Running head: CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 1

Catheter-Associated Urinary Tract Infections

Ammon Jensen BYU-I SN

Brigham Young University Idaho

NURS 420 Understanding Nursing Research

Sara Hawkins

April 5, 2017
CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2

Catheter-Associated Urinary Tract Infections

Introduction

Healthcare associated infections (HAIs) have been plaguing the hospitals in the United

States and other modernized countries. Research, policies, and procedures are directed towards

the reduction of these infections. Most HAIs are preventable with minimal effort such as hand

hygiene. One HAI in particular, catheter-associated urinary tract infection (CAUTI), has had

been studied but not effectively dealt with. Although there have been studies comparing

technique and different types of indwelling urinary catheters, the reduction of CAUTIs is non-

existent. This study is to understand the disconnect between the evidence-based research and

implementation.

Background

In 2011 the Centers of Disease Control (CDC) reported that there were 93,000 urinary

tract infections (UTIs) that occurred during a hospital stay. Of 93,000 UTIs, about 75% were

catheter-associated infections (Center of Disease Control, 2015). The most influential factors

contributing to the infections are duration and incidence of indwelling urinary catheters

(Bernard, Hunter, & Moore, 20012). There is a notable difference in rate of infection when

considering the material used in the indwelling catheter. Indwelling catheters formed with latex

material had a slightly higher rate of infection as compared to catheters made with nitrofurazone

silicone (Lo et al., 2014). Even though there are ways to reduce CAUTIs, it is estimated that

13,000 deaths are associated with UTIs (Center of Disease Control, 2016).

Significance

Millions of people enter into hospitals each year. There is 15-20% possibility of having a

catheter inserted during hospitalization (Center of Disease Control, 2015). In some instances
CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 3

catheters can be avoided, but catheters are essential in some plans of care and operations.

Catheters are needed when the patient cannot urinate on their own or when they are incontinent

due to paralytics and anesthesia during an operation. This exposes them to the possibility of

having a catheter-associated urinary tract infection (CAUTI). Hospitals are conducting research

to prevent CAUTIs. Many strategies are being tested to confirm the most reliable way to prevent

infections related to indwelling urinary catheters. Nurses as well as physicians are forming teams

to analyze the data and create guidelines that will prevent infections associated to indwelling

urinary catheters (Lo et al., 2014).

Problem Statement

Although other healthcare-associated infections such as central line-associated

bloodstream infections (CLABSI), surgical site infections (SSI), and hospital-onset methicillin-

resistant Staphylococcus aureus (MRSA) decreased between the years 2008 and 2014, the

amount of CAUTIs did not (Healthcare-associated Infections, 2016). Interventions such as hand

washing and disinfection have been introduced to reduce the amount of other hospital-associated

infections, but have not been effective in reducing the amount of CAUTIs in the space of 6 years.

Duration and incidence of indwelling urinary catheters have been found to be the most influential

on CAUTIs, but protocols are either not being taught, or not being followed.

Nightingales Environmental Theory

During the Crimean War, Florence Nightingale took care of soldiers that were injured but

also had infections that were not related to their injuries. Noticing the poor environment, she

started to make changes that increased the sanitation of the area which the soldiers were being

cared for. The changes she made reduced the percentage of deaths from 42 to 2. Nightingales

Environmental Theory focuses on the environment affecting the health of the patient (as cited in
CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 4

Nursing Theorist, n.d.). Categories listed under the environment included fresh air, nutritional

diet, cleanliness, quiet, and pure water (Nightingale, 1992).

Link between Nightingales Theory and the Problem

As Nightingale reasoned that the environment affects the health of an individual, it can be

reasoned that an external device such as an indwelling urinary catheter can affect the health of a

patient. Naturally the body is fighting foreign objects in the body. One such response is

inflammation caused by the bodys rejection of the foreign object. The increased duration of the

catheter leads to an increased possibility that the patient will have a urinary tract infection (UTI)

(Lo et al., 2014). In a study of the influence of Nightingales theory on modern practices,

Zborowsky (2014) found that a consequence of decreased resources is errors (2014). One

resource that is in short supply and mentioned by Zborowsky (2014), is education opportunities.

Continuing education is essential to maintain evidence-based practice. Errors made by nursing

and physicians can lead to infections such as a UTI. Renewed education is one resource that is

lacked among many medical staff members across the nation. Although there is evidenced-based

research leading to new techniques or methods which increase patient satisfaction and a

reduction in infection, these evidence-based practices are not being implemented by medical staff

(Melnyk et al., 2016).

Research Methods

It is hypothesized that if hospitals educated nurses and physicians on current evidence-

based CDC guidelines for indwelling urinary catheters and the staff followed the CDC

guidelines, then the amount of CAUTIs will be reduced. Nightingale encouraged the reduction of

environmental hindrances she thought contributed negatively to the patients health. The negative
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environmental factors contributing to CAUTIs are the indwelling urinary catheters and the lack

of current evidence-based practice from the medical staff.

Design

In this study a quantitative quasi-experimental research study will be done using a

comparison group and an experimental group. The purpose of the research is to find a cause and

effect on education of indwelling urinary catheters and the amount of CAUTIs (Grove, Gray &

Burns, 2015). The comparison group will have regular treatment with hospital staff that has not

received further CDC guideline training proceeding in their normal patterns of care with

indwelling urinary catheters. The experimental group will have medical staff educated on the

evidence-based guidelines of indwelling urinary catheter use provided by the CDC. Participants

will be assigned randomly into either the experimental or comparison group. The staff in the

experimental group will receive training for no less than 12 hours on the CDC guidelines. In the

experimental group, each staff member will be educated on current CDC guidelines from the

Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009 (CDC, 2009).

The training will include when to eliminate unnecessary catheterization for procedures, duration

of catheterization when required, and proper technique. There will be a form to fill out to

measure whether or not a patient received a UTI due to their stay in the hospital.

Population

The study will be done at 3 mid-sized hospitals in Idaho State. Patients will be included

in the population if they are male between the ages of 20 and 50 and being prepared for an

operation. The patients will be excluded if they already have a UTI upon admission or before

catheter use. The patients will be selected using systematic sampling. Every third male will be

part of the sample unless they refuse. They will be randomly assigned to the comparison group or
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the experimental group. The medical staff will be randomly chosen on the each operations

preparation floor.

Ethical Considerations

In this study protecting human rights is essential. This study will be conducted in an

effort to avoid physical and mental suffering. The participant will voluntary and have the choice

to refuse the experimental treatment. The individual will have the ability to end in the

participation of the experiment at any time during the experiment process. If afterward the

experimental treatment is effective, those in the comparison group will have the opportunity to

receive the same treatment. Each participant, both medical staff and patient, will have full

confidentiality, privacy, and anonymity. Every participant will be informed thoroughly of the

procedure and experiment before signing a consent form. Excluded from this experiment will be

those that have insufficient autonomy due to mental incapacities. This experiment will be

brought before the institutional review boards of each hospital to receive approval before

experimentation (Grove, Gray & Burns, 2015).

Annotated Bibliography

Bernard, M. S., Hunter, K. F., & Moore, K. N. (2012). A review of strategies to decrease the

duration of indwelling urethral catheters and potentially reduce the incidence of catheter-

associated urinary tract infections. Urologic Nursing, 32(1), 29-37.

This was a review of the many quasi-experimental studies done on the effects of duration

and incidence of indwelling urinary catheters and the prevalence of catheter-associated

urinary tract infections. This article is recommended for nurses. Michael S. Bernard is a

Nurse Practitioner at a clinic in Ontario, Canada. Kathleen F. Hunter and Kathleen N.

Moore are both doctorates in nursing. They conducted this review of studies to identify
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evidence-based practices used to reduce CAUTIs. For their review they used the key

words: Catheter-associated urinary tract infection, indwelling urinary catheters,

informatics, hospital-acquired infections, and bacteremia. Although there were many

experiments that improved the incidence rate of CAUTIs, they found that there was not

one method used that significantly decreased the rate of CAUTIs more than another

method. This article provided that duration was the greatest risk factor in developing a

CAUTI.

Lo, E., Nicolle, L. E., Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., . . . Yokoe, D. S.

(2014). Strategies to prevent catheter-associated urinary tract infections in acute care

hospitals: 2014 Update. Infection Control & Hospital Epidemiology, 35(S2).

This was a systematic review of previously published guidelines established by MDs

such as Evelyn Lo, Lindsey E. Nicolle, and Susan E. Coffin to name a few. The review

and update to the guidelines to prevent CAUTIs and other healthcare-associated

infections was put together by Society for Healthcare Epidemiology of America (SHEA).

SHEA also worked with Infectious Diseases Society of America (ISDA) and American

Hospital Association (AHA). This article is recommended for nurses. Concerned by the

amount of CAUTIs in the United States, they collaborated together to update the

guidelines previously established in 2008 to prevent CAUTIs. This article was useful in

noting the comprehensive effect of CAUTIs on the population and hospitals. It was stated

in the article that the most common infection acquired in hospitals is CAUTIs. CAUTIs

lead to lengthened stay and increased morbidity. These guidelines, if implemented, will

decrease the current rate of CAUTIs in the healthcare system.

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Mori, C. (2014). A-voiding catastrophe: Implementing a nurse-driven protocol. MEDSURG

Nursing, 23(1), 15-28.

Candace Mori was working at Wooster Community Hospital, Wooster Ohio on the

Medical/Surgical Unit with her masters in nursing and received certification as an adult

health clinical specialist. This article is recommended for nurses. In the literature review

before this experiment, it was found that nurses were noncompliant to nursing protocols

or without knowledge of new protocols. Mori viewed previously charted data to find the

rate of CAUTIs for quantitative inspection of the problem. Mori then used a measurement

tool to gather information after a protocol was installed. The study was to evaluate

protocols on duration of indwelling urinary catheter placements and the incidence of

placement. Mori found that after implementation of protocols there was a reduction in

CAUTIs by 0.42%. This article explored two depths of the protocol, the actual protocol

and compliance to the protocol.

Strouse, A. C. (2015). Appraising the literature on bathing practices and catheter-associated

urinary tract infection prevention. Urologic Nursing, 35(1), 11-17.

While being a clinical director of surgery, neuroscience, and orthopedics for Wellspan

Health in York, PA Abigail C. Strouse worked on a systematic review of HAIs in general

with a focus on CAUTIs. This article is recommended for nurses. This review was

seeking evidence on the effects of bathing and cleansing practices on CAUTIs. The

author sought to see evidence to suggest which type of bathing practice should be used to

prevent CAUTIs. The evidence suggested that using plain wipes rather than

chlorhexidine gluconate wipes is more effective and also that water basins are an

ineffective way of bathing as bacteria was found in 98% of the basins. This study was
CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 9

also informative about the unsuccessful effort of healthcare providers to reduce the

amount of CAUTIs between the years 2010 and 2013. This review is also effective in

describing the effects of CAUTIs on the hospitals and how the government plans on

punishing the hospitals inability to reduce CAUTIs.

Implications

Nursing Knowledge

A major source of healthcare-associated infections is the lack of knowledge of evidence-

based practice. Two variables affecting the CAUTIs in particular are duration and frequency of

use of indwelling urinary catheters. The knowledge gained from this study has the potential to

further raise an awareness of the education needed to perform evidence-based practice required

to reduce the risk of CAUTIs.

Nursing Theory

Nightingales environmental theory was physical objects that were around the patient (as

cited in Nursing Theorist, n.d.). The findings from this study support Nightingale that the

surrounding physical environment has an effect on patients based on the knowledge of hospital

staff members on indwelling urinary catheters being placed or how long it would remain. The

findings have the potential to contribute to new theories surrounding nursing competencies and

decision making by finding the source of evidence-based knowledge deficit. Findings could also

influence decision making made by both nurses and physicians on how and when to use

indwelling urinary catheters.

Nursing Practice

The influence of this study has implications for nursing practice in the development of

policies and procedures regarding indwelling urinary catheter use. The policies would form
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concerning the duration and the incidence of catheterization. Policies could also be placed

concerning the competency of nursing procedures. Policies may also require nurses to be tested

on the knowledge of current indwelling urinary catheter guidelines.

Improving Patient Care

The purpose of a hospital is to improve the life of the patient and patients family. If

patients receive a new complication, such as a CAUTI, then it may extend their stay and increase

the time it takes to improve the patients life. The cost of the stay will also affect the patient as it

may adversely affect their finances. Holistic care would take in consideration the effects of the

cost. Effectively teaching evidence-based practice on indwelling urinary catheters will improve

the patient care by reducing further complications related to stay at the hospital. The hospital

staff will more effectively care for the patient with proven methods of reducing CAUTIs. The

implementation of education classes would be relatively simple and feasible. The nurses could

receive training for a specified period of time and receive certification from the hospital as is

done with other trainings in the hospital.

Recommendation

A future study that should be considered is a qualitative grounded theory study about the

knowledge of nurses on evidence-based practice concerning indwelling urinary catheters. This

study could open the understanding of how competent nurses feel about their knowledge of

evidence-based practice. It would also provide understanding on where evidence-based practice

is not being communicated or taught. It could be comparative of new graduates, nurses with five

years of experience, and nurses with ten plus years of experience. Knowledge would be gained

about how experiences have affected practice and which generations of nurses are competent

about evidence-based practice.

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Conclusion

The reviewed literature suggests that nurses are deficient in evidence-based practice

knowledge. There is an argument that the nurses needed to be taught evidence-based practice as

they continue their career. Education is essential in reducing HAIs and more specifically

CAUTIs. The disconnect between evidence-based research and implementation in practice is the

deficit of knowledge. Nurses do not know the guidelines produced by the CDC and it has

allowed continued rate of catheter-associated urinary tract infections.

CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 12

References

Bernard, M. S., Hunter, K. F., & Moore, K. N. (2012). A review of strategies to decrease the

duration of indwelling urethral catheters and potentially reduce the incidence of catheter-

associated urinary tract infections. Urologic Nursing, 32(1), 29-37.

Center of Disease Control (2015, October 16). Catheter-associated urinary tract infections

(CAUTI). Retrieved from https://www.cdc.gov/hai/ca_uti/uti.html

Center for Disease Control. (2009, December 29). Guideline for prevention of catheter-

associated urinary tract infections 2009. Retrieved from

https://www.cdc.gov/hicpac/cauti/001_cauti.html

Center of Disease Control (2016, October 05). Healthcare-associated infections. Retrieved from

https://www.cdc.gov/hai/surveillance/index.html

Grove, S., Gray, J., Burns, N. (2015). Understanding nursing research, 6th Edition.

Lo, E., Nicolle, L. E., Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., . . . Yokoe, D. S.

(2014). Strategies to prevent catheter-associated urinary tract infections in acute care

hospitals: 2014 Update. Infection Control & Hospital Epidemiology, 35(S2).

Melnyk, B. M., GallagherFord, L., Thomas, B. K., Troseth, M., Wyngarden, K., & Szalacha, L.

(2016). A study of chief nurse executives indicates low prioritization of evidencebased

practice and shortcomings in hospital performance metrics across the United States.

Worldviews on EvidenceBased Nursing, 13(1), 6-14.

Nightingale, F. (1992). Notes on nursing: What it is, and what it is not. Philadelphia: Lippincott.

Zborowsky, T. (2014). The legacy of Florence Nightingale's environmental theory: Nursing

research focusing on the impact of healthcare environments. Health Environments

Research & Design Journal (HERD) (Vendome Group LLC), 7(4), 19-34.