A Focused Approach to CAUTI Rate Reductions

Urinary tract infections (UTIs) are one of the most common types of hospital-acquired infections. Upwards of 75 to 80 percent of all hospital-acquired UTIs are a direct result of Foley catheter use. Catheter-associated urinary tract infections (CAUTI) can lead to increases in morbidity, length-of-stay, treatment costs, and other complications.

Over the last three years, a multidisciplinary team at UPMC Children’s Hospital of Pittsburgh has developed and implemented a focused approach to CAUTI rate reductions. Since the program’s inception, CAUTI rates at UPMC Children’s have been reduced by more than 50 percent through a number of initiatives. Furthermore, the total number of Foley catheter days across the hospital has been cut by nearly 66 percent during the same three-year period.

“These successes across the hospital and its various care units are a direct result of the collaborative effort we developed between nursing leadership, pediatric urology, patient quality and safety, and specifically our partners in the intensive care units where the necessity of Foley catheter use is particularly high,” says Glenn M. Cannon, MD, chief of the Division of Pediatric Urology.

A New Committee and Outside Assessment Lead the Way to Reform Catheter Practices

In 2017, Lindsay Montoya, MPH, CIC, a senior infection control preventionist in the Quality Services Department at UPMC Children’s, worked to reconstitute a committee to tackle CAUTI rates across the hospital. One of the first steps in the process after reforming the multidisciplinary committee was an outside assessment by the hospital’s catheter provider that looked at various practices and procedures to help identify areas that could be targeted for some intervention or process improvement.

“The assessment was very enlightening. It showed us two big areas that we needed to address. The first was that our Foley catheter practices and steps in place at the time lacked adherence. The second was that we realized we were using older catheter technologies and that we could upgrade to a newer, closed system that would help cut down on infection rates,” says Ms. Montoya.
Later in 2017, new training was implemented at the same time a change was made to a closed Foley system, and it was timed such that it coincided with more robust annual competencies for nursing staff. 

“Closed systems are safer for patients since there is much less manipulation to the catheter system once it’s been sterilely inserted,” says Ms. Montoya.

Rewriting the Book on Catheter Policy

Coinciding with these initial first changes, Foley catheter policy for the hospital was largely rewritten and expanded in a more step-wise, instructional manner. While this was done at the same time as the change to the new technology, other changes were made to the electronic medical record to facilitate charting for nursing staff so they could more easily find and notate the daily care and even daily necessity for the catheter.

This latter point speaks to what was put in place to end Foley catheter use when it is no longer necessary: a nurse-driven removal protocol.

“While the order for a Foley is always going to be physician-driven, we assessed the ability for our hospital to implement a nurse-driven removal protocol and determined that with the proper training and education, it would be a viable option. Assuming the patient meets all the criteria of the protocol, the nursing staff can discontinue catheter use without the need for direct permission from the physician,” says Ms. Montoya.

Changing the Maintenance Bundle and Audit

Ms. Montoya indicates that one of the initiatives in the ongoing CAUTI fight launched in 2018 may have had the most significant impact on CAUTI rates to date: changing the maintenance bundle and audits for Foley use.

“We went from a three-point checklist to one that now incorporates 11 specific points in the maintenance of Foley catheters. The expanded checks include steps and procedures such as documenting cleaning, notes about why the catheter was in place, making sure it was necessary every day, and other areas,” says Ms. Montoya.

Bag and line placement, such as their being off of the floor, lines secured to the patient for safety and comfort, intact seal present are some of the other aspects of the daily Foley audit now in place at UPMC Children’s.

One impact over and above the reduction of CAUTI rates of these initiatives has been a reduction in the total number of Foley days across the hospital. It makes sense to assume that the fewer days catheters are placed, the lower the likelihood of infection occurring.While the CAUTI team does not have specific benchmarks for a reduction of Foley days, Dr. Cannon explains that in 2017, there were more than 6,000 days across the hospital. In 2018, that number was down to around 3,500.

“Along with everything we have been able to accomplish, I do not think we would have been as successful in our efforts so far without the full support and confidence of hospital leadership, who made it known this was a critical issue for the entire hospital. I think their level of involvement and support got people’s attention and created a desire to be successful,” says Ms. Montoya.

On the Horizon

While the initial steps in reducing CAUTI rates at UPMC Children’s have been quite successful, there is still more that can and will be done to lower incidence even further, improve patient care and safety, and drive costs out of the system.

One such project in the planning phases, according to Dr. Cannon and Ms. Montoya, is a urine testing protocol — not just for Foley catheter patients but for any specimens collected across the hospital. A new reflex test is being assessed for use where urine analysis is done first, and cultures are subsequently done only if analysis shows signs of infection through white blood cells or other inflammatory markers. This process will help to eliminate testing and obtaining false-positive cultures on what could likely be asymptomatic colonization of the urine.