Guidelines and Training Can Reduce Bladder Irrigation-Associated CAUTIs

Mandatory oncology nurse training on how to manage intermittent bladder irrigation (IBI) for cancer patients led to an 83% reduction in catheter-associated urinary tract infections (CAUTIs) at one oncology center, reported Christine Wallace, MSN, APRN-CNS, a surgical oncology clinical nurse specialist at the University Hospitals Seidman Cancer Center in Cleveland, Ohio, a National Cancer Institute-designated Comprehensive Cancer Center. 

Wallace spoke at the 48th Annual Oncology Nursing Society (ONS) Congress.

There are not yet national standards for IBI. Available recommendations suggest “limited routine irrigation, use of a closed drainage system, and at a minimum, aseptic maintenance of indwelling catheters,” Wallace said.

But nurse adherence with those recommendations is complicated when patients with urologic cancers must undergo postsurgical manual IBI. Making things worse, there are no approved closed systems for irrigation in the US “and manufacturers of indwelling Foley catheters do not recommend using the sample port for IBI,” Wallace noted.   

A retrospective chart review of CAUTI cases in 2020 indicated 15% of cases at the Seidman Cancer Center were associated with bladder irrigation practices, and anecdotal observations suggested inconsistent adherence, Wallace reported.

Postoperative IBI is most common when patients with urologic malignancies have blood clots, Wallace reported. But the center had no guideline for standard of IBI practice and IBI practice was inconsistent; irrigation trays are reused in some cases, and incompletely utilized overall. When IBI was performed, it was not done aseptically or in a sterile fashion, Wallace noted.

The center therefore developed its own IBI guidelines to improve quality of care and reduce CAUTI rates. Advanced practice registered nurses (APRNs) created a work group to review the available medical literature and determine best practices, and to author the guidelines. The team found no National Urological Association IBI recommendations and confirmed that closed system and sterile IBI kits are not available in the US. 

From the available literature, and based on general national infection prevention principles of maintaining a closed system and closed drainage system, the team reviewed published expert opinions and simulated sterile and aseptic IBI techniques. 

The center’s resulting IBI standard of practice was approved by senior nursing and provider leadership and center committees, and all oncology nurses caring for inpatients underwent mandatory training on the new guideline in November 2021. The sterile technique required 2 practitioners to perform, Wallace noted.

CAUTI rates had trended upward during 2021, peaking in November, the month of the mandatory training, with 9 cases per 1000 device days. The following month, there was a steep drop to zero CAUTI cases until April 2022. “Six months post-implementation of the IBI guidelines and education showed CAUTI rates were reduced 83%,” Wallace said.

During 2022 as a whole, none of the reported CAUTI cases followed IBI. The center continues to monitor IBI practice and plans to develop electronic patient medical record order sets for IBI that support the new guidelines. More research into IBI practice is needed to build the evidence base on which national guidelines can one day be formulated, Wallace emphasized.

Other institutions should follow the Seidman Cancer Center’s example, Wallace suggested.

“The lack of clear, evidence-based practice guidelines for the IBI procedure has the potential to negatively impact care of immunocompromised patients with cancer,” Wallace concluded. “A systematic process including literature review, outreach to professional organizations and manufacturers, simulation of new guidelines, and comprehensive education of nursing staff was an effective method to reduce CAUTI.”  

Reference

Wallace C, Sopko E, Supan E. Catheter-associated urinary tract infections rate reduced for oncology patients after APRN-led implementation of a new intermittent bladder irrigation guideline. Oral presentation at: 48th Annual ONS Congress; April 26-30, 2023; San Antonio, Texas.