Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success

Clinical article

Restricted access

Object

To date, there has been a shortage of evidence-based quality improvement initiatives that have shown positive outcomes in the neurosurgical patient population. A single-institution prospective intervention trial with continuous feedback was conducted to investigate the implementation of a urinary tract infection (UTI) prevention bundle to decrease the catheter-associated UTI rate.

Methods

All patients admitted to the adult neurological intensive care unit (neuro ICU) during a 30-month period were included. The study consisted of two 1-month preintervention observation periods (approximately 1200 catheter days) followed by a 30-month intervention phase (20,394 catheter days). A comprehensive evidence-based UTI bundle encompassing avoidance of catheter insertion, maintenance of sterility, product standardization, and early catheter removal was enacted.

Results

The urinary catheter utilization rate dropped from 100% to 73.3% during the intervention phase (p < 0.0001) without any increase in the rate of sacral decubitus ulcers or other skin breakdown. The rate of catheter-associated UTI was also significantly reduced from 13.3 to 4.0 infections per 1000 catheter days (p < 0.001). There was a linear relationship between the decreased quarterly catheter utilization rate and the decreased catheter-associated UTI rate (r2 = 0.79, p < 0.0001).

Conclusions

This single-center prospective study demonstrated that a comprehensive UTI prevention bundle along with a continuous quality improvement program can significantly reduce the duration of urinary catheterization and rate of catheter-associated UTI in a neuro ICU.

Article Information

Address correspondence to: J Mocco, M.D., M.S., Department of Neurosurgery, University of Florida, P.O. Box 100265, Gainesville, Florida 32610. email: jmocco@neurosurgery.ufl.edu.

Please include this information when citing this paper: published online January 6, 2012; DOI: 10.3171/2011.11.JNS11974.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Flow chart showing the daily process for review of indwelling urinary catheters. Each patient in the neuro ICU was evaluated daily for both the presence of a urinary catheter and necessity of said catheter. First, catheter placement was reviewed by both unit nurses and by Clinical Nurse Leaders on Foley Rounds. Recommendations for removal were based on catheters not meeting 1 of the 5 previously specified indications. Requests for removal were then presented to an attending physician who either provided a clarification of catheter necessity or removed the catheter. If urine management was still necessary, then alternative methods were pursued. I/O Cath = in-and-out catheterization.

  • View in gallery

    Graphs showing reductions in urinary catheter utilization and catheter-associated UTI over time (months). Note that in all graphs, the time zero corresponds to October 2008. A: Average number of urinary catheters per day present in the 30-bed neuro ICU per quarter. B: The rate of urinary catheter utilization measured as a percentage of ICU patient beds, both 9 months prior to intervention and 30 months postintervention. C: Decrease in the total number of UTIs during the same period. This decrease correlates strongly with the UTI rate because the number of patients in the neuro ICU remained relatively constant through the study period. Note that the total numbers of UTIs during the preintervention 1-month study periods were normalized to reflect a quarterly amount. D: Catheter-associated UTI (CAUTI) rate tracked through the same time period. Note that the CAUTI rate fell prior to official implementation of the UTI bundle. Lines in panels B and D are the 25th, 50th, and 75th quartiles from the NHSN.

  • View in gallery

    Graph showing the frequency of pathogens responsible for UTI during the study period. Note the continual decline of E. coli with the periodic increases of Proteus and Pseudomonas and relative stability of Enterococcus, Candida, and Klebsiella species. “Other” pathogens include Serratia, S. aureus, Morganella, and Stenotrophomonas.

References

  • 1

    Anton HAChambers KClifton JTasaka J: Clinical utility of a portable ultrasound device in intermittent catheterization. Arch Phys Med Rehabil 79:1721751998

    • Search Google Scholar
    • Export Citation
  • 2

    Beattie MTaylor J: Silver alloy vs. uncoated urinary catheters: a systematic review of the literature. J Clin Nurs 20:209821082011

    • Search Google Scholar
    • Export Citation
  • 3

    Berwick DMCalkins DRMcCannon CJHackbarth AD: The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA 295:3243272006

    • Search Google Scholar
    • Export Citation
  • 4

    Chenoweth CESaint SUrinary tract infections. Jarvis WR: Bennett & Brachman's Hospital Infections ed 5PhiladelphiaLippincott, Williams & Wilkins2007. 507516

    • Search Google Scholar
    • Export Citation
  • 5

    Cromer ALHutsell SOLatham SCBryant KGWacker BBSmith SA: Impact of implementing a method of feedback and accountability related to contact precautions compliance. Am J Infect Control 32:4514552004

    • Search Google Scholar
    • Export Citation
  • 6

    Crouzet JBertrand XVenier AGBadoz MHusson CTalon D: Control of the duration of urinary catheterization: impact on catheter-associated urinary tract infection. J Hosp Infect 67:2532572007

    • Search Google Scholar
    • Export Citation
  • 7

    Danchaivijitr SDhiraputra CCherdrungsi RJintanothaitavorn DSrihapol N: Catheter-associated urinary tract infection. J Med Assoc Thai 88:Suppl 10S26S302005

    • Search Google Scholar
    • Export Citation
  • 8

    Darouiche ROGoetz LKaldis TCerra-Stewart CAlSharif APriebe M: Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: a prospective, randomized, multicenter clinical trial. Am J Infect Control 34:5555602006

    • Search Google Scholar
    • Export Citation
  • 9

    Dromerick AWEdwards DF: Relation of postvoid residual to urinary tract infection during stroke rehabilitation. Arch Phys Med Rehabil 84:136913722003

    • Search Google Scholar
    • Export Citation
  • 10

    Edwards JRPeterson KDAndrus MLDudeck MAPollock DAHoran TC: National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued November 2008. Am J Infect Control 36:6096262008

    • Search Google Scholar
    • Export Citation
  • 11

    Foxman B: Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med 113:Suppl 1A5S13S2002

  • 12

    Gardam MAAmihod BOrenstein PConsolacion NMiller MA: Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections. Clin Perform Qual Health Care 6:991021998

    • Search Google Scholar
    • Export Citation
  • 13

    Gokula RRHickner JASmith MA: Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 32:1961992004

    • Search Google Scholar
    • Export Citation
  • 14

    Goolsarran VJKatz TF: Do not go with the flow, remember indwelling catheters. J Am Geriatr Soc 50:173917402002

  • 15

    Gould CVUmscheid CAAgarwal RKKuntz GPegues DA: Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol 31:3193262010

    • Search Google Scholar
    • Export Citation
  • 16

    Hakvoort RAThijs SDBouwmeester FWBroekman AMRuhe IMVernooij MM: Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for incomplete voiding after vaginal prolapse surgery: a multicentre randomised trial. BJOG 118:105510602011

    • Search Google Scholar
    • Export Citation
  • 17

    Ho CHKirshblum SLinsenmeyer TAMillis SR: Effects of the routine change of chronic indwelling Foley catheters in persons with spinal cord injury. J Spinal Cord Med 24:1011042001

    • Search Google Scholar
    • Export Citation
  • 18

    Horan TCAndrus MDudeck MA: CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36:3093322008

    • Search Google Scholar
    • Export Citation
  • 19

    Huang WCWann SRLin SLKunin CMKung MHLin CH: Catheter-associated urinary tract infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters. Infect Control Hosp Epidemiol 25:9749782004

    • Search Google Scholar
    • Export Citation
  • 20

    Jain PParada JPDavid ASmith LG: Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 155:142514291995

    • Search Google Scholar
    • Export Citation
  • 21

    Johansson IAthlin EFrykholm LBolinder HLarsson G: Intermittent versus indwelling catheters for older patients with hip fractures. J Clin Nurs 11:6516562002

    • Search Google Scholar
    • Export Citation
  • 22

    Klevens RMEdwards JRRichards CL JrHoran TCGaynes RPPollock DA: Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 122:1601662007

    • Search Google Scholar
    • Export Citation
  • 23

    Kunin CMMcCormack RC: Prevention of catheter-induced urinary-tract infections by sterile closed drainage. N Engl J Med 274:115511611966

    • Search Google Scholar
    • Export Citation
  • 24

    Lee YYTsay WLLou MFDai YT: The effectiveness of implementing a bladder ultrasound programme in neurosurgical units. J Adv Nurs 57:1922002007

    • Search Google Scholar
    • Export Citation
  • 25

    Lo ENicolle LClassen DArias KMPodgorny KAnderson DJ: Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol 29:Suppl 1S41S502008

    • Search Google Scholar
    • Export Citation
  • 26

    Munasinghe RLYazdani HSiddique MHafeez W: Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service. Infect Control Hosp Epidemiol 22:6476492001

    • Search Google Scholar
    • Export Citation
  • 27

    Nicolle LE: The prevention of hospital-acquired urinary tract infection. Clin Infect Dis 46:2512532008

  • 28

    Patel MIWatts WGrant A: The optimal form of urinary drainage after acute retention of urine. BJU Int 88:26292001

  • 29

    Pilloni SKrhut JMair DMadersbacher HKessler TM: Intermittent catheterisation in older people: a valuable alternative to an indwelling catheter?. Age Ageing 34:57602005

    • Search Google Scholar
    • Export Citation
  • 30

    Reilly LSullivan PNinni SFochesto DWilliams KFetherman B: Reducing foley catheter device days in an intensive care unit: using the evidence to change practice. AACN Adv Crit Care 17:2722832006

    • Search Google Scholar
    • Export Citation
  • 31

    Robinson SAllen LBarnes MRBerry TAFoster TAFriedrich LA: Development of an evidence-based protocol for reduction of indwelling urinary catheter usage. Medsurg Nurs 16:1571612007

    • Search Google Scholar
    • Export Citation
  • 32

    Rosenthal VDGuzman SSafdar N: Effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in Argentina. Infect Control Hosp Epidemiol 25:47502004

    • Search Google Scholar
    • Export Citation
  • 33

    Saint S: Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 28:68752000

  • 34

    Saint SElmore JGSullivan SDEmerson SSKoepsell TD: The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med 105:2362411998

    • Search Google Scholar
    • Export Citation
  • 35

    Saint SMeddings JACalfee DKowalski CPKrein SL: Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med 150:8778842009

    • Search Google Scholar
    • Export Citation
  • 36

    Saint SWiese JAmory JKBernstein MLPatel UDZemencuk JK: Are physicians aware of which of their patients have indwelling urinary catheters?. Am J Med 109:4764802000

    • Search Google Scholar
    • Export Citation
  • 37

    Schumm KLam TB: Types of urethral catheters for management of short-term voiding problems in hospitalised adults. Cochrane Database Syst Rev 2CD0040132008

    • Search Google Scholar
    • Export Citation
  • 38

    Schumm KLam TB: Types of urethral catheters for management of short-term voiding problems in hospitalized adults: a short version Cochrane review. Neurourol Urodyn 27:7387462008

    • Search Google Scholar
    • Export Citation
  • 39

    Stensballe JTvede MLooms DLippert FKDahl BTønnesen E: Infection risk with nitrofurazone-impregnated urinary catheters in trauma patients: a randomized trial. Ann Intern Med 147:2852932007

    • Search Google Scholar
    • Export Citation
  • 40

    Tambyah PAKnasinski VMaki DG: The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care. Infect Control Hosp Epidemiol 23:27312002

    • Search Google Scholar
    • Export Citation
  • 41

    Tambyah PAMaki DG: Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med 160:6786822000

    • Search Google Scholar
    • Export Citation
  • 42

    Tang MWKwok TCHui EWoo J: Intermittent versus indwelling urinary catheterization in older female patients. Maturitas 53:2742812006

    • Search Google Scholar
    • Export Citation
  • 43

    Todd RMTurner CDAnderson JMhoon DABrendler CB: A new technique for securing a foley catheter. Urology 56:1492000

  • 44

    Topal JConklin SCamp KMorris VBalcezak THerbert P: Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. Am J Med Qual 20:1211262005

    • Search Google Scholar
    • Export Citation
  • 45

    Wald HLKramer AM: Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. JAMA 298:278227842007

    • Search Google Scholar
    • Export Citation
  • 46

    Weinstein JWMazon DPantelick EReagan-Cirincione PDembry LMHierholzer WJ Jr: A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol 20:5435481999

    • Search Google Scholar
    • Export Citation
  • 47

    Zolldann DSpitzer CHäfner HWaitschies BKlein WSohr D: Surveillance of nosocomial infections in a neurologic intensive care unit. Infect Control Hosp Epidemiol 26:7267312005

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 1087 1087 44
Full Text Views 357 316 3
PDF Downloads 206 180 5
EPUB Downloads 0 0 0

PubMed

Google Scholar