Reduction of urinary catheter days versus catheter irrigation - Research Paper Example

Reduction of urinary catheter days versus catheter irrigation Purpose The purpose of this proposal is to support, educate, and demonstrate that only one intervention decreases the incident of CAUTI (Catheter Urinary Tract Infection) based on the evidence: reducing the length of time a urinary catheter is in place is the strongest predictor that CAUTI is likely to develop versus catheter irrigation, instillation of antimicrobial solutions into the catheter or drainage bag, and antibiotic ointments applied to the urinary meatus, which have not been shown to decrease CAUTI. This document is intended for use by infection prevention staff, healthcare epidemiologists, healthcare administrators, nurses, other healthcare providers, and persons responsible for developing, implementing, and evaluating infection prevention and control programs for healthcare settings across the continuum of care. The guideline can also be used as a resource for societies or organizations that wish to develop more detailed implementation guidance for prevention of CAUTI. Literature Review Catheter use-Risk factor for contraction of Catheter Urinary Tract Infection Inserted catheters form an entry point for microbes to colonize the patient’s rather sterile body. “Following finite colonization, the risk rate of bacteriuria is estimated at (3-10) % per day. The invading microbes could be of low virulence but nonetheless they are no match for the body’s host defense system, which is compromised” (Nicolle 2012, p.13). The immune-comprised patients succumb to nosocomial infections and in this respect, catheter urinary tract infection (CAUTI). Underlying malignancies and therapeutic interventions e.g. corticosteroids, parenteral nutrition are recognized as risk factors. The risk of suffering from nosocomial infections is mainly linked to duration of hospital stay. Multivariate analyses of evidence shows that catheters and implantable devices are risk factors for over 50% of patients with blood cultures that test positive for bacterial contamination. Consequently the duration at which a patient has an inserted catheter strongly predisposes him/her to contracting catheter-associated bacteriuria. However, even short-term use of catheters ranging from 3 to 11 days poses a risk of bacteriuria by up to 26%. Consequently, it is no wonder that bacteriuria develops in nearly all patients who have been catheterized for only 1 month. Of these patients who develop bacteriuria, the disease progresses to urinary tract infection (UTI) and the incidence of suffering bacteremia is about 5%. Hence, the prevalence of nosocomial CAUTI is 15% of the overall nosocomial bacteremia (Warren, 1997). Effective Catheter Management There is evidence on the overuse and misuse of catheters, and hence the prevalence of CAUTI. Evidence shows that catheters are used for unknown as well as unjustified medical conditions in about 20% of hospitalized patients. Moreover, this continued use of catheters is unnecessary for (0.3-0.5) % of catheterization days. This prompted the Center for Disease Control and Prevention (CDC) to form stringent guidelines concerning the use of catheters. According to the CDC (2011), catheter use should be streamlined and removal of catheters should be done promptly after an appropriate duration of usage. Most important, health workers are required to be responsible and to avoid misuse of catheterization. Guidelines concerning approved techniques of catheter insertion and care were also issued. However, there has been poor adherence and implementation of these guidelines (Furfari & Wald, 2008). Catheter Use Several health conditions warrant the insertion of catheters. For instance, a case of acute urinary retention requires the insertion of a catheter for the purpose of toning the bladder back to its normal form. The catheter is removed after about 10-14 days. Older patients are more likely to require catheterization (Herter & Kazer, 2010). However, nurses need to recognize that indwelling chronic catheterization is not the ideal care for incontinence management in senior citizens. In light of the susceptibility of older citizens towards bacteriuria, catheterization is inappropriate of collecting urine samples for the purpose of diagnostic testing. For patients who need intermittent catheterization for long-term management of their ailments, no significant difference in infection rate has been established between those receiving hygienic intermittent catheterization and those utilizing sterilized single-use catheters. Bacteriuria has been reported within 2-3 weeks of these patients (Cravens & Zweig, 2000). In addition frequent metal cleansing has no considerable impact in containing urinary tract infection in patients being administered sterile intermittent catheterization. There is no need to obtain periodic urine samples from catheterized patients. This is because bacterial flora undergoes change over time. Hence, these cultures are not useful in determining the appropriate antibiotic choice for future infections. Antimicrobial Intervention Asymptomatic bacteriuria occurs and treatment is usually discouraged. Administration of antibiotic prophylaxis serves to promote the proliferation of antibiotic-resistant micro-organisms. Hence, an isolated incidence of asymptomatic bacteriuria does not warrant the administration of antibiotic therapy. In addition, no causal relationship has been established between mortality and asymptomatic bacteriuria. However, symptomatic infection needs treatment for patients with long-term catheterization. Antimicrobial urinary catheters are viewed as an appropriate prevention mechanism for bacteriuria. Evidently, they can delay the progression of bacteriuria only with short duration administration. However, no conclusive evidence exists on the efficacy of antimicrobial catheters. There is inadequate data pertaining clinical endpoints in the prevention of bacteremia, symptomatic urinary tract infection as well as death (Wilson, 2011). Evidence: Comparison of complications arising from short-term and long-term Catheterization (Wilson et al., 2009). Complications of short term catheterization Complications of long term catheterization 1. Bacteraemia 1. Catheter obstruction 2. Acute pyelonephritis 2. Local periurinary infections 3. Fever 3. Chronic pyelonephritis, 4. Chronic renal inflammation 5. Urinary tract stones 6. Bladder cancer Evidence: Which of the following reduces the incidence of CAUTI? Routine catheter irrigation with 0.9% sodium chloride solution 0% Catheterization only when indicated and prompt catheter removal 78% Antibacterial ointment application to urethral meatus 0.6% All of the above 21% Evidence: Components of the CAUTI prevention "bundle" Staff education about catheter management 0.6% Regular monitoring of CAUTI incidents 0% Frequently changing the urinary irrigation bag 0% All of the above 21% Only the first and second choices above 76% Synthesis of the Evidence PICO question In hospitalized patients, reducing the duration of catheter use will reduce the occurrence of CAUTI as compared to other interventions such as catheter irrigation and use of antimicrobial solutions. A comprehensive search of the literature using CINHALL, COCHRANE, and MEDLINE data-bases was conducted. The results of all the evidences proved that catheterization plays a key role in the occurrence of CAUTI. According to Guggenbichler et al,(2011), plastic catheters are readily colonized by fungi and bacteria at the rate of 0.5 cm/hour. Within 24 hours a biofilm is formed and it covers the surface of the plastic catheters upon inoculation with minute amounts of bacteria. However, sterilization and intelligent application of antiseptics may prevent the occurrence of CAUTI. However the use of antibiotics has been linked to the emergence of resistant microbes such as Candida sp. This is coupled with the side effects of the antibiotics. Hence, antibiotics have been proven ineffective in preventing bacteriuria and also treating bacteriuria in asymptomatic patients who have been catheterized. Moreover, due consideration has to be made for immunocompromised patients during the administration of antibiotics. Two principles concerning the use of catheters have emerged and these are: A closed catheter system needs to be kept closed. Secondly, the catheter needs to be removed as soon as possible (Warren, 1997). Long-term catheters pose greater morbidity and harbor more potent/complex microbes as compared to short-term catheters. Alternative management options include use of condom catheters in case of men. In addition it is recommended to administer intermittent catheterization for individuals experiencing neurologic impairment (Nicole, 2012). Methodology / Ethical Considerations The proposed project will be done at Morristown General Hospital. The project will be conducted by Maria Haro who is a Registered Nurses and whom will collaborate with the Infection Control Department of the hospital. Patient charts will be reviewed for the length of stay in the hospital as well as all laboratory results that suggest signs of infection related to UTI. The progress reports on the recovery process of short-term catheterized patients and those who use intermittent catheterization will be made. Progress reports will also be made for the patients who will use catheter irrigation as well as application of antimicrobial solutions in their catheters. The urine and blood cultures will be tested to check for microbial infection. With the necessary consent, patient charts will be reviewed for a period of three months. Focus will be given to those patients whose hospital stay has been prolonged as a result of infections from Hospital Acquired Infection such as Urinary Tract Infection. In addition to lengthened hospital stay, patients who return to the hospital with Hospital Acquired Infection will be examined. Also, healthcare workers will be taught and observed for appropriate urinary catheter use (including prompt removal when no longer needed), sterile insertion of urinary catheters and proper urinary catheter maintenance. These guidelines and protocols are clearly within the scope of nursing and nurses can implement many interventions to fulfill these recommendations. Proposed Implementation Healthcare workers will be educated on the importance of following key components of the CAUTI prevention bundle, which include education and monitoring patients for CAUTI. A care bundle is a collection of guidelines and interventions that, when consistently followed, have been shown to improve outcomes. Research has shown that improved outcomes depend on all elements of the bundle being applied, not just some. The following bundle strategies are recommended by the CDC for prevention of CAUTI: (1) insert catheters for appropriate indications only, (2) leave catheters in place only as long as needed, (3) Ensure that only properly trained persons insert and maintain catheters, (4) insert catheters using sterile technique and sterile equipment (in acute care settings), (5) following sterile insertion, maintain a closed drainage system, (6) maintain unobstructed urine flow, (7) practice hand hygiene and standard precautions (in addition to other transmission-based precautions as appropriate) according to Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines (Herter & Kazer, 2010). Evaluation Evaluation of the project will be done at the end of three months. At the end of the three months patients chart review process, there will be evidence that patients undergoing short-term catheterization and intermittent catheterization have lower infection rates of bacteria. Conversely, patients subjected to catheter irrigation and antimicrobial solutions will report higher rates of bacterial infection and CAUTI. References CDC.(2011). Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Retrieved from http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf Cravens,D.D. & Zweig, S.(2000). Urinary Catheter Management. Am Fam Physician.  61(2):369-376. Furfari,K.& Wald,H.(2008). How can we Reduce Indwelling Urinary Catheter Use and Complications? The Hospitalist. Retrieved from http://www.thehospitalist.org/details/article/186502/How_can_we_Reduce_Indwelling_U Guggenbichler, J.P., Assadian, O., Boeswald. M., Kramer, A.(2011). Incidence and clinical implication of nosocomial infections associated with implantable biomaterials - catheters, ventilator-associated pneumonia, urinary tract infections. GMS Krankenhhyg Interdiszip. 6(1),1-15. Herter,R. & Kazer, M.W.(2010). Best Practices in Urinary Catheter Care. Home Healthcare Nurse. 28(6), 342-349. Nicolle, L.E.(2012). Urinary catheter-associated infections. Infect Dis Clin North Am. 26(1),13-27. Warren, J.W.(1997). Catheter-associated urinary tract infections. Infect Dis Clin North Am. 11(3), 609-622. Wilson, M. (2011). Addressing the problems of long-term urethral catheterization. Br J Nurs. 20(22), 1418-1424. Willson, M., Wilde,M., Webb, M., Thompson, D., Parker, D., Harwood,J., Callan, L. & Gray, M. (2009). Nursing Interventions to Reduce the Risk of Catheter-Associated Urinary Tract Infection Staff Education, Monitoring, and Care Techniques. Journal of Wound, Ostomy and Continence Nursing. 36(2), 137-154. Read More