Ask the Experts Avoiding Infection When Adding a Urine Meter

Q

A patient comes back from the operating room with a urinary catheter in place but no urine meter and is on hourly outputs. What is the best practice to prevent catheter-associated urinary tract infection (CAUTI) while adding a urine meter?

Author Julie Miller is a staff development educator at Trinity Mother Frances Hospitals and Clinics in Tyler, Texas. Corresponding author: Julie Miller, RN, BSN, CCRN, Trinity Mother Frances Hospitals and Clinics, 800 E. Dawson, Tyler, TX 75701 (e-mail: julie.miller@ pawstolearn.com). To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. ©2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013301

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Julie Miller, RN, BSN, CCRN, replies:

Catheter-associated urinary tract infections (CAUTIs) are the most common type of health care– associated infections reported to the National Health Safety Network.1 It is estimated that more than 75% of UTIs are associated with an indwelling urinary catheter.1 The question regarding adding a urine meter is commonly encountered in intensive care units where accurate urine output measurements for hemodynamically unstable patients require hourly monitoring with a urine meter. Ensuring accurate assessment of urine output, while preventing CAUTI, is essential to maintaining patient safety. The Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the Institute for Healthcare Improvement (IHI), the Association for Professionals in Infection Control and Epidemiology (APIC), and the American Association of Critical-Care Nurses have all published resources and/or guidelines for reducing CAUTI.2-7 The CDC, SHEA, IHI, and APIC recommend maintaining a sterile continuously closed drainage

system.2,3,5,7 Additionally, the CDC guidelines recommend “using urinary catheter systems with preconnected, sealed cathetertubing junctions.”2 The CDC and SHEA guideline recommendations differ when dealing with management of a catheter disconnect. The CDC guidelines, published in 2009, recommend replacing the system (urinary catheter and bag) by using aseptic technique and sterile equipment if a break in aseptic technique, disconnection, or leakage occurs.2 Replacing the catheter drainage bag with a urine meter collection bag would cause a disconnect in the system. The 2008 SHEA guidelines, which are due to be revised in 2013, recommend replacing the collecting system by use of aseptic technique and after disinfecting the catheter-tubing junction when breaks in aseptic technique, disconnection, or leakage occur.3 When a patient arrives in the intensive care unit without a urine meter, the replacement of the collecting system with a urine meter breaks the preconnected sealed catheter-tubing junction. This practice does not maintain a sterile continuously closed drainage

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system, leaving the system prone to disconnects and the patient at risk for development of a CAUTI. Surgical patients often arrive from the operating room with a urinary catheter. Both SHEA and CDC recommend removal of the catheter as soon as possible after surgery, preferably within 24 hours, if it is no longer medically necessary. The guidelines also recommend reducing the use of indwelling catheters for surgical patients.2,3,5,7 CAUTIs are reduced when the urinary catheter and collection system remain continuously closed. Breaking the system to add a urine meter may increase the risk of CAUTI. The current guidelines do not specifically deal with the subject of replacing a catheter drainage bag with a urine meter; however, the CDC guidelines do offer the recommendation of replacing the system (urinary catheter and bag) for catheter disconnects.2 Replacing the system to add a urine meter could increase cost and discomfort for the patient. If it is current practice to break the presealed urinary drainage system to add a urine meter, analysis of system factors contributing to this practice may be necessary.8 A committee of stakeholders who transfer patients to the intensive care unit could review current practice and identify system factors that could be modified or changed to prevent the need to break the presealed connection to add a urine meter drain. Areas for analysis include the need for a urinary catheter,

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duration of urinary drainage, standardization of urinary drainage systems, culture of practice regarding insertion and management of urinary catheters, and educational needs of staff. The CDC and SHEA guidelines offer similar and different recommendations for insertion and management of urinary catheter patients (see Table, available online only at www.ccnonline.org). The IHI offers access to mentor hospitals that have been successful in reducing the incidence of CAUTIs.4 These mentor hospitals offer recommendations on the IHI website as well as contact persons to assist professionals who are seeking help in their efforts to reduce the occurrence of CAUTIs. Preventing CAUTIs is essential to patient safety. In addition, hospitals are not reimbursed by the Centers for Medicare and Medicaid Services for the complication of CAUTI.6 Identifying means for implementing best practices for CAUTI reduction is essential by nurses. Eliminating the need to add a urine meter is one way to help reduce the risk of CAUTI for acute and critically ill patients. CCN

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infections in acute care hospitals. Infect Control Hospital Epidemiol. 2008;29(S1). http:// www.jstor.org/stable/10.1086 /591066 or http://www.shea-online.org /HAITopics/CompendiumofStrategiesto PreventHAIs.aspx. Accessed September 30, 2013. Institute for Healthcare Improvement: Catheter Associated Urinary Tract Infection Mentor Hospital Registry. http://www.ihi .org/offerings/MembershipsNetworks /MentorHospitalRegistry/Pages/CAUTI .aspx. Accessed September 30, 2013. Greene L, Marx J, Oriola S. Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIS). Washington, DC: Association for Professionals in Infection Control and Epidemiology, Inc (APIC); 2008. http://www.apic.org/Resource_ /EliminationGuideForm/c0790db8-2aca -4179-a7ae-676c27592de2/File/APIC -CAUTI-Guide.pdf. Accessed September 30, 2013. AACN Practice Alert: Catheter-Associated Urinary Tract Infections. 2011. http://www .aacn.org/WD/practice/docs/practicealerts /catheter-associated-uti-practice-alert.pdf. Accessed September 30, 2013. Institute for Healthcare Improvement. How-to Guide: Prevent Catheter Associated Urinary Tract Infection. http://www.ihi.org /knowledge/Pages/Tools/HowtoGuide PreventCatheterAssociatedUrinaryTract Infection.aspx. Accessed September 30, 2013. Flynn Makic MB, VonRueden KT, Rauen CA, Chadwick J. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31(2):38-62. .

Financial Disclosures None reported.

References 1. Centers for Disease Control and Prevention. Catheter Associated Urinary Tract Infections. May 17, 2012. http://www.cdc.gov/HAI/ca _uti/uti.html. Accessed September 30, 2013. 2. Gould CV, Umscheid CA, Agarwal RK, et al and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for prevention of catheter-associated urinary tract infections 2009. http://www .cdc.gov/hicpac/cauti/002_cauti _sumORecom.html. Accessed September 30, 2013. 3. Lo E, Nicolle L, Classen D, et al. Strategies to prevent catheter-associated urinary tract

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Avoiding Infection When Adding a Urine Meter Julie Miller Crit Care Nurse 2013, 33:72-73. doi: 10.4037/ccn2013301 © 2013 American Association of Critical-Care Nurses Published online http://www.cconline.org

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