Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update on JSTOR

I. Engagement
A. Some nurses may not be on board with indwelling urinary catheter removal Get buy-in before implementation. For example, ask, “Who do we have to convince on this floor?” Have that person help to develop the plan or participate in the education for that unit.
Listen to nurses’ concerns and address them to nurses’ satisfaction.
Provide education and equipment/materials to facilitate alternative nursing strategies for incontinence care.
B. Lack of or problems with nurse champions
• Nurse managers tell your team that they are “too busy” to implement the new practice.
• Individuals identified as champions do not go out on the unit and do not have direct contact with inpatients.
Identify the types of champions who work in your organization. Not a one-size-fits-all strategy. For example:
• Use nurse educators as champions.
• Have more than one nurse champion, eg, cochampions, all nurse managers and educators.
• An LPN can be the champion if she or he is someone who others on the unit respect and go to for advice.
Recognize nurse champions via such mechanisms as certificates of recognition, annual evaluation appraisals, newsletters, and notifying the chief nursing officer.
C. Lack of physician buy-in to new practice or physicians are resistant to change in general
• Do not see indwelling urinary catheters as a risk.
• “Way down on their priority list.”
• Can’t get physicians to buy in to the new practice bundle because they do not want to “make waves.”
Provide data about urinary catheter use and feedback to physicians about monthly indwelling urinary catheter prevalence and CAUTI rates.
Provide one-on-one education (evidence-based and patient-safety oriented).
Engage medical leadership support (eg, chief of staff).
Involve physicians as much as possible in planning, education, and implementation; include physicians on your team.
Identify a physician champion who will
• Meet with other physicians to get them on board.
• Back up nurses when there is a disagreement.
• Conduct CME. Present evidence, eg, highlight how often physicians have a patient with an indwelling urinary catheter and forget.
D. Lack of physician champion In some institutions, physicians may tend to go along with nurse recommendations, so they rely heavily on nurse champions. The new practice could be seen as a “nursing initiative.”
Also see lack of physician buy-in above.
E. Leadership does not see CAUTI as a priority Prepare and present a business case to help convince leadership that the time and cost factors for implementing the new practice would be worth it. Present a good business case.
Remind leadership about the CMS nonpayment rule.
Be sure leadership gets monthly CAUTI/catheter use data.
F. Large hospital makes unit-to-unit rollout difficult Create unit-based teams with stakeholders from different units/departments.
G. General guidance Get people on the team who feel that CAUTI is worth working on.
Highlight staff who have adopted the new practice.
Know the system and how to get practice changes through relevant committees.
II. Education
A. Gaps in knowledge of infectious and noninfectious consequences of CAUTI for patients
• CAUTI not seen to be as serious as other infections.
• Belief that since the patient is going to be on bed rest the catheter is indicated.
• Not thinking about an indwelling urinary catheter as an invasive device or as a less risky device compared with other devices, such as central venous catheters.
• Belief that catheters are helpful to prevent development of pressure ulcers.
• Distribute signs and pocket guides with insertion/DC criteria.
• Share safety and quality literature.
Options on how to educate staff
• Create tailored educational materials. Use different materials for infection preventionists, nurses, physicians, clinical leadership, and perhaps for each unit, depending on what motivates staff in that unit (eg, decrease length of stay, ambulate patient, decrease UTI risk).
• Nurses
• Education mandated by nurses’ direct supervisor.
• Educate on the floor, in grand rounds, other venues.
• If it is difficult to educate all staff, as in a large hospital, create computerized education modules.
B. Not knowing what to do to prevent CAUTI HICPAC guidelines
C. Nurses’ schedules are inflexible, so difficult to do education
• Overtime not allowed.
• No “dedicated” time away from patient care.
Rather than having the nurses attend education sessions, bring the education to the bedside (eg, doing competencies on the unit, talking with nurses one to one during the point prevalence assessments).
Incorporate education on CAUTI into annual competency testing (eg, at the same time that CPR is renewed).
III. Execute
A. Eliminate unnecessary placement of indwelling urinary catheters
1. Nonindicated indwelling urinary catheters inserted in the ED
• Indwelling urinary catheter is inserted with no order written. When patient gets to the floor, nurses and physicians are unaware of catheter’s presence or reason it was placed.
• ED nurses think they are doing the floor nurses a favor by inserting the indwelling urinary catheter and assume that the patient might need it.
• ED nurses use catheter for specimen collection and then leave it in place.
• Alternate practices (eg, closed straight catheter system) eliminated due to cost.
Involve ED medical and nursing directors as champions or supporters of practice change.
Work with ED to put a process in place that assures that an order was written and appropriate indications for use are followed.
Education about indications for insertion for the ED nurses and physicians.
Reimplement alternative practice (eg, closed straight catheter system).
2. No catheter policy regarding insertion standards in place Develop a policy on catheter insertion indications.
3. Patient request
• Clinicians give in to patient or family requests for indwelling urinary catheter or believe that the patient wants the catheter in.
Discuss risks of indwelling urinary catheters with patients and families.
Review documentation of the rationale for placement if indications are not met and reinforce use of appropriate indications.
4. Lack of physician buy-in once the new practice is initiated
• See lack of physician buy-in above.
Collect and report data on catheter use and CAUTI physician/service: physicians may be responsible to type of data collection.
Meet with resisting physician to address concerns.
Consider involving resisting physicians in potential champion role, as accountable for catheters and CAUTI rates.
B. Ensure proper insertion technique
1. Nonaseptic insertion technique, by nurses, aides, nursing care assistants, medical students. Develop competencies for those who insert catheters.
Restrict catheter insertion practice to RNs.
Develop a policy on catheter insertion techniques if none is in place.
C. Timely discontinuation of indwelling urinary catheters
1. Nursing workload
a. Nurses are concerned that they will have to spend more time cleaning up patients if the indwelling urinary catheter is removed.
b. General feeling of being overworked (“just trying to get through my shift”).
c. What you might see:
• Nurses tell the physician or other nurses, “I do not want this catheter out” (or that the physician needs ins and outs).
• Especially problematic on weekends—no one is monitoring catheter removal.
• Catheter patrol: daytime charge nurses monitor which patients have indwelling urinary catheters, assist with toileting, and assess indications. If not indicated, talk with bedside nurse or ask physicians to DC.
• Daily assessment tool: bedside nurse assesses indications for continued use and, if not indicated, nurses discuss removal with physician.
• Data board in nurse units with monthly indwelling urinary catheter prevalence and CAUTI rates.
Nurse aides delegated to prioritize toileting activities over other activities (eg, stocking supplies or cleaning equipment).
Share experiences where nurses report positive experiences from catheter removal programs.
2. Shift schedules hamper communication among nurses
• 3-day, 12-hour shifts and block schedules can make it difficult to share information across shifts and departments.
Identify a nurse champion on each shift.
3. No catheter policy on discontinuation in place Develop a policy on discontinuation.
4. Patient or family request
• Nurses and/or physicians believe their patients want to keep the catheter. Some patients do (eg, because they are incontinent or do not want to get out of bed) and will ask their nurses and physicians to keep it in even if it is not indicated.
Discuss risks of indwelling urinary catheters with patients and families.
Review documentation of the rationale for use and reinforce use of appropriate indications.
5. Patient safety: balancing risk of falls
• Competing priorities: well-intended misconception that urinary catheters prevent falls, as a fall is a “never event” that is also being assessed as a quality measure.
Institute fall prevention strategies. For example:
• Instruct the patient to request assistance.
• Provide the patient with nonskid footwear.
• Ensure that the path to the restroom is free of obstacles.
• Evaluate chair and bed height.
• Ensure that assistive devices (if being used) are within patient reach.
• Engage the patient and family in efforts to provide assistance as needed.
• Use other strategies as determined by nursing care plan and institutional policy.
Incorporate urinary management (eg, planned toileting) as part of broader fall prevention program.
Remind nurses that urinary catheters do not reduce fall rates and can increase fall rates if patients trip over catheters.
6. Nurses are not confident speaking with physicians about removal Find a physician champion to support nurse requests for removal.
Nurse manager prompts nurses to speak with physicians.
Education on communication.
Identify if nurses are reluctant to speak to all physicians or just particular physicians; tailor solution if individual physicians resist catheter removal.
If nurses are confident to place catheters autonomously (without orders) but not remove them, highlight this contradiction.
7. Physician resistance to nurses discontinuing indwelling urinary catheters using an automatic stop order Nurses prompt physicians for DC order as an initial strategy to build rapport.
Identify a physician champion who can act as an advocate.
8. Lack of physician buy-in
• See lack of physician buy-in above
9. Resistance to early indwelling urinary catheter removal—surgeons and urologists Physician champion presents information at medical staff meeting about indwelling urinary catheter indications and nonindications.
Work with the physician assistants to DC indwelling urinary catheters on day 2 after surgery.
Engage a surgeon and/or urologist as a physician champion and work with then to establish conditions under which the catheter can be retained.
Recognize that urology patients may have unique and appropriate indications for placing and keeping catheters beyond the HICPAC indications.
Also see lack of physician buy-in above.
10. Indwelling urinary catheters left in when patient is transferred within the hospital (eg, catheter placed in surgery, patient goes up to ICU, then to floor) Establish process to ensure that all lines and devices are reviewed and removed (if appropriate) prior to transfer.
Consider changes to transfer forms to include information about catheter presence, date of insertion, and indication.


Domen keys Domen urls

Keys in the title of the site

The keys on which they find this page