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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 20  |  Issue : 2  |  Page : 116-121

Role of “bladder care bundle” and “infection control nurse” in reducing catheter-associated urinary tract infection in a peripheral hospital


Department of Anaesthesiology, Command Hospital Air Force, Bengaluru, Karnataka, India

Date of Submission22-Jan-2018
Date of Acceptance15-Nov-2019
Date of Web Publication10-Jan-2019

Correspondence Address:
Gp Capt Parli Raghavan Ravi
Command Hospital Air Force, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_8_18

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  Abstract 

Background: Care bundles are an effective means of reducing catheter-associated urinary tract infection (CAUTI) when they are implemented with high impact interventions. Care bundle approach only works when every element of the bundle is implemented for every appropriate patient, every time and with high impact. Aim: This study aims to study the efficacy of CAUTI Care Bundle and of infection control nurse (ICN) in reducing the incidence of CAUTI in a zonal hospital. Materials and Methods: The study was with an initial baseline phase (observational) of 8 months followed by an intervention Phase of 21 months. The intervention phase was further divided into intervention Phase I (8 months) and intervention Phase II (13 months). Intervention Phase I included a multidimensional approach of education and training of health-care staff for catheter management and prevention of CAUTI and implementation of catheter care bundle. In intervention Phase II education of health-care workers and implementation of catheter care bundle was done under constant supervision and guidance of ICN. Results: We recorded a total of 834 urinary catheter days: 309 in baseline phase, 314 in intervention Phase I, and 211 in intervention Phase II. It was found that the incidence rate of CAUTI, measured as episodes per 1000 catheter days is 64.72 in baseline phase, 25.47 in intervention Phase I, and 18.95 in intervention Phase II. The catheter care bundle approach along with education of the staff reduced the CAUTI incidence by 60.64 and when the same was applied under the constant supervision of ICN for the CAUTI reduction rate was clinically significant with 70.72. Conclusions: The catheter care bundle approach along with the education of the staff reduced the CAUTI incidence by 60.64 episodes/1000 catheter days and when the same was applied under constant supervision of ICN for the CAUTI reduction rate was clinically significant with 70.72

Keywords: Catheter-associated urinary tract infection, catheter control bundle, hospital acquired infection


How to cite this article:
Ravi PR, Joshi M C. Role of “bladder care bundle” and “infection control nurse” in reducing catheter-associated urinary tract infection in a peripheral hospital. J Mar Med Soc 2018;20:116-21

How to cite this URL:
Ravi PR, Joshi M C. Role of “bladder care bundle” and “infection control nurse” in reducing catheter-associated urinary tract infection in a peripheral hospital. J Mar Med Soc [serial online] 2018 [cited 2019 May 23];20:116-21. Available from: http://www.marinemedicalsociety.in/text.asp?2018/20/2/116/249772


  Introduction Top


The National Healthcare Safety Network (NHSN) has reported that urinary tract infections (UTI) is the commonest type of healthcare-associated infections (HAI) and majority of them (75%) is associated with an indwelling urinary catheter (UC).[1] Prolonged use of UC is considered as the most important risk factor for developing UTI.[2] It has been postulated that reduction of UTI happens only when multiple issues with respect to its etiology is addressed simultaneously. “Care Bundle” approach is a strategy, wherein a series of action are done in a prescribed and formulated way so as to decrease the incidence of catheter-related UTI. The Centre of Disease Control (CDC) Atlanta has issued several guidelines for the prevention of catheter-associated UTI (CAUTI) and other HAI. Internal audits are necessary of each of the elements of the bundle to ensure compliance of guidelines for prevention of HAI.

As per Hospital Infection Control Committee (HICC) of our hospital, the rates of CAUTI in the hospital were on the rise. Unlike other HAIs, there was no catheter care bundle in practice for the prevention of CAUTI in the hospital. This study was conducted to study the effectiveness of catheter care bundle and the role of infection control nurse (ICN) in the reduction of CAUTI rates in the zonal service hospital.


  Materials and Methods Top


The study was conducted in a peripheral hospital with 410 beds. The hospital has a Level 2 intensive care unit (ICU) with 18 beds. Level 2 ICU as defined by the Indian Society of Critical Care Medicine is where patients need single organ support (excluding mechanical ventilation) such as renal hemofiltration or inotropes and invasive blood pressure monitoring. They are staffed with one nurse to two patients. This hospital caters predominantly to the needs of the population residing in North-Eastern part of the country their dependents. The average annual inpatient load of this hospital is about 5000. The study was a prospective observational and interventional study involving all in-patients with UC during hospitalization. The study was divided into two phases – baseline phase and intervention phase. The intervention phase was further divided into intervention Phase I and intervention Phase II. The study was conducted to determine the possible reduction in the rate of CAUTI in the hospital with the use of catheter care bundle and staff education, and effectiveness of ICN in effecting the same. The ICNs of the hospital are graduate holding a Bachelor's degree in nursing science, trained in infection control practices through certificate course in the same. The ICNs did not change during the study. A user-friendly bundle was required to be formulated, for universal application to prevent the incidence of CAUTI in the hospital. As this study was a quality improvement project, the approval of the Institutional Ethical Board and the scientific committee was taken to conduct the study. Data were obtained through existing methods of quality control and monitoring without affecting current standards of patient care hence the consent of the patient was taken.

All the patients admitted to the ICU, family ward (female ward) and male wards from the age group of 15–75 years, having indwelling UC were part of the study. Patients with preexisting sepsis or infection, patients who were admitted to the hospital with UC, patients with positive urine culture at the time of admission, and patients who were on catheter for home-based care were excluded from the study.

CAUTI in our study was defined as per the definition given by CDC in 2015. CAUTI is defined as “UTI where an indwelling urinary catheter has been in place for more than two calender days on he date of event, with the day of placement of device being day one, and an indwelling urinary catheter was in place ont he date of hte event or till the day before.”[3]

Definition of catheter-associated urinary tract infection

The diagnosis of CAUTI was designed by the HICC based on the CDC Atlanta guideline wherein the patient met one of the following criteria: (a) The first criterion was satisfied when a patient with a UC had one or more of the following symptoms with no other recognized cause: fever (temperature −38.8° C), urgency, and suprapubic tenderness; the urine culture was positive for 10[4] colony-forming units per milliliter or more, with no more than two microorganisms isolated. (b) The second criteria were when a patient with a UC had the following findings in his urine sample with no other recognized cause: positive dipstick analysis for leukocyte esterase or nitrate and pyuria (>10 leukocytes/ml).

Catheter care bundles modified from the CDC guidelines for ease of use in our setting were as follows:

  1. Complete sterility was maintained during the procedure of catheterization
  2. Silicone UCs were only used
  3. Every day the indication to catheterization was reviewed, and all possibility to remove was explored.


The study was started in with an initial baseline phase of 8 months followed by an intervention phase of 21 months. The intervention phase was further divided into intervention Phase I (08 months) and intervention Phase II (13 months). The baseline phase was an observational phase during which the existing interventional methods and precautions followed by the hospital for preventing the development of CAUTI were observed. The data included total number of patients catheterized, catheter days, and urine culture reports (no growth, mixed growth, and growth positive). Intervention Phase I included a multidimensional approach based on the CDC guidelines. This approach included education and training of health-care staff for catheter management and prevention of CAUTI and implementation of catheter care bundle by the health-care staff working in the wards. This included first, the implementation of an infection prevention bundle based on the guidelines published by the HICC which provide evidence-based recommendations and cost-effective infection control measures that can be feasibly adapted. Second, the education of health-care workers (HCWs) about infection prevention measures. Third, CAUTI outcome surveillance by applying the definitions for CAUTI developed by the US CDC and Prevention NHSN. Fourth, CAUTI process surveillance to monitor compliance with easily measurable infection control measures, including hand hygiene performance according to the recommendations of the World Health Organizations. Fifth, the feedback on CAUTI rates routinely provided to the HCWs. Sixth, performance feedback on process surveillance, which was provided particularly by reviewing and discussing chart results at monthly infection control meetings. In intervention Phase II, the implementation of catheter care bundle was done under constant supervision and guidance of the ICN. There were three ICN who were trained in the similar way, certified the similar way. Hence, one ICN was always present during the study. Since the knowledge, skill, and attitude toward the study were similar of the ICN the continuity was maintained. ICN monitored and ensured the control process through constant surveillance. The ICN ensured that the multidimensional approach which was practiced by the hospital is followed by each HCW involved in the process. The ICN was responsible for weekly training in catheter care bundle and hand hygiene aspects of the involved HCW in the study. The ICN collected data from wards, compiled laboratory reports, and generated statistical data.

Statistical analysis

The statistical analysis was done using SPSS program statistical package for the social sciences (SPSS) version 16 (SPSS Inc., Chicago, USA).
  1. The analysis for growth positive and no growth in culture was performed using the Wilcoxon signed-ranks test
  2. Characteristics of the patients at baseline and during the past 3 months of the intervention period were compared using Fisher's exact test for dichotomous variables and the unmatched Student's t-test for continuous variables. 95% confidence intervals (CI) were calculated using VCStat (Castiglia). Relative risk ratios with 95% CI were calculated for comparisons of rates of CAUTI using Epi Info Ver 7 (CDC, Atlanta, Georgia, US). P < 0.05 by two-sided tests was considered statistically significant. Further, we used Poisson regression to compare the rates of CAUTI at baseline and during the follow-up period divided into 9–24-month period
  3. A power analysis was done keeping alpha level (P < 0.05), which revealed the statistical power for this study as 0.40 for the detection of small effects, whereas the power exceeded 0.95 for detection of large effects. A sample size of 52 in the nonintervention phase and 85 in the intervention phase was used which calculated the effect size to be 1.91 for detection of growth positive cultures and gave the power as 1.



  Results Top


In the baseline phase, 51 patients were catheterized and 85 in the intervention phase. Of 85 patients in intervention phase, 50 were catheterized in intervention Phase I and 35 in intervention Phase II [Figure 1]. The incidences of the CAUTI rates were measured as episodes per 1000 catheter days according to the standard formula, i.e., incidence rate is equal to number of CAUTIs divided by number of catheter days and multiplied by 1000.
Figure 1: Consort flow diagram

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It is found that the incidence rate of CAUTI, measured as episodes per 1000 catheter days is 64.72 in baseline phase, 25.47 in intervention Phase I and 18.95 in intervention Phase II as given in [Table 1]. The total number of patients catheterized, numbers with no growth, mixed growth, and CAUTI positive in the three different phases are as given in [Table 2]. From these data, the incidence of no growth, CAUTI positive, and mixed growth was measured as cases per 1000 catheter days in the three consecutive phases reflects increase in incidence of no growth, decrease in the incidence of CAUTI positive and mixed growth. The common organism isolated in the study was Escherichia coli. The incidence of CAUTI positive was calculated per 1000 catheter days for different wards shows the highest incident rate in ICU followed by surgical, medical, and then female ward. The incidence of CAUTI was more in female patients as compared to male patients. Gender-wise distribution is demonstrated in [Figure 2]. The patient characteristics data are represented in [Table 3].
Table 1: CAUTI incidence in baseline phase and intervention Phase I and II

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Table 2: Details of incidence of CAUTI during various phases of study

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Figure 2: Incidence of catheter-associated urinary tract infection among men and women

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Table 3: Patient characteristics

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The Wilcoxon signed ranks test was used to compare the rates of CAUTI in the three phases. CAUTI incidence rates in baseline phase, intervention Phase I, and intervention Phase II were measured as 64.72, 25.47, and 18.95, respectively per 1000 UC days, showing an of CAUTI reduction of 60.64% (P = 0.01) in interventional Phase I from baseline phase and 25.6% in intervention Phase II from intervention Phase I and when the reduction rate was calculated from baseline phase to intervention Phase II, it was 70.72% (P = 0.004) evidencing the effectiveness of use of multidimensional approach under high impact interventions by ICN. The incidence of CAUTI in intervention Phase II was lesser in comparison to intervention Phase I (18.95/1000 vs. 25.47/1000), it was not statistically significant. The compliance of the HICC guidelines for insertion of UC was found statistically significant in the intervention phase in comparison to the baseline where the compliance was only 82.69%.


  Discussion Top


The most significant and recognized risk factor for the development of UTI in patients who are hospitalized is the presence of the indwelling catheter.[2] A rough estimate by CDC Atlanta gives an incidence of 1.7 million annually. UTI comprises 36% of the total hospital-acquired the infection in acute care set up.[2]

The preventive strategies which include educational intervention, clinical skills, and behavioral intervention which ranges from maximum days of keeping catheter in situ to catheter removal protocols when are bundled together is known as “bladder bundle.” These are key in preventive HAI similar to “Ventilator-associated Pneumonia bundle and catheter-related bloodstream infection bundle.”[5]

CDC Atlanta recommendations emphasize that the placement of the UC should be done by a trained HCW in a totally aseptic conditions. Apart from these, it also stresses the requirement of a completely closed drainage system, with no obstructed flow of urine and use of ultrasound of the bladder for detection of residual urine.[4],[6]

Many other interventions are recommended by various studies which are to be used along with the catheter care bundle. Among the few of which are, outcome surveillance of CAUTI rates and their consequences, processing of these surveillance, and involvement of HCWs in the whole process of preventing UTI.[3],[7],[8],[9],[10],[11]

It is found that the incidence rate of CAUTI, measured as episodes per 1000 catheter days was 64.72 in baseline phase, 25.47 in intervention Phase I, and 18.95 in intervention Phase II. Thus, the rates of CAUTI measured as the episodes per 1000 catheter days were clinically and statistically significant with P = 0.004. And therefore, the multidimensional approach along with constant guidance and supervision of ICN is fundamental to combat occurrences of CAUTI. The CAUTI form and catheter care bundle provides consistency in care as a reminder to staff to perform all aspects of CAUTI prevention.

The well-established practices of minimizing the number of insertions, early discontinuation, and catheter care form the cornerstone of bladder care bundle being practiced to prevent CAUTI.[9],[10],[11] While studies have also been conducted on the role of nurses working in the wards/units, in prevention and control of CAUTIs, no information could be found in the literature regarding the role and effectiveness of ICN of the hospital in the prevention of CAUTI.[10],[11] In our study, when the CAUTI reduction rate was calculated from baseline phase to intervention Phase II, it was 70.72% (P = 0.004) which was statistically significant when compared with the baseline. The use of multidimensional approach under the direct supervision of ICN provides consistency in the care to perform all aspects of CAUTI prevention. We recommend that all hospitals should formulate and adopt a catheter care bundle. The staff should undergo the necessary education periodically. The implementation of the care bundle should be monitored by mandatory checklists and CAUTI surveillance forms. ICN of the hospital should be actively involved in monitoring all cases on UC.

Our study is the first in the health-care scenario from our country to report intervention and surveillance by a designated ICN to reduce the incidence of CAUTI. It also assumes great significance coming from a peripheral hospital, as these systems may be similarly implemented in other peripheral hospitals around the world. The limitations of this study were that we did not have a control group during each of the phases to better correlate outcomes.


  Conclusions Top


This study reports a substantial reduction in CAUTI rates in peripheral hospital, showing that simple infection control approach is needed to reduce the HAIs. Although the intrinsic risk in some patients must have been higher, a multidimensional approach including improved compliance with CAUTI prevention measures resulted in significant reductions in the CAUTI incidence rate. Good as it is, it is worth highlighting that the reduction in CAUTI rates does not derive from surveillance itself. These systematically collected data should serve to guide health-care professionals working in smaller hospitals in their strategies for improving patient care practices.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gould CV, Umscheid CA, Charles PK, Eithebottom CV, Dexter F, Rickets DJ. Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009. CDC-Report of Healthcare Infection Control Advisory Panel; 2009. p. 14-65.  Back to cited text no. 1
    
2.
Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: Rationale, design, analysis, and reporting. BMJ 2015;350:h391.  Back to cited text no. 2
    
3.
Saint S, Greene MT, Krein SL, Rogers MA, Ratz D, Fowler KE, et al. Aprogram to prevent catheter-associated urinary tract infection in acute care. N Engl J Med 2016;374:2111-9.  Back to cited text no. 3
    
4.
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee, et al. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol 2010;31:319-26.  Back to cited text no. 4
    
5.
Fasugba O, Koerner J, Mitchell BG, Gardner A. Systematic review and meta-analysis of the effectiveness of antiseptic agents for meatal cleaning in the prevention of catheter-associated urinary tract infections. J Hosp Infect 2017;95:233-42.  Back to cited text no. 5
    
6.
Hall L, Farrington A, Mitchell BG, Barnett AG, Halton K, Allen M, et al. Researching effective approaches to cleaning in hospitals: Protocol of the REACH study, a multi-site stepped-wedge randomised trial. Implement Sci 2016;11:44.  Back to cited text no. 6
    
7.
Jeong I, Park S, Jeong JS, Kim DS, Choi YS, Lee YS, et al. Comparison of catheter-associated urinary tract infection rates by perineal care agents in intensive care units. Asian Nurs Res (Korean Soc Nurs Sci) 2010;4:142-50.  Back to cited text no. 7
    
8.
Rosenthal VD, Al-Abdely HM, El-Kholy AA, AlKhawaja SA, Leblebicioglu H, Mehta Y, et al. International nosocomial infection control consortium report, data summary of 50 countries for 2010-2015: Device-associated module. Am J Infect Control 2016;44:1495-504.  Back to cited text no. 8
    
9.
Kanj SS, Zahreddine N, Rosenthal VD, Alamuddin L, Kanafani Z, Molaeb B, et al. Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in an adult intensive care unit in Lebanon: International nosocomial infection control consortium (INICC) findings. Int J Infect Dis 2013;17:e686-90.  Back to cited text no. 9
    
10.
Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32.  Back to cited text no. 10
    
11.
Clarke K, Tong D, Pan Y, Easley KA, Norrick B, Ko C, et al. Reduction in catheter-associated urinary tract infections by bundling interventions. Int J Qual Health Care 2013;25:43-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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