WIXLIB

Speaker Notes: Slide 4 continuedWithin the space of 20 minutes, she has a central line andindwelling urinary catheter placed. It is pretty chaotic in hercubicle: lots of people doing lots of procedures all at the sametime. During the catheter insertion the tip of the urinarycatheter inadvertently touches the nurse’s scrub top. The nursedoes not get another catheter, but instead continues to insertthe “dirty” catheter. Four days later the patient still has theindwelling urinary catheter, and now she has a fever and hasbecome hypotensive. Blood cultures are positive for Serratiamarcescens. The patient’s length of stay is significantlylengthened as a result of this complication.30

Speaker Notes: Slide 5Employing indwelling urinary catheter insertion andmaintenance bundles is a great way to promote evidence-basedbest practices and proper aseptic technique. The components ofthe catheter insertion and maintenance bundle are listed on theslide. First, if you determine that an indwelling urinary catheteris clinically indicated, then the evidence suggests that you shoulduse an indwelling urinary catheter insertion kit standardized foruse in a facility. Second, ensure proper insertion technique, andwe’ll talk in a bit about what this entails. Finally, once thecatheter is inserted, maintaining it according to evidence-basedguidelines is crucial to prevent CAUTI. The remainder of thismodule explores these three components in more detail.31

Speaker Notes: Slide 6This slide describes some components of a standard indwellingurinary catheter kit. Although there are several differentcatheter types on the market, it is recommended that a closedsystem indwelling urinary catheter insertion kit be used becausea closed system eliminates a possible entry route for bacteria.Standardized kits allow inserters to become familiar with aconsistent order in which supplies are presented. Thatconsistency reduces cognitive load so that the inserter can focuson what’s important—the insertion itself, instead of locating thesupplies. Frontline staff should provide input as to what kind ofkits to stock; other kits should be removed from supply. Keep thepatient population in mind. Engaging frontline clinicians indecision making helps to ensure buy-in.32

Speaker Notes: Slide 6 continuedThe decision to remove individual catheters from stock has to becarefully made. Sometimes a larger or smaller sized catheter isneeded, depending on the patient’s situation. For femalepatients there may be more than one insertion attempt, and thecost of starting again with a whole new kit has to be weighedagainst the cost of one catheter. For elderly males, a bent tipcatheter may be needed, and these usually do not come prepackaged in a standard kit.33

Speaker Notes: Slide 7Evidence-based guidelines have always recommended asepticinsertion technique, which is the proper technique. All clinicianswho will be inserting catheters should receive competencybased training on aseptic catheter insertion technique and beable to demonstrate competency. Often, these trainings fornurses and other clinicians occur in very controlled conditions.Even when clinicians get to insert catheters during clinicalrotations, the instructor is often hovering nearby, with a helpinghand. In simulation labs it is easy to find the urethra on femaledummies, and male dummies do not have enlarged prostateglands. Physicians, too, learn how to insert catheters on the job.34

Speaker Notes: Slide 7 continuedFor example, they’ll catheterize patients in the operating room,which again, is a very controlled environment. The take homepoint here is that some of the lessons we learn about how toinsert catheters aseptically do not apply once we are out in thereal world35

Speaker Notes: Slide 8The research team found that in observing 81 catheter insertionattempts, 59 percent of attempts had at least one major break inaseptic insertion technique. In many cases, there was more thanone break in aseptic insertion per case. These breaks in aseptictechnique include contamination of the sterile field,contamination of the catheter and breach of the sterile barrier.The examples on this slide show what constitutes each of thesebreaks in sterility.Many catheter insertions were observed in the trauma bays. Asense of urgency pervades EDs, especially in the trauma bayswhere the sickest patients are triaged. Because of the urgency,clinicians perform multiple procedures at the same time so thatpatients can be quickly stabilized, just as in the story earlier.36

Speaker Notes: Slide 8 continuedAs a consequence, aseptic technique may be difficult to maintainwhen multiple staff—in parallel—care for an unstable patient.Multiple procedures are performed by multiple clinicians: twopeople are inserting peripheral IVs, while another is intubatingthe patient and yet another is inserting a new arterial line. Whatif we waited until the dust settled before inserting a urinarycatheter? The patient may urinate on the sheets during theseother procedures, that’s true, but the sheets would have to bechanged anyway after the other procedures are completed.Urinary catheters do not contribute to patient stabilization, soconsider changing your practice to hold off on urinary catheterinsertion until the procedure can be done using aseptic insertiontechnique.37

Speaker Notes: Slide 9To overcome the challenges faced when inserting urinarycatheters aseptically, both technical and socio-adaptivestrategies are needed. Technical strategies include providingcompetency-based training for all staff inserting catheters,confirming availability and ease of access of all supplies neededfor aseptic insertion, ensuring staff are appropriately performinghand hygiene and using personal protective equipment (PPE) forall catheter insertions, and using catheter insertion checklists.Insertion checklists provide structured guidance, making thesteps for aseptic insertion easier to follow.38

Speaker Notes: Slide 9 continuedThrough consistent use of a checklist, the insertion processbecomes more standardized, closing the gaps in practicevariation that could possibly lead to breaks in aseptic technique.Lastly, hospitals should conduct routine audits of catheterinsertions to confirm aseptic technique is being properlyfollowed and provide feedback to staff on their technique.Socio-adaptive strategies can be difficult to identify and morechallenging to tackle. There’s a lot that could be said about theculture of a unit or hospital. Culture refers to “the way we dothings around here.” A unit or hospital culture that is committedto evidence-based practice will be more likely to work hard atimproving insertion technique.39

Speaker Notes: Slide 9 continuedSimilarly, does the unit or hospital culture encourage staff tostop procedures and start again if breaks in aseptic technique arenoticed? Creating an environment where staff feel empoweredto speak up to stop procedures, like catheter insertions, if thereare breaks in technique can be an important socio-adaptivestrategy to improve insertion practices. Finally, recruitinginsertion champions who can help support other staff duringinsertion and keep best practices and evidence-based guidelinelines top of mind can also be a strategy to improve a hospital’sindwelling urinary catheter insertion practices.40

Speaker Notes: Slide 10Here’s one example of a checklist.The American Nurses Association (ANA) tool includes both analgorithm to help in deciding whether or not to insert a catheter,as well as a simple checklist to guide the insertion process. Hereis a glimpse of what the insertion checklist portion of the ANAtool looks like. You can see that the checklist is divided intosections, with each section consisting of just a few items. Thereare other types of checklists available for use as well, but theANA tool, by combining an algorithm and checklist together, maymake it easier to use the evidence on CAUTI prevention.41

Speaker Notes: Slide 11No matter what checklist you use, aseptic insertion comes down to thesesix elements:1. Perform hand hygiene immediately before (and after) insertion;2. Use appropriate antiseptic or sterile solution for peri-urethral cleaning,remove gloves and perform hand hygiene after peri-urethral cleaning andprior to insertion3. Set up a sterile field;4. Use sterile gloves, drapes, sponges;5. Use appropriate antiseptic single-use packet of lubricant jelly for catheter tip;6. Secure the device;7. Keep collection bag below bladder level.If at any point the catheter is accidentally contaminated, discard it andobtain a new sterile catheter (or kit).It may seem simple, but implementing these seven elementsconsistently, in all situations, can be very challenging.42

Speaker Notes: Slide 12Some of the barriers to aseptic insertion that we found included: Supplies are not readily available or supplies are not designed tofacilitate aseptic insertion. For example, wisps from cotton balls tendto cling to tongs in some kits, so that a new cotton swab becomescontaminated by wisps from the previous swab, so many insertersjust discard the tongs without using them. Remember that tongsprovide an additional barrier between the inserter’s hand and thepatient. We observed many nurses swab genitalia with their sterilegloves to avoid the tong and wisp dilemma, but of course as soon asthe glove touched the patient, the glove was no longer sterile.43

Speaker Notes: Slide 12 continued Also, some units may find that the work space is not aligned withworkflow. Inconsistent or inconvenient locations for hand gel orinconvenient location of sinks can either disrupt workflow or to keepto their workflow routines, clinicians will not use hand gel. If there islittle room to set up a sterile field then there is a greater chancethere could be a break in sterility of the field.44

Speaker Notes: Slide 13But, there are a number of strategies to overcome the barriersjust presented. These strategies focus on four key areas: Having the best type of kit to stock for your patient population; Making sure you have other necessary supplies, such as over-thebed tables, an Environmental Protection Agency (EPA)-registereddisinfectant to clean and disinfect the workspace, hand sanitizersand sterile gloves; Ensuring there are adequate facilities for hand hygiene; and Locating the kits, so that the kits are easily accessible to wherethe procedures will take place.45

Speaker Notes: Slide 13 continuedAnother strategy to overcome the barrier of supplies not beingreadily available includes working with other clinical areas inyour hospital that also house patients likely to have indwellingurinary catheters. The hospital as a whole may benefit fromstocking one type of kit, or depending on patient needs, you mayhave to have a couple of different kit types available. The pointhere is to have the conversation with other clinical areas, andnot to make decisions based on assumptions.46

Speaker Notes: Slide 14The next topic to discuss is indwelling urinary catheter care andmaintenance essential practices. The image on the left of theslide is the Agency for Healthcare Research and Quality or AHRQCatheter Care Pocket Card, which you can download by clickingthe image. It reviews interventions that should be in place tohelp prevent infection when a patient has a documented needfor an indwelling urinary catheter. The list on the right provideshighlights of the maintenance phase of an indwelling urinarycatheter. The next slide explores these catheter care essentials ingreater detail next.47

Speaker Notes: Slide 15First and foremost should be an emphasis on hand hygiene. Boththe Centers for Disease Control and Prevention or CDC andWorld Health Organization Guidelines emphasize the need forhand hygiene. Of course, hand hygiene prevents the spread ofbacteria and viruses in general, not just CAUTI.Both the CDC HICPAC Guidelines and the 2014 Compendium ofStrategies to prevent HAIs recommend that health care workerswho are involved in both insertion and maintenance of anindwelling urinary catheter receive education. Education can bedone in many ways: online modules, annual competency testing,or the “see one, do one, teach one” method, among others.48

Speaker Notes: Slide 15 continuedThere are even well done, easy- to-watch videos on hand hygiene, soit is worthwhile spending some time figuring out the right type ofeducation for your staff.Auditing compliance and providing feedback are importantstrategies too. In a true safety culture, a person who identifies aclinician handling a urinary catheter without hand hygiene or use ofstandard precautions should speak up and remind the clinician. It’srecommended that you always begin by highlighting something theclinician has just done well. For example, “I noticed that you usedthe hand sanitizer as you left your patient’s room, so thank you forthat. Then you went to gather some supplies, but you didn’t use thehand sanitizer before going into the next patient’s room.”.49

Speaker Notes: Slide 15 continuedEnforcing hand hygiene may require a change in culture as wellas a change in workflow. Some people become defensive aboutreceiving feedback, so it is important to emphasize that thefeedback is focused on the observed behavior and in no way is areflection on the person’s integrity or competence. We all wantto do the right thing all the time, but frequently the systems inwhich we work are not configured in ways which are best for us50

Speaker Notes: Slide 16Maintaining a closed system is another important component ofcatheter maintenance. It is important to consider replacing theurinary catheter, which means the entire system, if breaks orleakage occur. Pre-connected sealed catheters arerecommended, because they serve as a reminder especially tonewer staff or students for example, who may not yet have hadthe benefit of education.51

Speaker Notes: Slide 17This slide describes some strategies to help ensure a closedsystem is maintained. Remember, most patients who areadmitted come through the ED, so it is in the ED where thedecision to insert a catheter or not is made. It is important toemphasize that urinary catheters should not be routinelyinserted, rather they should only be inserted when medicallyindicated. Some EDs do not insert catheters unless absolutelynecessary and allow the admitting unit to decide, thuseliminating the potential to break the closed system.52

Speaker Notes: Slide 17 continuedDeciding whether or not to use a urimeter is another issue thatcan impact the hospital’s ability to maintain a closed cathetersystem and is best answered by each hospital based on theirpatients, resources and clinical need. Urimeters are urinemeasuring devices commonly used with critically ill patientswhen precise, frequent urine output monitoring is necessary.Urimeters that come pre-connected to catheters can helpmaintain a closed system. A number of hospitals haveimplemented a process that requires all EDs to place catheterswith pre-connected urimeters in patients who will be admittedto specialty units.53

Speaker Notes: Slide 17 continuedOther hospitals have moved to implementing an approach inwhich only urimeters are used for all indwelling urinarycatheters, regardless of the type of unit to which the patient istransferred. If urine is emptied from the collection bag onlyevery eight or 12 hours, a urimeter may not be necessary.Irrigation is always a challenge, but if the seal is broken, it isadvisable to change the catheter and entire system. A preconnected three way should be used if frequent flushing isrequired. It is important to work with your supply chain torequest pre-connected specialty catheters.54

Speaker Notes: Slide 18Maintaining unobstructed urine flow is another component ofthe maintenance bundle. Keeping the bag below the level of thebladder is important because when a drainage bag is raisedabove the level of the bladder, contaminated urine from thedrainage bag or tubing may reflux into the bladder, or organismsmay be introduced when there are breaks in the closed drainagesystem. The bulb of the indwelling catheter prevents completebladder drainage, and a residual pool of undrained urine remainsin the bladder. Organisms, once introduced, persist in this pool ofurine putting the patient at risk of infection.55

Speaker Notes: Slide 18 continuedEmptying the collection bag prior to transport helps preventurine reflux. Catheter securement devices act as an anchor toprevent tugging and pulling which can cause irritation andinflammation. When catheters are not secured in male patients,the tugging and pulling can cause pressure sores on the penistip. And keeping the urine bag off the floor just makes goodsense.56

Speaker Notes: Slide 19Every unit needs to develop their own set of strategies to routinelymonitor the maintenance issues just described. Observation of theurinary catheter and the drainage bag can be incorporated intodaily rounds, or even nurse-to-nurse handoff at shift change, or aspart of a safety checklist. At one hospital, after a nurse gets areport from the off-going nurse, both nurses go into the patient’sroom together and do a brief safety check: Bed low and locked, IDband on, IVs patent and running, head of bed, or HOB, elevated.Observing things such as chest tubes, drainage tubes and urinarycatheters are also incorporated. Similarly, as part of a transportcheck, nurses routinely check for IV patency, so including themaintenance of urinary catheters could be an eas

catheter inadvertently touches the nurse’s scrub top. The nurse does not get another catheter, but instead continues to insert the “dirty” catheter. Four days later the patient still has the indwelling urinary catheter, and now she has a fever and has become hypoten