place or in other words, the higher the use of catheter, the higher the risk of bacteriuria (Juliet.E, Colville.A, 2008). The risk of developing bacteria in the urine is 3%-10% per day a catheter remains in place. (Eloy.J, Colville.A, 2008). Evidence also shows that more than 90 % of catheter associated bacteriuria may be asymptomatic (Elvy.J, Colville A, 2008). Symptomatic bacteriuria should not be treated with antibiotic since it has not been shown to be of any benefit and besides it can promote development of antibiotic resistance. (Elvoy. J, Colvile. A, 2008). The Center for Disease Control (CDC) in 2009 stipulates in their guidelines that to diagnosis a patient with symptomatic urinary tract infection it must meet at least 1 of the following criteria. Patient had an indwelling urinary catheter in place at the time of specimen or symptoms with no other recognized causes: Fever (>38 C). Researches have also shown that each year, 3,000 deaths are associated with urinary tract infections (CDC, 2009). The expert panel of International Clinical Practice (IDSA), states, “Signs and symptoms compatible with CAUTIs include new onset or worsening of fever rigors and altered mental status” (IDSA guidelines 2009). Comparative Evaluation My place of practice, which is a long-term care facility, has an increasing number of patients with CAUTIs. Most of the patients show signs of infection within 48 hours post discharge from the hospital. Some of these patients had foley catheter, others none and yet some others were nursing home related due to poor invasive protocol, example: insertion of foley. UTIs include catheter associated infections. Older individuals with invasive UTI have an enhanced incidence of bacteremia and sepsis (O’Donnell. J, Hofmann. M, 2002). Most UTIs in the community living and nursing home patients without catheters are monomicrobic (O’Donnell. J, Hoffmann.M, 2002). Catheter associated infections are often polymicrobic and may include both gram negative rods or gram positive organisms such as methicillin resistant staphylococcus aureus (MRSA) (O’Donnell. J, Hofmann. M, 2002). Antibiotic treatment for uncomplicated UTI is 7 to 10 days. Ambulatory patient with CAUTI with the use of catheters had a much longer period of stay, cost to patients and the facility. “Discharges occurring on or after 1, October, 2008, hospitals paid by the inpatient prospective payment system will not receive additional payment for the conditions when acquired during hospitalization e.g.: CAUTIs, decubitus ulcers.” (Saint. S et al 2009). This also applies to nursing home facilities according to Medicare. These incidences become a priorityof concern to the administrator, director of nurses, case managers and nursing supervisors as well as staff nurses. The focus is on infection control and how to decrease or eradicate the number of infections in the patients especially those who remain admitted in the facility. “Preventing infections in long term care facility are the same for acute care facility. There is a difference, long term care patient are domicile. In long term care facilities there are fewer resources; employees with many other responsibilities are often responsible for infection control and computer resources limited. The educational level of the staff is often lower than in acute care facilities, medical records often is inadequate and access to physician resources is limited. Finally, limited clinical research is available to validate either and overall infection control program” (Nicolle. L, 2001) A comparison of the practices in my work place with the findings from the literature reviewed reveals that, our protocol is poorly revised in 2010. It needs to be changed in order for the nursing staff to implement the system in an efficient manner and to decrease the occurrence of CAUTIs. The literature reviews contend regarding prevention of CAUTI: avoid inserting a catheter, use an aseptic technique on insertion, use evidence based ongoing care, including use of a closed system, good personnel hygiene and the prompt removal of catheter (Dailly. S, 2011). No antibiotic treatments are to be given for precatheter insertion and post catheter. Prophylactic antimicrobials are not recommended, because of the risk of acquisition of infection with resistant bacteria.(Nicolle.L,2005). The protocol in my facility mandates the use of foley catheters when necessary for terminal illness, urinary retention, stage 3 or greater decubitus and severe contractures. All foleycathers must be changed monthly. “There is currently no evidence that routine catheter changes are beneficial,” (Nicolle. L, 2005). Infection control through good hand washing before and after foley catheter insertion will help to a great extent in controlling UTIs. Even though the present protocol for foley catheters is not effective as it should be, most nursing staffs have too many responsibilities and the turn over staff is high because almost 80 % of the nurses are per diem and few full time nursing employees. It is important that infection control nurse and director of nurses get involved to ensure that implementation of a protocol for the nursing staff is strictly followed, keeping in mind. Decision Stage Any changes to be made to the infection control protocol must be authorized by administration: administrator, director of nurses and nursing supervisors. Nursing staff would not be involved in the decision making but will play a major role in implementing and proving feedback concerning the new protocol. In our nursing home facility the infection control nurse is the educator for the establishment. Educating the nursing staff needs to be taken up as a monthly in-service exercise and with the help of visual aids and hand out printed materials. The infection control nurse will meet with the weekend nursing staff to educate them on the new UTI protocol. This way, all the nursing staff will be able to familiarize themselves with and incorporate the new protocol into the process of patient care. Proposed Protocol Title: Foley Catheter: To Prevent Catheter-Associated Urinary Tract Infections Purpose: To educate the staff about the importance of prevention of urinary tract infection related to the use of foley catheters in elderly patients. The use of catheters creates a potential risk for contracting the infection. It will also teach the nursing staff when it is necessary to use Foley catheters. Procedure: 1. All new orientees will be provided an in service education and training on CAUTIs. 2. They will be advised to use indwelling urethal catheter only after exhausting other alternative methods of management (e.g. Bladder control programs with assessment made every 2 hours). 3. They will be discouraged from inserting a foley catheter, including intermittent catheter, without a doctor’s orders. 4. All foley catheters must be discontinued for the newly admitted patients, after proper evaluation of the purpose for the catheter. They will also seek a physician’s orders (e.g. urinary retention prostate problems and neurogenic bladder). 5. Records of newly admitted patients must be assessed for any previous foley catheters within 48 hours of their arrival from hospitals. If the patients had a foley then their urine must be collected for analysis, culture and sensitivity test, to monitor for UTIs. 6. All patients with stage 3 or greater decubitus must not use a foleycatheter. Consult for wound care department to evaluate patient for wound vac. 7. Maintenance: a) Connect indwelling urethral catheters to a sterile closed urinary drainage system. b) Wash hands and wear a new pair of clean non-sterile gloves before manipulating a patient’s catheter to avoid contamination and wash hands after removing gloves. c) Position urinary drainage bags below the level of the bladder and do not allow the bag to come into contact with the floor. d) Obtain urine samples from a sampling port using an aseptic technique. e) Empty the urinary drainage bag frequently to maintain urine flow and prevent reflux. f) Do not add antiseptic or antimicrobial solutions into urinary drainage bags. g) Do not change catheters unnecessarily or as part of routine practice except where necessary to adhere to manufacturer’s guidance. h) Routine care personal hygiene is all that is needed to maintain peritoneal. i) Bladder irrigation, instillation and washout should not be used to prevent catheter associated infection. Educating nursing staff periodically will help decrease the rate of CAUTIs. Plan for Evaluation The protocol can be evaluated by means of a monthly in service orientation program. A survey should also be introduced at the end of every in service to obtain feedback. Direct hands on training given during insertion of Foley catheter techniques, which patient care to assess pericare techniques will also be very effective. This can be done by infection control nurse. The protocol will be evaluated every two months to monitor for the decline in CAUTIs. Again, the infection control nurse will keep a record. If there is no improvement of CAUTIs then the problem must be reevaluated for the causes of the recurrent UTIs. Nursing staff must follow the protocol to ensure that aseptic technique is used and continuous ongoing care with proper hygiene practice is provided besides complying to the instructions that foley catheters remains in place only when necessary. Empowering all staff to carry out best practices will reduce the instances of CAUTIs and associated morbidity and mortality that these infections can cause. References Dally, S. (2011). Prevention of Indwelling Catheter Associated Urinary Tract Infections. Nursing Older People.23(22). Pg. 14-49. Dumont, C. PhD, RN, CRNI & Wakeman, J. BSN.RN. (2010). Preventing Catheter Associated Nursing. Retrieved from http://www.ovidsptx.ovid.com.ezproxy.liberty.edu:2040/sp3.3.1a/ovidweb.cai/weblinkframeset. Elvy, J. & Colville, A. (2009). Catheter Associated Urinary Tract Infection: What Is It, What Causes It and How Can We Prevent It? Journal of Infection Prevention.10(2). Pg. 36-39. Hooton, T., Bradley, S., et al. (2010). Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Disease Society of America. Lindsay, N. (2001). Preventing Infections in Non-Hospital settings: Long-Term Care.Emerging Infectious Disease.7(2).pg.205-207. Retrieved from http://www.cdc.gov/ncidod/eid/vol7no2/pdfs/nicolle,pdf-windowsinternetexplorer. Nicolle, L. (2005). Catheter- Related Urinary Tract Infections.Drugs Aging.22(8). Pg. 627-639. Pellowe, C. (2009). Using Evidence Based Guidelines to Reduce Catheter Related Urinary Tract Infections In England. Journal of Infection Prevention.10(2). Pg. 44-47. Saint, S. MD.MPH & Meddings, J. MD, et al. (2009). Catheter-Associated Urinary Tract Infection and the Medicare Rule Changes.Annals of Internal Medicine. 150(12), pg. 877-882. Retrieved from http://www.ebscohost.com.ezproxy.liberty.edu:2048/ehost/pdfviewer/. Wakeman, J. (2010). Reducing Rates of Catheter-Associated Urinary Tract Infection.American Journal of Nurses. 110(8), pg. 40-45. 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