The use of Foley catheter in ICU patients is an important predisposing factor to catheter related urinary tract infection. It is one of the leading causes of nosocomial infections. The aim of this thesis to review the literature regarding the practice problem of catheter related urinary tract infection and suggest how to develop evidence based practice plan to change the current strategy. The basic elements are to have a clear insight of indications of insertion. Reducing the period of catheter insertion and the use of close system for urine collection are essential simple steps towards better results. A multidisciplinary team should be in charge of planning evidence-based practice change of strategy, performing preintervention study, getting an internal board approval and performing a pilot postintervention study to judge the potential success of the plan.
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Introduction and background
Nosocomial infections (acquired during hospital stay) represent a major threat to patient safety. Infections induced by devices such as ventilator associated pneumonia, and catheter induced urinary tract infections are serious for patients in special settings like the ICU (Rosenthal and others, 2006). Before discussing the practice problem of Foley catheter related urinary infections, appreciation should be given to the volume of the problem and recognize its definition.
Saint and colleagues, 2002, stated that catheter related hospital acquired infections are the most common iatrogenic infection seen in ICUs in the US. They assumed that it accounts for 31% of nosocomial infections, the daily incidence of bacteruria because of urinary catheterization is between 3 – 10% and 3% of these patients show bacteremia. They showed that each symptomatic case of hospital-acquired catheter related urinary tract infection (UTI) costs extra $676, and each case of hospital-acquired catheter related UTI costs an extra $2,836 (Saint and others, 2002). In a recent report, Tenke and colleagues, 2008, showed that nearly 40% of nosocomial infections are urinary tract infections and that 80% of cases result from premature urinary catheterization.
Most references agree that a value of 102 colony-forming units per ml (CFU/ml), in patient’s urine collected directly from the catheter (unvoided) is an important measure for bacteriuria (or urinary tract infection, as many authors use both terms interchangeably). In catheterized patients, rapid progression to double the number occurs in the first 72 hours. The criteria 102 CFU/ml urine may not apply for all patients as physical medicine and rehabilitation specialists claim that this figure holds true for disabled patients undergoing intermittent catheterization. Nevertheless, for male patients using external condom catheters, a criterion of 104 CFU/ml is accepted (Saint and Lipsky, 1999 and Maki and Tambyah, 2002).
A recent report by the National Healthcare Safety Network (NHSN), 2007, defined catheter associated urinary tract infection (CAUTI); as a urinary tract infection that occurs in a patient with an indwelling (Foley) catheter within 7 days from placing the catheter or within two days from discharge from the healthcare location. NHSN classified the event of CAUTI into symptomatic urinary tract infection (SUTI) and asymptomatic bacteriuria (ASB), thus identified the two interchangeable terms each to a specific condition. The CDC criteria for diagnosis of SUTI in adults are; first, the patient may have a fever (more than 38 degrees) with other urinary symptoms as urgency, frequency and tenderness in the suparpubic region with no other cause for the patient’s complaints. Alternatively, if urine culture show 105 organisms per ml of urine with no more than two organisms isolated. Either of these two criteria or one of them is diagnostic. Alternative criteria were given to suite different clinical situation and healthcare facilities (NHSN report, 2007).
The aim of this work is to; briefly, review the practice problem of urinary tract infection related to the use of Foley catheters in the ICU patients. In addition, to review the way to minimize the risk of this problem and suggest how to develop evidence based practice change of the current strategy.
Definition of Evidence Based Practice
Sackett and colleagues, 1996, defined Evidence Based Practice (EBP) as integrating individual clinical expertise with the best available external clinical evidence from systematic research. Therefore, knowing the standards of a particular EBP should provide the framework used to evaluate research literature for implementation of EBP into a practice setting. EBP that have attained generalization and proven effective in different clinical settings are likely those that can achieve high levels of effectiveness. Thus, for implementation of EBP we need to integrate research with guidelines and outcomes of met-analytic or multi-center studies (DeBourgh, 2001).
A review of multiple types of literature when researching this practice problem. The researcher sought for articles using the following databases:
- National Center for Biotechnology-National Library of Medicine-National Institutes of Health.
- Medscape medical database,
- The New England Journal of Medicine, and
- Yahoo and Google databases. The researcher considered.org,.edu, and.gov terms with only one exception.
Keywords were urinary catheterization, urinary tract infection related to urinary catheterization and urinary catheterization in the ICU.
Particulars of Foley catheter
A Foley catheter is a sterile thin rubber tube, and is used to drain the urinary bladder. Its main character is the presence of a balloon at the rounded end, at the other end, it has two portals, one is for urine, which into a urine bag. Alternatively, an attendant can perform bladder wash through this end; the other portal is for inflation (by injecting sterile water) or deflation of the balloon to take the catheter out. Because of the balloon, it called an indwelling (a within) catheter and can stay in place for many days (Desai and others 2001). Desai and colleagues, 2001 investigated UTI in ICU patients and studied urine samples collected from catheterized ICU patients versus 100 samples from non-catheterized patients of the same ICU. Their results showed the most common bacteria isolated were, E. coli, Proteus and Staphylococcus aureus. The most common source of E. coli was Foley’s catheters (48.21%), although the same strain colonizing the catheters was isolated in only 8.92% of UTI catheterized patients. They suggested that the high rate of colonization is because of long duration of catheter stay, the underlying condition of the patient or empirical usage of antibiotic. They inferred that high rate of colonization of Foley’s catheters plays a significant role in augmenting the risk of E. coli UTI infection in catheterized ICU patients (Desai and others, 2001).
Particulars of the ICU
Ylipalosaari, 2007, pointed out that ICU patients, despite the care and attention they get, are more vulnerable to nosocomial infections. Ylipalossaari, 2007, summarized the risk factors in ICU patients into three categories; first, factors related to patients characteristics (how acute the disease process is? Does the patient suffer neurological lesions and multiple traumas? Is the patient on immunosuppressive drugs or immune-compromised? …etc). Second, is the period of stay in the ICU, although it is difficult to determine whether the longer the patients stays, the more the possibility of infection. Alternatively, the patient stays for a greater number of days because of acquiring a nosocomial infection. Third, the risk may be exogenous as insertion of urinary catheters. In this study, Ylipalosaari, found that 95% of UTI occurring in the ICU are catheter associated, it is also higher in those who previously received antibiotics and is commoner in females (Ylipalosaari, 2007).
The practice of catheterizing critically ill patients has developed over the past 20 years. Alavaren and others, 1993, mentioned only few lines, the target was to use a sterilizing solution before catheter insertion (Povidone iodine), wearing gloves and using pre-sterilized instruments. With increasing awareness of the volume of the problem, the procedure became like performing a minor surgery. Thomsen and Setnik, 2006, stated that since most equipments needed for catheterization come in a pre-packaged tray, attention should be directed to elements not included in the tray. Examples of such elements are lidocaine gel, adhesive tapes, or other instruments to secure the catheter and the antiseptic solution. The process of catheterization includes injection of lidocaine (needless syringe) into the urethra (in non-circumcised males), using sterile gloves, and towels to wrap the lower patient area. The used in holding the skin of the genital area for sterilization is considered non-sterile. Despite these precautions, the incidence of catheter associated UTI is still high.
Early diagnosis and management is essential to prevent further deterioration of the patient’s health. In this context, the question is when to start treatment, as 90% of cases of bacteriuria during catheterization are asymptomatic; moreover, antibiotics are of limited value especially if the catheter is to stay for long time (Jacobson and others, 2008). Most physicians agree that careful observation for fever, problems related to the catheter (subjective or during daily examination), associated immunosuppressive or corticosteroid treatment represent a good indication for a complete urinalysis and start of antibiotic treatment (Jacobson and others, 2008).
Change of pattern of organization practice
Laupland and others, 2005, studied 4465 patients admitted to one ICU for more than 48 hours over three years to explore the incidence, microbiology, and risk factors for acquired urinary tract infection. Their results showed that 6.5 % of patients acquired ICU urinary tract infection. Females showed a higher relative risk and patients in medical care units showed the highest incidence (9%) followed by non-cardiac surgery ICU patients and the least were patients of cardiac surgery ICUs. A significant observation of this study was the significantly lower rate of UTI in ICU patients over the last two years of the work (2001-2002). The authors assumed the change was because of increased awareness of the problem and increased and or better use of antibiotics in the management. Better lab diagnosis or perhaps physicians did not ask for the same number of urinalysis, which reduced the diagnosis rate were other possible reasons.
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Canes, agreed with Thomson and Setnik, 2006, that lesser rates of ICU acquired URTI are coming up because of increased commitment to aseptic techniques and increase maintenance of closed drainage systems.
Who is interested (Stakeholders) in catheter induced UTI
In 2006, Rosenthal and nine colleagues from eight countries (Brazil, Argentina, Morocco, Turkey, Peru, India, Mexico, and Colombia) conducted a study on device induced ICU acquired infection on 55 ICUs of 46 hospitals in the eight countries. They conducted the study for the International Nosocomial Infection Control Consortium. This study on such a scale reflects the international interest in this healthcare practice problem. The NHSN report in 2007 on the same problem reflects the interests of the US Department of Health and Human services. Regional offices of the World Health Organization are investigating the problem of device induced ICU acquired infections (the Regional Office of South East Asia, 2002 and the Regional Office of the East Mediterrenian report in 2005) which indicate global interest. These studies were motivated by the high rate of hospital-acquired infection in ICU patients in the developing countries (approximately three times higher than any other hospital setting) (Sallam and others, 2005).
On the level of a healthcare establishment, a multidisciplinary team should be interested. Infection control department, critical care staff, nephrologists, urologists, infective diseases physician, administration (ICU and hospital level) should all be involved directly or indirectly. ICU and hospital staff is encouraged to participate and engage in discussions (Reilly and others 2006).
Review of literature
Decision making for Foley Catheterization
Urinary catheters are either external (condom catheters) or internal, which in turn may be either urethral (Nelton and Foley catheters) or supra pubic. Indications of urinary catheterization can be diagnostic to obtain a sample of unvoided urine, in cases of cystography or cystourethrography or to distend the bladder prior to transvaginal or low abdominal ultrasonography. Alternatively, indication can be therapeutic as in patients with acute or chronic urinary obstruction, following urinary tract operations of nearby operation (hysterectomy). The only absolute contraindication to urinary catheterization is suspected or actual injury to the urethra (Thomson and Setnik, 2007).
Urinary catheters for therapeutic uses can be for short term (0-7 days) as in cases of instillation of chemotherapeutic drugs or acute urinary retention. They can be used for long term (up to 28 days), as in cases untreated bladder neck obstruction (as in cancer prostate), some cases of neurogenic bladder or neurogenic urinary incontinence especially when associated with skin complications. Alternatively, urinary catheters can be used on intermittent basis to reduce the incidence of catheter complications (Ramakrishnan and Mold, 2005).
Pathogenesis of catheter-induced UTI
Bacteria causing UTI have specific approaches to produce infection these include colonization of catheter, damaging urinary tract mucosal cells and multiplication. Introducing a device as Foley catheter may launch infection by introducing bacteria into the urinary tract. This may occur at the time of catheter insertion either through the lumen or along the interface between the catheter and urethral mucosa (in 66% of cases). Bacteria use the interface between the catheter and urethral mucosa as a scaffold to enter the bladder or, being forced by the introduction of the catheter, to enter directly to the bladder (34% of cases). Moreover, indwelling catheters favor bacterial colonization and may result in injury to the urethral epithelium during introduction or because of prolonged contact in long-term urinary catheterization. Long-term catheterization favors infection by disturbing the bladder mechanism of emptying with residual urine that favors growth of microorganisms. Causative bacteria (uropthogens) are fecal contaminants (E.coli), skin microorganisms or transitory bacteria that reside in pre-urethra. The most common causative bacteria are E. coli, Proteus mirabilis, Pseudomonas auregenosa and Staphylococcus aureus (Jacobson and others, 2008).
How to minimize the risk
There are five main strategies to minimize the risk of Foley catheter related urinary tract infection. First, to clarify decision making and reduce the time for catheter use, second, the use of closed system Foley catheter, third, the use of alternatives (condom catheters and supra-pubic catheters) whenever possible. Fourth, safeguard against bacterial colonization of the urethra and the urinary tract, lastly, to consider the use of alternative catheters (with new surfaces or catheters containing antibacterial agents) (Jacobson and others, 2008). Gokula and others, 2007, studied inapt use of indwelling catheterization in an emergency department. They also studied the effect of having a checklist with each catheter kit to complete by the staff. Result showed that proper use rate rose significantly from 37% to 51% and physician request to insert a catheter rose significantly as well, from 43% to 63%.
This resulted in marked decrease in the total number of catheter insertion (from 2188 in 2003 to 512 in 2005). They inferred that clarification of indication should make the decision making process appropriate and clearer. Jacobson and colleagues, 2008, reviewed studies that assumed 21-38 % of urinary catheterizations were initially not justifiable. Moreover, in one survey, they reviewed a 28 % incidence of catheters stayed longer than needed because they were “forgotten. Other studies reviewed by Jacobson and others, 2008, showed that 10 – 50 % of patients with short term catheters develop catheter related UTI and almost 100 % of patients with long term catheters develop catheter related UTI. Therefore, they suggested changing the catheter every 8-10 days to minimize the risk of infection.
In 2006, Reilly and colleagues stated that criteria-based Foley catheter guideline, clear indications and a daily checklist may result in reduction of catheter related UTI.
A closed system Foley catheter is one where the collection tube of the catheter fuses to the collection bag. It is reported to reduce the rate of Foley catheter related UTI from 100% after two weeks to 25%. Further reduction is aided by choosing the right size of the catheter and proper catheter care (Jacobson and others, 2008). Although the use of alternative catheters may reduce the risk of UTI, yet it is not without problem. Condom catheters are suitable for males with bladder neck obstruction and it needs special care to avoid skin excoriation, which in itself a predisposing factor to UTI. There are no controlled studies to elucidate the benefit of supra pubic catheters in reducing the rate of UTI (Jacobson and others, 2008). Proper catheter insertion under aseptic condition reduces the risk of UTI as it reduces trauma and possibly bacterial colonization. Irrigation of the bladder and the catheter with non-absorbed antibiotics (as neomycin) may help in reducing UTI risk (Reilly, and others 2006 Jacobson and others, 2008).
New types of long-term catheters are either new surface catheters (silver-coated) or antimicrobial urinary catheters (Saint and others, 2002). Johnson and others, 2006 performed an evidence based review study on the use of antimicrobial urinary catheters. They reviewed articles over a period of 40 years (1966-2005) in electronic databases. Only 12 studies qualified for systematic review, with all studies suggested protection bacteriuria. They concluded that based on fair quality evidence, antimicrobial urinary catheters can prevent bacteriuria in hospitalized patients with short term catheters inserted, however, success rate may vary according mainly to antibiotic coating. Karchmer and other, 2000, examined the effect of silver-coated silicone catheters in reducing UTI in hospitalized patients. They claimed that UTI rate reduced by 21% in the group of the study wards randomized to silver-coated catheters while the rate reduced by 32% in the group of patients to whom silver-coated catheters were used on the wards. They also claimed that the use of these catheters result in hospital savings in the range $14456 to $573293. Srinivasan and colleagues, 2006, conducted a study on 3,036 patients with catheters to compare the effects of silicon-based, silver-coated and hydrogel coated catheters in reducing the rate of catheter related UTI. They inferred that was no significant difference among the types used in preventing UTI. However, there was a possible statistics bias because of the difference among groups of patients.
Implementation of findings
In the stage of planning, a multidisciplinary team is necessary for successful control of Foley catheter related URI, as in any other evidence based practice change of policy. The team as suggested by Reilly and others, 2006 is to be formed mainly of an infection control nurse and an ICU nurse (selected by the chief nursing officer). The team is to include ICU manager, and infection control manager and the organization’s Six Sigma department for consultation. Nephrologists, urologists, critical care physicians, infectious disease physicians, the ICU head nurse are all consulted to develop the criteria for a guideline of use of Foley catheter. The more the team members, the less resistance hospital staff shows in the implementing phase (Reilly and others, 2006).
Other hospital staff is encouraged to get involved through discussions during ICU meeting, luncheons or prearranged possibly poster announced staff invitation. Based on the previous review, the plane should include an indication sheet for ordering a Foley catheter for a patient preferably attached to the catheter kit (Gokula and others, 2007). Decision making checklists as to the criteria indicating appropriate Foley catheter use (Reilly and others, 2006) and the criteria of NSHN, 2007 for symptomatic catheter induced UTI and asymptomatic bacteriuria. Guidelines for proper Foley catheter insertion should be clear and a part of the strategy change (Reilly and others, 2006). A data collection checklist (tool) for cases of Foley catheters can help reducing the period of catheter stay (Reilly and others, 2006 and Jacobson and others, 2008).
Product evaluation, education and discussing practical issues are all integral to implementing evidence based practice change. Therefore, a prepared binder is useful to educate ICU nurses and to use in meetings with other staff members. A preintervention study as regards present status of patient outcome should be helpful to manifest the necessity to change and, at a later stage, to compare the results with those of a pilot postintervention study (Reilly et al, 2006).
Having done that, the plan is subjected to approval by an internal board before implementation. Following approval, the team performs a planned pilot study to measure the potential success of the plan. Criteria for measuring success should comply with Six Sigma approach, which is a measure of quality that aims for near perfect standards. The basic goal for Six Sigma is to execute of a measurement-based strategy that looks primarily at process improvement and reducing variability. This can be achieved through one of the Six Sigma sub-strategies, DMAIC (Define, Measure, Analyze, Improve and Control) or DMADV (the same but Design and Verify instead of Improve and Control). The main criticisms for Six Sigma methodology are lack of originality, it points to the negative effects and it is based on random standards. These criticisms the possible critique for the data analyzed (Goh, 2002). Patients outcomes are measured (Foley catheter days, incidence of catheter related UTI, patient stay in the ICU and any significant morbidity associated with UTI) and compared with the preintervention study.
Urinary tract catheter related infection is prevalent among ICU patients. This practice problem affects the morbidity of patients and costly. A group of evidence-based guidelines for Foley catheterization is presented in this study. The core of these guidelines is to minimize the period of Foley catheter insertion and to standardize the criteria for insertion and those of diagnosis of catheter related UTI.
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