Eli's Rehab Report

The QI effort didn't increase falls or pressure ulcers, says infection preventionist.

You might think that Madonna Rehabilitation Hospital did a CAUTI pilot project in order to prepare for the quality measure implemented by the final IRF rule. But that's not the case.

"I had wanted to try to lower our overall urinary tract infection rates for the past few years, and we were finally able to focus on it at the end of 2009," says Kristi Felix, BA, RN, CRRN, CIC, the infection control coordinator for the rehab hospital in Lincoln, Neb. Felix does believe, however, that "having the QMs helps the infection preventionist get administrative support for these types of priorities."

In Madonna Rehab Hospital's initial 14-month CAUTI pilot project, which ended this spring, Felix and an interdisciplinary team decreased the rehab hospital's catheter-associated UTI rate from 36.6 percent to 6.6 percent, says a press release on the pilot. Felix presented the findings at the recent annual Association for Professionals in Infection Control and Epidemiology (APIC) meeting.

Getting Rehab Therapists on Board

At first the CAUTI project was going to just include nursing, "with therapy called up in almost a consulting type role," reports Courtney Kossow, OTD, OTR/ L, an occupational therapist for the rehab hospital. Then as Kossow and other therapists took part, "it developed from there," she says. "Usually therapists hear about the plans to address infection control [issues], but we don't typically get involved in how to implement them," Kossow tells Rehab Report. "But this time we did."

Initially, the project team "spent a couple of meetings discussing why patients had catheters, and why they were left in place so long," Felix relays. "Some of the rehabilitation nurses and therapists thought that if someone is difficult to move [for toileting], they should have a catheter. But difficulty with mobility or moving someone isn't a reason for a catheter," Felix stresses.

"Therapists were key" in addressing mobility issues "because they came up with other equipment options such as different types of commodes or use of lifts," Felix tells Rehab Report. The [therapists] worked on making transfers to the toilet easier," she adds.

Also: "There were patients on the night shift who didn't want to get up to go to the bathroom and felt the catheter helped them get sleep," says Felix. But "we try not to encourage use of the bed pan because most patients are going home [and] have to be able to use the bathroom. And with reimbursement and length of stays being shorter, we have to make the most out of the time patients are in therapy. So the more opportunity for therapists [and nurses] to work on functional types of activities, such as using the toilet -- the better." Speech therapists are also involved "as they assess how the patient can make his/her needs known that they have to use the toilet."

Kossow notes that one of the first things that OTs "address with the patients is going to the bathroom again. We let them know there will be lots of support to get them to the bathroom in time to go, and we discuss continence management devices. We also talk about how removing the catheter helps them meet their goals [of going home], and we talk about infection rates associated with catheters."

Good news: The rehab hospital "didn't not have any increased falls or pressure-related areas" due to removing patients' catheters, Felix reports.

Shoring Up Catheter Management Practices

To identify accepted medical indications for indwelling catheters in the pilot study and currently, the rehab hospital uses the Centers for Disease Control & Prevention and APIC guidelines, Felix says.

"For example, we have a lot of patients with spinal cord injury. So one indication [for a catheter] is neurogenic bladder," she points out. Madonna Rehabilitation Hospital also admits people who have major wounds. "And trying to heal a wound affected by urinary incontinence" might be another reason to keep a catheter. Patients who have received renal or urological surgery may also require an indwelling catheter, she adds.

Also: "We have some very medically complex patients who need accurate intake and output, and this may be a reason to keep the catheter in until their condition improves," Felix relays.

Problem: "Before the [CAUTI] project began, we went back and looked at all of our positive culture results for the past two years ... to see how many were related to indwelling catheters," Felix reports. "While these were not all infections necessarily, we did see a bit of a pattern in the kind of bacteria that was growing. There were a large percentage of cultures that grew GI types of bacteria. This led us to think there could be an issue with hygiene."

Solution: Using the CDC and APIC guidelines, the team assessed the hospital's "policies and processes for indwelling catheter insertion, peri- and catheter care, and indwelling catheter bag and tubing management," Felix relays. "Then we did observations to see if our staff was following the best practice guidelines for care of the indwelling catheter."

"We didn't just focus on nursing, but included the therapy staff who move and position catheters and take patients to the bathroom and help patients relearn howto keep themselves clean," Felix says. For example, "physical therapists move the catheter bags when working with patients in the gym and needed to be aware of keeping them below the level of the bladder and off the floor," Felix adds.

Next step: The team is now preparing to start a pilot study on preventing UTI in patients with Traumatic Brain Injury or those who have had a stroke, says Felix. For more information, see the next Rehab Report.