Active training and surveillance: 2 good friends to reduce urinary catheterization rate

Patient engagement to counter catheter-associated urinary tract infections with an app (PECCA): a multicentre, prospective, interrupted time-series and before-and-after study

BACKGROUND

The risk of urinary tract infections (UTIs) is increased by unnecessary placement and prolonged use of urinary catheters.

AIM

To assess whether inappropriate use of catheters and catheter-associated UTI were reduced through patient participation.

METHODS

In this multicentre, interrupted time-series and before-and-after study, we implemented a patient-centred app which provides catheter advice for patients, together with clinical lessons, feedback via e-mails and support rounds for staff members. Data on catheter use and infections were collected during a six-month baseline and a six-month intervention period on 13 wards in four hospitals in the Netherlands. Dutch Trial Register: NL7178.

FINDINGS

Between June 25th, 2018 and August 1st, 2019, 6556 patients were included in 24 point-prevalence surveys, 3285 (50%) at baseline and 3271 (50%) during the intervention. During the intervention 249 app users and a median of seven new app users per week were registered (interquartile range: 5.5-13.0). At baseline, inappropriate catheter use was registered for 175 (21.9%) out of 798 catheters, compared to 55 (7.0%) out of 786 during the intervention. Time-series analysis showed a non-significant decrease of inappropriate use of 5.8% (95% confidence interval: -3.76 to 15.45; P = 0.219), with an odds ratio of 0.27 (0.19-0.37; P < 0.001). Catheter-associated UTI decreased by 3.0% (1.3-4.6; P = 0.001), with odds ratio 0.541 (0.408-0.716; P < 0.001).

CONCLUSION

Although UTI significantly decreased after the implementation, patient participation did not significantly reduce the prevalence of inappropriate urinary catheter use. However, the inappropriate catheter reduction of 5.8% and an odds ratio of 0.27 suggest a positive trend. Patient participation appears to reduce CAUTI and could reduce other healthcare-associated infections.

Intervention to reduce unnecessary urinary catheter use in a large academic health science centre: A one-group, pretest, posttest study with a theory-based process evaluation

Aim

To evaluate an intervention to reduce unnecessary urinary catheter use and prevent catheter‐associated urinary‐tract infections (CAUTI) in hospitalized patients across an academic health science centre.

Methods

We conducted a one‐group, pretest, posttest study with a theory‐based process evaluation. Phase 1 consisted of a pre/postintervention to test the impact of a CAUTI protocol. Audits on four units were conducted, and data were analysed descriptively. Phase 2 consisted of a theory‐based process evaluation to understand the barriers/enablers to the implementation. Semistructured interviews were conducted and then analysed using a systematic approach.

Results

In Phase 1, all inpatients with urinary catheters admitted to the units (N = 4) during the study period (N = 99, pre) and (N = 99, post) were included. CAUTI prevalence rate was 18.2% pre versus 14.1% post (p = .563). In Phase 2, participants (N = 18) who worked on the units were interviewed, and a total of 13 barriers and 19 enablers were found.

The impact of educational interventions for patients living with indwelling urinary catheters: A scoping review

Aim: To explore the impact of educational interventions for patients living with indwelling urinary catheters. Methods: Systematic scoping review in accordance with PRISMA guidelines, guided by Cochrane methodology, quality appraisal using Centre for Evidence-Based Medicine (CEBM) Joanna Briggs Institute (JBI), GRADE criteria and Quality Improvement Minimum Quality Criteria Set Version 1.0 (QI-MQCS V 1.0) tools. Studies (n = 446) were retrieved from CINAHL, Cochrane Library, Scopus and Medline from 2000 to 2020. Results: A total of 15 primary research studies were included in the narrative thematic synthesis, nine were from the USA, two from Australia, two from the UK, one from Italy and one from Turkey. These 15 studies were published between 2003 and 2019 and accounted for 19918 patients with an age range 15-99 years. Study design varied; there were 11 quantitative and 4 qualitative studies. Studies were of low-moderate quality. A total of four themes were identified; (i) information needs of patients living with long-term catheters; (ii) core learning content and educational approaches; (iii) feasibility and effectiveness of educational interventions to reduce complications and improve quality of life; and (iv) common outcome measures. Conclusion: The dissemination of information and the delivery of urinary catheter education to patients is inadequate. Core components of educational interventions should address fluid intake, bowel management, hygiene and self-monitoring/management, including adverse events. There is a need for future robust trials of educational and self-management interventions to improve the quality of life of patients living with indwelling urinary catheters in the community. Impact: This review addressed the educational needs of patients living with indwelling urinary catheters and the impact of educational interventions. Despite the heterogeneity in educational interventions, all studies included in this review reported the specific approach undertaken was effective in minimising catheter-associated complications and improving the quality of life of patients.

Change in staff perspectives on indwelling urinary catheter use after implementation of an intervention bundle in seven Swiss acute care hospitals: results of a before/after survey study

OBJECTIVE

To evaluate changes in staff perspectives towards indwelling urinary catheter (IUC) use after implementation of a 1-year quality improvement project.

DESIGN

Repeated cross-sectional survey at baseline (October 2016) and 12-month follow-up (October 2017).

SETTING

Seven acute care hospitals in Switzerland.

PARTICIPANTS

The survey was targeted at all nursing and medical staff members working at the participating hospitals at the time of survey distribution. A total of 1579 staff members participated in the baseline survey (T₀) (49% response rate) and 1527 participated in the follow-up survey (T₁) (47% response rate).

INTERVENTION

A multimodal intervention bundle, consisting of an evidence-based indication list, daily re-evaluation of ongoing catheter need and staff training, was implemented over the course of 9 months.

MAIN OUTCOME MEASURES

Staff knowledge (15 items), perception of current practices and culture (scale 1-7), self-reported responsibilities (multiple-response question) and determinants of behaviour (scale 1-7) before and after implementation of the intervention bundle.

RESULTS

The mean number of correctly answered knowledge questions increased significantly between the two survey periods (T₀: 10.4, T₁: 11.0; p<0.001). Self-reported responsibilities with regard to IUC management by nurses and physicians changed only slightly over time. Perception of current practices and culture in regard to safe urinary catheter use increased significantly (T₀: 5.3, T₁: 5.5; p<0.001). Significant changes were also observed for determinants of behaviour (T₀: 5.3, T₁: 5.6; p<0.001).

CONCLUSION

We found small but significant changes in staff perceptions after implementation of an evidence-based intervention bundle. Efforts now need to be targeted at sustaining and reinforcing these changes, so that restrictive use of IUCs becomes an integral part of the hospital culture.

A pre and post intervention study to reduce unnecessary urinary catheter use on general internal medicine wards of a large academic health science center

BACKGROUND

Urinary catheters are a common medical intervention, yet they can also be associated with harmful adverse events such as infection, urinary tract trauma, delirium and patient discomfort. The purpose of this study was to describe the use of the SafetyLEAP program to drive improvement efforts, and specifically to reduce the use of urinary catheters on general internal medicine wards.

METHODS

A pre and post intervention study using the SafetyLEAP program was performed with urinary catheter prevalence as the primary outcome on two general internal medicine wards in a large academic health sciences center.

RESULTS

A total of n = 534 patients (n = 283 from ward #1; and n = 252 from ward #2) were included in the initial audit and feedback portion of the study and 1601 patients (n = 824 pre-intervention and n = 777 post-intervention were included in the planned quality improvement portion of the study). A total of 379 patients during the quality improvement intervention had a urinary catheter. Overall, the adherence to the SafetyLEAP program was 97.4% on both general internal medicine wards. The daily catheter point prevalence decreased from 22 to 13%. After the implementation of the program, the urinary catheter utilization ratio (defined as urinary catheter days/patient days) declined from 0.14 to 0.12. Catheter-associated urinary tract infections (CAUTI) were unchanged.

CONCLUSION

The SafetyLEAP program can help provide a systematic approach to the detection, and reduction of safety incidents. Future studies should aim at refining and implementing this intervention broadly.

Successful strategy to decrease indwelling catheter utilization rates in an academic medical intensive care unit

BACKGROUND

Duration of indwelling urinary catheterization is an important risk factor for urinary tract infections. We devised a strategy to decrease the utilization of indwelling urinary catheters (IUCs). We also highlight the challenges of managing critically ill patients without IUCs and demonstrate some of the initiatives that we undertook to overcome these challenges.

METHODS

A retrospective observational outcomes review was performed in an adult medical intensive care unit (ICU) between January 2012 and December 2016. This period included a baseline and series of intervals, whereby different aspects of the strategies were implemented. IUC utilization ratio and catheter-associated urinary tract infection (CAUTI) rates were calculated.

RESULTS

Our IUC utilization ratio had a statistically significant decrease from 0.92 (baseline) to 0.28 (after 3 interventions) (P < .0001). Similarly, CAUTI rates had a statistically significant decrease from 5.47 (baseline) to 1.08 (after 3 intervention) (P = .0134). These rates sustained a statistically significant difference over the 2-year follow-up period from the last intervention. Incontinence-associated dermatitis (IAD) was identified as a potential complication of not using an IUC. There was no statistically significant change in the IAD rates during 2013-2016.

CONCLUSIONS

Our interventions demonstrated that aggressive and comprehensive IUC restriction protocol and provider training can lead to a successful decrease in IUC use, leading to a lower IUC utilization ratio and CAUTI rate in a large complex academic ICU setting.

Implementing clinical guidelines to prevent catheter-associated urinary tract infections and improve catheter care in nursing homes: Systematic review

BACKGROUND

Catheter-associated urinary tract infection is the most common health care-associated infection, is considered avoidable, and has cost implications for health services. Prevalence is high in nursing homes, but little research has been undertaken to establish whether implementing clinical guidelines can reduce infection rates in long-term care or improve quality of urinary catheter care.

METHODS

Systematic search and critical appraisal of the literature.

RESULTS

Three studies evaluated the impact of implementing a complete clinical guideline. Five additional studies evaluated the impact of implementing individual elements of a clinical guideline.

CONCLUSIONS

Prevention of catheter-associated urinary tract infection in nursing homes has received little clinical or research attention. Studies concerned with whole guideline implementation emerged as methodologically poor using recognized criteria for critically appraising epidemiologic studies concerned with infection prevention. Research evaluating the impact of single elements of clinical guidelines is more robust, and their findings could be implemented to prevent urinary infections in nursing homes.

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Good medical practices in the use of antibiotic prophylaxis in a surgery ward: Results of a 2013 Apulian study

This study describes the changes in the performance of health care workers regarding the control of health care-associated infection in a surgical ward of University Hospital Policlinico, Bari, Italy, before and after a training program and adoption of bundles on antibiotic therapy. There were 194 patients recruited (pre: n = 98; post: n = 96), of which 149 (76.8%) had undergone surgery. We documented a change in the proportions of patients who received in-ward prophylactic antibiotics (from 46/98 to 22/96, P < .05), surgical patients undergoing antibiotic prophylaxis in the operating room (from 18/64 to 36/85, P < .05), and average duration of prophylaxis (from 5.9 ± 4.9 to 2.9 ± 2.7 days, P < .0001). Results confirmed correspondence between the intervention and results recorded.

Catheter-associated urinary tract infection: Role of the setting of catheter insertion

BACKGROUND

This study aimed to describe the epidemiology of catheter-associated urinary tract infections (CAUTIs) in patients admitted to a surgical ward in Central Italy and to analyze the associated risk factors.

METHODS

An active surveillance program for CAUTI was carried out in patients catheterized for at least 48 hours. Place of catheter insertion (operating room, hospital ward, cystoscopy room, emergency care unit), indication for catheterization and its duration, among other risk factors were monitored until discharge. Antibiotic resistance profiles of isolates were analyzed.

RESULTS

There were 641 catheterized patients monitored for CAUTI onset. Of these, 40 (6.2%) developed a CAUTI (rates were 15.1/1,000 catheter days, 95% confidence interval [CI], 11.9-22.6; 8.7/1,000 patient days, 95% CI, 6.9-13.1). Patients with CAUTI were older (P < .05) and their durations of hospitalization and catheterization were both longer compared with those who were not affected (P < .05). Catheterization >4 days (odds ratio [OR] = 8.21; 95% CI, 3.79-17.73; P < .05) and place of catheter insertion different from the operating room (OR = 7.9; 95% CI, 2.83-22.08; P < .05, for catheters placed in the ward) were associated with CAUTI. Among the micro-organisms isolated in CAUTIs, the most common were Pseudomonas aeruginosa (41.5%), Klebsiella pneumoniae (19.5%), and Escherichia coli (12.2%); 82.5% of them were resistant to different classes of antibiotics.

CONCLUSION

These results highlight the role played by the setting of catheter insertion in CAUTIs onset, therefore reflecting the importance of hand hygiene and proper aseptic insertion techniques as crucial determinants in CAUTIs prevention.

Impact of Changes in the NHSN Catheter-Associated Urinary Tract Infection (CAUTI) Surveillance criteria on the Frequency and Epidemiology of CAUTI in Intensive Care Units (ICUs)

The impact of the 2013 NHSN CAUTI definition on CAUTI rates was analyzed. A total of 107 CAUTI episodes were identified; 60 according to NHSN 2013 definitions only and 47 according to the 2012 and 2013 definitions. Physician-diagnosed “other infections” were more common among patients who had CAUTI only according to NHSN 2013 definitions (P<.001).

Infect Control Hosp Epidemiol 2014;00(0): 1–4

Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA). the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Risk factors for catheter-associated urinary tract infection in Italian elderly

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are the most common cause of hospital-acquired infections, especially in elderly patients. Data on CAUTIs in older persons in acute care settings are lacking, however. This study aimed to describe the epidemiology of CAUTIs and related outcomes (ie, length of stay and mortality), in patients admitted to an acute geriatric care hospital in central Italy.

METHODS

A CAUTI surveillance program was implemented from October 2011 to April 2012, according to the Centers for Disease Control and Prevention's National Healthcare Safety Network methodology.

RESULTS

A total of 2773 patients aged ≥65 years were included in the study, and 483 catheterized patients were monitored for the risk of CAUTI. The catheterization rate was 16.7% (95% confidence interval [CI], 15.3%-18.2%), and the overall CAUTI incidence rate was 14.7/1000 device-days (95% CI, 11.7-18.3/1000). Mortality was significantly higher in catheterized patients with a CAUTI compared with noncatheterized patients (19.2% vs 10.5%; P < .05). Female sex (odds ratio [OR], 1.31; 95% CI, 1.06-1.67), increasing age (≥90 years: OR, 2.76; 95% CI, 2.00-3.83), and longer hospital stay before catheter insertion (≥15 days: OR, 2.90; 95% CI, 2.20-3.83) were independent risk factors for catheterization; increasing age (>90 years: OR, 2.75; 95% CI, 1.03-7.35), and duration of hospital stay before catheter insertion (OR, 2.41; 95% CI, 1.12-5.51) were associated with CAUTIs.

CONCLUSIONS

These results underscore the importance of the proper choice of patients for catheterization, particularly in individuals aged >90 years.

Catheter associated urinary tract infections

Urinary tract infection attributed to the use of an indwelling urinary catheter is one of the most common infections acquired by patients in health care facilities. As biofilm ultimately develops on all of these devices, the major determinant for development of bacteriuria is duration of catheterization. While the proportion of bacteriuric subjects who develop symptomatic infection is low, the high frequency of use of indwelling urinary catheters means there is a substantial burden attributable to these infections. Catheter-acquired urinary infection is the source for about 20% of episodes of health-care acquired bacteremia in acute care facilities, and over 50% in long term care facilities. The most important interventions to prevent bacteriuria and infection are to limit indwelling catheter use and, when catheter use is necessary, to discontinue the catheter as soon as clinically feasible. Infection control programs in health care facilities must implement and monitor strategies to limit catheter-acquired urinary infection, including surveillance of catheter use, appropriateness of catheter indications, and complications. Ultimately, prevention of these infections will require technical advances in catheter materials which prevent biofilm formation.

Rate of positive urine culture and double-J catheters colonization on the basis of microorganism DNA analysis

Introduction

The aim of the trial was to estimate the relationship between colonization of the Double–J catheter, and the microorganisms cultured from urine.

Material and methods

60 patients, who had Double–J catheters inserted, participated in the study. All the subjects had their midstream urine samples taken prior to the stent insertion and removal. A negative urine culture before catheterization was mandatory to participate in the study. The patients were assigned into three subgroups, according to stenting duration: 1) 20 to 30 days (18 cases); 2) 30 to 90 days (30 cases); 3) longer than 90 days (12 cases). Bacterial and fungal DNA was identified using electrophoresis in polyacrylamide gel with a denaturing gradient (PCR–DGGE). The relationship between the genetic analysis of the catheter and the urine culture was estimated.

Results

Urine cultures were positive in only 8 patients, while Double–J catheter analyses were positive in all cases. In 2 cases one type of microorganism was isolated from the stent surface while the remaining 58 catheters were colonized by more than one pathogen. In three cases fungi were isolated. There were only three types of pathogens cultured from urine specimens. Urine and stent cultures were consistent in 5 cases. In 3 cases urine culture and stent analysis were not consistent.

Conclusions

Double–J catheter retention in the urinary tract is associated with an extremely high risk of bacterial colonization, while the risk of urine infection is about 8–fold lower. There is a great inconsistency between urine infection and catheter colonization, indicating a low predictive value of urine culture for estimating stent colonization.