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Running head: CAUTI BUNDLE EFFECTIVENESS

Review of Current Research to Assess Whether the Sentara RMH CAUTI Bundle is Best

Practice

Corinne H. Flora

Old Dominion University: NURS 403

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Review of Current Research to Assess Whether the Sentara RMH CAUTI Bundle is Best

Practice

Working at Sentara Rockingham Memorial Hospital (SRMH) in the Emergency

Department (ED) for the past five years has provided many learning opportunities and chances to

improve clinical skills. SRMH is a 238-bed community hospital that serves seven counties,

stretched across Virginia and West Virginia; included in the service region are multiple

retirement communities as well as Massanutten Ski Resort that hosts guests and out-of-town

visitors of all ages throughout the year. This comprises a unique community that presents to the

ED for care related to a range of complaints, not uncommon among those are individuals with

genitourinary illnesses. Many times, in the ED catheterizations are performed for a plethora of

reasons.

Presentation of the Clinical Problem

A large majority of indwelling catheters are placed in the ED at SRMH. Indwelling

urinary catheters increase the risk of developing urinary tract infections (UTIs), UTIs comprise

forty percent of hospital acquired infections and 70 – 95% of these cases are catheter-associated

urinary tract infections (CAUTIs) (Tyson et al., 2018). “An estimated 500,000 cases of CAUTIs

occur in the United States every year and contribute to increased length of stay, morbidity,

mortality and cost” (Tyson et al., 2018). In the United States a single CAUTI can increase cost

by $600 to $20,000, averaging a national annual amount of $340 to $400 million (Tyson et al.,

2018). The Centers for Medicare and Medicaid Services has discontinued reimbursement for

costs related to hospital acquired CAUTIs; driving a large amount of research surrounding

reduction in incidence of CAUTIs. SRMH has developed a CAUTI prevention bundle which is a

multi-prong approach established to reduce CAUTIs in our facility.

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Current Clinical Practice

SRMH’s official policy and procedure outlines the following guidelines to reduce the risk

of CAUTIs within our facility. The core components of this bundle include: inserting catheters

only for appropriate indications, leaving catheters in place for only as long as needed,

considering use of alternatives, maintaining a closed drainage system, proper securement of

indwelling catheter to prevent movement and ureteral traction, maintain unobstructed urine flow,

keeping the drainage bag below the level of the bladder, routine hygiene, ensuring only properly

trained personnel are inserting and maintaining catheters, insertion takes place in a sterile

environment with aseptic technique and hand hygiene must be completed immediately prior to

and after indwelling catheter insertion (Elliot & Wilson, 2021). The insertion phase is most

applicable to the ED and its role in decreasing CAUTIs but in order to have a significant effect

on CAUTI occurrences a system wide approach really needs to be applied, such as the one

currently described in SRMH’s CAUTI prevention bundle.

Nursing Interventions

STOP Decision Tree Completed Before Every Insertion

There has been a STOP huddle form that is required to be filled out and turned in to the

ED unit manager with every foley placed on the unit. This aims at improving the critical

thinking surrounding whether an indwelling foley catheter has an appropriate indication prior to

insertion. In practice, this is a form that was frequently filled out after urinary catheter

placement occurred; thus, not fulfilling its intended effect. Recently, this decision tree has been

added into our electronic charting system, Epic; predicting that this will improve compliance

with the STOP huddle being completed prior to insertion and improve convenience of this tool.

This decision checklist focuses on identifying absolutely necessary indications for a foley
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catheter as opposed to indications that would be more appropriate to attempt alternatives instead

of inserting an indwelling catheter (Elliot & Wilson, 2021). Once this decision checklist has

established that foley insertion is indicated there is a list to ensure all of the required orders are

present in Epic for accurate documentation (Elliot & Wilson, 2021).

Two-Person Insertion Technique

Currently, SRMH’s policy states that all female indwelling foley catheter placement

procedures are required to have two qualified staff members present. In practice, two or more

qualified staff members are present for difficult insertions in situations such as obesity, patient

confusion or atypical anatomy. However, it has been established that two-person insertion is the

safest practice in all catheterization situations including male catheterizations, intermittent

catheterizations and one-time straight catheterizations (Briggs & Ross, 2017). This two-person

insertion technique improves compliance in hand hygiene prior to and after catheterizations,

improves perineal cleansing prior to insertion and an overall improvement in aseptic technique

(Briggs & Ross, 2017). An obvious barrier in implementing this technique is inadequate staffing

and an overwhelming task list already imposed upon nurses and techs, occupying two qualified

personnel to perform a catheterization requires planning and preparation.

Maintaining a Closed Drainage System

At this time when a specialty catheter is needed such as a smaller size or a coudé tip

catheter a sterile foley kit is opened and a sterile specialty catheter is dropped into the sterile

field. With sterile gloves, the red seal on the standard foley catheter is broken in order to attach

the specialty catheter needed. According to SRMH’s official policy a variety of sizes as well as

specialty catheters should be available in full foley kits that include the catheter needed with a

red seal intact on the drainage system. In five years of working in SRMH ED I have never seen
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a kit that varies from the standard 16 french catheter and specialty catheters include this size in

latex free as well as this size is temperature sensing. A seventy-three percent reduction in

CAUTIs has been associated with the implementation of a 5-S bundle that includes similar

components of SRMH’s CAUTI prevention bundle (Elkbuli et al., 2018). One of these

components is the importance of maintaining a closed sterile drainage system (Elkbuli et al.,

2018). When the red seal is commonly broken for specialty catheter use this sterile drainage

system could be disrupted, even though the catheter exchange is completed in a sterile fashion

the broken red seal could be a potential entry point for bacteria into the urinary catheter and then

into the urinary tract.

Intermittent Catheterization

Intermittent catheterization is one of the alternatives to indwelling foley catheters that is

underused at SRMH in inpatient units as well as in the ED. More common alternatives that are

implemented more often are foley catheters, Purewicks and scheduled bladder scanning.

However, intermittent catheterizations “can be a more effective option to manage urinary

retention, with a lower infection risk than an indwelling catheter, and if appropriate, is the

preferred option for bladder management” (Hallam & Shepley, 2017). In 2017, this small study

showed an overwhelming patient preference of favoring intermittent catheterizations over

indwelling foleys; reducing their CAUTI rates as well as improving their patient satisfaction

(Hallam & Shepley). Again, if implementing a two-person insertion technique for all

catheterizations as well as increasing the use of intermittent catheterizations a barrier to

completing this regularly will be inadequate staffing.

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Summary and Call for Additional Research

In conclusion there are variances in routine bedside practice when compared to SRMH’s

CAUTI prevention bundle policy that need to be addressed including: always completing the

STOP huddle documentation prior to insertion, unavailability of closed drainage systems when

specialty catheters are needed, always using a two-person insertion technique as well as utilizing

intermittent catheterizations more often. Significant barriers to implementing these practices

routinely at the bedside include inadequate staffing as well as not having indicated equipment

readily available.

The recent change in having the STOP bundle integrated into the Epic charting system is

predicted to improve the compliance of completing this checklist prior to foley insertion.

Strategies for implementing these other three practices and improving compliance with SRMH’s

CAUTI prevention bundle include improved staffing of the unit to better facilitate two-person

insertion technique. Another option would be to appoint the charge RN as the catheter wing

man; ensuring the STOP bundle has been adequately addressed prior to insertion and being the

second pair of hands for the insertion procedure. Improving availability of specialty catheter

foley trays that have sterile and enclosed drainage systems as well as increasing availability of

straight catheters for intermittent catheterizations. The costs associated with these interventions

would still be marginal in comparison to the cost of CAUTIs to the hospital, especially when

reimbursements from Medicaid and Medicare are not granted for urinary tract infections

acquired while in the hospital related to indwelling foley catheter use.

It is hypothesized that the use of green curos caps on urine collection ports would also

help to reduce CAUTIs while not greatly increasing stress on staff or new bedside equipment.

Inefficient research was found on this topic but the costs associated with additional curos caps
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would be minimal and they are already readily available in the ED for use in central lines and

port lines. If these caps help to reduce central line blood stream infections when placed on

similar hubs on port lines and central lines then it is not a far stretch to believe a similar effect

could be observed when placing the curos cap on urine collection hub of foley catheters.

Honor Code:

I pledge to support the Honor System of Old Dominion University. I will refrain from any form

of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a

member of the academic community it is my responsibility to turn in all suspected violations of

the Honor Code. I will report to a hearing if summoned

Signature Corinne H. Flora

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References

Briggs, J., & Ross, L. (2017). The positive effect of a two person process Utilizing direct

observation and checklist for urinary catheter Insertion. American Journal of Infection

Control, 45(6), 578-579. doi:10.1016/j.ajic.2017.04.199

Elkbuli, A., Miller, A., Boneva, D., Puyana, S., Bernal, E., Hai, S., & McKenney, M. (2018).

Targeting catheter-associated urinary tract infections in a trauma population: A 5-s bundle

preventive approach. Journal of Trauma Nursing, 25(6), 366-373.

doi:10.1097/jtn.0000000000000403

Elliot, R., & Wilson, S. A. (2021, February 22). SENTARA CAUTI PREVENTION TOOLKIT

[PDF].

Hallam, C., & Shepley, M. (2017). Intermittent catheterisation as an alternative to indwelling

catheters. Nursing Times Innovation, 113(9), 30-33.

Schiessler, M. M., Darwin, L. M., Phipps, A. R., Hegemann, L. R., Heybrock, B. S., &

Macfadyen, A. J. (2019). Don't have a doubt, get the catheter out: A nurse-driven cauti

prevention protocol. Pediatric Quality & Safety, 4(4). doi:10.1097/pq9.0000000000000183

Tyson, A. F., Campbell, E. F., Spangler, L. R., Ross, S. W., Reinke, C. E., Passaretti, C. L., &

Sing, R. F. (2018). Implementation of a NURSE-DRIVEN protocol For Catheter removal

to Decrease catheter-associated urinary tract infection rate in a SURGICAL Trauma ICU.

Journal of Intensive Care Medicine, 35(8), 738-744. doi:10.1177/0885066618781304

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