Transcript Slide 1

Insertion or Maintenance?
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Disclosure
• I am an employee of C.R. Bard, Inc., Bard
Medical Division. Any discussion regarding Bard
products during my presentation is limited to
information that is consistent with Bard labeling
for those products.
• For all Bard products please consult product
labels and inserts for any indications,
contraindications, hazards, warnings, cautions,
and directions for use.
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Foley Catheters: Risky Business
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Objectives
• Discuss indwelling urinary catheter (IUC)
insertion and maintenance practices
• Identify strategies to help maintain aseptic
technique during IUC insertion
• Discuss how variation in the insertion
process can impact adherence to aseptic
technique
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Indwelling Urinary Catheter
• A sterile closed system in which the path from
the tip of the catheter inserted into the bladder,
to the bag which catches urine.
• This is considered a closed system and should
not be disconnected.
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Catheter-Associated Urinary Tract Infection (CAUTI)
Infection of the urinary tract caused as a
result of bacteria moving through or migrating
around the catheter and infecting the mucosa
of the bladder and urethra
CAUTIs are among the most common
healthcare-associated infections
April 2013 CDC/NHSN Protocol Corrections, Clarification, and Additions
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Scope of the CAUTI Issue
• 100 million indwelling urethral catheters sold
worldwide annually1
• 24 million in the U.S.1
• 25% of hospitalized patients receive urinary catheters
during their stay2
• UTI = up to 40% of all HAI2
• Vast majority of HA-UTI are urinary catheter related2
• Not without increased cost and morbidity2
1Saint
S, Wiese J, Amory JK, Bernstein MI, Patel UD, Zemencutt JK et. al. Are physicians aware of which of their patients
have catheters? Am. J. Med, 2000 Oct 15; 109 (6): 476-80
2Saint
S, Kaufman S, Thompson M, Rogers M, Chenoweth C. A Reminder Reduces Urinary Catheterization in
Hospitalized Patients. Journal on Quality and Patient Safety. 2005 August. (31)8; 455-62
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Strides in CAUTI Prevention
2008 CMS
Deny additional hospital payments for
“serious preventable (never) events”
Stone, P. W., Gilead, S., McNair, P., Mattes, N., Cohen, B., Landers, T., & Larson, E. (2010). CMS Changes in Reimbursement for HAIs:
Setting a Research Agenda. Medical Care, 48(5), 433–439.
2009 CDC
Healthcare Infection Control Practices Advisory Committee (HICPAC)
Guideline for Prevention of CAUTIs
Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee
(HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009.
2012 The Joint Commission
National Patient Safety Goal:
To implement evidence-based practices to prevent a CAUTI
R3 Report: Requirement, Rationale, Reference (2011). Joint Commission
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Pathogenesis
• Routes of entry of uropathogens:
1. Extraluminal: along the external surface
1.
2.
Early: at insertion
Late: by capillary action
2. Intraluminal: through the catheter lumen
1.
2.
Break in closed drainage
Contamination of collection bag urine
3. General infection
Maki, Dennis G., and Paul A. Tambyah. "Engineering out the risk for infection with urinary catheters." Emerging infectious diseases 7.2 (2001):
342.
Newman, & Wein (2009). Managing and Treating Urinary Incontinence, 2nd Ed, Health Professions Press, Baltimore, Maryland:365-483.
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Consider Alternatives
• Bladder scanner to monitor bladder volume
• Intermittent catheter
• External catheter
• Bedside commode or urinal
Meddings J, Saint S. (2011) Disrupting the life cycle of the urinary catheter. Clin Infect Dis. Jun:52(11) :1291-3
Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory
Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. Available from:
http://www.cdc.gov/hicpac/ cauti/001_cauti.html.
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Indications for Indwelling Catheter Use
 Patient has acute urinary retention or bladder outlet
obstruction
 Need for accurate measurements of urinary output
 Perioperative use for selected surgical procedures
 To assist in healing of open sacral or perineal wounds
 Patient requires prolonged immobilization
 To improve comfort for end of life care if needed
Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee
(HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. Available from: http://www.cdc.gov/hicpac/
cauti/001_cauti.html.
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Foley Catheter Lifecycle
Aseptic
Insertion
Care and
Maintenance
Reinsertion
Removal
Adapted from: Meddings J, Krein SL, Fakih MG, et al. Reducing Unnecessary Urinary Catheter Use and Other Strategies To Prevent
Catheter-Associated Urinary Tract Infections: Brief Update Review. In: Making Health Care Safer II: An Updated Critical Analysis of the
Evidence for Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Mar. (Evidence
Reports/Technology Assessments, No. 211.) Chapter 9.
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ABCDE Bladder Bundle
• Adherence to general infection control principles (e.g.
hand hygiene, surveillance and feedback, aseptic
insertion, proper maintenance, education)
• Bladder ultrasound may avoid indwelling catheterization
• Condom external catheters or other alternatives to an
Foley catheter should be considered
• Do not use the Foley catheter unless you must
• Early removal of the catheter using a reminder or nurse
initiated removal protocol
Saint, Olmsted, Fakih, Kowalski, Watson, Sales, & Krein, (2009). Translating health care-associated urinary tract infection prevention
research into practice via the bladder bundle. Jt Comm J Qual Patient Saf. 35(9), 449-55.
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Asepsis
• Asepsis: state of being free from microorganisms1
• Aseptic technique:
– Method employed to maintain a state free from hospital
microorganisms and protect the patient from acquired infection by
preventing introduction of bacteria1
Insert urinary catheters using aseptic technique
(CDC Category IB Recommendation)2
1. Aziz AM. Variations in Aseptic Technique and Implications for Infection Control. British Journal of Nursing. 2009 (18)1: 26-31.
2. Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory
Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. Available from:
http://www.cdc.gov/hicpac/ cauti/001_cauti.html.
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Principles of Aseptic Technique
• Know what is clean, sterile, or contaminated
• Keep clean, contaminated and sterile items
separate
• Keep sterile sites sterile
• Resolve contamination immediately
• Recognize when aseptic technique has been
broken
Mangnall & Watterson (2006). Principles of aseptic technique in urinary catheterisation. Nurs Stand. Oct;Suppl:15-7, 19-22, 24
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Common Breaks in Sterile Technique
• Setting up and opening the sterile field
• Hand hygiene
• Gloving
• Prepping
• Draping
Hopper, William R., and Rose Moss. "Common breaks in sterile technique: clinical perspectives and perioperative implications." AORN
journal 91.3 (2010): 350-367.
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Importance of a Standardized Process
Variables during insertion may lead to breaks in aseptic
technique:
Scenario 1
Clinician fails to wash hands or use provided drapes
Scenario 2
Incorrectly donning sterile gloves
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Procedural Products
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Procedural Products
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Procedural Products
•
Prepare patient with 3 foam swab sticks saturated in Povidone-Iodine
•
Remove Foley catheter from wrap and lubricate catheter
• Use the non-dominant hand for the genitalia and dominant hand for the swabs
• Proceed with catheterization using the dominant hand
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A Look at Bacteria
Mixed biofilm of the
yeast-like fungus
Candida albicans and
the Gram negative
bacterium Serratia
marcescens
Shown on a 100% AllSilicone Catheter
Weinstein RA. Nosocomial Infection Update. Emerging Infectious Diseases. 1998; 4(3): 416-420.
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Stages of Biofilm Formation
Bacteria switch from a free-floating (planktonic) state where they
function as individuals to a sessile state where they function as
communities
Image: Used by permission. Dirckx, Peg. Center for Biofilm Engineering, Montana State University,
Bozeman, MT.
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RIGHT PRODUCT
Latex vs. Silicone
• All 10 BARDEX samples
tested were below the
detectable limits of this test
• The BARDEX catheter has
a significantly lower protein
content than the off-the-shelf
latex gloves and condoms
• The BARDEX catheter
demonstrated statistically
significant lower protein
content than the Covidien
and Medline latex catheters
• 10% of the Medline silicone
elastomer catheters tested
had detectable latex proteins
versus 0% of the BARDEX
catheters
‡ Data on file
‡ Data on file
23
1302-33a
Catheter / Tubing Junction
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Outlet Tube
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Care and Maintenance
• Maintain a closed drainage system
• Secure the catheter
• Keep the collecting bag off the floor
and below the level of the bladder
• Remove catheter as soon as
possible
Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee
(HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. Available from:
http://www.cdc.gov/hicpac/cauti/001_cauti.html.
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CAUTI Prevention
• All these guidelines/mandates, etc, point to the same
direction
Care Process
Strategies
Change in the culture of the organization
Medical Staff
Patient Care Staff
Administrative/Management Staff
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JCAHO: NPSG.07.06.01
• Elements of performance (insertion and use)
– Insert indwelling urinary catheters according to established
evidence based guidelines that address the following:
• Limiting use and duration to situations necessary for patient
care
• Using aseptic techniques for site prep, equipment and supplies
JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, 2011.
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JCAHO: NPSG.07.06.01
• Elements of Performance (catheter management)
– Manage indwelling urinary catheters according to
established evidence based guidelines
• Securing catheters
• Maintaining sterility of collection system
• Replacement when required
• Asepsis in urine sample collection
JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, 2011.
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JCAHO: NPSG.07.06.01
• Measure and monitor the processes and outcomes
– Select measures based on evidence based
guidelines or best practices
– Monitor compliance (ongoing audit or point
prevalence)
– Evaluate effectiveness
•
•
•
•
UTI Surveillance
Decreased indwelling catheter days
Decreased inappropriate use
Improved nursing care practices
JCAHO, 2012 National Patient Safety Goals, Hospital Accreditation Program, Pre-publication version, May 9, 2011.
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Restate Process Measures
• Make sure the catheter is indicated
• Adhere to general infection control principles
(aseptic insertion, proper maintenance, hand
hygiene, properly trained staff, feedback to care
providers)
• Remove the catheter as soon as possible
• Consider alternatives to indwelling catheters
Saint S. Preventing Catheter-Associated Urinary Tract Infection: Translating Research into Practice [Educational Slides]
CatheterOut.org website, University of Michigan.
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Number of Observations
Securement = Yes
% Securement Compliant
*TES Intact = Yes
% TES Compliant
Dependent Loop Compliant
% Loop Compliance
Below Bladder Level Compliant
% Bladder Level Compliant
Not Touching Floor Compliant
% No Touch Floor Compliant
Not Over-filled Compliant
% No Overfill Compliant
Example: Nursing Process Monitoring
Tool
MSU
10
2
20.0
10
100.0
5
50.0
9
90.0
10
100.0
10
100.0
SCU
8
1
12.5
3
37.5
4
50.0
7
87.5
6
75.0
8
100.0
JSC
2
0
0.0
2
100.0
1
50.0
2
100.0
2
100.0
2
100.0
GSU
6
1
16.7
6
100.0
3
50.0
6
100.0
6
100.0
6
100.0
5N
4
1
25.0
4
100.0
2
50.0
2
50.0
3
75.0
4
100.0
30
5
16.7
25
83.3
15
50.0
26
86.7
27
90.0
30
100.0
Unit
Overall
Ref: Bard Medical Division: Foley Catheter Observation Survey. Compliance Document # 1007-02, 7-14-10
Lo E, Nicolle L, Classen D, Arias K, Podgorny K, Anderson D, Burstin, H et. al. Strategies to Prevent Catheter-Associated Urinary Tract
Infections in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2008; 29:S41-S50
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What can you do?
• Address the whole lifecycle of the Foley catheter
• Conduct a gap analysis:
– Measure adherence to evidence-based guidelines
– Focus on insertion and maintenance practices at your facility
• Become a champion
Meddings J, Saint S. (2011) Disrupting the life cycle of the urinary catheter. Clin Infect Dis. Jun:52(11) :1291-3
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