Preventing FRUTI (Foley Related Urinary Tract Infection) in LTACH
While working as the Quality Manager for a LTACH (Long Term Acute Care Hospital) one of my responsibilities was Infection Control. As with most facilities our highest number of infections were FRUTI (Foley Related Urinary Tract Infections). There were a number of factors to consider.
The biggest was NOT getting catheters out as soon as possible. If the doctor doesn't address it then the nurse should ask if there are any reasons the patient still needs the catheter. If not ask for an order to remove it. However, if the foley is needed then it is of the utmost importance that foley care is done at least once per shift.
Our policy was revised to include clear guidelines for care.
Along with q shift peri care, staff was educated on importance of having a leg strap in place below the Y port to prevent tension on it, proper placement of the bag, never opening the closed sterile system and close observation of patient for any symptoms of a UTI. One of the most difficult issues was that many of out patients were placed into Low Boy beds due to high risk for falls. These beds had no place to hang the bag that did not have it touching the floor.
To keep it off the floor it ended up being higher than the bladder.
I called the manufacturer of the beds and the catheters to see if they had any suggestions. They were both completely baffled. I realized it was going to be up to me to figure this one out.
I considered blue pads but felt this would be a fall risk and would easily be kicked aside. I came up with a temporary plan until we could come up with something more permanent.
The foley bag was placed into the small plastic disposable bath tubs. They were less than 50 cents each, much less than the cost to treat an infection. I then set out on my quest to find a fluid impermeable cover for the bags.
Since they would touch the floor no matter where it was placed, the only solution was to protect it from allowing any contamination from the floors. It took a great deal of searching but I finally found just what we needed. The last step was that after each time the bag was emptied the spout was to be cleansed with alcohol wipe then placed back into the holder.
With a clear plan it was now time to not only educate but to get staff "buy in". I asked for volunteers and since the CNA's performed most of the foley care the majority of the team was made up of them with a few LPN's and RN's.
We decided that staff along with myself would police each other. To keep it positive, we decided that when one of the staff observed another correctly performing foley care they were given "tickets" to issue to the person "caught" doing a good job.
Once a staff member acquired a predetermined amount of tickets they were able to turn them in for a small "prize". From start to finish it took about 6 months for our infection rate to drop. We had a Pizza Party to celebrate our accomplishment. Even after we discontinued the prizes staff continued to be vigilent about the foley care and in the end it was the patients who were the real "WINNERS".Last edit by Joe V on Jan 8, '15
Sep 11, '09Hi maggiejrn
Thanks for sharing your experience, you came up with some great ideas. Since you made a number of changes, I am curious which variable influenced the decrease in UTIs. Did duration of the indwelling catheter decrease at the same time as the infection rate decreased? How were the infections measured?
dishesSep 11, '09FRUTI is a poor acronym.
Why not this one: Catheter Related Urine Stream Tract InfectionSep 11, '09Quote from maggiejrnthis is why i will never advance to management, i find this whole concept highly insulting!!!!!!!While working as the Quality Manager for a LTACH (Long Term Acute Care Hospital)
With a clear plan it was now time to not only educate but to get staff "buy in". I asked for volunteers and since the CNA's performed most of the foley care the majority of the team was made up of them with a few LPN's and RN's. We decided that staff along with myself would police eachother. To keep it positive, we decided that when one of the staff observed another correctly performing foley care they were given "tickets" to issue to the person "caught" doing a good job. Once a staff member acquired a predetermined amount of tickets they were able to turn them in for a small "prize". From start to finish it took about 6 months for our infection rate to drop. We had a Pizza Party to celebrate our accomplishment. Even after we discontinued the prizes staff continued to be vigilent about the foley care and in the end it was the patients who were the real "WINNERS".Sep 11, '09Where I worked we got balloons with a ribbon and a happy face sign. Ohhh wheeeee! Then they progressed to little plastic pins in bronze color. IF you got TEN you could trade them in for ONE silver color plastic pins. I liked the balloon better.
The best way to avoid indwelling catheter infection is to take the darn thing out. Intermittent in and out, fastitdious peri care, frequent skin assessment and WATCH the patient.Sep 11, '09After reading all the comments I realized again just how difficult it is to work in a female dominated profession. Yes, I am a woman so it pains me to say this but instead of either pulling out any information that you might have found usefull or just skip it entirely 3 out of the 4 posted replies were negative and petty.
P-RN: My very first paragraph addressed the need to get the foleys out asap. Unfortuneatly this actually ends up falling to the nurse admitting the patient. When you call to give report ask if the foley can be removed. It is everyone's job to ensure what is best for the pt. The "prize" was meant to show positive reinforcement since all too often we only hear the NEGATIVE.
Morte: I am sorry if you were offended by the "rewards". This was my first stab at management and trust me I was lower than low on the totem pole. When you can not get management buy in I am not wasting my time on them. They are not the ones out there on the front line" performing the care. If you remember this was a TEAM effort led by CNA's with a few LPN's and RN's. If this upsets you how do you think a patient who is already extremely ill feels when they unnecessarily end up with a UTI?
hypocaffienemia: What difference does it make what acronym you use as long as the staff understand it. You do realize your suggestion sounds like CRUSTI? As a pt if I heard staff using the word CRUSTI around me I would be offended. The information offered really had nothing to do with the acronym. It was about team work and coming up with a successful plan to decrease infections.Sep 11, '09DISHES: Thank you for the questions and understanding this was more than an opportunity to critique my experience. I believe it was the foley care being done q shift along with all the other hard work by staff that brought our infection rate down. Too many doctors just don't think about things such as foley related infections. There are a lot of nurses out there that would prefer to keep them in just for convenience of less bed changes. If no one is out there advocating for the patient the foley is not going to come out. CDC guidelines were used to determine an active vs colonized infection and at the time we used PHC4 guidelines to determine who "owned" the infection since most of our patients came from acute care hospitals.Sep 12, '09maggiejrn
Thanks for answering my questions. Your suggestion to put the drainage bag in a disposable plastic basin was new to me. My tips for patients who have urine drainage bags and are at home sleeping on regular beds, is to slip the urine bag inside a pillowcase and tuck the ends of the pillowcase in between the matress and the boxspring. Another suggestion is to make a hook by bending a coat hanger and wrapping it with tape and slipping it between the matress and boxspring.
In the future I am also going to suggest your tip to patients as a third option because it may be easier for some patients to manage. Again, thanks for sharing your tips on what you do to help prevent foley related UTIs.
dishesSep 12, '09Could you tell us more about the fluid impenetrable cover that you found?
BTW, good job trying to find positive ways to motivate people. Most places just use fear of getting in trouble. Random positive reinforcement is the most effective method according to psychological studies.Sep 12, '09Quote from maggiejrnYour discussion is very interesting and enlightening, but I think you'll find that hypocaffienemia knew exactly what he was writing, and I doubt that it was a serious suggestion, just an amusing little side note that was supposed to make people chuckle (well it made me chuckle anyway).hypocaffienemia: What difference does it make what acronym you use as long as the staff understand it. You do realize your suggestion sounds like CRUSTI? As a pt if I heard staff using the word CRUSTI around me I would be offended. The information offered really had nothing to do with the acronym. It was about team work and coming up with a successful plan to decrease infections.
I have found that serious stuff works well when there is laughter as it makes people think.Sep 13, '09I think that this may be a huge asset to the nursing profession!
Evidence based practice is so important to our profession.
Is there a way you can provide with data, maybe write it into an article for submission?
Guys the whole idea here is not to reward the staff (which is demeaning, sorry) but to educate us on how to decrease urinary tract infections!!
I think you did an amazing job.
The only thing I would want to see is some graphics, data....to show that this decreased the risks of infections.
Keep going with your ideas! I believe in positivity too! If we all keep looking at the negatives then we are not empowerd to change and help our profession, which needs more change.
Nurses are at the bedsides way more than MD's, patients families, CDC, and other entities. It is up to us to make positive changes for our patients. Even if it is one patient at a time.
-side note: we would get tickets for ice cream if we did a good job on our unit. The funny thing was that no one had time to get an ice cream to eat it. Plus who wants to eat an ice cream when we dont even have the time to eat lunch.Sep 15, '09I'm glad you chose the route of rewarding desirable behavior, as nurses are all too often told that the reason patients have complications is that we're lazy/not doing things right/not vigilant enough. LTACHs are a notoriously busy and difficult setting in which to give care, and my hat's off to anyone who can do well there and still committed to making it better, rather than becoming jaded like so many do.
Does anybody have suggestions on better incontinence management for women? For men, we can give them a pee bottle or put on a Texas catheter if incontinence is the problem. With women, there is no good way to keep urine off the skin. Even for my ladies that can use a bed pan, after a day or so they frequently start showing signs of breakdown from the rims of the pan or excoriation from urine touching the skin. Barrier creams can help, but become a problem when the patient moves her bowels and the cream becomes contaminated but is still difficult to remove from the skin.
Potty chairs can help, but it takes a long time to get one from central. I've had patients who waited for days for one to become available. I've even had them show up two hours after I transferred the patient upstairs! And my intubated ones cannot get up to use them until they get extubated or trached.Last edit by ShyViolet on Sep 15, '09 : Reason: to avoid someone stating the obviousSep 16, '09I am glad to hear you advocate the use of alcohol wipes on the drain of the foley. Working as an LNA, it was how I was trained by my teacher. But it is not what I have found out in the real world. I had a couple of people question me on the need to use alcohol wipes. As far as the bag laying on the floor, that happens a lot and I appreciate your suggestions to end that. It never crossed my mind as an issue since it is what I have seen as practice on the floor as an LNA and a student nurse. Thanks for sharing and keeping us all up to snuff.