Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP)

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SSHAIP

Catheter Associated Urinary Tract Infection (CAUTI) Surveillance

The programme of surveillance of Catheter Associated Urinary Tract Infections (CAUTIs) commenced in April 2004. Surveillance of CAUTI is a voluntary surveillance programme which is available to all those acute and primary care divisions who would like to participate.

For further information on this programme contact Sonja Millar in the first instance.

Project Manager: Jane McNeish, Senior Nurse Epidemiologist, Scottish Surveillance HAI Programme

Scientific Lead: Dr Jodie McCoubrey, Epidemiologist, HAI Surveillance

Why do surveillance in CAUTI?

Epidemiology of Healthcare Associated Urinary Tract Infections

Urinary tract infections (UTI) are the most common infections acquired in hospitals and long-term care facilities. Early studies estimate the incidence of healthcare associated UTIs at around 2-3 patients per 100 admissions and this is supported by the more recently published Plowman Report (Plowman et al, 1999; Kreiger et al, 1983 and Turck and Stamm, 1981). A number of risk factors for healthcare associated UTI have been suggested and it is now well established that the major predisposing factor for healthcare associated UTI is the presence of an indwelling urethral catheter.

Several studies have indicated that between 75 and 80% of all healthcare associated UTIs follow the insertion of a urinary catheter (Bryan and Reynolds 1984 and Turck and Stamm, 1981) and a study investigating 40 English hospitals estimated that around 26% of all hospitalised patients have a urinary catheter inserted during their stay in hospital (Glynn et al, 1997).

The problem of CAUTIs in long-term care facilities such as nursing homes is well recognised, however the full extent of the problem has not been fully established. Use of catheters is common in long term care facilities and many patients are catheterised for long periods, thus increasing their risk of acquiring a CAUTI. One study which investigated male patients in a nursing home illustrates the problem of CAUTI in long term care of the elderly. During the one-year study period 80% of patients had at least one CAUTI and 48% of patients had two or more CAUTIs (Ouslander, 1987).

Costs associated with Healthcare Associated UTI

The costs associated with healthcare associated UTIs result from additional diagnostic testing, treatment regimes and increased hospital stays of on average 5-6 days. The Plowman report published in 1999 estimated the additional NHS costs of treating a healthcare associated UTI were £1327 per case and the national burden of healthcare associated UTI was approximately £125 million per annum. The majority of theses costs result from extended hospital stays for the large numbers of patients affected by UTI and this places a significant burden on the healthcare system.

There are also considerable costs to the patient in terms of increased morbidity and mortality. CAUTI are also associated with bacteraemia, increased mortality and may lead to complicated infections of the urinary tract (Bryan and Reynolds, 1984 and Platt et al, 1982).

What are the risks for CAUTI?

A number of research studies have demonstrated that there may be associated risk factors for CAUTI. Factors including a history of previous catheter use, the duration the catheter is in situ , the length of hospital stay prior to catheter insertion, the reason for and location of catheter insertion (Leone et al, 2003; Stamm, 1991; Bryan and Reynolds, 1984 and Garibaldi et al, 1974).

The relationship between the duration the catheter is in situ and the development of CAUTI is well established. A number of studies have demonstrated an association between bacteriuria and the duration the catheter is in situ . One study reported that the risk of developing bacteriuria increased by 5% for each additional day the catheter is in situ and that after the tenth day, 50% of patients had acquired bacteriuria (Garibaldi et al, 1974). Shapiro et al, (1984) demonstrated that a catheter in situ for more than seven days was a risk factor for acquiring a CAUTI.

Innate risk factors such as gender, increasing age and general debilitation are associated with CAUTIs. Females are at increased risk of acquiring UTIs due to the relative ease with which bacteria colonising the perineum can reach the urethra and in common with other HAIs it is frequently the elderly and debilitated that are at risk of acquiring infections (Hussain et al, 1996).

Who can participate in the CAUTI surveillance programme?

Surveillance of CAUTI is a voluntary surveillance programme which is available to all acute and primary care divisions who wish to participate. Participation for a minimum of 3 months is required, however it is recommended that sites participate for six months.

Specialties included in surveillance

As listed in the protocol, surveillance of CAUTI can be carried out in any of the following specialties:

Medical

  • Cardiology
  • Geriatric Psychiatric
  • Gastroenterology
  • General Medicine*
  • Geriatric Medicine (Care of the Elderly) *
  • Haematology (including bone marrow transplantation)
  • Nephrology (including renal transplantation)
  • Neurology
  • Oncology

* Geriatric Psychiatric and Geriatric Medicine units have been chosen to include Primary Care.

Surgical

  • Cardiothoracic surgery
  • General surgery
  • Neurosurgery
  • Trauma & Orthopaedics
  • Urology

Gynaecology & Obstetrics

  • Gynaecology
  • Obstetrics

Which patients can be included in the surveillance?

All patients who have an indwelling urinary catheter inserted in the specialty chosen for surveillance are included.

Details of the surveillance programme can be found in the Catheter Associated Urinary Tract Infection Protocol and Resource Pack.

Data Collection for CAUTI Surveillance

Staff collect data at local level, the data can be collected on paper forms or on electronic forms. All data are returned to SSHAIP for quality checking and reporting on a quarterly basis.

Paper Data Collection

Paper forms are supplied to sites by HPS and should be returned on a monthly basis for processing. The data are quality checked at HPS and any anomalous data are returned to staff for checking locally.

Electronic Data Collection

An innovative electronic data collection tool has been developed for the CAUTI surveillance project. The data collection tool can be run from a Tablet PC or a laptop. This data collection tool comprises an "on-screen" data collection form which is displayed on the Tablet PC/laptop screen. Data is then entered directly to the "on-screen" form. Once data has been entered to the electronic data collection form it is automatically stored in the database for transfer to the SSHAIP team at HPS.

The data are quality checked at HPS and any anomalous data are returned to staff for checking locally.

How are the data reported?

A standard report is provided on a quarterly basis. In addition, an annual report for all sites participating in CAUTI Surveillance is published.

Training

Training in the data definitions and data collection process is provided to all staff who are involved in CAUTI surveillance.

Training resources can also been downloaded for training at local level.

Audit Tool for Urinary Catheterisation and Catheter Care

In addition to surveillance of CAUTI, the SSHAIP Team have developed an Audit Tool for urinary catheterisation. The audit tool was developed to audit against the Best Practice as laid out in the NHS Quality Improvement Scotland Statement for Urinary Catheterisation and Catheter Care. The Audit Tool can be used in combination with CAUTI surveillance or it can be used independently.

Audit of Best Practice for Urinary Catheterisation and Catheter Care

Under guidance from an expert working group a set of audit tools to measure current practice and policies for urinary catheterisation and catheter care against the standards set out in the BPS have been developed. The current set of audit tools focuses on indwelling catheters, audit tools for supra pubic and intermittent catheters will be developed in the future.

Audit of urinary catheterisation and catheter care practices will act as the basis to implementation of the best practices and improvements in patient care, including CAUTI. The audit tool can be used in conjunction with surveillance or it may be used independently to measure the quality of urinary catheter care.

The Audit Tools

A series of audit tools have been developed to facilitate audit of policy and practice; observational audit; knowledge and self-reported audit; audit of catheter materials management and audit of patient care documentation.

Each of the tools can be used alone or in conjunction with one another. The set of tools will facilitate audit in priority areas at local level.

Auditors could include ICNs, surveillance nurses, ward nurses, theatre nurses, community nurses or another suitable member of the multidisciplinary team. This would be agreed at local level.

More information on the audit tool and a copy of the data collection tools can be found in the CAUTI surveillance protocol.

Further Reading

  • Bryan CS and Reynolds KL (1984). Hospital-acquired bacteraemic urinary infection: epidemiology and outcome. Journal of Urology 132:494-8.
  • Garibaldi RA, Burke JP, Dickman ML and Smith CB (1974). Factors predisposing to bacteriuria during indwelling urethral catheterisation. The New England Journal of Medicine 291:213-219.
  • Hussain M, Oppenheim P, O'Neill C et al (1996). Prospective survey of the incidence, risk factors and outcome of hospital-acquired infections in the elderly. Journal of Hospital Infection 32:117-126.
  • Krieger JN, Kaiser DL and Wenzel RP (1983). Urinary tract aetiology of blood stream infections in hospitalised patients. Journal of Infectious Diseases 148:57-62.
  • Leone M, Albanese J, Garnier F, Sapin C, Barrau K, Bimar MC Martin C. Risk factors of nosocomial catheter-associated urinary tract infection in a polyvalent intensive care unit (2003). Intensive Care Medicine 29:929-32.
  • Ouslander JG, Greengold B and Chen S (1987). Complications of chronic indwelling urinary catheters among male nursing home patients: a prospective study. Journal of Urology 138:1191-5
  • Platt R, Polk BF,Murdock B, Rosner B (1982). Mortality associated with nosocomial urinary tract infection. New England Journal of Medicine 307(11):637-42.
  • Shapiro M, Simchen E, Izraeli S and Sacks TG (1984). A multivariate analysis of risk factors for acquiring bacteruria in patients with indwelling urinary catheters for longer than 24 hours. Infection Control 5:525-532.
  • Stamm WE (1991). Catheter-associated urinary tract infections, epidemiology, pathogenesis and prevention. The American Journal of Medicine 91(3B):65S-71S.
  • Turck A and Stamm W (1981). Nosocomial infection of the urinary tract. American Journal Medicine 70:651-654.