The effectiveness of different methods to prevent catheter-related urinary tract infection


 


 


Contents


 


Abstract                                                                                                                      4


Introduction                                                                                                               5


Preliminary Literature Review                                                                               6


Ethical considerations                                                                                         10


Methodology                                                                                                          10


Method                                                                                                                    14


Results                                                                                                                   18


Analysis                                                                                                                  23


Discussion                                                                                                             26


Limitations                                                                                                             27


Conclusion                                                                                                            28


Recommendations                                                                                               30


 


 


 


Acknowledgements


            First of all I would like to thank the almighty God for giving me good health and perseverance to be able to carry out this project. It has not been easy locating sources for this project, but I was able to go through it all. I would also like to thank my family and friends who have been there to support me, emotionally and financially, all throughout my project. Lastly, I would like to thank my professors who were very willing to share with me their knowledge for the good of this project.


 


  


Abstract


The aim of this paper is to examine different literature regarding the effectiveness of different methods to prevent catheter-related urinary tract infection. It also aims to provide recommendations after researching into the current conditions and infection control procedures. An extensive review of related literature and materials are used for this project. The papers critiqued for this project are researched from web databases such as Questia and Highbeam which both offer academic books and journals relevant for the project. Aside from that, books and opinions from professors are used for this project. The results of the project show that there are many ways by which hospitals and healthcare professionals perform catheter insertion and care. Incidence of catheter-associated urinary tract infections is also quite common in many healthcare settings. This has prompted the author to come up with the discussion that there are many reasons for this, including and most especially the lack of further education and training of many health care professionals. The success of the effectiveness of preventing and reducing catheter associated urinary tract infections depends largely on the healthcare professionals. Another hope for major reduction in catheter associated infections and indeed all nosocomial infections is likely to be vaccines.


 


 


 


 


Introduction


             As a health care professional, I have been witness to many health complications, most especially those that occur within my area of practice. I work as a nurse in the intensive care unit (ICU) of the hospital. ICUs are the place in the hospital where the most severely ill patients are admitted, with the use of multiple invasive devices and frequent prescription of broad-spectrum antimicrobial agents. Intensive care units (ICUs) are the place in the hospital where the most severely ill patients are admitted, with the use of multiple invasive devices and frequent prescription of broad-spectrum antimicrobial agents. For these reasons, optimization of nursing-care procedures and adherence to antibiotic prescription rules are strongly recommended for the control of nosocomial infections.


             Nosocomial infections are hospital-born infections and now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to intensive care units (2004). Infection after the procedure of urinary catheterization is one example of frequently occurring nosocomial infections. In many health care settings, catheters were placed by resident or staff physicians using aseptic technique. However, it cannot be denied that there are times when even when every possible care is being used, infections can still occur.    


For these reasons, optimization of nursing-care procedures and adherence to antibiotic prescription rules are strongly recommended for the control of nosocomial infections. Most patients in these units require an indwelling urinary catheter to monitor diuresis. A closed drainage system is strongly recommended to prevent catheter-associated urinary tract infections. However, to our knowledge, no comparative trial comparing open and closed drainage systems has been conducted in ICU patients.


This paper aims to examine the current practices of ICUs in hospitals in the procedure of catheterization and the role of the nurses. This will be done mostly through research and critique using literature relevant to the topic. This paper also aims to provide recommendations after researching into the current conditions and infection control procedures.


 


Preliminary Literature Review


            Good health depends in part on a safe environment. Practices or techniques that control or prevent transmission of infection help to protect individuals, especially patients and health care workers from disease. Patients in all health care settings are at risk for acquiring infections because of lower resistance to infectious microorganisms, increased exposure to numbers and types of disease-causing microorganisms, and invasive procedures.


            In acute care or ambulatory care facilities, patients can be exposed to pathogens, some of which may be resistant to most antibiotics. By practicing infection prevention and control techniques, health care workers can avoid spreading microorganisms to patients and fellow health care workers. In all settings, the patients and their families must be able to recognize source of infections and be able to institute protective measures. Patient teaching should include information concerning infections, modes of transmission, and methods of prevention.


             Nosocomial infections (NIs) are hospital-born infections and now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to intensive care units (ICUs) (2004). Infection after urinary catheterization is one example.


Each year, urinary catheters are inserted in more than 5 million patients in acute-care hospitals and extended-care facilities. Urinary tract infections are the second most common nosocomial infections in ICUs in Europe and the first in the United States (2001). Catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection in hospitals and nursing homes, comprising [is greater than] 40% of all institutionally acquired infections. Nosocomial bacteriuria or candiduria develops in up to 25% of patients requiring a urinary catheter for [is greater than or equal to] 7 days, with a daily risk of 5%. Catheter-associated urinary tract infection is the second most common cause of nosocomial bloodstream infection, and studies by Platt et al. and Kunin et al. suggest that nosocomial catheter-associated urinary tract infection are associated with substantially increased institutional death rates, unrelated to the occurrence of urosepsis (2001).


For centuries, the urethral catheter system consisted of a tube inserted through the urethra into the bladder and drained into an open container. The closed catheter system was developed in the 1950s and is still in use today (2000).


Urinary tract infections are the most common nosocomial infection, accounting for 40% of all hospital-reported infections and affecting approximately 600,000 patients annually. Catheter insertion is the primary risk factor for nosocomial urinary tract infections. Women and elderly patients are at increased risk for catheter-associated urinary tract infections, but several other risk factors exist. Pre-existing chronic illness, malnutrition, diabetes, renal insufficiency, and insertion of the catheter outside the operating room or late in hospitalization are each associated with increased risk of urinary tract infections. (1,3) In addition to causing morbidity, urinary tract infections also contribute directly to mortality in approximately 0.1% of patients annually in the United States. Urinary tract infections also add to the costs of care by prolonging hospitalization by 1 to 4 days and increasing the direct costs of treatment by an estimated 3 to 0 per infection ( 2005).


They may involve a urosepsis, which carries a mortality rate that may be as high as 25 to 60%. They often occur in patients with an indwelling urinary catheter. The lumen and external surfaces of the catheter are the routes for bacterial entry into the bladder. For preventing infection, the maintenance of a closed sterile drainage system is described as the most successful method. A closed drainage system was described for the first time in 1928, and its benefit was appreciated much later (2001).


Although most catheter-associated urinary tract infections are asymptomatic, rarely extend hospitalization, and add only 0 to ,000 to the direct costs of acute-care hospitalization, asymptomatic infections commonly precipitate unnecessary antimicrobial-drug therapy. Catheter-associated urinary tract infections comprise perhaps the largest institutional reservoir of nosocomial antibiotic-resistant pathogens, the most important of which are multidrug-resistant Enterobacteriacae other than Escherichia coli, such as Klebsiella, Enterobacter, Proteus, and Citrobacter; Pseudomonas aeruginosa; enterococci and staphylococci; and Candida spp (2001).


Excluding rare hematogenously derived pyelonephritis, caused almost exclusively by Staphylococcus aureus, most microorganisms causing endemic catheter-associated urinary tract infections derive from the patient’s own colonic and perineal flora or from the hands of health-care personnel during catheter insertion or manipulation of the collection system. Organisms gain access in one of two ways. Extraluminal contamination may occur early, by direct inoculation when the catheter is inserted, or later, by organisms ascending from the perineum by capillary action in the thin mucous film contiguous to the external catheter surface. Intraluminal contamination occurs by reflux of microorganisms gaining access to the catheter lumen from failure of closed drainage or contamination of urine in the collection bag (2001).


 


Ethical Considerations             In all countries, research works that involve human subjects and animals should be carried out in accordance with high ethical standards set by various ethics committee. The privacy and dignity of every individual involved in the research was protected. The participants in this study will be assured confidentiality and anonymity through identification coding and reports of aggregate data. The participants that will be involved will be notified of the aims, methods, expected outcome, benefits and potential hazards of the study conducted. Ethics committee approval is not required.

 


Methodology


The methodology rests on two parts since for one this project would like to find out the effectiveness of different methods to prevent catheter-related urinary tract infection within my area of practice in relation to other sites near the area where I work. Other than that, literature in the form of journals will be used for critique and comparison with the effectiveness of the methods sued for prevention of catheter-related urinary tract infections.


As the project had a short timeframe, a decision was taken with the advisory panel that four to six sites would provide sufficient patient numbers to allow improvement in practice to be detected between audits of certain healthcare systems near the area. Sites were included if they provided care to groups that need catheterization and considered to have a higher risk of catheter-associated urinary tract infection. As this was an audit project, ethics committee approval will not be required, however, confirmation of this will be sought and obtained from all hospital sites involved in the project.


            The audit criterion is that a practitioner with ‘appropriate and adequate training’ should undertake the initial risk assessment and document findings. For audit purposes, the grade of the nurse or health care professional will be recorded.


 


Dissemination and implementation strategy


The dissemination and implementation strategy was informed by evidence and reflected the advice of site link nurses and staff from the clinical areas on possible barriers to change. This ensured the strategy reflected best evidence to bring about change, and encouraged local ownership of the guideline. Dissemination comprised the identification of a nurse from each clinical area who could support clinical staff involved in the project and assist with the audits; circulating copies of the project proposal, quarterly newsletters and summaries of the guideline recommendations to all relevant staff.


 


Implementation


Implementation focused on the development of an evidence-based resource by the project team and provision of education sessions by the project manager. A resource pack was given to each senior member of staff in the clinical area to be audited, the site link nurses and directors of nursing, and included an implementation guide and copies of the audit tools.


            The project manager shall lead education sessions at each site, with the assistance of the site link nurse, following audit 1. The sessions were to be attended by nursing staff from the clinical areas to be audited, senior nurses and/or ward managers. The sessions focused on a description of evidence-based practice and clinical guideline development; the development and recommendations of the RCN guideline; an outline of the project; site specific feedback and recommendations for practice from audit 1.


            To ensure standardization of pressure ulcer grading for the audit, the EPUAP tool was used by the project team (Stephens, 2003). Reduction in prevalence of catheter-associated urinary tract infection in the long term is not a study outcome due to the time constraints and need to take account of potential contributory factors. Nevertheless, it is considered important to assess prevalence to enable audit findings to be more generalizable. Each site will be asked to identify clinical areas that met inclusion criteria and arrange dates for the project manager to undertake audit 1. Audit 2 will commence at each site five to six months later.


           


Development of Audit Tools


            Two audit tools will be developed; one for the patient and one for the clinical area. The tools are developed using recommendations for audit criteria proposed by (1995), which included the following:



  • Criteria should be based on evidence where possible.

  • Criteria should be prioritized according to the strength of the evidence and effect on patient outcome.

  • Criteria should be measurable and appropriate to the clinical setting.


 


Audit criteria will then be derived from the guideline. This will be followed with a consultation with the advisory panel where and agreement will take place on what the audit would comprise.


 


Measuring and comparing


            On the first audit and data analysis, to be included are all patients admitted to the hospital with no skin breakdown during a six-month period, but are at risk for pressure ulcer development. The nurse will collect the data, using the audit tool. The information sources are patients’ records, interviews with patients and/or patients’ families, and nurses.


This is form of research requires patient age range and mean to be computed both in the first and second audit. Pressure ulcer risk was elicited using clinical assessment and a tool to obtain a risk assessment score. Risk assessment scores for each patient were verified by the auditors ( 2003).


            Data from audit 2 will then be compared with audit 1. Data will be coded and entered onto an Excel spreadsheet, and results collated in an anonymised form using simple descriptive statistics to enable comparative analysis to be undertaken. Each site will then receive feedback comparing results from both audits by clinical area in an anonymised form.


 


Taking action to improve


            An intervention program will be prepared and implemented based on the results of the project. The program will be prepared as an addition to the basic health care practice that is common for patients who need catheters and other patients at risk for urinary tract infections due to catheter use.


 


Method


            The Critical Appraisal Skills Programme (CASP) was used to make sense of evidence gathered mostly from journals. This assessment tool has been developed for those who are not familiar with qualitative research and its theoretical perspective. This tool represents number of questions that basically deal broadly with some of the principles or assumptions that characterize qualitative research. It is not a definitive guide and more reading is recommended.


            The CASP should be used in consideration with the following issues:



  • Rigour – has a thorough and appropriate approach been applied to key research methods in the study?

  • Credibility – are the findings well presented and meaningful?

  • Relevance – how useful are the findings to you and your organization?


 


Screening questions can also be used. The following screening questions are used:


  • Was there a clear statement of the aims of the research?

  • Consider:


    -       what the goal of the research was


    -       why it is important


    -       its relevance


     


  • Is a qualitative methodology appropriate?

  • Consider:


    -       is the research seeks to interpret or illuminate the actions and/or subjective experiences of research participants.


     


  • Was the research design appropriate to address the aims of the research?

  • Consider:


    -       if the researcher has justified the research design


     


  • Was the recruitment strategy appropriate to the aims of the research?

  • Consider:


    -       if the researcher has explained how the participants were selected


    -       if they explained why the participants they selected were the most appropriate to provide access to the type of knowledge sought by the study


    -       if there are any discussions around recruitment


     


  • Were the data collected in a way that addressed the research issue?

  • Consider:


    -       if the setting for data collection was justified


    -       if it is clear how data were collected


    -       is the researcher has justified the methods chosen


    -       if the research has made the methods explicit


    -       if methods were modified during the study. If so, has the researcher explained why?


    -       if the form of data is clear


    -       if the researcher has discussed saturation of data


     


  • Has the relationship between researcher and participants been adequately considered?

  • Consider whether it is clear:


    -       if the researcher critically examined their own role, potential bias and influence during:


    - formulation of research questions


    - data collection, including sample recruitment and choice of location


    - how the researcher responded to events during the study and whether they considered the implications of any changes in the research design


     


  • Have ethical issues been taken into consideration?

  • Consider:


    -       if there are sufficient details of how research was explained to participants for the reader to assess whether ethical standards were maintained


    -       if the researcher has discussed issues raised by the study


    -       if approval has been sought from the ethics committee


     


  • Was the data analysis sufficiently rigorous?

  • Consider:


    -       if there is an in-depth description of the analysis process


    -       if thematic analysis is used. If so, is it clear how the categories or themes were derived from the data?


    -       Whether the researcher explains how the data presented were selected from the original sample to demonstrate the analysis process


    -       If sufficient data are presented to support the findings


    -       To what extent contradictory data are taken into account


    -       Whether the researcher critically examined their own role, potential bias and influence during analysis and selection of data for presentation


     


  • Is there clear statement of findings?

  • Consider:


    -       if the findings are explicit


    -       if there is adequate discussion of the evidence both for and against the researcher’s arguments


    -        if the researcher has discussed the credibility of their findings


    -       if the findings are discussed in relation to the original research questions


     


  • How valuable is the research?

  • Consider:


    -       if the researcher discusses the contribution the study makes to existing knowledge or understanding


    -       if they identify new areas where research is necessary


    -       if the researchers have discussed whether or now the findings can be transferred to other populations or considered other ways the research may be used.


     


    Results


    Build up of secretions or encrustation at the catheter insertion site is a source of irritation and potential infection. The nurses, in order to avoid such a situation, must provide perineal care and hygiene at least twice daily or as needed for a patient with a retention catheter. Soap and water are effective in reducing the number of organisms around the urethra. The nurse must not accidentally advance the catheter up into the bladder during cleansing or risk introducing bacteria.


    Catheterization of the bladder involves introducing a rubber or plastic tube through the urethra and into the bladder. The catheter provides a continuous flow of urine in patients who are unable to control micturition or those with obstructions. It also provides a means of assessing urine output in hemodynamically unstable clients. Because bladder catheterization carries the risk of urinary tract infections, blockage, and trauma to the urethra, it is preferable to rely on other measures for either specimen collection or management of incontinence (2004).


                The use of urinary catheters should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long- term catheterization. Suprapubic catheters offer some advantages, and condom catheters may be appropriate for some men. While clean handling of catheters is important, routine perineal cleaning and catheter irrigation or changing are ineffective in eliminating bacteriuria (2004).


    Bacteriuria is inevitable in patients requiring long-term catheterization, but only symptomatic infections should be treated. Infections are usually polymicrobial, and seriously ill patients require therapy with two antibiotics. Patients with spinal cord injuries and those using catheters for more than 10 years are at greater risk of bladder cancer and renal complications; periodic renal scans, urine cytology and cystoscopy may be indicated in these patients (2000).


    For centuries, the urethral catheter system consisted of a tube inserted through the urethra into the bladder and drained into an open container. The closed catheter system was developed in the 1950s and is still in use today (2000). Even if this device has been used for many years, incidence of infection related to the use of urinary catheters is still prevalent.


    Every year, urinary catheters are used in more than 5 million patients in extended-care facilities and acute-care hospitals. Urinary tract infections are the second most common nosocomial infections in ICUs in Europe and the first in the United States (2001). Catheter-associated urinary tract infection (CAUTI) is the most common infection in acquired in hospitals and nursing homes, which comprises more than 40% of all hospital and other healthcare-institution acquired infections (2001).


    Nosocomial bacteriuria or candiduria develops in almost one fourth of patients that require a urinary catheter for more than a week, with a daily risk of just 5%. This infection is also the second most common cause of hospital-acquired bloodstream infection, and studies by and suggest that there is an association between nosocomial CAUTIs with substantially increased institutional death rates, without any relation to the occurrence of urosepsis (2001).


    Catheter insertion is the primary risk factor for nosocomial urinary tract infections. Urinary tract infections are the most common nosocomial infection, accounting for 40% of all hospital-reported infections and affecting approximately 600,000 patients annually. Women and elderly patients are at increased risk for catheter-associated urinary tract infections, but several other risk factors exist. Pre-existing chronic illness, malnutrition, diabetes, renal insufficiency, and insertion of the catheter outside the operating room or late in hospitalization are each associated with increased risk of urinary tract infections.


    In addition to causing morbidity, urinary tract infections also contribute directly to mortality in approximately 0.1% of patients annually in the United States. Urinary tract infections also add to the costs of care by prolonging hospitalization by 1 to 4 days and increasing the direct costs of treatment by an estimated 3 to 0 per infection (2005).


    The whole process of infection from urinary catheters may involve a urosepsis, which carries a mortality rate that may be as high as 25 to 60%. They often occur in patients with an indwelling urinary catheter. The lumen and external surfaces of the catheter are the routes for bacterial entry into the bladder ( 2001).


    Even if most catheter-associated urinary tract infections occur without any symptoms rarely requiring extended hospitalization, and add only 3 to 0 per infection to the direct costs of acute-care hospitalization, asymptomatic infections such as this one commonly trigger unnecessary antimicrobial-drug therapy. Catheter-associated urinary tract infections make up perhaps the biggest institutional reservoir of nosocomial pathogens that are resistant to antibiotics, the most important of which are multidrug-resistant Enterobacteriacae other than Escherichia coli, such as Proteus, Enterobacter, Klebsiella, and Citrobacter; enterococci and staphylococci; Pseudomonas aeruginosa; and Candida spp (2001).


    Not including the rare hematogenously derived pyelonephritis which is caused almost exclusively by Staphylococcus aureus, most microorganisms which cause endemic catheter-associated urinary tract infections usually come from the patient’s own perineal and colonic flora or from the hands of the health-care personnel taking care of the patient during catheter insertion or manipulation of the collection system. Organisms can gain access in one of two possible ways. The first is extraluminal contamination which may occur early, by direct introduction when the catheter is inserted, or later, by organisms rising up from the perineum by capillary action in the thin mucous film found on the external catheter surface. The other way is by intraluminal contamination which occurs by reflux of the microorganisms which gain access to the lumen of the catheter from contamination of urine in the collection bag or a failure of closed drainage (2001)


    There are believed to be four pathogenic mechanisms that can lead to CC: the catheter can become contaminated during the insertion process; (2) the infusion fluid or connecting tubing can become Contaminated; (3) once the catheter is in place, skin flora can migrate along the subcutaneous catheter tract; or (4) blood-borne organisms can originate from a distant infected site and adhere to the IV portion of the catheter. Migration of skin flora down the transcutaneous tract is by far the most common cause of colonization, and these bacteria then can gain access to the blood. For example, one study used molecular subtyping to show an 80% concordance of colonized Swan-Ganz catheters and organisms cultured from the skin of the insertion site. The goal of the clinician is to minimize those conditions that can lead to colonization and subsequent bloodstream infection (1999).


     


    Analysis


    The development of catheters with surfaces that are anti-infective is perhaps the first major advance for preventing catheter associated urinary tract infections since the wide-scale adoption of closed drainage more than three decades ago. However, such developments should not be considered the ultimate answer. There are other technologies that should be further investigated such as new, more potent antiinfective materials; urethral stents; conformable (collapsible) urethral catheters; microbe-impervious antireflux valves; and vaccines for enteric gram-negative bacilli and staphylococci. Antiseptics are more able to confer greater resistance to surface colonization and avoid for infection with antimicrobial-drug resistant yeasts or bacteria than antibacterials. Catheter-associated urinary tract infections caused by intraluminal contaminants may be prevented by new surface technologies which release far more quantities of ionic silver or any other antiinfective agents into the aqueous environment contiguous to the catheter surface (2001).


                In my area of practice, there is also a prevalence of nosocomial infections related to catheter associated infections. Although health care professionals in our area of practice did our best to prevent the spread of nosocomial infections, there are still a few cases which occur in our hospital. Perhaps, a few recommendations could be followed in order to avoid the spread of nosocomial infections in our environment, particularly catheter associated infections.


    In addition to routine perineal care and hygiene, many institutions recommend that clients with catheters receive special care at least three times a day and after defecation or bowel incontinence to help minimize discomfort and infection.


                All patients with catheter should have a daily fluid intake of 2000 to 2500 ml if permitted. This can be met through oral intake or intravenous infusion. A high fluid intake produces a large volume of urine that flushes the bladder and keeps catheter tubing free of sediment.


                Maintaining a closed urinary drainage system is important in infection control. A break in the system can lead to introduction of microorganisms. Sites at risk are the site of catheter insertion, the drainage bag, the spigot, the tube junction, and the junction of the tube and the bag.


                In addition, the nurse has the responsibility to monitor the patency of the system to prevent pooling of urine within the tubing. Urine in the drainage bag is an excellent medium for microorganism growth. Bacteria can travel up drainage tubing to grow in pools of urine. If this urine flows back to the patient’s bladder, an infection will likely develop.


                Suggestions for ways to prevent infections in catheterized patients are the following:



    • Follow good hand hygiene techniques.

    • Do not allow the spigot on the drainage system to touch a contaminated surface.

    • Only use sterile technique to collect specimens from a closed drainage system.

    • If the drainage tube becomes disconnected, do not touch the ends of the catheter or tubing. Wipe the end of the tubing and catheter with an antimicrobial solution before reconnecting.

    • Ensure that each client has a separate receptacle for measuring urine to prevent cross contamination.

    • Prevent pooling of urine in the tubing and reflux of urine into the bladder.

    • Avoid raising the drainage bag above the level of the bladder.

    • If it becomes necessary to raise the bag during transfer of a patient to a bed or stretcher, clamp the tubing or empty the tubing contents to the drainage bag first.

    • Provide for drainage of urine from the tubing to the bag by positioning the tubing.

    • Empty the drainage bag at least every 8 hours. If large outputs are noted, empty more frequently.

    • Encourage fluid intake, if it is not contraindicated. Inclusion of cranberry juice has been shown to decrease the adherence of bacteria to the bladder wall and to catheter lumen.

    • Remove the catheter as soon as clinically warranted.

    • Tape or secure the catheter appropriately for the patient.

    • Perform routine perineal hygiene per agency policy and after defecation r bowel incontinence.


     


    Discussion


               


    Strengths (internal)


    Weaknesses (internal)


    Competent staff


    Good clinical facilities


    Lack of education on catheter use and care


    Opportunities (external)


    Threats (external)


    Health authority support


    Staff support


    Shortage of staff


     


                The SWOT analysis table shows that although many hospitals are equipped with competent staff, there is still an increase in infection in relation to the use of catheters. This could be since majority of the healthcare and nursing staff are unaware of the recommended practice regarding the use of catheter resulting to unsafe practice. Good clinical facilities for the catheter use procedure are also present in my place of employment.


                Coming up with recommendations and implementing them at the place of employment is the most logical thing to do. An improvement for catheter care and a decrease in catheter-associated urinary tract infection incidence is expected as health authorities and the staff supports the programs that are designed for improvement of healthcare and nursing services and quality of patient care.


                 There are many areas worldwide wherein the healthcare profession is challenged by the shortage of healthcare professionals. This presents a threat to many areas of healthcare, especially in nursing practice. Not only that, this is a threat to patient care. If there is a decrease in the number of healthcare and nursing staff that are competent enough to handle catheter insertion and care, the problem regarding the increase in catheter-associated urinary tract infection would not be solved.


    It seems also that in some healthcare systems, there is also an apparent poor quality of management and leadership in this case resulting to the poor quality of service. To improve quality, organizations have to apply ‘Total Quality Management’ (TQM) to their organizations to help them plan their efforts. The promise of superior performance through continuous quality improvement has attracted a wide spectrum of business to TQM, with applications reported in many domains including healthcare (2002).


     


    Limitations


    Limitations of a study could include the sample size, the research design or methodology used. If researchers discuss these limitations it makes the study more credible as it demonstrates to readers that the researchers were aware of these limitations and took them in account when interpreting the data.


    For this project, the limitations include the fact that this project is done on a very short period of time and thus it is impossible for the researcher to be able to gather as much information that is reflective of the entire population. It is possible that the results of the findings of the literature review are not true for all populations and thus is limiting the validity of the study.


     


    Conclusion


    Patient safety should be the number one concern before, during and after each procedure in any hospital. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. In my area of work, the principles of general preventive measures such as the implementation of standard and isolation precautions should be reviewed.


    The process of urinary catheterization can cause many health problems. Alternatives to catheterization should be used whenever possible. Reduction of catheter associated infections is based primarily on preventive infection control practices. The cornerstones of effective prevention include thorough adherence to the guidelines promoted by higher health care agencies for hand hygiene, correct insertion, handling, positioning, and maintenance of catheters; avoidance or limited use of long-term indwelling catheters; and possibly selection of catheters that are designed to deter biofilm growth. Following appropriate practice and product interventions, it is possible to significantly reduce the number of catheter associated infections. This, in turn, reduces hospital stays and associated costs of treatment.


    Prevention of catheter-associated urinary tract infections is more effective, particularly for indwelling catheters, than relying solely on antimicrobial agents. The most effective practice interventions for reducing catheter-associated urinary tract infections include identifying patients who no longer need indwelling catheters, considering other catheterization options or alternatives to catheterization, and providing patient and caregiver education when long-term indwelling catheterization is needed (2005).


    Reducing the time a patient is catheterized can be accomplished by systematic reminders to review the duration of catheterization for each patient. An interventional study in which physicians were reminded daily to remove unnecessary catheters significantly reduced the number of catheter days from 7 to 4.6 (P<0.001), which reduced the rate of catheter-associated UTIs from 11.5 to 8.3 per 1000 catheter-days (P=0.009). This intervention also resulted in a 69% decrease in the monthly cost of antibiotics for catheter-associated UTIs. Reminders to remove unnecessary catheters can be issued by the nursing staff or by computerized ordering systems (2005).


    The greatest hope for a major reduction in catheter associated infections and indeed all nosocomial infections is likely to be vaccines against important nosocomial multidrug-resistant pathogens, such as the enteric gram-negative bacilli and staphylococci.


    The success of the healthcare professional who practices infection-control techniques is measured by determining whether the goals for reducing or preventing infection are achieved. A comparison of the client’s response, such as absence of fever or development of wound drainage, with expected outcomes determines the success of nursing interventions. Once the decision has been made to use an indwelling urinary catheter, efforts should be made to minimize problems.


     


    Recommendations


    The first major advance for preventing catheter associated infections since the wide-scale adoption of closed drainage 35 years ago is the development of catheters with antiinfective surfaces. These advances should not be considered the final answer, however. Other technologies that should be pursued include new, more potent antiinfective materials; microbe-impervious antireflux valves; urethral stents; conformable (collapsible) urethral catheters; and vaccines for enteric gram-negative bacilli and staphylococci.


    Antiseptics are far more likely than antibacterials to confer greater resistance to surface colonization and not to select for infection with antimicrobial-drug resistant bacteria or yeasts. New surface technologies that release far greater quantities of ionic silver or other antiinfective agents into the aqueous environment contiguous to the catheter surface might even prevent catheter associated infections caused by intraluminal contaminants (2001).


    Prevention of catheter-associated infections is more effective, particularly for indwelling catheters, than relying solely on antimicrobial agents. The most effective practice interventions for reducing catheter associated infections include identifying patients who no longer need indwelling catheters, considering other catheterization options or alternatives to catheterization, and providing patient and caregiver education when long-term indwelling catheterization is needed (2005).


    Reducing the time a patient is catheterized can be accomplished by systematic reminders to review the duration of catheterization for each patient. An interventional study in which physicians were reminded daily to remove unnecessary catheters significantly reduced the number of catheter days from 7 to 4.6 (P<0.001), which reduced the rate of catheter-associated infections from 11.5 to 8.3 per 1000 catheter-days (P=0.009). This intervention also resulted in a 69% decrease in the monthly cost of antibiotics for catheter-associated infections. Reminders to remove unnecessary catheters can be issued by the nursing staff or by computerized ordering systems (2005).


    In addition to practice intervention, the choice of catheters and related equipment can also reduce urinary tract infections substantially. Other methods of catheterization should he considered before inserting an indwelling catheter. Catheterization options are based on the reason for catheterization and the expected duration of need. Other options include condom catheters for males, suprapubic catheters for patients who require long-term indwelling drainage, and intermittent catheterization for patients with spinal cord injuries. Patients who must use an indwelling catheter should have a closed catheter system with a small catheter (14 to 18 French with a 5-cc balloon). Manufacturer’s recommendations for inflation and deflation, system maintenance, securing the catheter, and properly positioning the drainage bag below the patient’s bladder should be followed. Preventing encrustation and blockage are also very important. Following these steps and properly maintaining closed drainage catheter systems has been shown to substantially reduce the risk for urinary tract infections (2005).


    Build up of secretions or encrustation at the catheter insertion site is a source of irritation and potential infection. The nurses, in order to avoid such a situation, must provide perineal care and hygiene at least twice daily or as needed for a patient with a retention catheter. Soap and water are effective in reducing the number of organisms around the urethra. The nurse must not accidentally advance the catheter up into the bladder during cleansing or risk introducing bacteria (2004).


                In addition to routine perineal care and hygiene, many institutions recommend that clients with catheters receive special care at least three times a day and after defecation or bowel incontinence to help minimize discomfort and infection.


                All patients with catheter should have a daily fluid intake of 2000 to 2500 ml if permitted. This can be met through oral intake or intravenous infusion. A high fluid intake produces a large volume of urine that flushes the bladder and keeps catheter tubing free of sediment ( 2004).


    For preventing infection, the maintenance of a closed sterile drainage system is described as the most successful method. A closed drainage system was described for the first time in 1928, and its benefit was appreciated much later (2001). Maintaining a closed urinary drainage system is important in infection control. A break in the system can lead to introduction of microorganisms. Sites at risk are the site of catheter insertion, the drainage bag, the spigot, the tube junction, and the junction of the tube and the bag (2004).


                Furthermore, the nurse has the responsibility to monitor the patency of the system to prevent pooling of urine within the tubing. Urine in the drainage bag is an excellent medium for microorganism growth. Bacteria can travel up drainage tubing to grow in pools of urine. If this urine flows back to the patient’s bladder, an infection will likely develop.


    In addition to practice intervention as mentioned above, the choice of catheters and related equipment can also reduce infections substantially. Other methods of catheterization should he considered before inserting an indwelling catheter. Catheterization options are based on the reason for catheterization and the expected duration of need.


    Other options include condom catheters for males, suprapubic catheters for patients who require long-term indwelling drainage, and intermittent catheterization for patients with spinal cord injuries. Patients who must use an indwelling catheter should have a closed catheter system with a small catheter (14 to 18 French with a 5-cc balloon). Manufacturer’s recommendations for inflation and deflation, system maintenance, securing the catheter, and properly positioning the drainage bag below the patient’s bladder should be followed. Preventing encrustation and blockage are also very important. Following these steps and properly maintaining closed drainage catheter systems has been shown to substantially reduce the risk for UTI (2005).


                Suggestions for ways to prevent infections in catheterized patients are the summarized in the following: (a) Follow good hand hygiene techniques, (2) Do not allow the spigot on the drainage system to touch a contaminated surface, (3) Only use sterile technique to collect specimens from a closed drainage system, (4) If the drainage tube becomes disconnected, do not touch the ends of the catheter or tubing. Wipe the end of the tubing and catheter with an antimicrobial solution before reconnecting, (5) Ensure that each client has a separate receptacle for measuring urine to prevent cross contamination, (6) Prevent pooling of urine in the tubing and reflux of urine into the bladder, (7) Avoid raising the drainage bag above the level of the bladder, (8) If it becomes necessary to raise the bag during transfer of a patient to a bed or stretcher, clamp the tubing or empty the tubing contents to the drainage bag first, (9) Provide for drainage of urine from the tubing to the bag by positioning the tubing, (10) Empty the drainage bag at least every 8 hours. If large outputs are noted, empty more frequently, (11) Encourage fluid intake, if it is not contraindicated. Inclusion of cranberry juice has been shown to decrease the adherence of bacteria to the bladder wall and to catheter lumen, (12) Remove the catheter as soon as clinically warranted, (13) Tape or secure the catheter appropriately for the patient, and (14) Perform routine perineal hygiene per agency policy and after defecation r bowel incontinence.


                In all settings, the patients and their families must be able to recognize source of infections and be able to institute protective measures. Patient teaching should include information concerning infections, modes of transmission, and methods of prevention. These recommendations for practice could also be utilized in my area of practice. Along with other health care professionals, we could help decrease the incidence of nosocomial infections particularly catheter associated infections by following these recommendations for safe practice.


     



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