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Root Cause Analysis: Catheter Associated Urinary Tract Infections

Kamari Dunston Parris
Bon Secours Memorial College of Nursing
NUR 3206
Dr. Dowling
June 26, 2016
“I Pledge…”
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Catheter Associated Urinary Tract Infections

Among the numerous issues that can be identified as problems in nursing

practice, the occurrence of Catheter Associated Urinary Tract infections (CAUTIs)

seems to still be on the rise and should be investigated. “A urinary tract infection

(UTI) is an infection in the urinary system, which includes the bladder and the

kidneys”. “If you have a urinary catheter, bacteria or yeast can travel along the

catheter and cause an infection in your bladder or kidney (also called Catheter-

Associated Urinary Tract Infections (CAUTI)” (The American Nurses Association,

2016). Since I am currently practicing in the hospital wide nursing float pool I am

no longer associated with a unit therefore I was unable to research an issue in my

unit/department. Instead I choose to interview a couple of my peers from different

areas of nursing to come up with an issue that would be beneficial to research. My

friend who is a nurse in the ICU reported they have had 4 CAUTI’s since January.

The National Healthcare Safety Network (NHSN) reported of all the UTI’s acquired

in the hospital, 75% of them were the result of an indwelling urinary catheter (ANA,

2016). To reduce the occurrence of CAUTI’s, my friend’s unit has put into place

special protocols to reduce this issue. This paper will include an analysis of the root

cause of my friend’s unit having an increase in CAUTI”S and the protocols that are

being put in place to prevent them and a visual display of my findings.

Reasons why this is a problem for this unit is because there hadn’t been

protocols put in place to limit the use of Foley catheters. The ICU generally has a

more acute population than the rest of the hospital therefore it is often necessary for
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a patient to have a Foley catheter. Nurses on theses units are used to patients

needing catheters so they may be reluctant to advocate for removal. In general it is

easier to manage a patient with a catheter because it takes the guesswork out of

measuring output or having to change numerous wet diapers and beds, but in the

long run the patient is the one who suffers from our convenience.

Sometimes the requirement of a Foley catheter is beyond our control, for

example, the patient who has urinary retention from a neurogenic bladder. In this

case they must always have an indwelling catheter to empty their bladders. This

population unfortunately is at a greater risk for developing a UTI; especially those

who reside in long term care facilities. A study by Grunier and colleagues found that

residents of long term care facilities are at a 20.3% greater risk for hospital

admission for UTI’s (Bowman & Forbes, 2015). This population can also be exposed

to the same risk when hospitalized. It is imperative that we are especially

meticulous when documenting on patients whose Foley catheter is present on

admission (POA). Things that should be included are the insertion date, if it was

POA, and when it is due to be changed to help avoid the development of a CAUTI.

The ICU that I gathered my information from has put a protocol in place to limit the

use of Foley catheters by straight catheterizing patients for 24 hours for urinary

retention unless they are extremely unstable. Once they are placed they strive to

remove them as soon as possible.

Many hospitals have adapted protocols that require using chlorehexidine to

combat the development of CAUTI’s. The nurse who I interviewed reported that

they have a new protocol that requires them to clean all Foley catheters with
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chlorehexidine-impregnated wipes every 4 hours after having an increase in their

CAUTI’s this year. An article from the Journal of Wound, Ostomy and Continence

Nurses Society found that best practice recommends “good personal hygiene” for

Foley care and evidence didn’t necessarily recommend the use of antiseptics to

reduce infection risk which was an interesting find (Wilson et al., 2009 p.143).

CAUTI’s can also be avoided by reviewing the necessity of them daily; the

nurse who was interviewed also listed this as part of their action plan. A specialized

nurse such as a Clinical Care Lead (CCL) would be responsible for finding out which

patients had indwelling catheters and if they where needed. This checklist would be

performed on a daily basis. If the catheter was not necessary they are required to

contact the physician to receive permission to remove it then relay the information

to the primary nurse for the patient. Since patients in the ICU are at a greater risk

for developing UTI’s, hospitals have begun to incorporate a bundle of interventions

for these patients. One particular hospital in Brazil uses the following bundle for

their ICU patients including, hand hygiene, keeping insertion equipment in close

proximity, using sterile technique, chlorhexidine cleansing, only using one catheter

per attempt, proper balloon inflation, daily review of necessity and prompt removal

(Galiczewski, 2015). This bundle could be useful in prevention of CAUTI’s because

it specifically addresses all avenues where infection could possibly be introduced.

Finally, this unit is on the right tract for reducing the development of CAUTI’s

on their floor, but they will benefit most by being certain they remain compliant

with the protocols put in place. This particular ICU is up to date with the latest

recommendations from the CDC on CAUTI prevention in addition to these

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approaches from the Ochsner Journal including the use of mandatory prompts and

reminders in the electronic medical record, daily patient tracking, and the urine

retention protocol (Bell, Alaestante, & Finch, 2016).

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Root Cause Analysis Fishbone Diagram

Cause
Lack of proper
documentation when
n
Foley’s are in use
Foley being left in too long
Cause
Aseptic technique
not performed with
insertion
Lack of education on the importance of hand hygiene
Staffing shortage
Cause nurses to cut corners

Constant issues with computers being down

Problem
It’s easier to manage a 4 CAUTI’s in ICU since
Patient with a Foley January
Some pts. require a chronic Foley
Daily rounding not done on patients with Foleys

Cause
Cause No Foley care Q
Not avoiding the use of shift
Foley Catheters
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References

The American Nurses Association, Inc. (2016). Catheter Associated Urinary Tract

Infection (CAUTI). Retrieved from www.nursingworld.org

Bowman, B., Forbes, A. (2015). Addressing Needs of Long-Term Care Facility

Residents During Acute Hospitalization. Medsurg Nursing, 24(6), 403-406.

Wilson, M., Wilde, M., Webb, M., Thompson, D., Parker, D., Harwood, J., . . . Gray, G.

(2009). Nursing Interventions to Reduce the Risk of Catheter-Associated

Urinary Tract Infection. Journal of Wound, Ostomy and Continence Nurses

Society, 36(2), 137-154.

Galiczewski, J. M. (2015). Interventions for the prevention of catheter associated

urinary tract infections in intensive care units: An integrative review.

Intensive and Critical Care Nursing, 32, 1-11.

Bell, M. M., Alaestante, G., Finch, C. (2016). A Multidisciplinary Intervention to

Prevent Catheter-Associated Urinary Tract Infections Using Education,

Continuum of Care, and System wide Buy-In. Ochsner Journal, 16 96-100.