Catheter-Associated Urinary Tract Infections

This blueprint outlines the steps that frontline staff can follow to prevent CAUTI:

Admission

1. If an indwelling urinary catheter is present on admission, assess
2. Check for signs of infection and assess for necessity and
3. Consider the possibility of varied symptoms that may be somewhat
4. Determine need for removal, insertion of new indwelling catheter, or use of alternative collection device.
5. Adhere to aseptic

Routine Care

1. Catheters should only be inserted if appropriate.
2. Justify insertion of the catheter based on evidence-based recommendations, as the best way to prevent CAUTI is to avoid insertion in general.
3. Appropriate indications for catheter use include:
   1. Urinary retention or bladder obstruction
   2. Voiding difficulties
   3. The need for measurements of output
   4. Use for long surgical procedures
   5. The need for intraoperative monitoring or urinary output
   6. Immobilization for a long period of time
   7. Comfort for end-of-life care
4. Do not use indwelling catheters in place of nursing care or to obtain a urine culture when the patient is able to perform voluntarily.
   1. Consider alternatives to an indwelling catheter, such as intermittent catheterization or suprapubic catheters.
   2. Ask patients if they have a preference for which staff member (male or female) inserts the catheter and maintain the patient’s privacy (e.g., curtains, etc.).
5. Minimize duration of catheter use.
   1. If inserted perioperatively, remove as soon as possible post-op.
   2. Consider the use of a bladder scanner to assist in determination of urine volumes.
6. Certain steps should be included in day-to-day care to avoid and monitor for presence of infection.
   1. Ensure hand hygiene with soap and water is performed routinely by providers, patients, and visitors.
   2. Assess for catheter necessity and document. Ensure clarity of this assessment in the hand-off.
      1. Include patients and family members in the hand-off whenever possible. As the clinical hand-off is being conducted by a frontline clinician, watch the nonverbal communication of the patients and family members to try to understand unspoken needs.
   3. Select the best catheter size for the patient.
   4. Assess if an alternative/external urine collection device can be implemented.
   5. Conduct assessment of urine output.
   6. Adhere to aseptic technique.
   7. Perform meatal hygiene with unscented wash.
   8. Use sterile supplies/equipment.
      1. Catheter insertion kit (sterile gloves, drape, sponges)
      2. Antiseptic or sterile solution to clean meatal area

• Lubricant jelly

1. Maintain unobstructed urine flow.
2. Keep the catheter and collecting tube free from kinking.
3. Verify catheter securement device is in place.
4. Ensure closed drainage system.
5. Always keep the collecting bag below the level of the bladder. Do not rest the bag on the floor.
6. Assess skin.
7. Empty drain bag using a clean container and safe emptying practices. Do not hold the bag upside down while emptying, and empty the bag every eight hours (or when 2/3 full).
8. Verify unobstructed flow.
9. Unless contraindications exist, do not use antimicrobials routinely to prevent CAUTI.
10. Encourage fluid intake of at least 2 liters if there isn’t a contraindication for fluids (e.g., CHF patients).

Discharge

1. Upon discharge, communicate with patient and patient family members the guidelines for catheter use and infection prevention.
2. Assess necessity and promptly remove indwelling urinary catheters if no longer necessary.
3. Assess for signs/symptoms of infection.
4. If the patient is going home with an indwelling catheter in place, begin preparation for discharge as soon as possible while the patient is still in the hospital to allow for thorough education on maintenance, need, and next steps.
5. Educate patients and family on CAUTI prevention, including maintenance information and expectations of catheter use based on the patient’s circumstance.
6. If patient is being transferred, include indwelling urinary catheter information in report/hand-off. Anticipate gaps in the receiving clinician’s understanding of the hand-off report and work to mitigate these potential gaps early on.
7. Anticipate the patient’s journey after they leave your direct care and screen for patient needs for future safety. Connect the patient with these resources, whether clinical resources or community-based resources.
8. Remain sensitive to the patient’s spoken and unspoken needs (e.g., socioeconomic challenges that may compromise patient’s recovery). If resources don’t exist based on the needs of the patient, elevate this gap to leadership.

Education for Patients and Family Members

The following outlines information that should be conveyed to the patient and family members by someone on the care team in a consistent and understandable manner. In all communication with patients and family members, start by trying to understand their level of health literacy without making any implicit assumptions of their literacy level. Once this literacy level is established, work to communicate in this way in all discussions.

1. Equip patients and family members with tools and knowledge needed to be involved in their loved one’s care (e.g., provide them with a copy of the care plan, ask to see their notes on their care plan, help them to maintain a log of assessments that should be and were conducted, etc.).
2. Before providing information, ask how the patients and family members prefer to learn (e.g., verbal discussion, writing, etc.) and accommodate as much as possible (e.g., with pamphlets, etc.).
3. Explain why a catheter is needed and what is involved in insertion. Ensure the patients do not misinterpret catheter insertion as a sexual procedure.
4. Discuss what the care team is doing to prevent infection and how the patient and family members can get involved in prevention with tangible examples (e.g., wash hands, don’t touch the urine collection bag, etc.).
5. Explain how long the catheter is expected to remain in place, provide the anticipated date of removal, and share any updates in the days leading up to removal. Make the information specific to their circumstance (e.g., “Based on your scheduled procedure, the catheter use may be increased by day(s)”).
6. Explain the importance of removing the catheter as soon as possible and the implications of leaving the catheter in for extended periods of time, whether in the hospital or upon discharge.
7. Indicate what patients and family members can watch out for. Patients and family members may be able to detect and raise a concern if:
   1. The catheter has been in for a long time. (Ensure patients and family members are clear about how long is long).
   2. They witness a lack of hand hygiene before manipulating the catheter (e.g., touching the door handle with gloves already on before manipulating the catheter).
   3. The position of the urine bag is not below the level of the bladder.
   4. The catheter tubing is twisted.
   5. The bag needs to be emptied or if the bag is about to overflow.
   6. There’s blood in the urine.
   7. A sterile pack is not used before catheterization. (Explain what a sterile pack looks like before making this recommendation.)
   8. There’s a lack of daily care from the care team.
8. Instead of taking place, leaving capacity for questions and repeat-back strategies. When patients and family members understand the signs and symptoms that could be indicative of a problem, they are able to serve as an extra set of eyes in order to elevate this concern as early as possible.
9. Questions patients and family members might ask:
   1. “Is this catheter necessary?”
   2. “How long will this catheter remain in place?”
   3. “Are there alternative methods?”
   4. “Why do I have a urinary catheter in place?”