How the Neurological Intensive Care Unit at UCSF Decreased CAUTI events by 28%

Neurological patients in the critical care setting are uniquely at risk for CAUTI due to cognitive, motor, and sensory deficits. In fiscal year 2016, the Neurological Intensive Care Unit had 32 CAUTIs, which contributed to 42% of the total adult hospital-wide CAUTI harm events.

Beginning FY2017, 8/11 NICU’s goal was to support the institution’s effort to reduce harm events by decreasing CAUTI incidence from FY2016’s baseline of 32 events by at least 2 events (5%).

Team Members:   

  • Theresa Mueller, MS, RN, CCRN Assistant Patient Care Manager 8/11 Neurological Intensive Care Units
  • Susan Chim, MAT, Associate Lean Consultant
  • Janice Elzinga, MSN, RN, CNL, CCRN, Assistant Patient Care Manager 8/11 Neurological Intensive Care Units
  • Kelly Bushman, BSN, RN, CNRN, Unit Director 8/11 Neurological Intensive Care Units
  • Amy Dunne, MS, RN, ACCNS-AG, CCRN Clinical Nurse Specialist – Adult Critical Care
  • Nerissa U. Ko, MD, MAS, FANA, FNCS, Professor of Neurology, UCSF Neurovascular and Neurocritical Care, Medical Director of 8/11 Neurological Intensive Care Units

•        #1 Barrier/Root Cause: Due to an increased risk of urinary retention, incontinence, and altered mental status, patients with acute and chronic neurologic disorders often have extended durations of urinary catheterization. This is problematic considering the duration of catheterization is itself an important risk factor in the development of CAUTI. The risk of acquiring a CAUTI increases 3-7% each day the catheter remains indwelling. The average LOS in this NICU is 3 calendar days with 30% of neurological patients staying 72 hours or greater, often with indwelling urinary catheters in place.

•        Hypothesis: If we can prevent bacterial growth in patients with indwelling urinary catheters, then we can decrease CAUTI.

•        Intervention: Silver alloy coated catheters have natural antimicrobial properties. While evidence is equivocal on their efficacy, these catheters are recommended in clinical populations with a high incidence of CAUTI. For this project, these special catheters were used for patients with a length of stay greater than 72 hours.

•        #2 Barrier/Root Cause: 8/11 NICU had 2nd highest number of urine cultures ordered per 100 pt days across all inpatient units; possibly contributing to high rates of CAUTI due to high volumes of urine specimens sent for culture. Inappropriate ordering of urine cultures may also result in false-positive results, i.e. a colonized catheter or bladder

•        Hypothesis: If urine cultures are reserved for only those patients with positive urinalysis, number of false-positive urine cultures.

•        Intervention: The unit workflow was revised to wait for positive urinalysis results prior to ordering and sending urine specimens for culture. This ensured only urine specimens with a positive urinalysis were cultured, reducing false positive urine cultures results due to colonization.

•        #3 Barrier/Root Cause: Since FY15, greater than 50% of all positive CAUTIs in 8/11 NICU contained E. Coli or enterococcus bacteria, which are bacteria primarily found in stool.

•        Hypothesis: If we can prevent urinary tract contamination from stool, we can decrease the number of CAUTIs.

•        Intervention: One on one clinical bedside education of all RNs and PCAs was provided in situ by unit CAUTI champions and focused on fecal management strategies, proper urinary catheter and perineal cleaning techniques, and appropriate indications of indwelling urinary catheter necessity. 

•        #4 Barrier/Root Cause: There was minimal real-time feedback to front line clinicians on compliance with project interventions as outlined above.

•        Hypothesis: If nursing staff receive real-time feedback on areas needing improved compliance, they can adjust their behaviors to course-correct.

•        Intervention: Distributed information to staff on “root cause” of each CAUTI event in the NICU. This information and feedback provided increased awareness of the project and the progress being made. Additionally, this information serves to empower nurses to effectively advocate to other members of the inter-professional team that may not be aware of unit initiatives. 

Outcome: By addressing the identified barriers and root causes of CAUTI, the NICU decreased CAUTI events by 28% from 32 events in FY2016’s to 23 events in FY 2017.