Preventing FRUTI (Foley Related Urinary Tract Infection) in LTACH

[maggiejrn]

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".

[Becky8]

I 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.

[Wishinonastar, BSN]

I am a QI nurse in home health and am looking at improving this outcome in our 2010 project year. It is a tough outcome. Glad to hear you had results, and your ideas are good ones. Thanks for sharing. Long term foleys are an endless source of frustration for all of us, and the poor patient who has recurrent UTIs must suffer terribly. I often see staff plop the bag on the patient's lap when transferring from chair to bed, etc. Especially in PCH settings. I think teaching the staff in these facilities will definitely be a part of my plan. Your patients are lucky that you are so motivated. Great work!

BTW we have been suggesting patients keep the bag in their hospital plastic basin or a clean bucket for ages. At home there is no one to keep an eye on them and they often end up leaking since the caths and bags are only changed monthly. Home beds also have no siderails usually, so they either jerry rig (sp?) a hanger, or hook them on the footboard post (hard to reach). Hence the basin.

[HazeKomp, BSN, RN]

Is there a non-offensive way to re-teach and reevaluate how experienced nurses place foley catheters? On occasion I just happen to be at a bedside when another RN is placing a foley...and am appalled at their technique, or lack thereof! They often have poor exposure of the urethra, often contaminate the area by relaxing their "exposing" fingertips between each betadine wipe, and let go of the labia when advancing the catheter thereby contaminating the catheter.

I have to work closely with these folks, and I am FAR from a perfect nurse... BUT I have very, very meticulous about my catheter insertion technique.

Any hints?

[champion#1]

maggie

Thanks, for this information. I am the nurse educator for a LTACH facility. What a wonderful idea to empower staff in helping to prevent FRUTI. I am going to pass this information to our infection control nurse as well. We use the Low Boy beds for our high fall risk patients also. It is a challenge to prevent FRUTIs. I applaud your efforts and keep up the good work.

Wen-Wen:yeah::loveya:

[Wishinonastar, BSN]

Is there a non-offensive way to re-teach and reevaluate how experienced nurses place foley catheters? On occasion I just happen to be at a bedside when another RN is placing a foley...and am appalled at their technique, or lack thereof! They often have poor exposure of the urethra, often contaminate the area by relaxing their "exposing" fingertips between each betadine wipe, and let go of the labia when advancing the catheter thereby contaminating the catheter.

I have to work closely with these folks, and I am FAR from a perfect nurse... BUT I have very, very meticulous about my catheter insertion technique.

Any hints?

If you are a staff nurse, you must involve infection control in this. If it comes from you they will see you as a threat and a know it all. I suggest a general review of the techniques for everybody - maybe a video from the local nursing school or something? I am sure there is information out there. Then, have the staff do competency testing. It is going to be offensive no matter what but we all forget things and need a review sometimes. If it comes from the infection control dept. as a "project" it will be better accepted. In the name of QI or education nurses will at least understand why.

[guniwan]

Great idea to share maggiejrn. Kudos given

[Cyn2school]

I was a Special Education teacher who used motivators like tickets/trinkets for my students with mental retardation and Autism. I think a better buy in would be evidence based education presented @ informal in services with ceu units offered for CNA's. Skip the tickets and treat the CNA's and your peers like the health professionals they are.

[paul cloonan]

Thanks you, great article. We were having the same problems with the Foley bag touching the floor when the bed was in the lowest position also. What I had maintenance apply was hooks on the foot boards, which maintained the gravity for drainage and kept the Foley bags off the floors. We used the 3M self adhesive hooks. It was your article that inspired this. Thanks

[goodneighbor]

Thanks! I think the idea to place the bag inside one of those pink buckets is wonderful. It is true that low beds make it almost impossible to hang a bag. I also like the idea of using an alcohol wipe after emptying the bag. Tell me this.. I worked at a place that advocated "changing the bag" once a month (for those who had permanent catheters). This sounds like you are breaking a sterile field, although on the other hand it does seem like it cannot stay there forever. It was a LTC and patients had their foleys for months. My Lewis says dont break a sterile field. What is current best practice?

[cory39]

Wow, this post amazes me. For one, I cannot believe that nurses were allowing the catheters to be higher than the bladder, just to keep them off the floor. Where are your critical thinking skills? Two, it is a closed system, and I highly doubt that you were getting your infections from having the bag touch a floor. What does the bag touch when you hang it? Or put it anywhere else for that matter? I find it absolutely ridiculous that you would think infections are happening this way. You might want to focus your energy on training your staff to clean around the catheters and I would also look into starting a protocol where nurses can remove foleys without a doctors order if certain criteria is met. Most infections come from having them in for to long.

If your not part of the answer, your part of the problem. In this instance, I would have to say that your part of the problem

[tcroc]

This article was very helpful to me. I am a student nurse, and I am currently in clinical at a LTC facility. I have a patient that has a foley that stays in, and is always getting UTI's. Its mostly because the cna's that turn him aren't using proper technique. Twice Ive seen them raise the bag over patient to the other side of bed, and once I found it on the bed next to him! It frequently is touching the floor, and Ive told the RN on the floor about teaching the cna's. I am only there 2 days a week, I cant imagine what is happening when I am not there. I like the idea to use a disposable wash tub.

thanks

PS to cory39, the first thing I learned was that the floor of a facility is the dirtiest place ever, never touch it! never touch anything that has touched it! I place the soles of my shoes in a 1:10 bleach solution every night! They never go inside my house! If the port on a foley bag touches the floor, believe me infection is possible!!

[cory39]

TCROC, if you like the idea of the disposable wash tub, how is that different than the bottom of the catheter touching anything else? None of what the bag touches is even close to being sterile so you cannot possibly say that it is the floor that is causing the infections. When the port opens, urine flows out and down, not up and in. When the port is closed, it's closed and sealed off. So you need to make up your mind on where you say the infections are coming from. Is it because of the CNA's that are turning the pt? Is it because the foley bag is on the bed next to him? Or is it because your only there 2 days and therefore the pt. could not possibly be getting the right care? Sounds like to me that pt. has had a foley catheter in for way to long and THAT my dear is the source of your UTI's, NOT because the bag was touching the floor, NOT because the CNA's were turning him wrong, NOT because the bag is on the bed.

The point I'm trying to make is that if you are going to say that the cause of the infections is because the bag touches the floor, then you also have to say that the bag cannot touch ANYTHING else that is not sterile. And another thing, your probably not in a position where you can be telling the nurses that work there how to do their job.