Aseptic Recommendations, Research Paper Example

Building a Field of Practice for reduction of CAUTI

Clinical question

According to the Center for Disease Control (CDC) in the United States, health care facilities caring for patients that require urinary catheterization offer high-priority recommendation strategies for implementation of risk assessment and management of clinical care of patients with catheters so as to avoid infections (CDC, 2009). In recent years, health care facilities caring for patients that require urinary catheterization offer high-priority recommendation strategies for implementation of risk assessment and management of clinical care of patients with catheters so as to avoid urinary tract infections. Parallel concern regarding cardiac patients with central venous catheter insertion points to the critical need for attention to sterilization in treatment.

The CDC Healthcare Infection Control Practices Committee (HICPAC), 2009 guidelines define the parameters of aseptic technique with,

“a strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (e.g. aseptic technique) supported by low to very low quality evidence” (CDC, 2009).

According to the CDC the institution of quality improvement (QI) programs is toward 1) assurance of appropriate utilization of catheters; 2) daily identification of catheters requiring maintenance and/or removal; and 3) to ensure adherence of nursing and medical staff to hand hygiene and proper care of the catheter patient. Demonstrated models of comprehensive care of post-procedure catheter insertion to removal are evidenced to include: a system of alerts, nursing guidelines and protocols, training and patient education on catheter and cleansing, and algorithm instruments for perioperative catheter management (CDC, 2009). The latter must include: 1) procedural steps for placement and removal; and 2) protocols for management of postoperative urinary catheterization for prevention of catheter acquired urinary tract infection (CAUTI).

Appropriate catheter use as defined by the CDC follows recommended criteria for determination of patient requirements regarding indwelling catheters. Patients not recommended for use include nursing home patients for management of incontinence. Aseptic insertion must only be done by properly trained assistance, and may include nursing or other hospital staff, family and patient application of correct techniques and maintenance. Acute care hospital settings are mandated to use aseptic cleaning techniques and sterile instruments, with ongoing maintenance of a closed drainage system and unobstructed flow of urine (CDC, 2009).

In the United Kingdom, the Department of Health’s (DH) Essence of Care instrument outlines proper protocol for application of aseptic techniques in catheter insertion. In Mangall and Watterson (2006), Principles of aseptic technique in urinary catheterization notes that most nurses are keenly aware of the importance of sterilization measures toward mitigation against the careless use of an unclean instrument may introduce germs into the bladder – the primary cause of inflammation which leads an extended, and serious painful condition (Mangall and Watterson, 2006). Urinary catheterization is one of the most common healthcare interventions with millions of inserted annually in the UK, and approximately twenty five percent of hospitalizations requiring the procedure. Awareness of the dangers of catheter prompted urinary tract infections (UTI) is of central interest in nursing protocols, as nurses typically attend to the procedure.

Guidelines for UK practice for the diagnosis and management of methicillin-resistant Staphylococcus aureus (MRSA) infections has been central to avoidance of CAUTI caused by catheter insertion in hospital patients. The benefit of aseptic techniques and in practice settings is two-fold: 1) better patient care; and 2) reduction of the overall prevalence of health-care associated infections (HCAI), sometimes known as hospital acquired infections (HAI). Estimates of HCAI contraction in the UK are presently proximate to 300,000 patient cases per year. CAUTI is serious in that it leads to significant morbidity, and the risk of acquiring harmful bacteriuia is about five percent of patient cases per day. Of that percentage, approximately 1-4 percent will develop bacteraemia and 13-30 percent will die as a result (Mangall and Watterson, 2006).

Failure to adhere to, or even obtain adequate training in the area of CAUTI risk reduction meet criterion for review according to the standards set forth in the Nursing and Midwifery Council’s Code of Professional Conduct in the UK. Aseptic techniques are subject to mandate, yet practices vary to an extent institution to institution (Mangall and Watterson, 2006). Healthcare professionals are warned of the three (3) ways that patients contract CAUTI, and multifaceted problems might arise due to: 1) poor aseptic technique upon insertion; 2) via intraluminal advancement due to colonization of the drainage bag; and 3) via extraluminal advancement due to the colonization outside the catheter. Method of insertion of the indwelling device impacts risk of infection. Individual responses are furthered by external factors like: age, underlying disease, prior drug therapy, and surgery related foreign bodies. Risk prevention might not always be achieved but offers foundation to national nursing practice standards.

The protocol is a step-by-step ‘how to’ set of guidelines offered in publication by the DH annually. Topics such as Saving Lives: a Delivery Programme to Reduce Healthcare associated Infection Including MRSA, 2005 and Essential Steps to Safe, Clean Care, 2006 provide updated procedural paths for maintaining competent aseptic preparation, insertion and drainage system flows without harming or irritating the urethal meatus (Mangall and Watterson, 2006). Safe insertion techniques include: 1) choice of catheter size, with specific guidelines for children and male adult patients; 2) selection of catheter types based on projected duration of insertion, with silver alloy offering risk reduction of symptomatic CAUTI; 3) antibiotic prophylaxis; 4) continuous handwashing; and 5) scheduled audit of the catheter.

The National Audit Office (NAO) for healthcare oversight in the UK indicates a range of potential clinical practice guidelines regarding HCAI mitigation and those variations in catheter policy compliance create a potential gap – allowing both institutions and practitioners a wide margin of error in interpretation and application. Concern over ‘catheter apathy’ is cited within more recent publication of guidelines, so that responsibility to the obligation of aseptic practice is taken as a serious transgression of national healthcare standards and professional duty to patients (Mangall and Watterson, 2006). The aforementioned catheter safe insertion techniques should be undertaken by competent practitioners, as patients typically require catheter insertion immediately post surgery and other serious clinical procedures.

Essential attention to elimination of post-procedure micro-organisms reduces likelihood of those infectious bacterial agents entering wounds or susceptible sites. Aseptic procedures remove or kill those agents from hands, instruments, and patient wound areas. All post-procedure sterilization steps apply. Each component should be carried out in every catheter insertion and maintenance activity, including: 1) handwashing even when sterile gloves are used as colonized and transient bacteria comprised of mainly Gram-positive organisms might introduce MRSA to sutured or wound sites; 2) personal protective equipment during invasion procedures for achievement of ‘no touching’ technique, with contaminated gloves removed and replaced with intermittent hand washing and sterilization in between; 3) maintenance of a sterile field with new catheter packs laid out on sterile trolleys accompanied by requisite sterile procedure elements (i.e. alcohol-impregnated wipes) for resolution of all contamination beyond mere disinfection; 4) safe techniques also include informatics supplied from medical policy, adhered to by healthcare staff, and offered to patients during hospitalization toward furtherance of in-patient and aftercare including directive for prescription of antibiotic prophylaxis (Mangall and Watterson, 2006).

Personal protection measures extend to patient care with aseptic cleansing recommendations. When the catheter is inserted meatal cleansing involves an mechanical removal of exudates and smegma, so the area is inevitably sensitive (Mangall and Watterson, 2006). Emphasis on infections that can occur extraluminally should be attended to with unperfumed soap and water and disposable cotton swab. Principles of aseptic techniques should always encompass: 1) patient informatics on main elements of CAUTI risk; 2) an audit of those aspects toward accurate record of the asepsis; 3) known variance in practices should be identified with clear directive; 4) fixed procedural order; 5) time and cost efficient; and 6) centralize hand washing practice as priority.

In recent years, health care facilities caring for patients on both sides of the Atlantic have given priority to strategies directed at the ratification of standardized, recommended best practices for implementation of aseptic practices. In the United States, evidence based practice recommendations include incorporation of risk assessment and management procedures into institutional and clinical care environments toward elimination of CAUTI in catheter patients. An evidentiary problem in institutional practice across the board, the persistence of CAUTI in response to low to poor quality record of information on patient care and also aseptic practices presents a case for recommendation and standardization of a quality improvement (QI) model. Comparative analysis of the two national healthcare models is illustrated in Evidence Matrix Tables 1 and 2.

Conclusion

Oversight of hospital and clinical care institutions regarding responsibility and attendant liability to a ‘duty of a reasonable standard of care’ to patients by medical staff has led extensive query on options for creating better practices of HCAI and HAI mitigation. Healthcare informatics and related alert technologies offer much in terms of a viable, integrated solution toward realization of future QI based catheter insertion protocol, sterilization and treatment.

Works Cited

CDC recommends QI to reduce CA-UTIs (2009). Implement based on facility risk assessment. Healthcare benchmarks and quality improvement, 55.

Magnall, J. and Watterson, L. (2006). Principles of aseptic technique in urinary catherisation. Nursing Standard, 21 (8), 49-56.