PREVENTING CATHETER ASSOCIATED URINARY TRACT INFECTION

Elizabeth Quartey
Abstract
According to the CDC estimates in 2002 there were 1.7 million Healthcare-Associated Infections (HAI), and 99,000 HAI- associated deaths in the hospital. The report stated that the four largest categories of HAI, responsible for more than 80% of all reported HAI, are central line-associated bloodstream infections (CLABSI, 14%), ventilator-associated pneumonia (VAP, 15%), surgical site infections (SSI, 22%), and catheter-associated urinary tract infections (CAUTI, 32%). HAI are a great financial costs to health care facilities. The Centers for disease Control and Prevention (CDC) estimates the medical cost of HAI in the U.S. hospitals as $6.65 billion in 2007, and that number has increased to almost $10 billion a year currently.

Statement and Significance of the Problem One in 20 patients who are admitted to a hospital will be a victim to an infectious agent they are exposed to during their hospitalization according to the Centers for Disease Control (CDC) (Goodman, Brenda, 201, Hospital-Acquired Infections cost $10 Billion a year). The five most common infections are surgical site infections, infections associated with the use of devices like central lines, catheters, ventilators and clostridium dificile are costing the health care System in the USA almost $10 billion a year to treat. In the article Vitamin D has the potential to reduce the risk of Hospital-Acquired Infections, the writer stated that HAI is the leading cause of death in the USA with an overall estimated annual incidence of 1.7 million cases and 100,000 deaths. The writer also claimed that HAIs cost the hospital an estimated $28.4 billion to $45 billion in excess healthcare cost annually. When hospitals prevent these infections they are able to save a substantial amount of money. “If hospitals could eliminate surgical site infections tied to the procedure they studied, they would see an increase in revenue of more than $2 million a year.” (Goodman, B. 2013). It is of vital importance that facilities come up with successful programs to minimize if not eliminate HAIs.

Literature Review

The greatest risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter and poor catheter care. Catheter-associated urinary tract Infection is the most common and has the highest percentage rate of HAI. UTIs account for 32% in acute care settings and up to 40% of all health care settings. The prevention of CAUTI is very important to healthcare facility and will be a “cost saver” if these facility can come up with a successful CAUTI prevention programs. “Because CAUTIs are considered preventable medical harm, they are also included on the Centers for Medicare & Medicaid Services’ list of hospital-acquired conditions for which reimbursement will not be made. Thus, health care organizations have a formidable financial incentive to reduce CAUTIs. “(Scott R.D, II: (March 2009). www.cdc.gov).” Urinary catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed. Hospitals, Nursing Homes and Clinics are falling short when it comes to prevention of the spread of infection. 47% failed to comply with processes to reduce the risk of infections associated with medical equipment, devices and supplies and 37% of outpatient clinic failed too. (Evans, Melanie, August 2013). The storage and cleaning of the equipments are also likely to create these infection. With all the cuts in the healthcare budgets, and the facilities unwillingness to pay overtime to their employees, the time pressure and insufficient staffs poses a challenge to the employees in carrying out their daily duties. Insufficient staffs can pose a threat to the patient’s wellbeing, as these same staffs maybe carriers of infectious agents from one patient’s room to another due to lack of practicing proper hand-washing techniques between patient care. Burnout of staffs is also a major threat to patients’ wellbeing, as these burnout staffs makes a lot of mistakes, and are not able to think critically.

JCAHO is also pushing to reduce the frequency of HAI by emphazing proper hand hygiene as the most important factor in preventing nosocomial infections. (Kate Traynor, n.d.)

A study focus on eliminating nosocomial infections at Ascension Health created different “bundles” to achieve the goal of reducing HAI. IDT rounds and daily goal sheets and hand washing are methods used to decrease HAI. Raising the Vitamin D levels concentration in hospitalized patients will reduce greatly the risk of HAI, as it plays an important antimicrobial role. (Vitamin D Has the Potential to reduce the Risk of Hospital-Acquired Infections (July 5th 2012)

In the article “Who is steering the Ship? External Influences on Infection control Programs, the writer stated that invasion of the mainstream media, consumer interest and legislative activity and government regulation are forcing Healthcare facilities to focus on managing the HAI in their facility. $2 million a year revenue will be made by the 4 hospitals in the John Hopkins Health Systems if they can eliminate surgical sites infection according to Brenda Goodman.

Developed and resource-poor countries are also burden with HAI, as a result
National surveillance systems are put in place to aid in the reduction of HAI according to Haidee T, et all. Most of these studies are Quantitative studies and their focused is on the cost effects of HAI in the health industry.

A Qualitative study should be done to determine the percentages of life saved when proper and effective infection control measures are put in place.

The CDC guidelines for catheter used must be strictly adhere to in order to prevent CAUTIs. Hand washing, universal precaution, and proper sterile technique must be adhere to during catheter insertion to prevent CAUTI. By using alternatives methods to indwelling catheters such as condoms, bladder scanners to check the bladder emptying capability, and incontinence products we can prevent CAUTIs. Only leave catheters in place for as long as it’s warranted and discontinue immediately when it’s no longer needed. Only trained personnel should be allowed to insert the catheter under aseptic technique using sterile equipment. A weekly review of patients with Foley catheter to determine if the catheter meets the CDC guideline for use should be done by the IDT.

In light of all these reviews one can conclude that there is a vital need for
Healthcare facilities to research an effective method to minimize or eradicate the CAUTI incidents in their facilities. Not until recently when the Medicare & Medicaid Services were adopted to not reimburse Healthcare facilities for HAIs, one could have concluded that the hospital stands to make a profit instead of loss with a higher rate of HAIs., e.g. If a patient is admitted for a knee surgery the length of stay for that patient might be a week before discharging home or a Rehabilitation Facility. If that same patient contracted an infection, the length of stays changes from 1 week to up to six weeks depending on the microorganism and the antibiotic used to treat the infection. This changes in the patient length of stay will result in the hospital gaining an additional 5 weeks of payment for room and board, medications and treatments needed to care for this patient.

Research Question OR Hypothesis Could healthcare workers prevent patients admitted to their facilities from acquiring Catheter Associated Urinary Tract Infections (CAUTI) during their admission to the facility using aseptic techniques and Standard Precautions?

In utilizing a quasi-experimental design in relation to reimbursement, all Insurance companies, Medicare and Medicaid Services inclusive should delay payment to Healthcare facilities that continues to have a higher infectious rate. Additional rates should not be paid for any in-house acquired infections.

Methodology
Study Setting The study will take place in five Long Term Care Centers in Catonsville, Maryland area. The average census population totally the five buildings is 724. The study setting is focus on the 194 bed Rehabilitation units in the facilities.

Research Design The Quasi-experimental research will best fit this study because in this research type a quantitative research is conducted to explain the relationship between healthcare workers, and catheters associated urinary tract infection in the facility. This research aids to clarify why patients with Foleys ends up with a urinary tract infection and examine the causality between the nursing staffs providing catheter care to such patients. With the notion that healthcare facilities stands to gain from a high infectious rate, unless they are mandated to decrease in-house acquired infection, I will propose to delay payment and reject any bills for conditions developed 48hrs -72hrs after admission to the facility. In utilizing the quasi-experimental research, I will have an opportunity to see the correlations between HAI, length of stay, nursing care, and treatment cost.

Sample and Sampling Procedure I will be obtaining a sample from a convenience sample pool, as all the residents will be admitted to the various facilities rehabilitation units. All admission from June 30th to July 30th 2014 with indwelling Foleys will be inclusive in the sample, be it male, female, of any age and socioeconomic status are all included. The only inclusion criteria is to be admitted to this study will be admission with indwelling Foleys catheter during June 30th 2014 to July 30th 2014.

Ethics/Institutional Board Review I will sort approval from the appropriate institutional review board and ethics committee of each facility to make sure the residents rights are protected before conducting the study.

Data Collection Upon admission to the facilities every residents with an indwelling Foley catheter will be included in the study. Upon admission assessment by the license nurse, the patient with an indwelling Foley catheter will be assessed for continuous use of the catheter utilizing the CDC’s criteria for continuance catheter usage. If the patients does not meet the criteria the indwelling catheter will be discontinued after obtaining a physician order. For those patients who meets the criteria for continuance catheter usage the nursing staffs will focus on prevention of CAUTI. Staff will be educated on hand washing techniques, catheter care, using aseptic techniques and sterile equipment during catheter insertion.

Data Analysis
“The researcher as a whole person is completely involved- perceiving, reacting, interacting, reflecting, attaching meaning and recording” (Grove, S. et all, The practice of Nursing Research, pg. 269). In my data collection, the nurses in these facilities will observe the patients for signs and symptoms of urinary tract infection, i.e. burning on urination, complaints of pain during urination, foul urine odor, cloudy urine, elevated temp, changed in mental status, etc... The nurses will document these findings on a preapproved checklist on every shift. I will review the checklist weekly and revise it as needed. They will also collect urine specimens when one or more of these symptoms are noted and sent to the lab for analysis. Upon the receipt of the lab results from the Laboratory all positive UTIs will be treated immediately with antibiotic therapy. For the nursing staffs another checklist will be provided for them to document how often they wash their hands before treating the patients. They will also be in-service on the CDC’s list below to aid in the prevention of CAUTI.
1). Insert catheters only for appropriate indications
2). Leave catheters in only as long as needed
3). Ensure that only properly trained persons insert and maintain catheters
4). Insert catheters using aseptic technique and sterile equipment (acute care setting)
5), following aseptic insertion, maintain a closed drainage system
6). Maintain unobstructed urine flow
7). Hand hygiene and Standard (or appropriate isolation) Precautions.

Also consider:
1). Alternatives to indwelling urinary catheterization
2). Use of portable ultrasound devices for assessing urine volume to reduce unnecessary catheterizations
3). Use of antimicrobial/antiseptic-impregnated catheters

Strengths and Weakness The weakness I noticed in this study are based on my convenience collection of sample size my estimated numbers may be inaccurate, as not everyone who is admitted to the facility Rehabilitation units has an indwelling Foley. My data collection tool used in this study might be compromise if the nursing staff failed to document truthfully. For instance if a nurse decided not to document the sign and symptoms that she assessed on her patient because she doesn’t want to do a change in condition documentation, she has negatively affected the result of the study. If a Nurse and/or the Nursing assistant failed to document correctly/accurately on the Hand-washing checklist provided to collect the data, the result will be compromise as well. The provision of two separate checklist is also a weakness, as nursing staff dislike multiple checklist as they may found it to be cumbersome.

The strength of this study is to quickly and accurately identify the patients at risk for CAUTI, and to prevent infection. The study will also aid the nursing staff in infection preventions methods that will decrease the infection rate in the Healthcare facilities.

e.g. If a patient is admitted for a knee surgery the length of stay for that patient might be a week before discharging home or a Rehabilitation Facility. If that same patient contracted an infection, the length of stays changes from 1 week to up to six weeks depending on the microorganism and the antibiotic used to treat the infection. This changes in the patient length of stay will result in the hospital gaining an additional 5 weeks of payment for room and board, medications and treatments needed to care for this patient. In relation to reimbursement, all Insurance companies, Medicare and Medicaid Services inclusive should delay payment to Healthcare facilities that continues to have a higher infectious rate. Additional rates should not be paid for any in-house acquired infections.

References
Scott R.D, II: (March 2009). The direct medical costs of healthcare-Associated Infections U.S. Hospital and the Benefits of Prevention. Center for disease Control and Prevention, Retrieved from http://www.cdc.gov.

Evans, Melanie (August 30th, 2013). Healthcare providers fall short in preventing spread of Infection, Joint Commission says. Retrieved from http://www.modernhealth.com

Traynor, Kate, JCAHO Acts to Reduce Hospital-Acquired Infections. American Society of Health-System Pharmacists, (n.d.)

Lindsay, Lo E, (October 5th 2008). Strategies to prevent catheters-associated urinary tract Infections in acute care hospitals. Infection control Hospital Epidemiology.

The Quarterly Journal for Health Care Practice and Risk Management Infocus, (Volume 13 fall 2010). CMS Rules for Hospital-Acquired Conditions pose Challenges and Opportunities. Retrieved from www.FOJP.com

National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination. Retrieved from: www.Health.gov/hai/prevent_hai.asp

Hospital-Acquired Infections a Menacing Trend in Health care Settings Guidance for Hospital Personnel and Patients Offered. (n.d.) retrieved from www.waterandhealth.org

Weinstein, Robert A. (2008) 2nd edition. Who Is Steering the Ship? External Influences on Infection control Programs. Oxford Journal Medicine clinical Infectious Disease. Volume 46, issues 11 Pp.1746-1750. Retrieved from http://cid.oxfordjournals.org.

Dixon, Richard, (October 7th 2011). Control of Health-Care-Associated Infections, 1961-2011. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR). Retrieved from www.cdc.gov/mmwr/preview/mmwrhtml/su6004a10.htm

Vitamin D Has the Potential to reduce the Risk of Hospital-Acquired Infections (July 5th 2012) Retrieved from www.infectioncontroltoday.com

Goodman, Brenda, (September 3rd 2013), Hospital-Acquired Infections Cost $10 Billion a Year: Study. Retrieved from www.everydayhealth.com

Top CDC Recommendations to Prevent Healthcare-Associated Infections (March 23th 2012), Retrieved from http://www.cdc.gov?HAI/prevent/top-cdc-recs-prevent-hai.html

Custodio, Haidee, and Steele, Russell. (Jun 9th 2014), Hospital-Acquired Infections. Retrieved From http://emedicine.medscape.com

Grove, Susan K, Burns, Nancy and Gray, Jennifer R, (7th edition) The Practice of Nursing Research Appraisal, Synthesis, and Generation of Evidence (2013), Saunders, St. Louis, Missouri.