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Catheter-associated UTIs in the neuro ICUpositive Gram stain, and 2 urine cultures 102 CFUs/ml of a single pathogen in a patient undergoing treatmentusing antimicrobials. Asymptomatic catheter-associatedD#! %3"43"#'.3'!#0&"&43"#' #,'&%10%&'#,'#' .," "B%'43"0%'culture ( 105 CFUs/ml) in a patient who had a urinarycatheter placed within the previous 2 days and who hadno signs or symptoms of catheter-associated UTI. Asymptomatic catheter-associated bacteriuria or candiduriawas not counted as catheter-associated UTI in this study.Patients were not routinely monitored for asymptomaticbacteriuria. Urinalysis as well as urine and blood cultures were performed whenever the patients developedsystemic or local signs of infection. These signs includedfever (temperature 38.5 C), urinary urgency, urinaryfrequency, dysuria, and suprapubic tenderness.The infection control investigation of possible catheter-associated UTI was triggered by positive urine culture. An infection control nurse practitioner would thenperform a chart review to gather data. These data werepresented to the hospital epidemiologist to decide wheth%3'#0'"05%! ".0'D#,%&'.0'JKLJ'&%10" ".0,' #&'.!!433%&9) %' 3# %' .5' !# % %3I#,,.!"# %&' ()*' #,' &%10%&' #,'the number of patients with catheter-associated UTI divided by the number of indwelling urinary catheter days64- " -"%&' D2' 7;;;9' F# % %3' 4 "-"C# ".0' #,' &%10%&' D2' %'JKLJ'&%10" ".0G' "! ' #,' %' . #-'046D%3'.5'!# eter days divided by the total number of patient days multiplied by 100.Pressure UlcersAll pressure ulcers regardless of stage (“deep tissueinjury” through Stage IV) were counted using the National Pressure Ulcer Advisory Panel standards (http://www.npuap.org/). The incidence of patients with pressure ulcerswas determined through weekly skin care rounds by anOstomy and Wound Liaison nurse. The denominator wasthe total number of patients admitted to the unit at the timeof rounds. Averaged monthly values are presented.InterventionAs part of a hospital-wide CQI program, a multidisciplinary team was formed and charged with the responsibility of examining the scope of the problem related tocatheter-associated UTI, determining its impact, and de10"0/' %'&%,"3%&'.4 !.6%9') %'MNOPQ'6% .&' 5.!4,G'analyze, develop, execute, and evaluate)5 was used. Anextensive review of the literature was conducted, baselinedata were collected, and an action plan was developed toexecute a program aimed at reducing the number of catheter-associated UTIs below the NHSN mean for both ICUand medical-surgical groupings. This CQI initiative provided a constant feedback method, allowing for reviewand adaptation of interventions. Recommendations fromthis CQI team were then distributed to ICU and medicalsurgical nursing units for implementation. Study approvalwas granted by the Institutional Review Board at the University of Florida and Shands Hospital.Evidence-Based Best-Practices RecommendationsA literature review including a Cochrane Databasesearch was used to develop a best-practices and evidenceJ Neurosurg / Volume 116 / April 2012based medicine UTI “bundle.” A bundle is a set of evidence-based practices that are implemented together toaffect a disease process.3 The UTI prevention bundle focused on 4 key factors to reduce the incidence of catheter-associated UTI: 1) avoidance of catheter insertion, 2)product standardization, 3) maintenance of catheter sterility, and 4) timely removal of catheters. Avoidance ofcatheter insertion was accomplished by development ofcriteria for insertion of urinary catheters and default removal of catheters postoperatively if not explicitly orderedotherwise. Product standardization resulted in the use ofantimicrobial catheters and closed systems. Maintenanceof sterility was accomplished through nursing education.Lastly, timely removal of catheters was accomplished by a043,%I&3"B%0'3%6.B#-' 3. .!.-9'P#! '#, %! '.5' ",'D40&-%'and the particular method of implementation are detailedbelow. The UTI prevention bundle was distributed to eachICU and medical-surgical unit to implement and adaptthe recommendations to their unit according to what their&# #' 3.1-%'"0&"!# %&'#,'. .3 40" "%,'5.3'"6 3.B%6%0 9Avoidance of Insertion. Appropriate indications forurinary catheter placement were also discerned from theliterature and distributed to the individual units (Table 1).Alternative methods to indwelling catheters were explored.Intermittent or “in and out” catheterization in conjunctionwith frequent bladder scanning was promoted as the preferred method for bladder management over indwellingcatheterization.Product Standardization. A single closed cathetersystem was adopted hospital-wide. This adoption prevented the use of incompatible parts resulting in breakageof sterility and makeshift compatibility. A hospital-wideadoption of the Bardex IC silver hydrogel Foley cathetersystem was recommended. In addition, the StatLock Foley catheter stabilization system for securing catheters tothe leg was implemented to reduce urethral trauma.Maintenance of Catheter Sterility. If a catheter wasdeemed necessary, every effort was made to place the catheter aseptically and maintain the sterility of the catheterwhile it was in place. Guidelines stated that collecting bagsshould remain below the level of the bladder to prevent reR4S'.5'43"0%'"0 .' %'D-#&&%3'#0&', .4-&'D%'%6 "%&'3.4tinely. Additionally all collection bags were to be placed onthe door side of the bed to ensure dependent drainage andcontinuous visualization of the system. Finally, dependentloops in collection system tubing were discouraged, collection bags were to be kept below the level of the bladTABLE 1: Approved indications for urinary catheter placementperiop use for selected surgical procedures 3 hrs!"# %&'!()!(&*' #('"# &# &,"#(#,-./&#.&)-(#% (0&1'"&-&2 #(%&)%"#'3management of acute urological conditions when “in & out” catheteri zation is not prudentneurogenic bladder or retention only if “in & out” catheterization failsassistance in severe pressure ulcer healing (nonhealing Grade 3 or 4)*comfort during end of life* According to National Pressure Ulcer Advisory Panel standards.913

W. L. Titsworth et al.der during transport, individual emptying containers wereused, and proper hand hygiene was emphasized. It has beenpreviously shown that only skilled, dedicated health carepersonnel should insert urinary catheters.25 Therefore, eachnurse in the neuro ICU completed an online educationalmodule for UTI rate reduction prior to implementation.Timely Removal of Catheters. In an effort to promote%#3-2'!# % %3'3%6.B#-G'!# % %3,' #&' .'D%'T4, "1%&'D2',%lection of one of the approved indications for placementfrom preprinted progress notes. At the beginning of theinitiative, the target for catheter removal was 4 days afterplacement. The slogan accompanying this goal was “Day4, Foley no more” and was adopted house-wide. Nurseswere educated that catheters were to remain in place nomore than 4 days unless indicated, and nurses and physician staff were educated about the documentation requirements. In response to the CMS changes, in Octoberof 2009 the Surgical Care Improvement Process measure #,' "6 -%6%0 %&U' ",' 3%A4"3%&' , %!"1!' &.!46%0 # ".0'by a medical doctor, physician assistant, or advanced registered nurse practitioner if a catheter was left in placefor longer than 48 hours. This necessitated a reduction inthe acceptable time frame for catheterization to 48 hoursand the slogan was changed to “Day 2, no Foley for you.”As awareness grew, the time frame for Foley catheterremoval was later shortened again to 24 hours and then#/#"0' .'"66%&"# %-2' ., . %3# "B%-2'5.3', %!"1!' # "%0 'populations. It became more and more common for elective craniotomies of relatively short duration ( 4 hours)not to involve catheters at all during surgery.Despite increased awareness, Foley catheter utilization continued to remain somewhat elevated near the 50thpercentile nationally. Therefore, in October 2009, a systems improvement measure was implemented to facilitate nurse-driven catheter removal. Clinical Nurse Leaders began rounding on every patient in the neuro ICU fora 6-month window and focused on indications for eachcatheter placed. This was referred to as “Foley Rounds.”P#! ' # "%0 ' #,' 3%B"% %&G' #,' #,' %"3' "0&"!# ".0' .3'indications for a catheter and compliance with the UTIbundle. If no clear indication was found, the name of thepatient was given to the critical care medicine attendingphysician who then ordered the catheter to be removedif no indication could be found (Fig. 1). This information was also verbally communicated to the physicianextender. Additionally during rounds the Clinical NurseLeader spoke with individual nurses, educated them, andaccepted nursing recommendations and feedback. Finally, primary attending physician compliance was trackedand additional education was performed as necessary tofacilitate individuals’ adherence. Later in the study, in3%, .0,%' .' #0' "0!3%#,%' "0' /#, 3."0 %, "0#-' R.3#' #,' ()*'pathogens, Clinical Nurse Leaders made recommendations during Foley Rounds for use of a fecal containmentsystem (Flexi-Seals, ConvaTec) in patients with bowelincontinence to help prevent catheter contamination. Ingeneral, Foley Rounds were performed each day by theClinical Nurse Leaders of the nursing management teamat 9 am and took approximately 2 hours (depending oncensus and/or interruptions).914EducationPhysicians were educated through their respectivedepartments as well as a newsletter prominently post%&' "0' %' 0%43.' *F(' VWW 90%43.,43/%3294R9%&4Wresidency/images/lwt jns11-974apdx1.pdf; Appendix 1).Slogan promotion was also used to increase awarenesson the unit. Best practices were built into order sets as de5#4- ,9'P#! '&% #3 6%0 ' #,' 3.B"&%&'#'6.0 -2'4 &# %'of their current infections and targets, as well as the percentage of physicians in compliance with the UTI bundleand Foley Rounds recommendations. Myth-versus-factdocumentation was distributed to nurses and physiciansthat included not changing catheters for fever if no signsof UTI were present17 (Appendices 2 and 3). Nurses wererequired to complete an online education module withcompetency evaluation, and each nurse had to demonstrate competency in sterile catheter technique. Thiscompetency requirement was put in place in the operating room, the emergency department, and the neuro ICU.Finally, patients were given printed education material toeducate them on the necessity of in-and-out catheterization and bladder scanning for urinary retention.Continued Process Review*0 %3B%0 ".0,' %3%' 13, ' "6 -%6%0 %&' "0' L% %6D%3'2008. However the interdisciplinary neuro ICU infection control team continued to meet monthly with UTIinfections discussed as a standing agenda item. A unitbased “drill down” was performed for each UTI with aroot cause analysis predominantly focusing on protocoladherence and barriers to implementation (Appendix 4).F.66.0' %6%,' %3%'"&%0 "1%&'#0&'D3.4/ 'D#!E' .' %'committee for policy changes. Also, as the formal recommendations from the Institute for HealthCare Improvement and American Practitioners in Infection Controlwere developed, additional recommendations were incorporated into our existing UTI prevention bundle.Data CollectionCatheter days were determined manually by charge043,%,'&43"0/' %"3'#!4" 2'!-#,,"1!# ".0'.5' # "%0 ,'#0&' .taled in the WinPFS system (Medicus). The total numberof patient hospital days was provided electronically byShands Hospital at University of Florida Decision Support Services. The number of catheter-associated UTIswere tracked by Infection Control and reported back tothe neuro ICU team as well as the individual departmentsmonthly. Clinical Nurse Leaders rounded on each patientdaily in the neuro ICU (Foley Rounds). They recorded theindication for each catheter placed and compliance withthe UTI bundle and tracked whether recommendationsfor removal were followed by physicians. Informationwas collected daily and analyzed quarterly.Statistical AnalysisCategorical data are presented as absolute values and %3!%0 #/%,9'L"/0"1!#0 '! #0/%,'"0'()*'3# %'#0&'!# % %3'utilization rate were determined by linear regression withthe rate as the response variable and time as the independent variable. Pearson product moment correlation wasJ Neurosurg / Volume 116 / April 2012

Catheter-associated UTIs in the neuro ICUFIG. 1. Flow chart showing the daily process for review of indwelling urinary catheters. Each patient in the neuro ICU wasevaluated daily for both the presence of a urinary catheter and necessity of said catheter. First, catheter placement was reviewedby both unit nurses and by Clinical Nurse Leaders on Foley Rounds. Recommendations for removal were based on cathetersnot meeting 1 of the 5 previously specified indications. Requests for removal were then presented to an attending physicianwho either provided a clarification of catheter necessity or removed the catheter. If urine management was still necessary, thenalternative methods were pursued. I/O Cath in and out catheterization.used to assess the correlation between quarterly catheterutilization, the rate of catheter-associated UTI, and pressure ulcer incidence. A p value 0.05 was considered sta ", "!#--2',"/0"1!#0 9:'*.3%*In November 2007 the national average for catheterassociated UTI among neuro ICUs was 6.8%.10 Preintervention data, totaling more than 1200 catheter days,showed that the UTI rate at Shands Hospital at the University of Florida was 13.8% in all ICUs and 13.3% within the neuro ICU. It was also discovered that no universalstandard of practice existed in either antiseptic insertionor maintenance of urinary catheters. As has been shownin other studies, placement of most catheters occurred inthe emergency department or operating rooms. In our institution, catheters in these locations were supplied by different vendors. A patient who had clinical needs such asa catheter with a temperature probe might not have been"&%0 "1%&'#,',4! ' %0' %'43"0#32'!# % %3' #,'"0" "#--2'J Neurosurg / Volume 116 / April 2012placed; therefore a catheter placed in the emergency department was not compatible with the collection systemin the neuro ICU. This resulted in open and noncompatible collection systems. While closed systems were available in certain areas, only 2 sizes were stocked. Productstandardization to increase the availability of the rightproducts and to maintain the integrity of a closed cathetersystem was a key part of the UTI prevention bundle.Decreased Utilization of Urinary CathetersFor the intervention period of August 2008 throughDecember 2010, the mean number of catheters per dayin the 30-bed neuro ICU decreased from 25.8 to 18.5(Fig. 2A). Likewise at the initiation of the study, virtually 100% of patients had urinary catheters in the neuroICU (Fig. 2B). It should be noted that since charge nursescounted the number of catheters per room, if 2 patientswith a urinary catheter inhabit the same room in 1 day(during transition), then 2 catheters were recorded forthat room. This explains the greater than 100% utilization present in Fig. 2B and presents the distinct possibil915

W. L. Titsworth et al.FIG. 2. Graphs showing reductions in urinary catheter utilization and catheter associated UTI over time (months). Note that inall graphs, the time zero corresponds to October 2008. A: Average number of urinary catheters per day present in the 30 bedneuro ICU per quarter. B: The rate of urinary catheter utilization measured as a percentage of ICU patient beds, both 9 monthsprior to intervention and 30 months postintervention. C: Decrease in the total number of UTIs during the same period. Thisdecrease correlates strongly with the UTI rate because the number of patients in the neuro ICU remained relatively constantthrough the study period. Note that the total numbers of UTIs during the preintervention 1 month study periods were normalizedto reflect a quarterly amount. D: Catheter associated UTI (CAUTI) rate tracked through the same time period. Note that theCAUTI rate fell prior to official implementation of the UTI bundle. Lines in panels B and D are the 25th, 50th, and 75th quartilesfrom the NHSN.ity that utilization rates could be even lower. Six monthsafter initiation of the UTI prevention bundle, the utiliza ".0'3# %' #&'5#--%0',"/0"1!#0 -2' .'XQY'#0&'!.0 "04%&' .'fall to 75% at 15 months, and an absolute low of 73.3%,following the initiation of Foley Rounds (r2 0.794, p 0.0001; Fig. 2A and B). This was below the NHSN catheter utilization benchmarks of 88%, 82%, and 77% for the75th, 50th, and 25th quartiles, respectively.10 After the 6months of Foley Rounds were completed, this utilizationrate remained stable, likely indicating a culture change.Currently, Clinical Nurse Leaders perform UTI prevention bundle/Foley Rounds twice weekly and periodicallyremind the critical care medicine team of indications asnecessary, but no ongoing evaluation is performed outside of tracking UTI and catheter days.It was anticipated that compliance with the UTI prevention bundle would be challenging prior to initiation.However during the 6 months in which Foley Rounds oc916curred daily, the monthly compliance with the UTI bundleranged from 96% to 100%. Previous studies have shownthat only 46% of patients who undergo catheterizationhave a correct indication and only 13% of patients whoundergo catheterization have a documented reason forplacement.13 A chart review of neuro ICU patients priorto the intervention showed that less than 15% of patientshad a documented indication for catheter insertion. Afterintervention this number steadily increased with the implementation of the Surgical Care Improvement Processmeasure that mandated the requirement for documentation. If documentation was lacking, the indication waslisted in the subsequent progress notes. The indicationsfor catheter placement during the study period are shownin Table 2. There tended to be little month-to-month variability of these indications. The number of catheters recommended for removal by the Clinical Nurse Leadersduring Foley Rounds varied greatly between 6% and 32%J Neurosurg / Volume 116 / April 2012

Catheter-associated UTIs in the neuro ICUTABLE 2: Indications for urinary catheterization in the neuro ICUIndicationPercentagestrict “in & out”polyuria or oliguriahemodynamic instabilityinvasive procedureshyper or hyponatremiaStage III or IV pressure ulcers*urinary obstructioncomfort during end of lifeunstable spine requiring immobility3919946542* According to National Pressure Ulcer Advisory Panel standards.of catheters present on the 30-bed unit. Of these recommendations, physicians complied with removal 81.6% ofthe time. In the remaining cases, physicians provided additional documentation to clarify the indication.Decreased UTI Rate and Total Number of UTIsNot surprisingly both the total number of UTIs as well#,' %'()*'3# %'&%!3%#,%&',"/0"1!#0 -2'5.--. "0/' %'"0 %3vention (r2 0.695, p 0.001). The total number of UTIsper quarter in the neuro ICU fell from a high of 32 to 7infections per quarter over a 40-month period (Fig. 2C).Similarly UTI rates fell from a preintervention high of 13.3infections per 1000 catheter days to a current and sustainedlow of approximately 4 infections per 1000 catheter days(Fig. 2D). This compares quite favorably to the NHSNbenchmarks of 9.0, 7.3, and 4.4 infections per 1000 catheter days for the 75th, 50th, and 25th quart

NHSN data from 2006 to 2007, catheter-associated UTI rates ranged from 3.1 infections per 1000 catheter days in medical/surgical ICUs to 7.7 in burn ICUs and 6.8 in neuro ICUs.10 Rates on general care wards actually tend to be higher, ranging from 4.7 infections per 1000 catheter days in adult stepdown units to 16.8 infections in rehabilitation