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Catheter-Associated Urinary Tract
Infection (CAUTI)
Tier 2 Interventions
Presenter
Linda Greene, RN, MPS, CIC, FAPIC
Manager Infection Prevention
University of Rochester, Highland Hospital
Contributions by
Kristi Felix, RN, BSN, CRRN, CIC, FAPIC
Madonna Rehabilitation Hospital
Karen Fowler, MPH
University of Michigan
Milisa Manojlovich, PhD, RN, CCRN
University of Michigan
Jennifer Meddings, MD, MSc
University of Michigan
Sanjay Saint, MD, MPH
University of Michigan
Barbara W. Trautner, MD, PhD
Baylor College of Medicine
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Learning Objectives
• Outline the Tier 2 enhanced interventions to prevent
catheter-associated urinary tract infections (CAUTI)
• Describe when implementation of Tier 2 CAUTI
interventions may be necessary
• Identify strategies to overcome barriers associated
with the additional CAUTI interventions
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Tier 2 Overview
*
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Conduct Catheter Rounds
Team Members
• Ideally multidisciplinary
• Physician, nurse caring for patient, infection
preventionist, charge nurse or designee
Expected Outcomes
• Minimize extra work
• Real time data available to
frontline staff
• Decrease CAUTI infections
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Barriers to Rounding
• Time
• Availability of staff
• Competing priorities at the bedside
– Patient education
– Fall prevention
– Basic care
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Strategies to Overcome Barriers to
Catheter Rounds
• Incorporate into “plastics rounds”
• Consider nursing rounds
• Use it to promote mentoring and critical thinking:
–
Why does my patient have the catheter?
– Does this patient still need it?
– Is it properly maintained?
• Use as patient engagement tool
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Feedback CAUTI and Catheter Use
Information in Real Time
• Infection information is more relatable if the
information is fed back as soon as the infection is
identified and if the patient is still in the unit or
hospital
• An infection preventionist should contact the unit
manager or charge nurse when a CAUTI is identified
• Consider using huddles or debriefs to talk about the
case with the unit staff
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Barriers to Providing Real Time Feedback
• Infection Preventionist’s time – may not look at data
immediately
• Staff availability or time
• Staff competing priorities
• Culture – b
elief that the CAUTI is not preventable
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Strategies to Overcome Barriers to
Providing Real Time Feedback
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• Appoint unit champions
• Assess possible infections even while awaiting
confirmation
• Celebrate success
9 Months without
a CAUTI!
Observation of Competency
Observe and document competency of
indwelling urinary catheter insertion and
maintenance
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Observe and Document
• Findings
– No hand hygiene prior to 74% of insertions
– No hand hygiene in 91% post insertions
– 59% of insertion attempts were associated with a major break in
sterile technique
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(Manojlovich M, Infect Control Hosp Epidemiol, 2016)
Study by Manojlovich and
colleagues
• Directly observed insertion of
urinary catheters in an emergency
department
• 65 patients, 81 insertions
Barriers to Competency Training
• Lack of time or labor intensive
• Staff turnover
• Lack of resources to evaluate competency
• Temporary staff
• Failure to include all professional categories of staff
th
at insert catheters.
• Lack of administrative support
• Lack of champions
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Strategies to Overcome Barriers
• Incorporate competency into unit-based education
• Enlist and engage nursing champions to conduct
audits
• Incorporate checklists into daily activities
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Knowledge
AttitudeSkill
Competence
• Identify all individuals who
insert urinary catheters and
ensure competence
Perform Root Cause
Learning From Defects Tool
• Events such as a CAUTI can
be an opportunity for
improvement
• Consider using the Learning
From Defects tool
• The tool is most helpful
when discussed as close to
the event as possible
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Perform Root Cause Analysis or
Focused Review
(Learn From Defects Tool, AHRQ, 2012, https://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.html )
Root Cause Analysis Tool
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Barriers to Conducting RCAs and
Strategies to Overcome Them
Barriers Strategies to Overcome
May be perceived as finding fault
• Keep the discussion focused on
the patient
Time intensive
• Include the discussion in regular
shift reports
Physician and nursing reluctance
• Demonstrate the value of
reviewing cases
• Have open discussions
• Use aggregate data on findings
to change behavior
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Take Home Messages
If CAUTI rates are not declining despite best
efforts:
• Involve nursing and physician champions
• Establish regular rounding
• Ensure insertion and maintenance competency
• Regularly audit practices and provide feedback
• Perform root cause analysis on CAUTI cases
Ce
lebrate successes!
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References
• Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract
infections in acute care hospitals: 2014 Update. Infection Control Hosp Epidemiol. 2014;
35(5): 464-79.
• Learn from Defects Tool. Content last reviewed December 2012. Agency for Healthcare
R
e
search and Quality, AHRQ, Rockville, MD. Accessed January 12, 2017. Available at
http://www.ahrq.gov/professionals/education/curriculum-
tools/cusptoolkit/toolkit/learndefects.html
• Manojlovich M, Saint S, Meddings J, et al. Indwelling urinary catheter insertion practices in
the emergency department: an observational study. Infect Control Hosp Epidemiol. 2016;
37(1): 117-9.
• TeamSTEPPS 2
.
0. Agency for Healthcare Research and Quality, AHRQ. Rockville, MD.
Content last reviewed September 2016. Accessed January 30, 2016. Available at
http://www.ahrq.gov/teamstepps/instructor/index.html
• Streamlined Evidence-Based RN Tool: Catheter Associated Urinary Tract Infection (CAUTI)
Prevention. American Nurses Association. Accessed May 18, 2016. Available at
http://nursingworld.org/CAUTI-Tool.
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Speaker Notes
Speaker Notes: Slide 1
Welcome to this module, titled “Catheter-Associated Urinary
Tract Infection (CAUTI) Tier 2 Interventions.” This is the second
module of the Tier 2 interventions for CAUTI Prevention. This
module will discuss other interventions that may be necessary to
implement if CAUTI rates remain high after consistent
application of Tier 1 interventions.
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Speaker Notes: Slide 2
This module was developed by national infection prevention
experts devoted to improving patient safety and infection
prevention efforts.
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Speaker Notes: Slide 3
After completing this module you will be able to:
• Outline the Tier 2 enhanced interventions to prevent CAUTI;
• Describe when implementation of Tier 2 CAUTI interventions
may be necessary; and
• Identify strategies to overcome barriers associated with these
additional interventions.
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Speaker Notes: Slide 4
Your hospital might have worked hard to implement all of the
recommended guidelines described in the Tier 1 modules. You have
policies and practices for placing indwelling catheters for only appropriate
reasons, you have encouraged the use of alternatives, ensured proper
aseptic technique, and optimized removal of unneeded catheters and have
a urine culture stewardship program. However, your CAUTI rates remain
elevated. In addition to using the CAUTI Guide to Patient Safety, GPS
and/or the Centers for Disease Control and Prevention’s, or CDC’s,
Targeted Assessment for Prevention, or TAP, Strategy to assess CAUTI
prevention practices, it may be time to implement additional enhanced
activities to prevent CAUTI. These include:
• Conducting catheter rounds,
• Giving immediate feedback in real time to frontline staff,
• Observing and documenting competency of catheter insertion, and
• Performing a full root cause analysis of each CAUTI case.
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Speaker Notes: Slide 5
One of the first Tier 2 interventions is to conduct catheter
rounds. Ideally, this would involve a multidisciplinary team
consisting of the nurses caring for the patients, the physician, the
charge nurse or designee and the infection preventionist. The
expected outcome is to minimize extra work by providing
discussion at the bedside with real time data available to
frontline nurses. Obviously, discussing whether or not the
patient still needs a catheter and removing it promptly can
decrease CAUTIs, patients cannot develop a CAUTI if they don’t
have an indwelling urinary catheter.
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Speaker Notes: Slide 6
There are several barriers to rounding which will be discussed
further in this module. First of all, it is sometimes difficult to
assemble the entire team at the same time. In addition, nurses
can have several competing priorities such as patient education,
fall prevention and basic patient care
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Speaker Notes: Slide 7
One strategy to overcome the aforementioned barriers is to
incorporate indwelling urinary catheter rounds into “plastics
rounds,” or rounds that focus on all indwelling devices. Another
option is to incorporate urinary catheter rounds into regular
nursing rounds. This would provide great mentoring and critical
thinking opportunities for bedside nurses. For example, unit
managers or educators could ask, why does this patient need a
catheter? What criteria do they meet?
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Speaker Notes: Slide 7 Continued
Additionally, some hospitals have found this type of rounding
helpful to discuss the removal of the device with the patient. For
example, rounding staff can explain, “We’re going to remove
your urinary catheter today. We want to help prevent you from
acquiring a urinary tract infection. In the meantime, we’ll help
you to the bathroom and check on you. Don’t hesitate to ring
your bell if you need assistance.” Thus, implementing rounds can
be part of hospital’s patient engagement initiative and can help
boost overall patient satisfaction with care.
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Speaker Notes: Slide 8
The second Tier 2 strategy for CAUTI prevention is feeding back
CAUTI and catheter use information to frontline staff in real
time. When staff receive feedback in real time, they can more
easily relate to the information, especially if the patient is still on
the unit or in the hospital. Putting a name and a face to an event
is a powerful tool. When possible, an infection preventionist
should contact the unit manager or charge nurse as soon as a
CAUTI is identified. It is also helpful to call a huddle or debrief to
talk about the case with all of the unit staff.
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Speaker Notes: Slide 9
Despite the benefits of real time infection feedback, there are
often barriers that can make it difficult. One of the barriers to
feedback may be other activities of the infection preventionist
that delay recognition of a newly diagnosed CAUTI. In some
instances, staff may be too busy to take the time to review the
case given their many competing priorities. Finally, if the
organizational culture does not support the belief that many
healthcare-associated infections such as CAUTI are preventable,
it may be difficult to engage staff.
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Speaker Notes: Slide 10
In order to overcome barriers to real time feedback, it is
important to appoint unit champions. It may be helpful to have
more than one champion on a unit. Assessing a suspicious
infection even before it is confirmed may be another strategy to
help staff initiate prompt review of their processes. Finally,
celebrate success! The picture on the slide shows an example of
a banner posted on a patient care unit to celebrate nine months
without a single CAUTI.
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Speaker Notes: Slide 11
Another Tier 2 strategy is to ensure that all staff who insert and
maintain indwelling urinary catheters are competent in these
practices. Competency is really a two-step process, it requires
the knowledge as well as the observation of the desired
behavior. Demonstrating competency cannot be overstated or
underestimated. In addition, auditing and providing feedback are
of the utmost importance
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Speaker Notes: Slide 12
This study by Manojlovich and colleague demonstrates how
important competency assessment is. In this study, the
researchers directly observed 81 indwelling urinary catheter
insertions in 65 patients in an emergency department (ED). They
found that in 74 percent of insertions the inserter did not
perform hand hygiene. In addition, in 91 percent of insertions,
hand hygiene was not performed post insertion. And finally, 59
percent of insertion attempts were associated with a major
break in sterile technique.
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Speaker Notes: Slide 13
Ideally, education and competency-based training should be
included in staff orientation and conducted annually. There are
several available competency checklists for assessing indwelling
urinary catheter insertions. The American Nurses Association, or
ANA, spearheaded an initiative to reduce CAUTIs in hospitals.
This initiative led to the development of an indwelling urinary
catheter assessment and decision-making tool for registered
nurses and other clinicians. This assessment can be used at the
bedside to determine the best way to provide care. The tool
shown on this slide can serve both as a checklist and
competency assessment for catheter insertion.
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Speaker Notes: Slide 14
As you think about enhancing your indwelling urinary catheter
insertion competency training, it is once again important to
consider barriers you might encounter. One issue that occurs in
some health care settings is that there is limited time for new
staff orientation. As the demand for more and more orientation
training at the time of hire increases, there may be competing
demands and priorities to cover at orientation. Likewise, staff
turnover or the use of temporary staff may create unique
challenges. Some individuals who insert catheters might not be
included in competency training (e.g. Surgeons). Finally, there
may be lack of administrative support or champions to support
these efforts.
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Speaker Notes: Slide 15
One way to overcome barriers is to incorporate competency into
unit-based education. Many organizations have unit or
department educators who can assume this role. Recruit
champions to help conduct audits. Identify all individuals who
insert indwelling urinary catheters and ensure their competence
or identify an alternate team member to perform the procedure.
For example, ensure that the surgeon is competent to insert the
urinary catheter, or perhaps have a nurse who is competent,
insert the catheter instead.
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Speaker Notes: Slide 16
The last strategy to target CAUTIs if your rates remain elevated is
to conduct a full or mini-root cause analysis. A root cause
analysis, or RCA, is a structured method used to analyze serious
adverse events. In recent years, such analyses have provided
valuable information about the root cause of HAIs, by taking a
“deep dive” into potential causes of HAIs. There are many tools
available to help with the RCAs, and they can be modified to
facilitate team discussion, and are often referred to as a “focused
review.” One recommended tool is the Learning From Defects
Tool available on the AHRQ website.
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Speaker Notes: Slide 17
A general tool, such as the Learning from Defects Tool, can be
used for a focused review or root cause analysis. However, teams
may also benefit from a tool that focuses specifically on the
CAUTI. The tool on this slide includes information such as
placement, length of time the catheter was in place, whether the
catheter could have been removed earlier and other helpful
information. Aggregate information from this tool may be helpful
in identifying process deficiencies that may have led to increased
rates.
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Speaker Notes: Slide 18
Staff may be sensitive to the use of focused reviews and may feel
that they are made to feel personally responsible for the CAUTI.
One strategy to overcome this is to keep the discussion focused on
the patient, not on individual staff. In addition, staff time may be
an issue. Shift reports or quick huddles may be good opportunities
to share information and have these focused discussions. If nurses
or physicians are reluctant to be involved, it is helpful to
demonstrate the value of these discussions, and how this
aggregate information can lead to additional insight and
potentially change behaviors. For example, if a pattern exists in
which patients who develop CAUTIs could have had their catheters
removed sooner, this could lead to more prompt removal..
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Speaker Notes: Slide 19
Take a moment to review the key take home points.
If CAUTI rates are not declining despite your best efforts to
implement the Tier 1 interventions, consider the following
strategies:
• Involve nursing and physician champions,
• Establish regular rounding,
• Ensure insertion and maintenance competency,
• Regularly audit practices and provide feedback, and
• Perform root cause analysis on CAUTI cases
And don’t forget to celebrate success, because nothing succeeds
like success!
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Speaker Notes: Slide 20
No notes.
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