Zeroing in on Safety: A Pediatric Approach to Preventing Catheter-Associated Urinary Tract Infections

Urinary tract infection is the most common nosocomial infection reported by acute care hospitals.1–4 The presence of an indwelling urinary catheter is a major risk factor for the development of a catheter-associated urinary tract infection (CAUTI). CAUTIs increase morbidity, mortality, and hospital costs.5,6 CAUTIs are considered to be reasonably preventable in hospitalized adults if recommended infection prevention measures are put into place; therefore, no additional payment is provided to hospitals by the Centers for Medicare and Medicaid Services for costs related to treatment of CAUTIs in adults.7–9 Although payment changes have not affected pediatric hospitals yet, lessons can be learned from successful approaches in the adult population.10Our academic medical center, the University of Wisconsin Hospital and Clinics, developed an interdisciplinary clinical improvement work group to reduce the incidence of CAUTIs. At the time, the CAUTI rate was 4.7 CAUTIs per 1000 catheter days, representing 85 CAUTIs in the adult units in the first 6 months of 2011.10 Nine of the 22 units were underperforming compared with benchmarking data from the National Database of Nursing Quality Indicators (NDNQI) for similar units. During the next 2 years, a variety of interventions were put into place, including staff reeducation on catheter insertion, optimization of electronic health records, evidence-based urinary catheter practices, bladder management protocols, and data reporting. With the implementation of these strategies, the CAUTI rate decreased to 2.4 per 1000 patient days. In addition, the number of catheter days consistently trended downward over time.After observing the success achieved in the adult hospital, the children’s hospital, American Family Children’s Hospital, convened an interdisciplinary work group representing all inpatient units to see if we could mimic the same success. The work group consisted of administrative support persons, a quality improvement analyst, clinical nurse specialists (CNSs), a pediatric urologist, an infection control practitioner, and nursing staff who were trained as CAUTI champions. We quickly added representation from the operating room as many of our catheters were inserted in the perioperative area. Over time, we added representation from the emergency department, trauma program, and the specialty clinics because some patients arrive from outside hospitals and clinics with indwelling catheters. The physician residency program has explored the use of catheters, particularly during surgery. Two recent projects explored what population of children needed catheters during surgery, and what population could have catheters removed in the postanesthesia care unit (PACU). Both of these projects have resulted in a significant reduction in the number of catheters in the pediatric postoperative population.We have adopted tools and practices surrounding indwelling catheter insertion that were modeled after our successful program for reducing central catheter–associated bloodstream infection (CLABSI). These practices include the development of guidelines that include indications for indwelling catheter insertion. These guidelines ensure that indwelling catheter placement is limited to patients who meet identified indications.9,11 Indications have also been added to the electronic order for catheter insertion to provide decision support during the ordering process. Before catheter placement, the patient is assessed for acceptable indications (Figure 1). The indication is documented in the order. Patient and/or nurse convenience is no longer considered an indication for catheter insertion. Alternatives to catheterization are also considered. These may include condom catheters, female urinals, various incontinence products, intermittent catheterization, and use of bladder scanners.12,13Aseptic technique is adhered to during catheter placement. All staff responsible for catheter insertion were retrained in aseptic technique for insertion and manipulation.12,14 An observation checklist was introduced consistent with our CLABSI initiative. The observer was charged with ensuring aseptic technique was maintained during the procedure. Initially, the checklist was on paper and was supplied near the catheter insertion kits to improve compliance with use. Now the form is a part of the electronic health record (Figure 2). We audit compliance with the use of an observer regardless of who inserts or where the insertion takes place. In the children’s hospital, compliance is typically 100% with checklist completion each month.Aseptic technique is adhered to during manipulation and maintenance of indwelling catheters. The catheter is maintained as a closed system with an intact seal at all times.10 The catheter is secured to the leg or abdomen, the tubing is free of kinks or dependent loops, and the drainage bag is maintained below the bladder at all times to prevent reflux of urine.15 The collection bag is also emptied regularly.15 As part of our CLABSI initiative before this CAUTI work, daily chlorhexidine bathing for children older than 2 months of age had already been adopted, abandoning the use of bath basins.16 It has continued to be the expectation that perineal care including catheter care be performed twice daily and after stooling. Nursing staff were reeducated on perineal care, the policy on indwelling catheter care was updated to include current practice, and resources for ongoing staff education were developed (see Table). Hand hygiene initiatives were implemented and strongly embraced, which also contributed to our success.The need for the catheter is discussed daily during medical rounds.12 The presence of the indwelling catheter was added to the daily rounding checklist of lines and drains on the inpatient units to assist daily discussion of the continuing need for the catheter because we found it was quite common for providers to be unaware that the patient had a catheter. An area was added to the initial screen for all health care providers when opening the clinical record to maintain current and accurate documentation of the catheter and the number of days it has been present (Figure 3). This change has been helpful in increasing awareness of catheter use.Use of an intervention reminder that a catheter is in place and/or a stop order for prompt removal of unnecessary catheters has been reported to reduce CAUTI rates by 53%.17 We chose to pilot test an electronic chart alert that provides a daily reminder to providers and nurses that a catheter is in place. The alert fires once each morning for providers and nursing staff to prompt a discussion of the continuing need for the catheter. We have found that discontinuation orders occur about 20% of the time as a result of acknowledging this alert. The remaining 80% of removal orders are prompted by the nurse during medical rounds as the ongoing need for the catheter is discussed. We believe that this alert has been integral to bringing our catheter use from days to hours. We have found that catheter removal occurs at all hours of the day, not just after rounds have occurred, so nurses continue to discuss catheter removal as the patient demonstrates readiness to have the catheter removed. Removal indications are discussed in the operating room and PACU. The PACU has implemented a bladder scanning protocol before the patient leaves the area. The emergency department screens all patients who arrive with a catheter and removes it in the emergency department if the catheter is not needed. The emergency department has greatly reduced the number of catheter insertions in their department.Indwelling catheters are promptly discontinued as soon as the indications for insertion are no longer applicable. Every hour increases the risk for infection, so nurses are encouraged to remove the catheter when the order is received instead of waiting until later in the shift.14The timing of indwelling catheter removal for patients with thoracic epidural catheters has been questioned. It was our routine to remove the indwelling catheter 6 hours after the removal of the epidural catheter. This may or may not have had a relationship to the timing of epidural analgesia discontinuation. Findings from our adult hospital and other researchers have shown that postoperative patients with thoracic epidurals do not need indwelling urinary catheters.10,18–20 We have partnered with the acute pain service to have the indwelling catheter removed 6 hours after the analgesic infusion has been discontinued, which is usually several hours before the epidural catheter has been discontinued. This change required reeducation for many of our experienced staff and has resulted in very little need for straight catheterization due to inability to void.A bladder management protocol was developed to guide nurses in decision-making regarding when to perform straight catheterization10,15,21–24 (Figure 4). Agreement was obtained to identify patients who meet exclusion criteria for the protocol. Excluded patients included urological patients who had their indwelling catheter placed by the urological service, gynecologic patients after a procedure, patients who have undergone complex pelvic surgery, and patients with a spinal cord injury, long-term indwelling catheter, a lumbar epidural, or who are receiving end-of-life care. Linking the protocol to the catheter discontinuation order in the patient’s clinical record provided easy access to the protocol for all members of the health care team. This link eliminated the difficulty in finding the most current version of the protocol. We chose to focus on bladder scanning, intermittent catheterization, and being patient if the child was not uncomfortable as pediatric patients usually do not have urinary retention. We used one of the many published formulas to determine expected bladder volume based on age, and added 20% upon the recommendation of our pediatric urologist consultant as a beginning point to consider the need for intermittent catheterization. Although it was very difficult initially, we were educated to wait up to 24 hours before intervening unless the child was uncomfortable. As we put our protocol into play, we found that very few patients needed to be catheterized. Of those, only 2 needed to have their catheters replaced. Both of these patients had opioid-induced urinary retention.Focusing attention on CAUTI prevention and having everyone in the organization being able to speak to it regardless of their position in the organization has led to our success. We have a very engaged staff at every level. We have engaged our patients and their families to be concerned about infection and not to see the catheter as a convenience. Staff is receptive to feedback about the state of bundle elements observed during audit activity. Every member of the team is involved when action plans are developed to address needed improvements. Members of the nursing staff are involved in audit activity, including compliance with insertion checklists and daily audits of catheter maintenance. Our interdisciplinary group continues to meet monthly to review CAUTI number and rates, catheter hours by unit, number of urine cultures obtained, delays between time of order and catheter removal time, and compliance with insertion and maintenance elements, as well as to perform event review as needed.As of this writing, we are close to celebrating 1 year without a CAUTI at the American Family Children’s Hospital. The 2 newest units have not had a CAUTI since they opened in May 2014. The hematology/oncology unit has not had a CAUTI in 4 years. The intensive care unit has been CAUTI-free for close to a year. Taking the lessons learned from our adult colleagues, applying the available evidence, bringing experts from all areas to the table, and partnering with our patients and their families has led to a number we never thought we could achieve. Zero is a real number!The author would like to acknowledge the work of the UW Health Core Team CAUTI Prevention Project for their vision and leadership, and the American Family Children’s Hospital Pediatric CAUTI Prevention Work Group. A special thank you to Dr Patrick McKenna for guiding us in the creation of our resources for pediatric bladder management.