Evidence Based

Nursing
Recommendation:
CAUTI Prevention
Javi Perez, Devonne Husband, Alex Cole, Tatiana Facer,
Noelle Olm-Trujillo, Patricia Duenas, Justin Fordham,
Kacie Terry, and Katie Valencia

University of Arizona Lab Group C EBP Presentation

Introduction
Catheter-Associated Urinary Tract Infections (CAUTI) are
preventable infections yet they occur very frequently and rates are
rising.
According to the CDC, CAUTIs are the most commonly reported
Healthcare Associated Infections (HAI) to the National Healthcare
Safety Network (NHSN).
Nursing research has found there is no universally accepted
evidence-based tool to reduce CAUTI as there are for other HAIs.
It has been found that incorporating a bundle including insertions,
management and removal guidelines with no education are effective
in reducing CAUTI rates.
The significance to the nursing profession is that our role as nurses
is to provide safe and high quality care that will ultimately result in
better patient outcomes. When safe care is not carried out, it can be
detrimental to patients, healthcare providers, and hospitals.
Clinical Question: PICOT

Is using a CAUTI prevention bundle combined with

nursing education for one year more effective in
reducing CAUTI than only implementing a bundle in
ICU high acuity patients?
CAUTI Prevention: Bundles with
Education vs. Bundles without
Education
Our research involved the application of CAUTI prevention bundles
with nursing education versus bundles that did not include nursing
education.
For the purposes of our project, we defined education as:
Outside of scheduled hours with compensation, including all
nursing staff on each ICU unit, having an educator hired to teach
about catheter maintenance, management, and alternatives to
indwelling catheters.
The implementation of a bundle without education can involve the
nursing leaders and staff of each unit being told about the new
bundle through emails and flyers (not educated on catheter
maintenance etc.)
Current Practice

CAUTI -- catheter associated urinary tract infection

The 4th most common type of healthcare associated infection
This infection can lead to a large spectrum of medical
complications
About 5 million patients receive a urinary catheter in the US
every year
12-25% of all hospitalized patients will contract a CAUTI during
their stay
More than 560,000 patients develop CAUTIs each year
Current Practice
There is no current universal practice because each institution varies
on their implementation, but the American Nurse Association
recommends a bundle approach that includes
Prevention of inappropriate short-term catheter use
Timely removal of catheters
Urinary catheter care during placement
CAUTI occurrence in Arizona is 1% lower than the national baseline
Arizona Health Improvement Plan recommends compliance with
ANAs checklist
Locally, Carondelet hospitals (St. Marys/St. Josephs) implement a
bundle approach that includes indication for use, proper insertion
and timely removal
Current Literature

The current research indicates that implementation of bundles to

prevent CAUTIs is more effective than bundles plus education
 Current Literature
The research indicates that CAUTIs are often one of the most prevalent
hospital acquired infections in hospital facilities around the world

The literature indicates that ICU patients are at a higher risk for infections
than patients on other units due to their rapidly changing disease
processes and invasive treatments

The reduction of CAUTI rates in ICU units after the implementation of

specific bundles to prevent and control infections was shown to be
statistically significant

The research indicates that establishing specific CAUTI prevention

bundles and educating healthcare workers on its implementation is more
effective than conducting CAUTI prevention educational sessions and
establishing a bundle
Research: Strengths and
Weaknesses
 Evaluation of an intervention program to prevent
hospital-acquired catheter-associated urinary tract
infections in an ICU in a rural Egypt hospital

Strengths: Weaknesses:

Exclusive criteria for Small sample size (77

population; if they already participants)
had signs of a UTI they were Low compliance rates
excluded from the staff in the
Use of the arithmetic mean, beginning of the
Chi-square and Spearman intervention phase
coefficient
Specific diagnostic criteria
for CAUTI (American
National Healthcare Safety
Network)
Impact of an International Nosocomial Infection Control
Consortium multidimensional approach on catheter-associated
urinary tract infections in adult intensive care units in the
Philippines: International Nosocomial Infection Control
Consortium (INICC) findings

Strengths: Weaknesses:

Large sample size (3,183) Only two ICUs included

Feedback was collected The baseline period was
monthly during the study short and could have
Evaluated the interventions overestimated the effect of
using RR, 95% Cis, P-values, the intervention
and Poisson regression
analysis
Specific diagnostic criteria for
CAUTI
Impact of a multidimensional infection control approach
on catheter-associated urinary tract infection rates in adult
intensive care units in 10 cities of Turkey: International
Nosocomial Infection Control Consortium findings (INICC)

Strengths: Weaknessess:

Large sample size (4,231) Short implementation of

Bundle specificity bundle intervention; 3 months
Studied 13 adult ICUs; allows No control group in the
for a wide distribution of experiment
patients
Poisson regression to
compare the rates
of CAUTI with baseline and
the follow-up period
Specific diagnostic criteria for
CAUTI
Impact of a multidimensional infection control approach
on catheter-associated urinary tract infection rates in an
adult intensive care unit in Lebanon: International
Nosocomial Infection Control Consortium (INICC) findings

Strengths: Weaknesses:

Large population (1506) No exclusion criteria

Length of study: 4 years
Used Poisson regression to
compare the rates of CAUTI
at baseline and during the-
follow up period
Specific diagnostic criteria for
CAUTI
Evaluation of each individual
intervention in the bundle was
not implicated
3-month baseline period may
have been too short- leads to
an overestimation of the
effectiveness of the bundle
Uneven distribution of sexes;
39%(females), 61%(males)
Impact of a Bundle on Prevention and Control of
Healthcare associated Infections in Intensive
Care Unit

Strengths: Weaknesses:

Large population (2774) Uneven distribution of sexes;

Comparison of rates was
obtained using a 2 test
Patients discharged were
followed for another 48 hours
to evaluate for infections
Specific diagnostic criteria for
CAUTI (HAI Diagnosis
Standard by the Ministry of
Public Health)
males (63.1%) females
(36.9%)
There were no exclusion
criteria to be met for this
study
Results of the study cannot
be generalized because the
study was conducted in a
single ICU in China.
A multidisciplinary Intervention to Prevent
Catheter-Associated Urinary Tract Infections
Using Education, Continuum of Care, and
Systemwide Buy-In
Strengths: Weaknesses:

Quantitative study, allowed Does not state the population

for descriptive data of the
CAUTI rate and results
CAUTI bundle was based on
current evidence based
guidelines
size
No exclusion criteria
Definition of CAUTI changed
during the study, possibly
altering the results; reduced
the studys CAUTI by 25%-
30%.
The Effects of Bundles on Catheter- Associated
Urinary Tract Infections in the Pediatric
Intensive Care Unit

Strengths: Weaknesses:

Specific inclusion and exclusion Small population (390)

criteria that the study utilized The results cannot be
including age, hospital length of generalized because the study
stay, history of infection on was only conducted in one
arrival, and UTI development single ICU in Turkey
while on the unit
Participants were diligently
monitored based on
physiological and physical
parameters and infection status.
A Multifaceted Approach to Reduction of Catheter-
Associated Urinary Tract Infections in the Intensive
Care Unit With an Emphasis on Stewardship of
Culturing

Strengths: Weaknesses:

All ICUs in the facility were
included in this study (MICU,
NeuroICU, SICU, CVICU, PICU,
NICU, and CCU)
Chi-square was used to evaluate
differences between rates
(CAUTI rates, Hospital acquired
bloodstream infection (HABSI),
HABSI due to Enterobateriaceae,
Device utilization ratios (DURs))
Small sample size (215 adult
patients and 25 pediatric
patients)
Interventions were only
implemented at a single
institution, which limits the
generalizability of the results
No specific diagnostic criteria
for CAUTI mentioned
Reduction of catheter-associated urinary tract
infections among patients in a neurological
intensive care unit: a single institutions success
Strengths: Weaknesses:

Pearson product moment As a tertiary referral center, a

correlation was used to large percentage of patients
assess the correlation arrived to the hospital already
catheterized, so the rate of
between quarterly catheter
outside catheter placement
utilization, the rate of
could not be controlled
catheter-associated UTI, and
Multiple interventions were
pressure ulcer incidence. implemented so the efficacy of
Exclusion criteria used for each intervention is
patients with CAUTI already indeterminable
30-month intervention period
Specific diagnostic criteria for
CAUTI (National Healthcare
Safety Network)
Evidence Based Nursing Recommendations

Research has shown that a bundle for preventing and controlling

CAUTI could effectively decrease the incidence of CAUTI.
These bundles should be structured and detailed
Enhancing the execution of the bundle for preventing and controlling
HAIs in the ICU will help to lower CAUTI rates. This encompasses
complete adherence from the staff (residents, physicians, and
nurses). It should become a part of a culture of patient safety to
adhere to prevention bundles.
Current research also suggests that including nurse education in
CAUTI prevention involves a change of culture, which takes time and
is difficult.
CAUTI Bundle: Insertion
CAUTI BUNDLE: Management
CAUTI: Removal
Overall Application and Implementation

Action Item: Obtain baseline data and contact The Infection and
Prevention Force

When: January 1, 2018-January 14, 2018 (Two weeks)

Data Collected:

Collect ICU admission data

Obtain ICU nurse staffing
Determine CAUTI rates in St. Marys ICU units
Determine catheter days in St. Marys ICU units
Overall Application and Implementation

Action Item: Contact St. Marys ICU nurse managers

When: January 15, 2018-January 31, 2018 (Two weeks)

Data Collected:

Roll out implementation to nurse managers via email on

January 15, 2018
Email nurse managers presenting bundle specifics in an
attachment on January 22, 2018 and January 29, 2018.
Obtain staff emails on January 22, 2018
Overall Application and Implementation

Action Item: Preparation for Implementation

When: February 1, 2018-February 28, 2018 (One month)

Data Collected:

Print bundle into a pamphlet and create a CAUTI binder first

week of February 2018
Print bundle paper forms to post on ICU bulletin boards and
in staff restrooms first week of February 2018.
Send out emails to all ICU staff initiating bundle pilot project
on the ICU unit chosen each Monday for remaining weeks of
February 2018 (February 12, 19, and 26, 2018)
Overall Application and Implementation

Action Item: Pilot project on one ICU unit with the highest CAUTI
rates at Carondelet St. Marys Hospital, Tucson AZ.

When: March 1, 2018-May 31, 2018 (Three months)

Data Collected:

Bundle roll out begins March 1, 2018 on one ICU unit.

For the entire month of March 2018, charge nurses will report
to ICU staff during each shifts huddle daily.
During huddle, charge nurses will remind staff to check emails
regarding the bundle implementation as well as making staff
aware of pamphlets and posted papers in staff restrooms and
bulletin boards.
Overall Application and Implementation

Action Item: Evaluation of pilot bundle implementation

When: June 1, 2018-June 17, 2018 (Two weeks)

Data Collected:

Analyze staff compliance and bundle efficacy through

nursing audits.
Make adjustments needed in relation to compliance of
nurses and nurse managers for implementation of bundle.
Overall Application and Implementation

Action Item: Implement project on all ICU units at Carondelet St.

Marys Hospital, Tucson AZ

When: June 18, 2018-December 16, 2018 (Six months)

Data Collected:

Bundle roll out begins June 18, 2018 on other two ICU units.
For the entire month of June 2018, charge nurses will report to
ICU staff during each shifts huddle daily.
During huddle, charge nurses will remind staff to check emails
regarding the bundle implementation as well as making staff
aware of pamphlets and posted papers in staff restrooms and
bulletin boards.
Overall Application and Implementation

Action Item: Evaluation of bundle intervention on all St. Marys ICU

units

When: December 17, 2018-December 31, 2018 (Two weeks)

Data Collected:

Analyze staff compliance through nursing audits.

Make adjustments needed in relation to compliance of nurses
and nurse managers for a continuation of bundle
implementation in St. Marys ICU units.
Cost Analysis
COST OF CAUTIs
1 CAUTI = $911 X
40 ICU beds at Saint Marys
6,409 ICU patients per year 32 CAUTIs in the ICU per
On average, 80-100% of ICU year
patients get catheters
$29,152 per year
Total Savings
COST OF THE BUNDLE
$10 per month for binders and flyers

SAVINGS
8.78% reduction in CAUTIs = saving $2,559.50 per year

WHY EDUCATION IS NOT COST EFFECTIVE

100 nurses hired to a 40 bed ICU

Floor nurses making $35.47 per hour
2 hour class twice per year
$139 for a nurse educator for 4 hours total

= $14,327.84
Risks and Benefits for: Hospital

Risks:
Losing accreditation due to
high CAUTI rate if hospital
does not comply with bundle
Losing money due to high
CAUTI rates if bundle fails
Benefits:
Less CAUTI rates
Saving money: from less
CAUTIs and less days of
hospital stay
Having a better reputation
with fewer CAUTIs
Risk and Benefits for: Patients

Risks: Benefits:
Premature removal of Reduced CAUTI risk
catheter leading to Timely removal of
reinsertion catheter
Acquiring a CAUTI
Increased hospital stay
Risks and Benefits for: Nursing

Risks: Benefits:
Non-compliance Less litigation
Increased workload from Higher pay due to
implementing bundle less cost to hospital
Spending time and Decreased workload
resources and bundle from less infections
does not work on unit
Not providing safe,
quality care at the best of
the nurses ability if
bundle is not
implemented
Evaluation
Registered nurses working in the St. Marys ICU will report all
ordered urinary catheter placements to the ICU charge nurse via
Vocera immediately when a new order is recognized
The charge nurses will check the CAUTI Binder once within one
hour of the end of the shift to ensure maintenance of urinary
catheters are done correctly
Nurses on the unit will be evaluated a total of at least two times
during the duration of the CAUTI bundle. The nurses will not be
aware of the amount of times they will be audited
Duration: 9 Months (In the 3 St. Marys ICU units)
The charge nurses will have a list of the nurses at St. Marys ICUs
and will keep track of the nurses in the ICU who have been audited.
Summary

CAUTIs are a preventable infection and as nurses it is our

role to provide safe and quality care for our patients.
ICU patients are at higher risk for CAUTIs due to their
rapidly changing disease processes and invasive
treatments.
The current research indicates that implementation of
bundles to prevent CAUTIs is more effective than bundles
plus education
Our CAUTI prevention bundle includes necessity of
insertion of catheter, maintenance, and timely removal.
Summary Cont.
Over the span of one year our CAUTI prevention bundle
will be implemented at St. Marys hospital in the ICUs.

Implementing the bundle will only cost an additional

$10 per month. With an 8.78% reduction in CAUTIs and
no need for education there will be a yearly savings of
$16,887.34.
Possible risks of implementing the bundle include
increased CAUTI rates, increased cost to hospital due
to CAUTIs, and increased workload for nurses.
Benefits include decreased CAUTI rates, less litigation,
and saving money.
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