Closed Is the Word: Creating a Closed Urinary Catheter System in a Pediatric Intensive Care Unit

ISSUE: Catheter-associated urinary tract infections (CAUTIs) account for 40% of all healthcare-associated infections. Studies show that a closed catheter system has a direct effect on the prevention of CAUTIs. However, this system is not available for the pediatric population. Evaluation of our 12-bed Pediatric Intensive Care Unit (PICU) in June 2003 revealed a CAUTI rate of 9.7 per 1000 catheter days for the previous 15 months and a catheter utilization ratio of 35%. PROJECT: An initiative was started in July 2003 to reduce our catheter days with the goal of decreasing CAUTIs. Despite a 37% reduction in our catheter utilization ratio, there was no change in the incidence of our CAUTIs (for the 15 months post-intervention there were 10.81 infections per 1000 catheter days). Since our outcome was not one we anticipated, a root cause analysis was done. We investigated nursing practices, procedures and products. These analyses lead us to focus on catheter insertion, maintenance practices and product. A survey that included questions about these specific practices was developed and given to all nursing staff in the PICU. RESULTS: The survey on urinary catheter maintenance did not reveal any reported breaches in infection control practices. However, when nurses were questioned about the steps in catheter insertion, 76% answered that connecting the catheter to the collection bag was the final step in the procedure. Based on this information, we developed a plan to change practice in inserting urinary catheters. Our practice was changed to include the connection of the catheter to the collection bag prior to insertion, thus creating a “closed system” from the start. A multi-faceted educational program was provided to all nursing staff to alert them of this change. LESSONS LEARNED: As Infection Control Professionals, we are challenged to seek out methods/technology to improve patient outcomes. We must remember that not all technological advances aimed for improvement in clinical outcomes target every population at risk. Therefore, there will be times we may need to improvise to obtain our outcome. “Necessity is the mother of all invention.”