No Foley-ing Around: \
Preventing CAUTI in Surgery Patients
Presented at the AORN of Twin Cities Fall Workshop, November 4th, 2017
By Stacy Johnson, MS, APRN, CNS, CNOR, CNS-CP & Ellie Carter, CLS, MPH, CIS Infection Preventionist
Article written by Stacy Johnson
This presentation discussed the impact of catheter-associated urinary tract infection (CAUTI) on patients and hospitals and the methods implemented in perioperative services by Abbott Northwestern Hospital (ANW), part of Allina Health, to reduce CAUTI in surgery patients.
Urinary tract infections cause 40% of hospital acquired infections. Most of these infections are due to urinary catheters. Up to 25% of hospital inpatients are catheterized. CAUTI can lengthen a patient’s hospital stay, cause pain, restrict ambulation and even lead to death. Healthcare costs related to CAUTI are increased $0.4-0.5 billion nation-wide. CAUTI identified in ICU and on med/surg units are reportable to the CDC. CAUTI reduction is an Allina-wide priority.
On any given day, a majority of Foley catheters in patient use in the hospital are inserted in surgery. The number of Foley catheters placed in the perioperative care areas (pre-op, intra-op, and PACU) was determined. Data collection identified CAUTI developing within 5 days of insertion, and these “5-day CAUTIs”/1000 Foley catheters inserted in surgical services *1000 was used to determine the rate. 27% of all CAUTIs in the hospital were identified within 5 days of insertion in surgery.
Improving Insertion Asepsis:
ANW performed an assessment of 24 RNs inserting a Foley catheter into a manikin. These RNs represented a broad range of nursing experience. 1 out of 24 attempts were observed to be aseptically inserted. These results were not unlike insertion assessment results at other hospitals nation-wide. The Minnesota Hospital Association identified establishment of criteria for catheter insertion, and use of 2- person insertion technique, having a “buddy” assist and monitor for breaks in asepsis, in their “Cut CAUTI Bundle” practices. Starting in the ICU, RN CAUTI Champions provided training to review best practices for catheter insertion, including 2- person insertion technique, with one RN using a step by step aseptic insertion checklist.
Surgery nurses were engaged as CAUTI Champions to participate in a team to collaborate with the hospital CAUTI reduction efforts. To reduce CAUTI in surgery patients, the strategy aimed at improving insertion technique to prevent breaks in asepsis, and reduce unnecessary placement of catheters. CAUTI Champions elected to teach a standard insertion technique for all Foley catheters inserted in the perioperative setting. Three standard practices for surgery were established to enhance aseptic technique:
- Use of sterile surgical blue towels to define the sterile field.
- A 2-person team for indwelling catheter insertion, using surg techs as the “buddy” for observing aseptic insertion and assistance to the RN.
- Securement of the device in the OR to minimize urethral tears during positioning and transfer.
A video was filmed in the OR to engage staff in perioperative services and facilitate training the new standard practices. Mandatory return demonstration using a simulation model was required for all perioperative nurses. CAUTI data specific to surgical services insertion technique was shared with the surgery teams at staff meetings.
Perioperative Bladder Assessment Protocol
At the same time, to reduce unnecessary Foley catheter insertions, orthopedic surgeons approved a perioperative bladder assessment protocol for patients having total hip and knee joint surgery. Over 1200 total joint surgeries were performed each year with routine Foley catheter insertion. The total joint protocol aligned with CDC guidelines to use urinary catheters only as necessary, rather than routinely. Bladder scanning devices were purchased for use in surgery. Educational sessions were conducted to train nursing staff on use of bladder ultrasound scanning (BUS) devices.
- CAUTI Champions helped to facilitate communication and promote use of the total joint surgery bladder management protocol.
- Pre-Op RNs screened patients presenting for total joint surgery for risk factors for urinary retention and need for Foley catheter.
- Patients mobilized in pre-op area to void prior to procedure and a post void residual BUS performed.
- Time of last pre-operative void and the amount of post void residual documented and communicated to OR RN.
- End of procedure, BUS assessment for urinary retention was performed by intra op RN.
- Intermittent straight catheter algorithm followed by OR and PACU RNs.
The communication between the perioperative units and patient bladder management awareness was increased. The “5-day CAUTI” rate in patients with a Foley catheter inserted in the surgery department decreased from 1.94 to 1.44 the first year after implementation of the 2-person technique. The annual goal to reduce CAUTI by 20% was achieved. The implementation of the bladder management protocol has been successful, reducing the number of Foley catheter use in patients on the orthopedic inpatient unit.
More recently, there has been an increase in CAUTI rates in patients having their Foley catheter placed in surgery. A CAUTI Clinical Action Team (CAT) was implemented to continue to investigate CAUTI cases, review charts for trends, and continue to audit practice and champion best practices. The success of the perioperative bladder assessment protocol is now well established. Surgeon groups are reviewing the protocol for use in other surgical populations.
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