Business Accent

Tackling Catheter Related UTIs

The incidence of UTI was reduced to zero for a four-month period

The problem of Catheter-Related Urinary Tract Infections, known as CR-UTI, is one of the most serious hospital acquired infections that is challenging to prevent and treat. We at Fortis hospital Mohali (FHM) decided to attack this problem, and the extent of the problem, as well as the strategies we used, are outlined in this article. We feel that these strategies can be used efficaciously in any modern tertiary care hospital. The NHS of England says that there are 1,00,000 such infections in the United Kingdom every year, and these result in 5,000 deaths every year. This could result in an expense of one billion pounds to the exchequer! This is not only a huge public concern, it also raises issues of how hospitals can manage this and how healthcare workers can handle this problem. The accountability of hospitals comes under the scanner. It has received a lot of attention in the print media abroad, and sporadic cases are reported in the Indian press.

Facts

The most important to note is that CR-UTI is preventable. About 40 per cent of patients in a tertiary care hospital would have an indwelling catheter draining their urine. About 2.5 per cent of patients who have a catheter tend to develop a UTI, and this would increase the length of stay by at least five or six days, if not more. Many cases can end-up with life-threatening septicemias. As far as hospital acquired infections are concerned, about 45 per cent are UTIs, Surgical Site Infections (SSIs) account for another 29 per cent, Ventilator Associated Pneumonias (VAPs) account for about 19 per cent, while blood stream infections cause three per cent and others account for the remaining six per cent. As far as UTIs are concerned, patients who are elderly, diabetic, on catheters for a prolonged time, or are immuno-compromised (like patients getting immuno-suppressants) are more prone to succumbing to it. In the foreseeable future, hospitals may have to pay for Hospital Acquired Infections (HAIs). There are some common errors of omission which cause UTI and these are—no hand hygiene, improper glove usage, improper technique and violation of no touch technique, no single use jelly, catheter not secured properly, lack of local toileting, and unclear protocols. Some common errors of commission are: unnecessary catheterisation, inappropriate catheter size, improper balloon inflation, and frequency in changing the catheter.

The 4s

Experience shows that there are four main sites of entry for the infections, and careful and scrupulous attention to these can actually prevent UTIs. These four main points are:

lJunction between urethral meatus and catheter. lConnection between catheter and drainage tube. lConnection between drainage tube and collecting bag (Urobag). lThe tap outlet of drainage bag.

One

Catheters should only be introduced when the bladder is full, for a washout effect. The meatus area should be thoroughly cleaned with an antiseptic solution like Betadine before introduction of catheter. Single use Lignocaine jelly should be used. The peri-urethral area should be kept clean and dry, and the catheter should be properly secured.

Two

In case of faecal contamination, the catheter should be changed. The catheter should not be disconnected from the drainage tube unless absolutely necessary and culture samples should be collected by clamping the catheter proximal to junction, wiping area with spirit swab, and aspirating urine with a sterile needle and syringe. Irrigation should be avoided as much as possible, and if necessary, all sterile precautions to be observed during irrigation.

Three

Reflux of urine from bag to catheter should be avoided- by keeping the bag below level of bladder at all times, emptying of bag to be done carefully every eight hour or when full, and not holding bag upside down.

Four

The collection bags (Urobags) must never touch the floor. When the urine is emptied into the collection jug, hand hygiene protocols to be followed. The collection jug should be emptied, washed, dried and disinfected before every use. A clean jug should be used for each collection. All attempts should be made to remove the catheters as early as possible, and doctors can be reminded by the nurses as often as possible.

The Fortis Approach

At Fortis Hospital, Mohali, we used the DMAIC method of surveillance: Define, Measure, Analyse, Improve and Control. This involved defining what outcomes to measure, ensuring that everyone involved was aware about the outcomes, reliably collecting the data in a standardised manner, analysing the data for comparison, and using the data in a timely manner to improve quality of outcome.

A healthcare associated UTI is considered to be catheter associated if certain critieria are met: an indwelling catheter is in situ at the time of diagnosing UTI, or an indwelling catheter was removed within three-days prior to the onset of UTI and the first positive urine specimen is taken or the physician makes a diagnosis more than 48-hours after the catheter was inserted.

All patients who have had catheters inserted in the emergency room or operation theatres or ICUs are included. However, all patients who come into the hospital with catheters which have already been inserted are excluded from the study. For all patients who are included in the study, data is collected from wards about catheterisation, and also evidence of infection is collected from charts and culture reports. We were able to collect data from the different critical care areas or units of our hospital, and we plotted this on graphs to show the trends. We found out that one particular ICU had a high incidence of UTI. It was decided to take certain steps to bring this down, or completely eradicate it.

The Strategy

Practices were monitored, certain observations were made, and a team under the stewardship of sister-in-charge of that ICU was constituted. Education sessions were held with entire staff of the unit. Changes were made in practices, and these were documented and accounted for. These changes have been mentioned in the preceding paragraphs.

As a result, the incidence of UTI was reduced from zero for a four month period. The staff was felicitated, they were publicly rewarded, and motivational levels went up considerably. However, over a period of time, UTIs started again. This only emphasises the need for constant efforts and re-dedication to the cause of stamping out HAI. The ward leadership has to be motivated— they must know what has to be done, and ensure that all staff from the nurse to the cleaning staff (including the doctors) know what their role is.

In conclusion, HAI are here to stay, and hospitals all over the world are battling this scourge. Although there are many battles to be fought, there are definite strategies available, which have been tested over time and are known to work. The main problem is keeping the staff motivated, and ensuring that every single healthcare worker knows what to do. A lot of motivation is required, and constant reinforcement is a must. One can never pay enough attention to these issues.

ashish.banerji@fortishealthcare.com
The writer is Director Fortis Hospital, Mohali