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As nurses, we have a responsibility to improve the outcomes of our patients when opportunities arise. Urinary tract infections (UTIs) have been a focus for healthcare quality improvement for some time and catheter-associated urinary tract infections (CAUTIs) are often more complicated, resulting in more adverse affects and long-lasting medical problems. Considering the United States' healthcare system so enthusiastically utilizes indwelling urinary catheters (IUCs) often for more reasons than necessary and for longer than necessary, we as nurses are presented with both the opportunity and responsibility to make an impact on our patients' care and on the healthcare industry as a whole.

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What is the nurse doing or not doing in relation to this issue?
Nursing scope of practice includes the insertion, maintenance, and removal of indwelling catheters.  Additionally, nurses are able to independently utilize IUCs for patients with acute urinary retention, though physician's orders are needed for long-term use.

How is this improving or exacerbating the issue?
The quality of nursing care provided is a strong indicator of CAUTI rates. For example, improper hygiene standards exacerbate the likelihood for nosocomial infection.  According to one study, 11% of nurses do not use proper hand hygiene before IUC placement, 3% do not use sterile gloves, and 19% do not utilize sterile barriers during placement (Umer et al., 2017).
Another study found that 59% of IUC insertion attempts had at least one "major break" in aseptic technique (Meddings et al., 2019).

Additionally, unnecessary IUCs and miscommunications between nursing staff and physicians can lead to extended dwell times, especially considering a majority of physicians may be unaware that a patient has a catheter in the first place (Meddings et al., 2019).

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Pathophysiology, Treatment, and Prevention of Catheter-Associated Urinary Tract Infection
Urinary tract infections are among the most common infections, with almost 11 million cases in the US annually. Complicated UTIs can result in a number of adverse effects, increasing patient morbidity and mortality. Urinary catheterization further increases UTI risk, especially given the ubiquity of their use within the healthcare industry. The mechanisms involved with IUC use result in physiologic changes in the bladder, lowering the threshold for bacterial colonization from more diverse strains. CAUTI risk increases up to 7% per day of use, until an infection is nearly unavoidable.
The most effective methods of CAUTI prevention include measures to reduce IUC use and decrease dwell time, followed by focus on improving hygienic practices.
Prophylactic antibiotic treatments, including antimicrobial bladder irrigation, are not recommended due to increased risk for antibiotic resistance. Some promise has been shown regarding antimicrobial-impregnated catheters; however, more research is needed to evaluate their efficacy.
If a patient does develop a UTI, the catheter should first removed and replaced before starting the patient on narrow-spectrum antibiotics dependent on their culture results (Flores-Mireles et al., 2019).

A Tiered Approach for Preventing Catheter-Associated Urinary Tract Infection
In this quasi-experimental study, a multidisciplinary team developed a two-tiered plan for reducing CAUTI rates, with the second tier only applicable if rates were not sufficiently lowered through Tier 1.
Tier 1 consisted of:

Only utilizing IUC for approved indications

Encouragement of staff to implement IUC alternatives

Ensuring correct aseptic technique and management

Automatic prompts to encourage IUC removal

Specifying circumstance in which urine cultures should/should not be sent for analysis

Tier 2 consisted of:

A self-administered needs assessment by administration

Frequent catheter rounds with targeted education and real-time feedback

Observation of IUC insertion for technique and competency

Root-cause analysis or focused review of each CAUTI event

Each of these interventions showed further reduction in CAUTI rates (Meddings et al., 2019).

Improving Catheter Associated Urinary Tract Infection Rates in the Medical Units
This study focused on targeting frontline staff members, regarding education, training, ownership, responsibility, and accountability.  It also utilized a tier-style approach, with each cycle applying new interventions.
Cycle 1 included:

Standardized IUC bundles based on EBP

Compliance monitoring and just in time coaching

Education campaigns and competency training

Cycle 2 included:

Development of approved IUC indications with EMR entry and standardized removal reminders

Daily assessment of catheter need

Cycle 3 included:

Standardization of IUC insertion, maintenance, and removal

Education on the avoidance of clamping and flushing, as well as proper perineal care

Increased bladder scanner availability

Each of these 3 cycles proved effective, with CAUTI rates per 1000 lowering from 6.8 to 2.14 by the end of cycle 3 (Taha et al., 2017).

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What is the problem?
Nosocomial infections pose a significant burden on the healthcare industry, with catheter-associated urinary tract infections accounting for 40% of these infections worldwide.
CAUTIs are often complicated infections which can lead to bloodstream infections, sepsis, pyelonephritis, renal damage, antibiotic resistance, and clostridium difficile infections (Flores-Mireles et al., 2019).  These infections extend patient hospital stays by an average of 2-4 days and cause an estimated 13,000 deaths annually worldwide.
Meanwhile, up to 60% of CAUTIs are considered to have been preventable (Taha et al., 2017).

Who is affected?
In the United States, 11 million people are affected by UTIs annually (Flores-Mireles et al., 2019). Other patients at higher risk for CAUTI are patients over 55, females, as well as patients with concurrent infections, malnutrition, renal insufficiency, and other pre existing conditions.  Additionally, surgical patients who have undergone either open or emergent surgeries are at higher risk (Umer et al., 2016).

How and why does infection occur?
Indwelling urinary catheters cause mechanical stress that can result in impaired defenses and an inflammatory response that triggers fibrinogen release into the bladder.  Bacteria utilize this fibrinogen to create biofilms and establish colonization within the bladder.  Because of the bladder's impaired immune response, CAUTIs may be caused by a more diverse range of pathogens than uncomplicated UTIs (Flores-Mireles et al., 2019).
These risks are exacerbated through improper aseptic technique during insertion, insufficient maintenance of the the catheter, unnecessarily long dwell times, and inappropriate indications for use.

Where do we see them used and when does infection start?
Indwelling catheter usage is still quite prevalent throughout the United States, with 30 million being used annually.  Most commonly, IUCs are used for surgical patients, intensive care units, and nursing home residents.  Risk for infection is associated with how long a catheter is placed, with CAUTI rates increasing by 3-7% daily until risk nears 100% in prolonged cases (Flores-Mireles et al., 2019).

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Analysis: Importance of Nurse Involvement

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Analysis: Importance of Nurse Involvement

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How would the nurse be able to help?
Nurses have the opportunity to minimize much of the risk catheterized patients face regarding CAUTIs. For example, by ensuring they and their peers are utilizing proper aseptic techniques during insertion and maintenance, nurses can mitigate the opportunities for pathogens to be introduced to the urinary tract.  Nurses should also be empowered to question unnecessary orders or prolonged usage of urinary catheters, and consider alternative urinary management devices instead.

By holding both physicians and other nursing staff accountable for the utilization and management of urinary catheters respectively, nurses will be able to reduce the numbers of infections and patients who are are catheterized in the first place.

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One study found that the biggest barrier for CAUTI prevention was a lack of resources, such as time or equipment to implement alternatives.  This study also listed challenges such as lack of knowledge of clinical guidelines, false perceptions about the risks vs benefit of catheterization, social influences such as family requests or decisions made without medical rationales, and a lack of accountability for catheter-related decisions (Atkins et al., 2020).
In other cases, it has been found that nursing staff are reluctant to remove indwelling catheters and physicians may often be unaware of their placement (Umer et al., 2016).

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Ensure that units are well-stocked with IUC alternatives and that bundles are convenient and intuitive to utilize.
Considering time and equipment availability were considered to be one of the top barriers for substituting IUC alternatives, ensuring that the supply rooms have adequate stock on hand is likely to have a positive impact on IUC prevention.  These alternatives should also be organized into intuitive kits containing all the necessary supplies for convenience of use and correct application, similar to pre-existing Foley catheter kits.
Availability of supplies should also be expanded to include bladder scanners on the unit, in order to most accurately gauge residual urine volume and determine if the need for urinary catheterization is legitimate.

Evaluate staff competency and provide education regarding IUCs and CAUTI prevention.
Most successful studies aimed at lowering CAUTI rates involved at least some aspect of nursing education, which focused on proper techniques for insertion and maintenance. In addition, with another major barrier to lowering IUC use being nursing staff's lack of knowledge regarding the risks versus benefits of prolonged urinary catheterization, these educational programs should be expanded to include the severity of CAUTIs, their rates, and some of their complications.
If hospitals are still experiencing unsatisfactory rates, these education programs should become more hands on. By periodically observing catheter insertion by staff, requiring a second person during insertion, and implementing daily catheter huddles, CAUTI rates should diminish even further.

Utilize hard-stops and screening tools in the EMR to promote safe IUC practices.
Electronic medical records (EMR) allows us the opportunity to lower rates of inappropriate catheter use, and should be implemented to do so. For example, one study found that an automatic screening tool was able to accurately assess patient CAUTI risk by evaluating a patient's length of stay, acuity, lab values, mobility, and catheter duration (Hur et al., 2019). Another study found that daily alerts and mandatory drop-down menus for patient indications during IUC usage encouraged prompt removal of catheters, therby reducing CAUTI rates (Uer et al., 2016). By implementing these practices at our hospitals, we can prevent prolonged usage of IUCs, one of the biggest factors leading to CAUTI.

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Infection Prevention
At the heart of it, CAUTI rates are an issue with infection prevention in the hospitals.  Between the anatomy of the bladder and urethra, mechanics of the device, and lapses in hygiene, IUCs offer the perfect set of circumstances for pathogenesis.
Ensuring that all of our nursing care for our catheterized patients is evidence-based, we can mitigate some much of the risk for infections and thus complications. To allow the best outcomes for our patient, we need to perfect our aseptic techniques during insertion; we need to keep up with catheter maintenance, including perineal hygiene, frequent bag emptying, and proper securement; and we need to push for timely catheter removal or prevent the usage of IUCs in the first place.

Patient Advocacy
Additionally, focusing on decreasing rates of infection in our catheterized patients will often involve us speaking up for our patients. We should not allow IUCs to be placed simply because they are convenient. This may include us questioning physicians regarding long-standing orders for indwelling catheters and allow our patients the best chances during voiding trials.
Advocating for our patients may involve educating family members on the risks of long-term catheterization and proper at-home maintenance so they can make fully informed decisions regarding their care.

Leadership
As a leader, I would apply what I have learned to best support my staff in CAUTI prevention. I would ensure that nurses are educated regarding the topic and are can demonstrate competent insertion techniques and catheter management to lessen the risk for infection. I would also empower nurses to best advocate for their patients' best interests, using their critical thinking skills, and possibly questioning the more common practices that could lead to higher infection rates. By creating an environment that is supportive of nurses' ideas and develops their practical skills, I would hope to lower infection rates on the unit.

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The nursing scope of practice allows us to make a significant impact on the prevalence of catheter-associated urinary tract infections within a healthcare system.  By empowering nursing staff to take accountability for their patients' medical outcomes, educating them about the risks and proper use of indwelling urinary catheters, and allotting the proper resources and infrastructure for alternatives, we can ensure that best-practice will be utilized and patient outcomes will be improved.