Keywords

CAUTI, CHG bathing, Evidence-based practice

 

Authors

  1. Schmudde, Yvonne MS, RN, CCRN, CNE
  2. Olson-Sitki, Kristi MSN, RN, NE-BC
  3. Bond, Jennifer MS, RN-BC, CCRN-K
  4. Chamberlain, Jill PhD, RN, CNE, CHSE

Abstract

Urinary tract infections are the most common type of health care-associated infection, and greater than 75% of them are attributed to an indwelling urinary catheter. A catheter-associated urinary infection may lead to a longer hospital length of stay by as many as 4 days. A new patient care standard requiring twice-daily chlorhexidine cleansing from umbilicus to knees was implemented on all patients of the pilot unit with a urinary catheter. This same technique was used after a patient with a urinary catheter had an incontinent bowel movement. The 9-month average catheter-associated urinary infection rate decreased from 3.06/1000 urinary catheter days to 0.46/1000 urinary catheter days after implementation of the new standard. The use of chlorhexidine for routine urinary catheter care and after bowel movements from umbilicus to knees for patients with urinary catheters may significantly decrease catheter-associated urinary tract infections when compared with the standard of care using soap and water. Standards for Quality Improvement Reporting Excellence guidelines were used in reporting these data.

 

Article Content

INTRODUCTION

Problem

Urinary tract infections (UTIs) are the most common type of health care-associated infection (HAI) reported to the National Healthcare Safety Network of the Centers for Disease Control and Prevention. Greater than 75% of UTIs can be attributed to an indwelling urinary catheter.1 Each catheter-associated UTI (CAUTI) is associated with an average increased medical cost of $758 to $10 197, depending on patient acuity and population-specific factors.2,3 To deter CAUTI-related complications and decrease medical cost of care, many organizations have implemented bundles with interventions directed toward catheter maintenance and reducing catheter utilization. These interventions include identifying inappropriate placement, protocols for early removal, and infection control standards such as aseptic insertion by trained personnel and maintaining a closed drainage system.4-7

 

Each day a urinary catheter remains, bacteriuria risk increases by 3% to 7%, and patients who develop a CAUTI may have a longer length of stay by as many as 4 days.8 According to the Agency for Healthcare Research and Quality (AHRQ), the average length of a hospital stay in 2012 was 4.5 days. The average length of stay in an intensive care unit (ICU) was 3.3 days with an additional 1.5 days in a non-ICU bed for every day spent in an ICU bed.9 Prolonged lengths of stay for critically ill patients are strongly associated with HAI such as CAUTI.10,11

 

There is an abundance of literature concerning evidence-based practices for urinary catheter care and CAUTI prevention2-10; however, there seems to be a lack of information regarding practices specific to the critically ill patient population who require a longer catheter dwell time. Studies have demonstrated that critically ill patients are more at risk of CAUTI, and the need for rapid assessment and resuscitation may increase health care provider reluctance to remove indwelling urinary catheters.12 In these clinical scenarios, proper maintenance of the catheter is critical to CAUTI prevention.

 

Literature Review

It has been well established that the most effective way to prevent CAUTIs is to avoid the use of a urinary catheter.4-6 However, critically ill patients often require a urinary catheter for acute urinary retention or obstruction, accurate measurement of urinary output, support in healing a sacral wound, or spinal immobilization.8 The question asked by many organizations is: What is the best method to prevent CAUTIs in patients who require a urinary catheter for an extended period of time due to critical illness?

 

Successful strategies to decrease CAUTI rates include a restrictive urinary catheter policy with daily review of need, allowing only trained personnel to insert urinary catheters, maintaining a closed drainage system,4-6 positioning of the drainage bag below bladder, and perineal care daily and with fecal incontinence.7 Interpretation of the literature on CAUTI prevention strategies, however, is challenging. Published findings do not specify the medical acuity of the patients and the products used for perineal care, such as soap and water or no-rinse disposable bathing cloths.

 

Chlorhexidine has been used for several decades for general skin cleansing and surgical site preparation because of its exceptional safety rate and broad range efficacy against gram-positive and gram-negative bacteria, anaerobes and aerobes, yeast, and some viruses.13 Chlorhexidine not only kills existing bacteria on the exposed area, but it may also leave a protective barrier, further reducing the risk of HAI.14,15 The association between chlorhexidine gluconate (CHG) bathing and prevention of HAI in critically ill patients for the purpose of central line-associated bloodstream infection reduction is prevalent in the literature.16-22

 

Instructions for use regarding CHG for patient cleansing are limited to preadmission daily showering using CHG to prevent surgical site infection,14,23 and daily CHG bathing to prevent hospital-acquired infection.24,25 The AHRQ recommends that caregivers also clean 6 inches of the tubing nearest to the body with CHG as part of a universal decolonization protocol for the reduction of methicillin-resistant Staphylococcus aureus (AHRQ, 2013). Guidelines on CAUTI prevention do not currently recommend the use of antiseptics for meatal cleaning and recommend cleansing of the meatal surface during daily bathing or showering with soap and water.5,26,27 A few studies, however, have documented an association between CHG and decreased CAUTI rates.17-25,28

 

Cassir et al17 compared CAUTIs for two 6-month periods. During the first period (control group), 150 patients were bathed according to routine practice with soap and water. The second period (experimental) evaluated 175 patients who were bathed with CHG. The study reported a significant decrease (P = .01) in CAUTI infections from 17 infections in the control group to 4 infections in the experimental group.

 

Martinez-Resendez et al28 compared CAUTIs across three 6-month periods. The first period (control) followed current practice of soap and water bathing, the second period (experimental) used CHG bathing, and the third period (postintervention control) returned to soap and water bathing. The sample size was more than 1000 patients, and CAUTI rates were reported per 1000 catheter days. The first period CAUTI rate was 16.68, the second period decreased to 12.62, and the third period went back up to 20.32. The study demonstrated a significant difference between the soap and water and CHG bathing groups (P = .0001).

 

There are no known guidelines regarding how much of the skin's surface area should be cleansed during catheter care. Skin fold cleansing is an important aspect of infection prevention, especially for patients with an indwelling urinary catheter where yeast and bacteria can complicate care.29 Cleansing with CHG from navel to knees for patients with indwelling urinary catheters was chosen for this project to prevent bacterial migration to the urinary tract.

 

Project Purpose

The CAUTI prevention bundle currently in use at this organization includes interventions that address qualifying indications for an indwelling urinary catheter, nurse-driven urinary catheter removal protocol, stabilization of the urinary catheter, ensuring unobstructed urine flow, maintaining a closed system, and catheter care every 12 hours with soap and water or no-rinse, disposable bath cloths. Patients within ICUs and on the intermediate care (IMC) unit also receive a daily bath with CHG. Despite these interventions, the organization's CAUTI rates continued to vary. The purpose of this quality improvement project was to determine the impact of extending catheter care to include all anterior skin from the umbilicus to the knees and adding CHG to the catheter care procedure.

 

METHODS

Intervention

In a Midwestern 500-bed level 1 trauma center and Magnet-designated hospital, this quality improvement project was spurred by an increase in CAUTI rates in the organization's IMC unit. The IMC unit consists of 38 beds and has an average length of stay of 2.59 days, a urinary catheter utilization rate of 0.29, and registered nurses providing patient care for 3 to 5 patients, depending on patient acuity with shared patient care technician support.

 

Institutional review board approval was not needed for the project as no protected health care information was collected on patients. Organizational leadership approved the project as a quality improvement project. A Lean Six Sigma quality improvement team was established to identify interventions to target the root causes of CAUTIs within this patient population. The team discovered 2 primary root causes of CAUTI: improper indwelling urinary catheter insertion technique and inconsistent patient hygiene practices. Several interventions were identified to address these factors, including a 2-person indwelling urinary catheter insertion technique to ensure sterile technique was not compromised and urinary catheter care with CHG from umbilicus to knees twice daily and after each bowel movement. This article focuses on the CHG catheter care as it is was determined by the Six Sigma group to have the greatest potential of influence on the pilot unit's CAUTI rates. Through root-cause analysis of past unit CAUTIs, it was determined that most CAUTIs occurred well after 2 days, signifying that the CAUTI was not from an insertion issue but a maintenance issue.

 

The practice change started in October 2017 for the IMC pilot unit. Education included the catchphrase "navel to knees with CHG" to remind staff of the new patient care standard. The staff was familiar with the use of CHG, as they already bathed patients daily with CHG (baseline). However, urinary catheter care at baseline was done twice a day with soap and water only to urinary meatus and catheter itself. The revised protocol was discussed during unit-based council meetings, shared during daily safety huddles, and posted on unit flyers. In addition, unit champions provided one-on-one education with each unit team member.

 

Twice-daily CHG cleansing from umbilicus to knees was performed on all patients with a urinary catheter. This same technique was used after a patient with a urinary catheter had an incontinent bowel movement. Concerns about the use of CHG in the perineal area were eliminated after confirmation from the CHG vendor that there are no contraindications to CHG use in the perineal area for patient hygiene. Permission from the vendor was sought to add 30 mL of 2% CHG to a package of disposable bath cloths containing a no-rinse foam cleanser. Product information on the bath cloths indicates that they are compatible with CHG. Staff kneaded the packet thoroughly to disburse the CHG for patient cleansing. The urinary catheter, perineum, and umbilical area to knees including inner thighs and skin folds were cleansed. After the area was cleansed, the CHG was allowed to air dry for 2 minutes, and if necessary, any damp skin folds were patted dry with a clean towel to prevent skin breakdown or irritation.

 

RESULTS

Pre and post measurements of the unit's CAUTI rates were obtained. Catheter-associated UTI rates were determined by dividing the number of infections per month by the number of catheter days for the unit times 1000. The organization's Infection Prevention health care team determines if a patient develops a hospital-acquired CAUTI utilizing the National Healthcare Safety Network surveillance criteria. In order for a CAUTI to be identified, the patient must have had an indwelling catheter in place for more than 2 consecutive dates and at least 1 or more of the following symptoms: fever greater than 38[degrees]C, suprapubic tenderness, costovertebral angle pain tenderness, urinary urgency, urinary frequency, or dysuria, along with a positive urine culture.

 

The 9-month average CAUTI rate prior to the implementation of catheter care with CHG was 3.06/1000 urinary catheter days (January 2017 to September 2017). The 9-month average CAUTI rate postimplementation was 0.46/1000 urinary catheter days (October 2017 to June 2018). One CAUTI occurred in the month of May 2018 (Figure). A paired-samples t test showed a statistically significant decrease in CAUTI scores from prepractice change (M = 2.99, SD = 6.33) to postpractice change (mean, 0.53 [SD, 2.50]; t = 2.57, P = .02; Table). A report was generated to monitor compliance with the new practice change. The average monthly rate of compliance for the first 9 months of the practice change was 81%, compared with the 51% baseline adherence to catheter care.

  
Figure. Catheter-ass... - Click to enlarge in new windowFigure. Catheter-associated urinary tract infection rate per 1000 catheter days, March 2017 to March 2018.
 
TABLE Paired t Test ... - Click to enlarge in new windowTABLE Paired

A root-cause analysis was performed on the 1 CAUTI event postimplementation. It was discovered that this patient had frequent stool incontinence. This reiterates the importance of CHG cleansing from umbilicus to knees for patients incontinent of stool who have indwelling urinary catheters.

 

DISCUSSION

Summary

This quality improvement project was implemented on a small unit, and it is recommended that larger scale studies be conducted to confirm results. There are no research studies that specifically discuss CAUTI rates and CHG catheter care in the literature, making it difficult to compare study results. However, the results of this project support similar findings on HAI reduction with CHG cleansing.17-28 The average supply cost for each episode of CHG cleansing from umbilicus to knees was $2.63 ($1.27 for an 8-pack of disposable bath cloths containing a no-rinse foam cleanser and $1.36 for 30 mL of chlorhexidine solution). With an average length of stay of 2.59 days in this IMC unit and 2 to 4 catheter care episodes on average per day, the total cost of catheter care was estimated at $13.62 to $27.25 per patient. Considering the financial penalties for HAI associated with the Value-Based Purchasing program,30 the potential impact on hospital quality ratings, and the $758 average cost of a CAUTI,3 there is a strong value proposition for implementation of this prevention strategy.

 

Unit staff did not report any challenges to the Six Sigma team or their unit leaders in making the practice change from soap and water to catheter care with CHG. In fact, many staff voiced the enhanced efficiency of the process. The "navel to knees" practice change is reinforced on a regular basis to ensure sustainability and is included in the orientation process for all new unit staff. Because of the success of the project, the practice was adopted in all critical care areas of the organization.

 

The Federal Drug Administration did issue a safety announcement in 2017 that there were rare but serious allergic reactions with the skin antiseptic chlorhexidine gluconate.31 There have been no reports of CHG allergy or sensitivity since the practice began. There is also concern in the literature about acquired resistance to CHG32,33; however, other studies state they have not found any development of resistance.34,35

 

LIMITATIONS

The project was performed on a pilot unit of a single institution. Baseline practice did not include the practice of "navel to knee" with soap and water, and there was no randomization of the intervention, which limits generalization of results. In addition, the project was not able to distinguish which of the interventions-CHG navel to knees catheter care, 2-person insertion, improved adherence to catheter care in the intervention group, or inclusion of skin fold cleansing and drying-had the greatest influence of the outcome.

 

CONCLUSIONS

The use of CHG for routine urinary catheter care and after bowel movements from umbilicus to knees for patients with urinary catheters may significantly decrease CAUTIs when compared with the standard of care using soap and water. This preventive care strategy is a safe, efficient, and cost-effective method that can serve as an adjunct to traditional CAUTI prevention practices and aligns with the prevention strategies that many organizations already have in place for the prevention of other HAI such as central line-associated bloodstream infection. It is imperative that each organization assesses current practice and continues its quality improvement journey to ensure patients are receiving the most current, safe, and effective care.

 

References

 

1. Centers for Disease Control and Prevention (CDC). Healthcare-associated infections. 2018. https://www.cdc.gov/hai/ca_uti/uti.html. Accessed March 5, 2019. [Context Link]

 

2. Hollenbeak CS, Schilling AL. The attributable cost of catheter-associated urinary tract infections in the United States: a systematic review. Am J Infect Control. 2018;46(7):751-757. [Context Link]

 

3. National Healthcare Safety Network. CAUTI outcome measure. 2018. http://www.hospitalsafetygrade.org/media/file/CAUTI.pdf. Accessed March 5, 2019. [Context Link]

 

4. Chenoweth C, Saint S. Preventing catheter-associated urinary tract infections in the intensive care unit. Crit Care Clin. 2013;29:19-32. [Context Link]

 

5. Lo E, Nicolle LE, Coffin SE, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2014;35:464-479. [Context Link]

 

6. Meddings J, Rogers MA, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. Br Med J Qual Saf. 2014;23:277-289. [Context Link]

 

7. Panchisin TL. Improving outcomes with the ANA CAUTI prevention tool. Nursing. 2016;46(3):55-59. [Context Link]

 

8. AHRQ. Preventing CAUTI in the ICU setting. https://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/facil Accessed March 4, 2019. [Context Link]

 

9. Hunter A, Johnson L, Coustasse A. Reduction of intensive care unit length of stay: the case of early mobilization. Health Care Manag. 2014;33(2):128-135. [Context Link]

 

10. Al-Hazmi H. Role of duration of catheterization and length of hospital stay on the rate of catheter-related hospital-acquired urinary tract infections. Res Rep Urol. 2015;7:41-47. [Context Link]

 

11. Roberts RR, Scott RD 2nd, Hota B, et al. Costs attributable to healthcare-acquired Infection in hospitalized adults and a comparison of economic methods. Med Care. 2010;48(11):1026-1035. [Context Link]

 

12. Maxwell M, Murphy K, McGettigan M. Changing ICU culture to reduce catheter-associated urinary tract infections. Can J Infect Control. 2018;33(1):39-43. [Context Link]

 

13. Milstone AM, Passaretti CL, Perl TM. Chlorhexidine: expanding the armamentarium for infection control and prevention. Healthc Epidemiol. 2008;46:274-281. [Context Link]

 

14. Edmiston CE, Krepel CJ, Spencer MP, et al. Preadmission application of 2% chlorhexidine gluconate (CHG): enhancing patient compliance while maximizing skin surface concentrations. Infect Control Hosp Epidemiol. 2016;37(3):254-259. [Context Link]

 

15. Lewis SR, Butler AR, Evans DJ, Alderson P, Smith AF. Chlorhexidine bathing of the critically ill for the prevention of hospital-acquired infection (protocol). Cochrane Database Syst Rev. 2016; (6). [Context Link]

 

16. Armellino D, Woltmann J, Parmentier D, et al. Modifying the risk: once-a-day bathing "at risk" patients in the intensive care unit with chlorhexidine gluconate. Am J Infect Control. 2014;42:571-573. [Context Link]

 

17. Cassir N, Thomas G, Hrajech S, et al. Chlorhexidine daily bathing: impact on health care-associated infections caused by gram-negative bacteria. Am J Infect Control. 2015;43:640-642. [Context Link]

 

18. Climo MW, Yokoe DS, Warren DK, et al. Daily chlorhexidine bathing effect on healthcare-associated BSI and MDRO acquisition. N Engl J Med. 2013;368(6):533-542. [Context Link]

 

19. Strouse AC. Appraising the literature on bathing practices and catheter-associated urinary tract infection prevention. Urol Nurs. 2015;35(1):11-17. [Context Link]

 

20. Karki S, Cheng AC. Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organism: a systematic review. J Hosp Infect. 2012;82:71-84. [Context Link]

 

21. Viray MA, Morley JC, Coopersmith CM, Kollef MH, Fraser VJ, Warren DK. Daily bathing with chlorhexidine-based soap and the prevention of Staphylococcus aureus transmission and infection. Infect Control Hosp Epidemiol. 2014;35(3):243-250. [Context Link]

 

22. Wang EW, Layon AJ. Chlorhexidine gluconate use to prevent hospital acquired infections-a useful tool, not a panacea. Ann Transl Med. 2017;5(1):14. [Context Link]

 

23. Graling PR, Vasaly FW. Effectiveness of 2% CHG cloth bathing for reducing surgical site infections. AORN J. 2013;97(5):547-551. [Context Link]

 

24. Denny J, Munro CL. Chlorhexidine bathing effects on health-care-associated infections. Biol Res Nurs. 2017;19(2):123-136. [Context Link]

 

25. Shah HN, Schwartz JL, Luna G, Cullen DL. Bathing with 2% chlorhexidine gluconate. Evidence and costs associated with central line-associated bloodstream infections. Crit Care Nurs. 2016;39(1):42-50. [Context Link]

 

26. Association of Professionals in Infection Control and Epidemiology. Implementation guide: guide to preventing catheter-associated urinary tract infections 2014. http://apic.org/Resource_/EliminationGuideForm/6473ab9b-e75c-457a-8d0f-d57d32bc2. Accessed March 4, 2019. [Context Link]

 

27. Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of catheter-associated urinary tract infections 2009. https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf. Accessed March 4, 2019. [Context Link]

 

28. Martinez-Resendez MF, Garza-Gonalex E, Mendoza-Olazaran S, et al. Impact of daily chlorhexidine baths and hand hygiene compliance on nosocomial infection rates in critically ill patients. Am J Infect Control. 2014;42:713-717. [Context Link]

 

29. Schrank G, Branch-Elliman W. Breaking the chain of infection in older adults. Infect Dis Clin North Am. 2017;31(4):649-671. [Context Link]

 

30. Centers for Medicare & Medicaid Services. Hospital-acquired condition (HAC) reduction program. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/. Accessed July 30, 2018. [Context Link]

 

31. US Food and Drug Administration Drug Safety Communications. https://www.fda.gov/downloads/Drugs/DrugSafety/UCM539059.pdf. Accessed February 2, 2017. [Context Link]

 

32. Knapp L, Amequita A, McClure P, Stewart S, Maillard JY. Development of a protocol for predicting bacterial resistance to microbicides. Appl Environ Microbiol. 2015;81(8):2652-2659. [Context Link]

 

33. Kampf G. Acquired resistance to chlorhexidine-is it time to establish an 'antiseptic stewardship' initiative? J Hosp Infect. 2016;94:213-227. [Context Link]

 

34. Dormstetter K, Olson LKM, Bennaars-Eiden A, Bernatchez SF. Evaluation of activity and potential for development of antimicrobial resistance to a new tinted 2% chlorhexidine gluconate/70% isopropyl alcohol film-forming sterile peroperative skin preparation. J Glob Antimicrob Resist. 2018. doi: 10.1016/j.jgar.2018.12.006. [Context Link]

 

35. Septimus EJ, Schweizer ML. Decolonization in prevention of health care-associated infections. Clin Microbiol Rev. 2016;29(2):201-222. https://cmr.asm.org/content/cmr/29/2/201.full.pdf. [Context Link]