Strategies for Reducing and Eliminating CLABSI And CAUTI in the Intensive Care Unit

The reduction and elimination of central line-associated blood stream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) is a priority for intensive care units. These infections can cause long-term harm and life-threatening conditions such as sepsis.

The Society of Critical Care Medicine (SCCM) held a session at the 48^th Critical Care Congress that offered best practices for reducing CLABSI and CAUTI infections. Subject matter experts discussed quality improvement strategies as well as overcoming challenges and resistance to change.  We’ve outlined the questions from the session and curated responses.
 
SCCM has been collaborating with the Agency for Healthcare Research and Quality (AHRQ) and the American Hospital Association’s Health Research & Educational Trust (HRET) on collaboratives to reduce CLABSI and CAUTI infection and develop best practices for critical care professionals.

The session addressed several strategies to move quality improvement projects forward:

Comprehensive Unit-based Safety Program
The Comprehensive Unit-based Safety Program (CUSP) is a method that can help clinical teams make care safer by combining improved teamwork, clinical best practices, and the science of safety. The Core CUSP toolkit gives clinical teams the training resources and tools to apply the CUSP method and build their capacity to address safety issues. TeammSTEPPs
An evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals.

Just Culture
A method of understanding human behavior as it applies to patient safety.

Experts discussed factors that subvert successful elimination of device-related ICU infections. They identified contributing factors common to ICUs that interfere with high reliability in infection prevention.

Faculty from this session included: William S. Miles, MD, FCCM, Kathleen M. Vollman, CCNS, CNS, RN, MSN, and Patricia J. Posa, BSN, MSA, CCRN-K

To download the full transcript, visit LearnICU.

How do I manage the education of nurses and physicians when there is high turnover and constant onboarding?

• Each ICU has to use multimodal strategies for education (lectures, videos, real-time short messages, etc.). Use of computer learning can support consistent and structured sharing of didactic information. Huddles are a place to communicate small messages that focus on each component of the bundle. Another way to share and reinforce messages is through blitz emails. But, a big part of ensuring actions are consistent with expectations is daily reinforcement.
• A piece of the daily reinforcement is auditing the maintenance components of the bundle. This should be done by nurse champions so there is coaching and education in real-time. In this way, you can identify drift in clinical practice and address it immediately. Incorporating it into the practice and using your champions are ways to get consistent and constant education beyond computer learning. Another opportunity for reinforcement is to utilize your institution’s nursing shared governance structure with an ICU practice committee. Allowing them to disperse it through their infrastructure out to staff provides an additional focused communication/education process.
• Physician education is also important, but it can be challenging to handle their varying clinical schedules. All clinicians want their patients to do well and utilize evidence-based practices. Physicians need to know their utilization of catheters and infection incidence; share data with them to support new learning.
• With new medical trainees, consider communicating expectations and evidence-based practices at the beginning of the rotation. Using Clinical Nurse Specialists together with attending physicians helps with education and accountability when new residents onboard for a rotation. Select a time to address the new processes, initiatives, and projects for evidence-based practices. The attending presence aids in reinforcing best practices.
• Engaging the senior residents to help train the younger residents helps reinforce practices. Multiprofessional rounding that is scripted and utilizes all members of an ICU team (Nursing, MDs, residents, ACPs, Pharmacy, RT, PT/OT, etc.) to create an independent check for workflows has been a great way to sustain successful gains. Utilizing simulation labs for nurse and physician trainees helps reinforce the best practices around the use of all catheters—not just the insertion technical aspect, but also the adaptive process. Utilizing ACGME regulations for residents in training to highlight system integration documentation is another way to incorporate system-based learning projects.
• Finally, there needs to be strong education in the techniques of catheter placement as well as proficiency training in any updates of techniques. There is also evidence-based literature supporting a two-person placement of all catheters—one to place, and one to observe and assist as needed.

 
How do we manage when clinicians push back on lack of results because they argue, “my patients are sicker”?

• Clinicians become focused on their own patients and a specific way to manage them and lose focus on standards because they are not seeing that other ICUs have similar or even higher acuity than their ICU. There are specialty ICUs (cardiac surgery, neurology, trauma, etc.) that have specific, unique patients with diseases or problems that meet specific catheter needs. By collaborating with other similar units in a program like the AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI, you realize that your specialty ICU is not that unique and there are specialty ICUs that have gotten to zero HAIs. Additionally, many of the evidence-based practices hold true for all ICU patients.
• Alternatives to catheters can be just as reliable for measuring urinary output.
• A urinary catheter can be considered a hemodynamic monitoring device so should be considered when true hour-by-hour urine outputs are essential for managing an unstable patient. Network with like ICUs and learn standardized processes from each similar ICU including use of catheter alternatives to reliably measure urinary output.

 
We are having troubling implementing our nurse driven protocols. What strategies can we use to help integrate these into our multiprofessional practice? How do we empower and engage nurses and physicians in this work?
 

• Nurse Driven Protocols (NDP): NDPs are evidence based and work but must have buy-in by all parties. The development and implementation of the protocol needs education, auditing, and adjusting. In some ICUs, it doesn’t get support mainly due to communication. Education of nursing staff is strong, but there can be lack of education, implementation, and understanding on the physician provider side.
• How do we empower staff? We cannot empower a nurse or physician to do something, but as ICU leaders, we can lay the foundation and create the environment and culture to allow a person to be empowered. There will be problems with nurse empowerment if they get push back from physicians. In other words, if a nurse gets yelled at or there is a frank discussion of, "Why did you pull it out? I didn't order it" – this results in not feeling empowered and problems with using an NDP. Physician engagement is essential in the processes of patient safety. If there are issues, then utilize a physician’s data in catheter utilization and infections and start with the obvious simpler patient issues where a catheter can be removed earlier.
• How do we improve physician engagement? Physicians want to take care of their patients in an evidence-based fashion and do not want their patients to suffer complications. While they may disagree with a new process or protocol, it can mean that they do not know all of the outcomes or the potential harm to their patients, or not wanting to lose control of management decisions. When you have a physician who is not wanting to follow a catheter removal protocol or multi-professional rounds, it is usually due to several factors: time management, lack of formal education, and not being engaged in the new processes. Have physician groups be a part of protocol development. Have specific individualized physician data presented to the physicians in a real-time basis. Have physician peers or chief medical officers assist in engaging physicians in the new guidelines and in following protocols. In doing so, these physicians who were barriers to success can become champions of the process.
• Bladder Scan Guidelines: These allow for earlier removal of urinary catheters and the ability to use alternatives. They can be altered for individual patient needs depending on an issue. Use of bladder scans and in-and-out catheterization allows appropriate adjustment of care around not placing another urinary catheter.
• There can also be an issue with over stressing the NDPs, having the pendulum swinging too far in not placing a urinary catheter even when a patient may need one. A urinary catheter is a hemodynamic monitoring device and should be used when this information is needed (i.e., sepsis, organ failure). Then with a bladder scan protocol, early removal can be instituted along with alternatives to a urinary catheter. No literature supports nor do any of the bundles say, "Never use a urinary catheter." It's actually clinically indicated in that shock patient, because you do want to monitor their urine output hourly and it's not realistic to scan them hourly. So, it is not appropriate to never use these things. There are criteria for when to use a urinary catheter (and for when and what type of central line to use). Your ICU or institution should not let the pendulum swing to never placing a catheter.
• How do I define the patient who truly needs the hourly I and O from a patient that is critically ill and may not require the hourly frequency? The point to make is that it’s not just monitoring the ins and outs, but how are you going to respond to it? Are you going to respond to it every hour or every two hours? Then you need to have that urinary catheter in. Many physicians, and especially surgeons, feel they need hourly outputs for patient management, but it is seldom responded to hourly. If a patient is truly being managed hour by hour, then hemodynamic devices like central lines and urinary catheters should be used. As soon as the indication for a catheter is gone, then it's time to remove it—that's where the balance is between hourly critical management and preventing hospital acquired infections. A great way to utilize this question in multiprofessional rounds is to ask, “are we responding hourly or every other hour to the data?” If you are not, then the use of alternatives can be explored and, unless they have urinary restrictions or retention issues, the catheter can be removed.
• Where can I find examples of nurse driven protocols? Examples of NDPs can be found on catheterout.org, or the ANA CAUTI prevention tool at nursingworld.org. People are using those NDPs on the front end now. Plus, bladder scanning is usually every four to six hours, but can be adjusted based on patient needs. Most people don't urinate every hour, but may need occasional bladder scanning and I/O catheterization every 3-4 hours. It is prudent to have all members of patient management teams or their representatives assist in development of the protocols. This assists in education, implementation, and engagement of these technical and adaptive processes. It will also assist in onboarding new staff and trainees.

 
How do I change the current practices around our blood and urine culturing processes?
 

• By changing the practices around culturing to mirror current evidence and away from pan culturing, this will help prevent unnecessary false positive tests that can result in inappropriate use of antibiotics and antibiotic resistance. If it was your own family member in the ICU, you’d want to make sure the right infection is being treated and you're not off in the wrong direction and treating a false positive.
• Reflex culturing allows a culture to be performed only if a urinalysis is positive. When you need a culture, you need to draw it. It's really the bedside team figuring it out—we need to avoid pan culturing for every fever, because that's where the problems come. Many practitioners have varying training and may have not kept up with the evidence-based practices that are being utilized. There should never be a “pan culture” ordered unless it is in septic shock and it is a life or death situation. Even then, there are techniques to utilize, such as with a urinalysis first, that could be helpful in preventing a false positive sample. So just to emphasize the culture of culturing—it doesn't mean no culture; it's mindfully culturing. So, if you're caring for a patient and their FiO2 needs on the ventilator and their x-ray is showing something different and they spike a fever—that's not when you need a urinary culture, it's probably the lungs. This is what the purpose of the culture of culturing is. It doesn't mean no cultures. Also remember that an off color urine or a funny smell of urine is NOT a reason for a urine culture unless there are concurrent symptoms.
• If a patient has an infection and you can determine the source (pulmonary, urinary, blood, etc.), then a culture should be performed. Obviously if a patient is in septic shock, then Surviving Sepsis guidelines should be followed.
• Methods to teach appropriate culturing techniques include using reference cards or pocket cards for your residents or trainees when they come into the ICU on service. A ring of cards can list protocols and policies in a portable reference for newer staff. Working to support nurse empowerment through leadership actions will allow the nurse to reinforce the use of these protocols. Through focused communication, a second check is created within the workflows.
• Utilizing EMRs for appropriate culturing is another way to make it easy to do the right thing. Having drop down boxes on the culture order sets that emphasize the need for a urinalysis helps support culture processes. The design of the EMR order set could also make sure that all culture orders are separate thereby taking away cultures that happen by default. An example of this is to remove culture orders from admission order sets.

• There is published evidence on the influence of inappropriate ordering of urine cultures. Some institutions have developed decision trees, or urine culture algorithms, to help teams delineate best practices.

 
How do we address the issue of biofilms on catheters that remain for several days?

• There is a fair amount of science on biofilm accumulation. The science of culturing blood peripherally is superior, at least in the literature, and it's the same with the urinary catheter. The APIC infection prevention guidelines recommend if an indwelling catheter has been in place for longer than two weeks, that before a culture is obtained, a new catheter should be placed due to the amount of potential bacterial biofilm. However, there are some studies that show biofilms form on catheters as early as 3-5 days, especially in critically ill patients with a high inflammatory stress response. We have to be mindful of that biofilm. At this time, the existing guidelines recommend replacing the urinary catheter at two weeks time prior to a culture. However, there is literature to offer other practices and this would require your own QI project to evaluate and potentially support practice change specific to the patient population in your ICU.

 
How should an ICU deal with the complex patients that may require longer urinary or vascular catheters in place?

• Some burn centers and specialty surgery ICUs have experienced higher acuity patients with many challenges from severe wounds to anatomical issues. There are ways to adjust these “high hanging fruit” issues and attempt to develop ways to remove catheters earlier on in these more challenging patients. There are alternatives that wick fluid and urine away from patients quite well. There is an alternative to the condom catheter that secures onto the glans penis and does not require securement on the shaft. The neurologic patient with challenges of cerebral salt wasting is a unique type of patient. In these patients, a rapid RCA can be performed with any defects to see if there are times where a catheter could be replaced and not be a source of infection due to uro-biome formation on the catheter. Variation and maintenance practice, one of the biggest ones for urinary catheters, is incontinence cleansing and overall bathing. The process variation in those two nursing activities is pretty significant. Review maintenance practices to ensure a lower risk of infection.

 
Should an ICU use coated catheters (central venous lines and urinary catheters)?

• If you have done all of the insertion, maintenance, and evaluation/assessment components of catheters and you still have a significant infection rate, then consider the use of coated catheters. It is emphasized to really confirm that that insertion and maintenance practices are being done appropriately. If you have a specific population of patients that have higher risk of infections, then consider coated catheters. This is a CDC recommendation

 
How should an ICU manage emergency placed catheters?

• This type of line should be considered for removal or replacement as early as 24 hours or once a patient is stable. This is a great time to even consider removing a central line or urinary catheter and assess if they can utilize an alternative. With central lines, you may consider peripheral lines or mid-lines.

 
What are some novel ways to reduce catheter utilization in an ICU?

• Consider setting up a process for removing catheters prior to leaving the OR and have a discussion that if a catheter is to remain, then explain the reason and the time to consider removing it utilizing nurse driven protocols. The best time to address a catheter to be removed is at the third timeout of an OR case. If a catheter is to remain, then the reasons can then be explained to the ICU team on report and arrival of the patient to the ICU. Another area where catheter removal can be addressed is prior to leaving the ICU as well.
• Emergency departments are an area to look to not place catheters automatically. Educating outside units, such as the ED and OR, can address many unnecessary catheters. Once a catheter is placed and a patient transfers to another unit, the average catheter remains for 48-72 hours. Many of the outside units that send patients to the ICU may need to be instructed in the technical and behavioral aspects of the catheter protocols so that when a patient arrives in the ICU, there is a continuum of care and patient safety practices are already in place.

 
How can mindfulness affect patient safety?

• Mindfulness in preventing hospital acquired infections means that the culture of the unit is all focused on patient safety and preventing infections. It is where everyone has become of one mindset with communication, discussion, and a focus on supporting a positive safety culture. We do this when there is a crisis, a cardiac arrest, or a bad trauma patient—everyone is focused on the outcome. Preventing CAUTIs and CLABSIs are of the same mindfulness mold, where the culture needs to consistently be focused on patient safety.

 
Once zero is achieved, how can an ICU sustain its gains?

• Celebrate success!
• The team must continue to assess if best practices are being reliably provided through process audits. Add independent checks into the typical workflow, such as discussing lines and tubes and their necessity during rounds.
• Address new defects with rapid Root Cause Analyses. Reflect on actions that brought successes toward achieving zero in the beginning, use that to determine what happened for any new infections and troubleshoot the issues, educate, and celebrate.