What Impact Does a Nurse Training What Impact Does a Nurse Training Program Designed to Decrease Urinary Program Designed to Decrease Urinary

Catheter Use Have on Bacteruria Rates in Catheter Use Have on Bacteruria Rates in the Community Hospital Setting?the Community Hospital Setting?

Jamie Bartley DO, Diane Lenk MSN, RN, Janet Moody BSN, RN, Amy Jamie Bartley DO, Diane Lenk MSN, RN, Janet Moody BSN, RN, Amy Brode DO.Brode DO.

From the Division of Urology, Wound Care Nursing, and The Infectious From the Division of Urology, Wound Care Nursing, and The Infectious Disease Department. Disease Department.

Botsford Hospital, Farmington Hills, MIBotsford Hospital, Farmington Hills, MI

IntroductionIntroduction

Urinary catheters are one of the most Urinary catheters are one of the most common causes of nosocomial infections common causes of nosocomial infections in the hospitalized patientin the hospitalized patient Patients with an indwelling foley catheter have Patients with an indwelling foley catheter have

a risk of bacteruria at 5% per daya risk of bacteruria at 5% per day Symptomatic urinary tract infection has been Symptomatic urinary tract infection has been

shown to occur in 20% of patients with shown to occur in 20% of patients with bacteruriabacteruria

Urinary catheters are often placed without a Urinary catheters are often placed without a clear indication for needclear indication for need

HypothesisHypothesis

We believe that a nursing education We believe that a nursing education program through the “Keystone program through the “Keystone Project” will decrease non-indicated Project” will decrease non-indicated catheter use in hospitalized patientscatheter use in hospitalized patients

Secondary analysis: We suspect this Secondary analysis: We suspect this will decrease the prevalence of will decrease the prevalence of positive urine culturespositive urine cultures

““Indicated vs. Non-Indicated Foley” Indicated vs. Non-Indicated Foley” Nursing InserviceNursing Inservice

Beginning fall 2007, nurses were Beginning fall 2007, nurses were inserviced on indications and non-inserviced on indications and non-indications for foley cathetersindications for foley catheters

Urinary tract obstructionNeurogenic bladder

Urologic study/urologic surgeryStage 3 or 4 pressure ulcer

Hospice, comfort care or palliative care only

Figure 1: Indications for Urinary Catheter Use

NephrologyTransferred from ICU

Patient requestsConfused

IncontinenceOther

Figure 2: Non-Indications for urinary catheter use

Collection of Catheter DataCollection of Catheter Data

Catheter use was documented for one week Catheter use was documented for one week (Monday-Friday) and recorded on two units (Monday-Friday) and recorded on two units according to the dates below.according to the dates below.

5 South Data Collection DatesWeeks 1-3 October 8-26, 2007 Pre-education data

Week 8  November 26 - 30, 20071st Quarterly  March 3 - 7, 2008 2nd Quarterly  July 14 - 18, 2008

3rd Quarterly  October 27 -31, 2008

PCU Data Collection Dates Week 1-3  Feb 18 - March 7, 2008 Pre-education data

Week 8  April 7 - 11, 2008 1st Quarterly  July 28 - August 1, 2008  2nd Quarterly  September 22 - 26, 2008 3rd  Quarterly  December 8 -12, 2008

Post-education data

Post-education data

Collection of Urine Culture Collection of Urine Culture DataData

Information on patients with bacteruria Information on patients with bacteruria was obtained from the Infectious Disease was obtained from the Infectious Disease DepartmentDepartment Bacteruria= >10^2 CFUsBacteruria= >10^2 CFUs

A retrospective chart review A retrospective chart review Did patients with bacteruria had a foley Did patients with bacteruria had a foley

catheter and if so, was it was indicated catheter and if so, was it was indicated according to the above criteria?according to the above criteria?

Study PopulationStudy Population

Pre-intervention- n = 1223 (378 and Pre-intervention- n = 1223 (378 and 845)845)

Post Intervention- n = 1737 (608 and Post Intervention- n = 1737 (608 and 879)879)

RESULTSRESULTS

Logistic regression analysis and Odds Logistic regression analysis and Odds Ratios (95% confidence limits) were Ratios (95% confidence limits) were performed to determine if there was performed to determine if there was a statistically significant decrease a statistically significant decrease ((=0.05) in non-indicated foley =0.05) in non-indicated foley catheter usecatheter use

PCU Catheter Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Patients w/ Foleys 30% 34% 20% 19% 15%

% Indicated Foleys 34% 40% 59% 37% 34%

% Non-Indicated Foleys 66% 60% 41% 63% 66%

Pre-Pilot Week 8 1st Qtr-08 2nd Qtr-08 3rd Qtr-08

PCU Catheter ResultsPCU Catheter Results

Contrast

P-value

Pre-education Mean Post- education < 0.0001*

Time

Odds Ratios (95% confidence limits)

P-values

Week 8 (compared to pre-intervention)

0.75 (0.46 , 1.23) 0.2551

Quarter 1 (compared to pre-intervention)

0.36 (0.20 , 0.64) 0.0005*

Quarter 2 (compared to pre-intervention)

0.85 (0.47 , 1.53) 0.5902

Quarter 3 (compared to pre-intervention)

0.97 (0.47 , 2.00) 0.9402

* statistically significant for α=0.05

5 South Catheter Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Patients w/ Foleys 35% 36% 40% 33% 27%

% Indicated Foleys 60% 76% 83% 78% 90%

% Non-Indicated Foleys 40% 24% 17% 22% 10%

Pre-Pilot Week 8 1st Qtr-08 2nd Qtr-08 3rd Qtr-08

5S Catheter Results5S Catheter Results

Time

Odds Ratios (95% confidence

limits)

P-values

Week 8 (compared to pre-

intervention)

0.49 (0.24 , 0.99) 0.0466*

Quarter 1 (compared to pre-

intervention)

0.32 (0.15 , 0.66) 0.0022*

Quarter 2 (compared to pre-

intervention)

0.43 (0.20 , 0.92) 0.0286*

Quarter 3 (compared to pre-

intervention)

0.18 (0.06 , 0.52) 0.0017*

Table 3: Outcome – Non-indicated foley use

Contrast

P-value

Pre-education Mean Post- education < 0.0001*

* statistically significant for α=0.05

Does the decrease in Does the decrease in catheter use we see lead to a catheter use we see lead to a

decrease in bacteruria?decrease in bacteruria?

Our ultimate GoalOur ultimate Goal Prevention of CAUTIPrevention of CAUTI

5S and PCU Urine Culture Data

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

% Positive U

rine Cultures

% Patients w/ Foleys 32% 26%

% Urine Cultures with Indicated orno Foley

90.3% 77.4%

% Urine Cultures with Non-IndicatedFoley

9.7% 22.6%

% + Urine Cultures 2.5% 1.8%

Pre-Pilot Post-Pilot

%

Pa

T

I

En

T

s

Can Decreasing Catheter Use Can Decreasing Catheter Use Decrease Bacteruria?Decrease Bacteruria?

Urine culture data was analyzed using Fisher’s exact Urine culture data was analyzed using Fisher’s exact test to determine if there was a decrease in the test to determine if there was a decrease in the incidence of positive urine cultures after the foley incidence of positive urine cultures after the foley education program was instituted education program was instituted

A decrease in percentage of positive urine cultures* A decrease in percentage of positive urine cultures* was seen but it did not reach statistical significance was seen but it did not reach statistical significance (2.5%, 1.8%)(2.5%, 1.8%)

Fisher's Exact Test

Two-sided Pr <= P 0.1921

*Note: This was determined by the number of positive urine cultures per total patient population, not total number of urine cultures. Since data was provided only on positive urine cultures, it is assumed that the other patients without cultures taken were either not indicated or were negative (this may represent a sample bias)

ResultsResults

Of interest (though not significant)Of interest (though not significant) Most of the positive urine cultures in our Most of the positive urine cultures in our

data were seen in patients with an data were seen in patients with an indicated catheter in both the pre-indicated catheter in both the pre-education and post-education periods education and post-education periods (90.32% and 77.42%)(90.32% and 77.42%)

DiscussionDiscussion

Decreasing hospital acquired infections is Decreasing hospital acquired infections is necessary to decrease patient morbidity and necessary to decrease patient morbidity and mortalitymortality

Financial incentive to hospital due to no Financial incentive to hospital due to no reimbursement for “reasonably preventable reimbursement for “reasonably preventable infections (including CAUTI)infections (including CAUTI)

Certain factors such as patient population Certain factors such as patient population will greatly influence the success of such a will greatly influence the success of such a programprogram PCU, compared to 5S, was 4 times more likely to PCU, compared to 5S, was 4 times more likely to

have a non-indicated foley (p<0.001).have a non-indicated foley (p<0.001).

ConclusionConclusion A nurse training program can be A nurse training program can be

successful in decreasing foley catheter use successful in decreasing foley catheter use when it may not be appropriatewhen it may not be appropriate

The effect on decreasing bacteruria by The effect on decreasing bacteruria by decreasing catheter use was not proven in decreasing catheter use was not proven in this studythis study

The majority of positive urine cultures still The majority of positive urine cultures still occur in patients who have a medical occur in patients who have a medical reason to have a foley in place. Improved reason to have a foley in place. Improved infection control techniques are needed for infection control techniques are needed for this high-risk populationthis high-risk population

ReferencesReferences1.Cravens, DD., Zweig, S. Urinary catheter management. American 1.Cravens, DD., Zweig, S. Urinary catheter management. American

Family Physician. 61 (2): 369-76, 2000 Jan 15Family Physician. 61 (2): 369-76, 2000 Jan 152. Hart, S. Urinary catheterization. Nursing Standard. 22(27): 44-8, 2. Hart, S. Urinary catheterization. Nursing Standard. 22(27): 44-8,

2008 Mar 12-182008 Mar 12-183. Hashmi, S., Kelly, E. Rogers, SO. Urinary tract infection in surgical 3. Hashmi, S., Kelly, E. Rogers, SO. Urinary tract infection in surgical

patients. American Journal of Surgery. 186(1) 53-6, 2003, Julpatients. American Journal of Surgery. 186(1) 53-6, 2003, Jul4. Lo, E., Nicolle, L., et al. Strategies to prevent catheter-associated 4. Lo, E., Nicolle, L., et al. Strategies to prevent catheter-associated

urinary tract infections in acute care hospitals. Infection Control urinary tract infections in acute care hospitals. Infection Control and Hospital Epidemiology. 29(1), 2008, Oct and Hospital Epidemiology. 29(1), 2008, Oct

5. Maki, DG., Tambyah, PA. Engineering out the risk for infection with 5. Maki, DG., Tambyah, PA. Engineering out the risk for infection with urinary catheters. Emerging Infectious Diseases. 7(2), 2001 Mar-urinary catheters. Emerging Infectious Diseases. 7(2), 2001 Mar-AprApr

6. Saint, S., Chenoweth, CE. Biofilms and catheter-associated urinary 6. Saint, S., Chenoweth, CE. Biofilms and catheter-associated urinary tract infections. Infectious Disease Clinics of North America. 17(2): tract infections. Infectious Disease Clinics of North America. 17(2): 411-31, 2003 Jun411-31, 2003 Jun

7. Saint, S., Lipsky BA. Preventing catheter-related bacteriuria: should 7. Saint, S., Lipsky BA. Preventing catheter-related bacteriuria: should we? Can we? How? Archives of Internal Medicine. 159(8): 800-8, we? Can we? How? Archives of Internal Medicine. 159(8): 800-8, 1999 Apr 261999 Apr 26

8. Sedor J., Mulholland, SG. Hospital Acquired urinary tract infections 8. Sedor J., Mulholland, SG. Hospital Acquired urinary tract infections associated with the indwelling catheter. Urologic Clinics of North associated with the indwelling catheter. Urologic Clinics of North America. 26(4): 821-8, 1999 NovAmerica. 26(4): 821-8, 1999 Nov

9. Trautner, B.W., Darouiche, R.O. Catheter-associated infections: 9. Trautner, B.W., Darouiche, R.O. Catheter-associated infections: pathogenesis affects prevention. Archives of Internal Medicine. pathogenesis affects prevention. Archives of Internal Medicine. 164(8): 842-50, 2004 Apr 26164(8): 842-50, 2004 Apr 26