The Effect of Catheter Associated Urinary Tract Infection (CAUTI)

Bundle of Care: A Systematic Review

Wardah Fauziah

, Nana Rochana

and Achmad Zulfa Juniarto

Department of Nurse, Faculty of Medicine, Diponegoro University, Semarang, Indonesia

Faculty of Medicine, Diponegoro University, Semarang, Indonesia

Keywords: Catheter, Care, CAUTI Bundle.

Abstract: The aim of this paper was to determine the effect of CAUTI bundle of care in reducing and preventing the

incidence of CAUTI. The inclusion criteria of this review were; experimental studies, adult patients as

samples, and urinary catheter installation for a minimum period of 72 hours; while the exclusion criteria was

patients with worsening conditions. The literature search was done through 6 bibliography databases

(CINAHL, Scientdirect, Proquest, Pubmed, Google Scholar and MEDLINE) from 2014 to 2018 in English

language using the keywords; CAUTI, urinary catheter, protocol, guideline, and bundle of care. A total of

171 articles had been identified but after the selection process, only 6 articles met the criteria. The selected

articles then were critically appraised using Critical Appraisal Skill Program (CASP). The result showed

that CAUTI bundle of care had a significant effect to reduce and prevent CAUTI. The CAUTI bundle

consisted of assessment, aseptic technique, catheter care, catheter removal if there was no further indication,

and catheter selection. This review recommends that the CAUTI bundle of care should be implemented in

Indonesia, in which no prior published study reported, for the best evidence of care.

1 INTRODUCTION

The Center of Diseases Control and Prevention

(CDC) defines Catheter Associated Urinary Tract

Infection (CAUTI) as an infection in patients who

have or still use an indwelling catheter. (Fletcher,

Tyszka, Jeanne T. Harrod, Molly. Fowler, Karen E.

Fowle. Saint, Sanjay. Krein, 2016). The biggest risk

factor is the use of catheters exceeding 6 days; it can

be said that CAUTI occurs because of long-term

catheter placement, not in accordance with the

indications and lack of aseptic procedures during

catheterization, both on the device and the medical

staff (Theobald, Resnick, Dittus, & Roumie, 2017).

The impact of CAUTI is the duration of hospital

stay, unnecessary morbidity and motility, and

increased costs for hospital care. Patients taking

catheters have a 3 times greater risk of being

hospitalized for longer periods of time and longer

antibiotic use, even reports say that the organism

that causing Urinary Tract Infection (UTI) due to

catheterization is an organism that has been resistant

to many antibiotics. If it is not immediately treated,

it will cause urosepsis and even death which reaches

9,000 cases per year. It is estimated that 17% - 69%

of UTI due to catheterization can be prevented by

good infection control (Semaradana, 2014).

Lee (2017) states that the incidence of catheter-

related urinary tract infections (CAUTI) was 30% of

the overall incidence of infections in hospitals in

Singapore (Lee, 2017). Catheter use is the most

common cause of urinary tract nosocomial

infections. The risk of bacteriuria is related to the

length of catheterization. The risk of bacteriuria

increases by 5-10% per day after catheter placement.

Bacteria can occur 90-100% in long-term catheter

use. Bacteria that occur are usually asymptomatic

(Tarmono, Renaldo, & Ghinorawa, 2015).

Some evidence based interventions had been

reported to reduce CAUTI incidences (Saint et al.,

2009). These interventions then were developed by

CDC becoming a bundle of care as a guidelines.

This guideliness is called CAUTI bundle of care.

(Josephine Anne Navoa-Nga, Regina Berbab, Victor

D. Rosenthalc,∗, Victoria D. Villanuevaa, María

Corazon V. Tolentinoa, Glenn Angelo S. Genuinob,

Rafael J. Consunjib, 2013)(Josephine Anne Navoa-

Nga, Regina Berbab, Victor D. Rosenthalc, Victoria

D. Villanuevaa, María Corazon V. Tolentinoa,

Fauziah, W., Rochana, N. and Juniarto, A.

The Effect of Catheter Associated Urinary Tract Infection (CAUTI) Bundle of Care: A Systematic Review.

DOI: 10.5220/0008205901230131

In Proceedings of the 1st International Conference of Indonesian National Nurses Association (ICINNA 2018), pages 123-131

ISBN: 978-989-758-406-0

123

Glenn Angelo S. Genuinob, Rafael J. Consunjib,

2013).

Futhermore, some studies showed that CAUTI

bundle of care decreased CAUTI occurence

significanly.(Al-Hameed Fahad, Ahmed Gulam , Al-

Saedi Asim & Al-Hameed Faisal, 2018)(Mody et al.,

2017)(Sushilkumar Satish Gupta; Pavan Kumar

Irukulla; Mangalore Amith Shenoy; Vimbai

Nyemba; Diana Yacoub, 2017)(Josephine Anne

Navoa-Nga, Regina Berbab, Victor D. Rosenthalc,∗,

Victoria D. Villanuevaa, María Corazon V.

Tolentinoa, Glenn Angelo S. Genuinob, Rafael J.

Consunjib, 2013)(Regagnin, , Debora Schettini da

Silva Alves, Ana Maria Cavalheiro, Thiago Zinsly

Sampaio Camargo, Alexandre R. Marra, Victor, &

Edmond, 2015). However, the effect of CAUTI

bundle of care on the CAUTI incidence is still

limited. Therefore, this review aims to determine the

effect of CAUTI bundle of care in reducing and

preventing the incidence of CAUTI.

2 METHODS

The inclusion criteria of this review were;

experimental studies, adult patients as samples, and

urinary catheter installation for a minimum period of

72 hours; while the exclusion criteria were patients

with worsening conditions. The literature search was

done through 6 bibliography databases namely

Cumulative Index to Nursing and Allied Health

Literature (CINAHL), Scientdirect, Proquest,

Pubmed, Google Scholar and Medical Literature

Analysis and Retrieval System (MEDLINE) from

2014 to 2018 in English language The search used

keywords; CAUTI, urinary catheter, protocol,

guidelines, and bundle of care. A total of 171 articles

have been identified but after the selection process,

only 6 articles met the criteria. The selected articles

uses PICO (population, intervention, comparisons,

and outcomes) and were then critically appraised

using the Critical Appraisal Skill Program (CASP).

The author evaluated the title and abstract of all

references. List of references from articles was

sought manually by searching for research relevant

to other inclusion criteria. Data extraction was done

using Microsoft Word. Information obtained from

each study included the following: title, journal, year

of publication, location, study population, study

design, time of intervention, characteristics of the

intervention and control groups, measurement tools,

and pre and post intervention results was shown on

table 1.

The following figure 1 shows the search strategy

and pre selection process carried out in this study:

Recordidentified

throughdatabase:

CINAHL,MEDLINE,

Scientdirect,

Proquest,Pubmed

andGoogleScholar

(n=171)

Excludedtitle

andabstract

(n=97)

Relevantarticlesforthis

review

(n=74)

Excludedby

inclusionand 

exclusion

criteria(n=67)

Protocol

excluded

low‐quality

ornospesific

data(n=2)

IncludeStudies

(n=5)

Relevantarticlesafter

screening(n=7)

Figure 1: Searching Strategy.

3 RESULTS

3.1 Effect of CAUTI Bundle of Care

A total 171 studies were initially identified as

results. After filtered by abstract and title total

studies, excluded by criteria inclusion and exclusion

and Protocol excluded low-quality or no spesific

data total studies were reviewed 5 studies.

The results showed that 3 out 5 of studies had

level II of evidence with good quality and two

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

124

studies had level III with good quality and low

quality data or major flaws. No study had high level

of evidence (level I).

Table 2 described the effect of CAUTI bundle of

care. The CAUTI rate decreased significanly with

the average of rates CAUTI mean pre implemention

7,90%, mean post 1,18% and mean difference 5,

59%. All studies had p value significant effect

CAUTI rates after interventions.

Population and sample performed of studies that

4 out 5 had at ICU and one studies medical surgical.

3.2 CAUTI Bundle of Care

The CAUTI of care Bundle consists of several

interventions that are interrelated with each other,

from several studies reviewed the interventions

carried out include, There bundles were: The use of

a catheter is only for the right indication, The use of

appropriate techniques for catheter placement,

Proper catheter care (antimicrobial urine catheter

can prevent bacteriuria in hospitalized patients

during short-term catheterization, depending on the

antimicrobial layer and several other variables

compared to standard catheters), Noting the use of

catheter material (choosing the right catheter aims to

delay the onset of bacteriuria and to prevent

bacterial attachment and growth), Obstruction

management (there is no consensus regarding the

time at which routine catheter changes must be

made. Shorter periods may be needed if there is

damage or catheter leakage. In general, long-term

catheters must be replaced before blockages occur or

may occur. Time of indwelling catheter use different

for each patient, some patients form deposits on the

lumen of the catheter very quickly), Specimen

Collection (get aseptic urine samples), Small

amounts of fresh urine can be taken from the distal

part of the catheter, or if it is better than the place

where the material is available, and before urine is

aspirated with sterile needles and syringes, the place

of extraction must be disinfected (if a large volume

of urine is needed for special analysis, then the urine

must be taken aseptically from the drainage bag and

routine urine culture in patients with asymptomatic

catheters is not recommended).

4 DISCUSSION

4.1 Effect of CAUTI Bundle of Care

The effect CAUTI of care bundle that has shown

that developing nurse driven protocol interventions

show that interventions has made the decline in

urinary catheter use from 37.6% to 26.3%, and

provide education about the diagnosis and definition

of CAUTI. increasing the right identification ability

so that the given antibiotic therapy is right, and the

last one using the CAUTI prevention bundles, one of

the studies conducted in America states that there

has been a decrease in the average CAUTI incidence

of 50% per month and a decrease from 5.41 to 2.49

per 1000 catheter days (Peter, Devi, & Nayak,

2018). While a study conducted by Al-Hameed

showed the results of the rate of UTI and the use of

urinary catheters during the study decreased the rate

of UTI significantly per 1000 days catheter from 2.3

to 0.3 (Al-hameed et al., 2018). Then another study

conducted by Navoa et al in 2013 showed the effect

of CAUTI of care bundle intervention on the

incidence of CAUTI from 11.0 to 2.66 per 1000

catheter days (Josephine Anne Navoa-Nga, Regina

Berbab, Victor D. Rosenthalc, Victoria D.

Villanuevaa, María Corazon V. Tolentinoa, Glenn

Angelo S. Genuinob, Rafael J. Consunjib, 2013)

Bundle CAUTI of care is some of the

interventions conducted to prevent the incidence of

CAUTI, which is a combination of several

interventions based on evidence practice

nursing.(Lona Mody,M Todd Greene, Jennifer

Meddings, Sarah L Krein, Sara E McNamara,

Barbara W Trautner, David Ratz, Nimalie D Stone,

LillianMin, Steven J Schweon, Andrew J Rolle,

RussellN Olmsted, Dale R Burwen, James Battles,

Barbara Edson, 2017)

Other studies show significant results between

bundles CAUTI of care for UTI rates, such as the

research conducted by Lona Mody in 2017, a decline

in UTI rate from 6.78 to 2.63 per 1000 catheter-days

(Mody et al., 2017). The study conducted by

Sushilkumar et al also showed significant results

between interventions carried out on the UTI rate of

5.47 before intervention to 1.08 per 1000 catheter-

days. (Sushilkumar Satish Gupta, Pavan Kumar

Irukulla, Mangalore Amith Shenoy, Vimbai

Nyemba, Diana Yacoub, 2017)

4.2 CAUTI Bundle of Care

An integrative review conducted by Michelle Henry

(2018) to evaluate Evidence Based Practice

preventive measures for infections that occur due to

catheter placement (CAUTI) in critical care settings.

The recommended intervention to prevent the

occurrence of CAUTI is the use of urine samples to

identify CAUTI in patients who have fever, some

studies recommend patient hand hygiene protocols

The Effect of Catheter Associated Urinary Tract Infection (CAUTI) Bundle of Care: A Systematic Review

125

Table 1: Extract Data.

No Author/Year Title

Sample

Population

Reseacrh

Design

Methods Outcome

Level Of

Evidence

Fahad M. Al-

Hameed, Gulam

R. Ahmed,

Asim A. AlSaedi,

Muhammad J.

Bhutta,

Faisal

Al-Hameed,

Majid M. Al

Shamrani, 2018

Applying

preventive

measures leading

to significant

reduction of

catheter-

associated urinary

tract infections in

adult intensive

care unit

ICU

quasy

experimental

-retropective

study

The proper use of silicon

catheter, aseptic insertion

technique, emptying bag

three-fourth via close

circuit, the use of

appropriate size catheter,

securing the draining tube

on the thigh to keep catheter

ag below patient’s bladder

level and removal of the

catheter as early as possible

were ensured in all patients.

The Rate of CAUTI

significant reduction from

2.3 to 0.3 per 1000

catheter days.

II-B

Josephine Anne

Navoa-Nga,

Regina Berbab,

Victor D.

Rosenthalc,

Victoria D.

Villanuevaa,

María Corazon

V. Tolentinoa,

Impact of an

International

nosocomial

Infection Control

Consortium

multidimensional

approach on

catheter-associated

urinary tract

infections in

Patients

characteristics

such as UC

duration mean,

surgical stay,

pulmonary

disease,

abdominal

surgery, cancer,

endocrine

metabolic

diseases, renal

quasy

experiment-

Prospektive

Perform hand hygiene (HH)

before insertion and

manipulation of a UC,

Maintain unobstructed urine

flow; i.e., UC on thigh

without strangulating, Keep

the collecting bag below the

level of the bladder at all

times; i.e., UC with

collecting bag hanging and

not allowing urine reflux,

Empty the collecting bag

regularly and to avoid

allowing the draining spigot

to touch the collecting

container and to monitor

CAUTIs using standardized

criteria to identify patients

with CAUTIs and to collect

UC-days as denominators.

Urinary Catheter use mean

0,67. The rate of CAUTI

was 11,0 days per 1000

UC-days at baseline and

decreased 2,66 per UC-

days after interventions.

II-B

No Author/Year Title

Sample/

Population

Reseacrh

Design

Methods Outcome

Level Of

Evidence

Glenn Angelo S.

Genuinob, Rafael

J. Consunjib,

Jacinto Blas V

2013

adult intensive

care units in the

Philippines:

International

Nosocomial

Infection Control

Consortium

(INICC) findings

impairment, and

immune-

compromised

condition, were

similar during

both periods.

However,he

mean age of

patients,

proportion of

women, and

presence of

infections were

higher during the

interventions

eriods

Lona Mody,;

M.Todd Greene,

Jennifer

Meddings

2017

A National

Implementation

Project to Prevent

Catheter

Associated Urinary

Tract Infectionin

Nursing Home

Residents

Older adults

nursing home.

ICUs and SDUs

(Step Down

Units)

experimental

study-

prospective

Catheter removal, aseptic

insertion, using regular

assessments, training for

catheter care, and

incontinence care planning,

as well as a socio adaptive

bundle emphasizing

leadership, resident and

family engagement, and

effective communication.

The rate of CAUTI

decreased from 6.78 to

2.63 infections per 1000

catheter-days.

II-B

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

126

Table 1: Extract Data. (cont.)

No Author/Year Title

Sample/

Population

Reseacrh

Design

Methods Outcome

Level Of

Evidence

Dejanira A.

Regagnin,

Debora Schettini

da Silva Alves,

Ana Maria

Cavalheiro,

Thiago Zinsly

Sampaio

Camargo,

Alexandre.

Sustainability of a

program for

continuous

reduction of

catheter-associated

urinary tract

infection

Medical-surgical

intensive care

unit and step

down unit.

quasy

experimental

study

ICU nurses and physicians

inserted urinary catheter,

remove made solely by the

patients’s physician,

catheter insertion audited,

process measures audited,

urinary catheter insertion

cart implemented, Nurse

appointed exclusively for

CAUTI prevention,

The rate of CAUTI in the

ICUs was 0,9 per 1,000

catheter days, and the

SDUs the rate was 1,0

UTI per 1,000 catheter

days.

III-B

No Author/Year Title

Population/

Sample

Research

Design

Methods Outcome Mean

Marra, Elivane

da Silva Victor,

Michael B.

Edmond.

2015

intensification of audits, and

catheter insertion team

developed.

Sushilkumar

Satish Gupta,

Pavan Kumar

Irukulla,

Mangalore Amith

Shenoy, Vimbai

Nyemba, Diana

Yacoub, Yizhak

Kupfer

2016

Successful strategy

to decrease

indwelling catheter

utilization rates in

an academic

medical intensive

care unit

ICU

quasy

experimental

retrospective

observationa

l study

to permit IUC use only in

the following predetermined

indications, futher narrow

down the criteria for urinary

catheter utilization to

urinary retention and

genitourinary procedures

only, and use sonographic

ladder scanning to identify

high-risk patients who may

need indwelling catheters in

the near future.

IUC utilization rasio had a

statistically significant

decrease from 0,92

(baseline) to 0,28 (after 3

interventions) (P <,0001).

The CAUTI rates had a

statistically significant

decrease from 5,47

(baseline) to 1,08 (after 3

interventions) (P=,0134).

III-C

No. Title Author Mean Pre Mean Post Mean Difference P

Applying preventive measures

leading to significant reduction of

catheter-associated urinary tract

infections in adult intensive care

unit

Fahad M. Al-Hameed, Gulam

R. Ahmed,

Asim A. AlSaedi, Muhammad

J. Bhutta,

Faisal Al-Hameed, Majid M. Al

Shamrani,

2,3 % 0,3%

0,001

Impact of an International

Nosocomial Infection Control

Consortium multidimensional

approach on catheter-associated

urinary tract infections in adult

intensive care units in the

Philippines: International

Nosocomial Infection Control

Consortium (INICC) findings

Josephine Anne Navoa-Nga,

Regina Berbab, Victor D.

Rosenthalc, Victoria D.

Villanuevaa, María Corazon V.

Tolentinoa, Glenn Angelo S.

Genuinob, Rafael J. Consunjib,

Jacinto

Blas V

11 % 2,66% 8,34%

0,0001

No. Title Author Mean Pre Mean Post Mean Difference P

A National Implementation Project

to Prevent Catheter Associated

Urinary Tract Infectionin Nursing

Home Residents

Lona Mody, M.Todd Greene,

Jennifer Meddings

6,78% 2,63% 4,15% < ,0001

Sustainability of a program for

continuous reduction of catheter-

associated urinary tract infection

Dejanira A. Regagnin, Debora

Schettini da Silva Alves, Ana

Maria Cavalheiro, Thiago

Zinsly Sampaio Camargo,

Alexandre R. Marra, Elivane da

Silva Victor, Michael B.

Edmond.

ICU :7 %

SDU:14,9%

0,9%

ICU; 6,1 %

SDU; 13,9%

All test of

statistical

significance

were 2-sided,

with the

significance

level set at

<,05.

Successful strategy to decrease

indwelling catheter utilization rates

in an academic medical intensive

care unit

Sushilkumar Satish Gupta,

Pavan Kumar Irukulla,

Mangalore Amith Shenoy,

Vimbai Nyemba, Diana

Yacoub, Yizhak Kupfer

5,47% 0,78% 4,69%

< .0001

Average of Mean 7.90 % 1,18% 5,59%

The Effect of Catheter Associated Urinary Tract Infection (CAUTI) Bundle of Care: A Systematic Review

127

(PHHP) as one of the interventions that must be

done to prevent CAUTI, some studies also

recommend strategies for preventing CAUTI

focusing on limiting the use and duration of catheter

installation, the use of aseptic techniques for catheter

insertion and catheter care, then a study (Henry,

2018) only for people in need, ensure that only

competent and experienced people do catheter

installation, use sterile equipment, keep the drainage

system closed, maintain urine flow, maintain hand

hygiene before and after put on a catheter.

(Sushilkumar Satish Gupta; Pavan Kumar Irukulla;

Mangalore Amith Shenoy; Vimbai Nyemba; Diana

Yacoub, 2017). Meanwhile the research conducted

by Vicki Parker etc states that CAUTI bundle care is

divided into several components which are

abbreviated to NOCAUTI namely need for catheter

assessed, Obtain the patient consest, Competency,

Asepsis, Unobstructed flow, Timely catheter,

Infection risk daily periurethal hygiene. (Lona

Mody,M Todd Greene, Jennifer Meddings, Sarah L

Krein, Sara E McNamara, Barbara W Trautner,

David Ratz, Nimalie D Stone, LillianMin, Steven J

Schweon, Andrew J Rolle, RussellN Olmsted, Dale

R Burwen, James Battles, Barbara Edson, 2017)

Then another study stated that bundle care to

prevent CAUTI consisted of Hand hygiene before

catheter placement, maintaining urinary

unobstructed flow, keeping the catheter sac under

the bladder, emptying the bladder, and monitoring

CAUTI using standard criteria to identify patients

with CAUTI. (Josephine Anne Navoa-Nga, Regina

Berbab, Victor D. Rosenthalc, Victoria D.

Villanuevaa, María Corazon V. Tolentinoa, Glenn

Angelo S. Genuinob, Rafael J. Consunjib, 2013)

Other studies say that the bundle technique to

prevent CAUTI is abbreviated with CAUTI which is

a component of Catheter Removal, Aseptic

Insertion, Regular Use Assessment, and Training for

Catheter Care, Incontinence Care Plan, and

Appropriate Indications for Indwelling Urinary

Catheters (Lona Mody,M Todd Greene, Jennifer

Meddings, Sarah L Krein, Sara E McNamara,

Barbara W Trautner, David Ratz, Nimalie D Stone,

LillianMin, Steven J Schweon, Andrew J Rolle,

RussellN Olmsted, Dale R Burwen, James Battles,

Barbara Edson, 2017)The basic principle of using a

catheter is the use of appropriate indications at the

time of installation and removal of the actuator,

when it is an indication such as the following:

Haematuria; Retention; Urology surgery; Decubitus

ulcer; Measurement of inputs and outputs; End of

life care; and Immobility. Other studies suggest that

hematuria does not require a catheter except patients

in retention. (Dawson, Gallo, & Prevc, 2017)

Research conducted by Al Hameed shows that a

multidisciplinary approach, stepwise intervention

strategies and CAUTI bundles, can significantly

reduce the IUC utilization ratio (Indwelling Urinary

Catheter) and CAUTI level. IAD (Intoctenensia

Associated Dermatitis) which is a potential

complication after catheter insertion can be

minimized by a variety of multidisciplinary

strategies, which involve nursing staff, nutritionists,

and care specialist wounds. (Sushilkumar Satish

Gupta; Pavan Kumar Irukulla; Mangalore Amith

Shenoy; Vimbai Nyemba; Diana Yacoub, 2017)

There is no definite definition of CAUTI Bundle

recommended so far, the researchers collected the

best evidence based that could be applied as a

CAUTI intervention. There are eight components

adopted including; screening all admission patients,

using Foley’s silicone catheters, aseptic techniques,

insertions, emptying catheter bags, selecting the

right catheter size, cleaning the catheter ducts in the

patient's thighs, placing a catheter sac lower than the

patient’s bladder and not touching the floor, and

releasing the catheter as soon as possible after the

patient's condition improves and no further catheter

assistance is needed (Al-Hameed Fahad, Ahmed

Gulam , Al-Saedi Asim & Al-Hameed Faisal, 2018)

While the research conducted by Mariam divided

the two phases of the intervention process to prevent

CAUTI, namely the Assessment phase and the

Protocol phase of care. In the assessment phase the

researcher made an assessment of the nurse

regarding nurse’s knowledge and educated the nurse

to carry out the protocol of care. Then in the

protocol of care phase is divided into several parts,

namely first to prepare the object settings (catheter-

mounted patients), then prepare the protocol of care

content that is knowing the anatomy and

pathophysiology of the urinary system, knowing

indications of catheter installation and infection

control in patients who are catheterized know

contraindications to catheter installation, prepare

catheter installation, perform catheter care, and find

out complications related to catheter placement.

After completion, proceed with the planning of

action protocol of care by paying attention to the

patient's condition. Then at the end of the phase an

evaluation was conducted on nurses related to the

protocol of care that had been done. (Shehab, 2017)

Some important things in CAUTI Bundle that

must be considered by nurses are among others: first

the catheter must remain closed and minimize the

duration of catheter use. Second, pay attention to the

risk of cross infection between patients who are

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

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catheterized also must receive attention. Third,

nurses must also pay attention to the fact that

patients should receive treatment from nurses when

the installation of the catheter includes hand washing

procedures and the use of sterile gloves in the

catheter installation must also be considered by the

nurse. Furthermore, patients should receive enough

fluids orally to maintain urine flow of 50-100 ml /

hour. Then, systemic prophylactic antibiotics are not

recommended for catheter placement or intermittent

catheterization. There is no benefit from antibiotic

irrigation through a catheter and bladder. When

changing catheters regularly depending on the

catheter material used. Take into account

alternatives for sedentary catheterization which often

causes symptomatic infections. In certain cases,

suprapubic catheters, catheter condoms and

intermittent catheterization are more recommended

than permanent catheters. (Tarmono et al., 2015)

Meanwhile other studies make programs to

prevent infection due to catheter placement. The

program was divided into 3 phases, namely phase 1

including ICU Nurse installing a catheter,

determining the discussion to remove the catheter,

and auditing catheter insertion consisting of

determining the type of catheter, Hand hygiene

before catheter placement, perineal hygiene using

antimicrobial soap, hand washing, prior connection

between catheters and catheter sacs, using aqueous

chlorhexidine antisepsis, introducing opportunities

for catheter placement as a unique opportunity and

hand washing after catheter placement. Then phase 2

consists of the audit process, and the implementation

of catheter installation is then followed by the third

phase, namely the appointment of nurses who are in

charge of preventing CAUTI, then looking at the

feedback to what has been done. (Josephine Anne

Navoa-Nga, Regina Berbab, Victor D. Rosenthalc,

Victoria D. Villanuevaa, María Corazon V.

Tolentinoa, Glenn Angelo S. Genuinob, Rafael J.

Consunjib, 2013) While other studies state that

interventions to reduce CAUTI by installing

catheters

Then Systematic Review conducted by Dinah

Gould et al entitled Implementing clinical guidelines

to prevent catheter-associated urinary tract infections

and improve catheter care in nursing homes using

the Systematic search method and critical appraisal.

The total studies reviewed and analyzed were 8

studies which included the study conducted by

Gokula and Gaspar which used guidelines for

prevention of CAUTI and carried out in a population

of 14 patients with long-term catheter use and used a

comparison for control groups using the SOP in

hospital and carried out for 3 months with the results

of the study saying there was no difference between

the application of the CAUTI guidelines and the

standard SOP carried out. Whereas 2 studies were

conducted by Galeon and Romero and the research

of Abraham and Debakey using the Uncontrolled

Before and After Study research methods. The study

was carried out by implementing a complete

guideline for CAUTI Prevention, stating that there

were significant differences after the CAUTI

prevention guidelines were implemented. While 5

other studies evaluated one part of the CAUTI

Prevention guidelines showing significant results.

What should be a concern in the application of the

CAUTI prevention guideline is the challenge that

comes from nurses to be able to properly implement

the guideline that has been made by the consensus

for the prevention of CAUTI (Gould, Gaze, Ba,

Cooper, & Cadwaladr, 2017)

Meanwhile another study conducted by Parker et

al. (2017) conducted a study using the intervention

study pre-post control method. The study was

conducted at 2 Health Districts with the population

being adult patients in several acute spaces in 4

hospitals (acute setting) and in NSW, Australia. The

study began by educating nurses on NOCAUTI

Interventions bundles consisting of guidelines for

IDC insertion, indications for collection of urine

specimens, guidelines for IDC removal and

education for nurses to implement CAUTI

prevention interventions. Saint Have made the

concept of NOCAUTI bundles through pilot

projects in Australia. The concept of NOCAUTI

consists of Need for catheter assessed (Assessment

is done for patients with appropriate indications for

catheter placement), Obtain patient consent and

Offer Patient Education (Giving informed consent

and education to patient / patient families),

Competency (Ensuring only nurses have competence

and experienced who put on a catheter), Asepsis

(Using asepsis technique), Unobstructed (Keeping

urine flow in the hose not having obstruction),

Timely Cateteher removal (Determining the time of

catheter up based on indications and medical needs

needed), and Infection (Performing care catheter and

taking urine specimen with asepsis technique). The

results of the research carried out can improve

patient safety through strong implementation and

evaluation of clinical practice and changes in

practice that will contribute to improving patient

experience and the results obtained by the hospital.

Research conducted adds evidence based practice

through increasing understanding of interventions to

reduce CAUTI. (Lona Mody,M Todd Greene,

The Effect of Catheter Associated Urinary Tract Infection (CAUTI) Bundle of Care: A Systematic Review

129

Jennifer Meddings, Sarah L Krein, Sara E

McNamara, Barbara W Trautner, David Ratz,

Nimalie D Stone, LillianMin, Steven J Schweon,

Andrew J Rolle, RussellN Olmsted, Dale R Burwen,

James Battles, Barbara Edson, 2017)

Interventions are targeted at nurses who have the

task of installing a urine catheter in the hospital and

are designed to reduce the use of inappropriate urine

catheters and improve the necessary catheter care.

The interventions consisted of education with lecture

methods from videos, installing reminders in the

room, and weekly infection prevention lectures by

the head of the room. (L. Gayani Tillekeratne,

Darren R. Linkin, Mariah Obino, Wanjiku,

Holtzman, & Cohn, 2014) Nurses must understand

indications of catheter placement namely acute

urinary obstruction or retention, the need for

measurement accurate from input and output in

critically ill patients, the presence of open sacrum or

perineal ulcers in patients with urinary incontinence,

prolonged immobilization, the need for continuous

urinary discharge during perioperative care and

increased comfort in patients who are near death (L.

Gayani Tillekeratne, Darren R. Linkin, Mariah

Obino et al., 2014)

Another intervention the researchers obtained

was that the interventions used in nursing home

implementation projects, which depend on technical

and social adaptive interventions, reduce the level of

ISTI associated with catheter installation in settings

where utilization is low but catheter use lasts longer.

Although this project focuses on reducing catheter-

related UTIs, an approach similar to evidence based

can be used to address the security issues of other

residents in community-based nursing homes. (Lona

Mody,M Todd Greene, Jennifer Meddings, Sarah L

Krein, Sara E McNamara, Barbara W Trautner,

David Ratz, Nimalie D Stone, LillianMin, Steven J

Schweon, Andrew J Rolle, RussellN Olmsted, Dale

R Burwen, James Battles, Barbara Edson, 2017)

Another study conducted on resident students

produced two important points, the first was the

simulation of providing optimal facilities for

evaluating clinical decision making and the second

the participants had experience and training in a

catheterization scenario that would be their

responsibility in the future. This information allows

opportunities for change in surgical education that

will emphasize important clinical topics, ongoing

assessment, and the method of feedback. Thus will

improve the performance of trainees and ensure

competency for independent practice (Nathwani,

Law, Witt, Ray, & Dimarco, 2017)

5 CONCLUSSION

Interventions that have been designed to reduce

initially high levels of CAUTI indicate that there is a

decrease in unnecessary use of urinary catheters and

a decrease in CAUTI levels. And the costs for

interventions are more affordable. (Tillekeratne et

al., 2014) CAUTI incidence has decreased

significantly after the implementation of strategies

and interventions to prevent CAUTI levels being

carried out in adult ICU patients. (Al-hameed et al.,

2018) Interventions apply a variety of approaches

including the following are: bundles of infection

control interventions, education, supervision of

CAUTI levels, feedback on CAUTI, supervision of

the nurse's performance feedback process (Josephine

Anne Navoa-Nga, Regina Berbab, Victor D.

Rosenthalc, Victoria D. Villanuevaa, María Corazon

V. Tolentinoa, Glenn Angelo S. Genuinob, Rafael J.

Consunjib, 2013)

CAUTI incidence declined significantly after the

adoption of strategies and interventions to prevent

CAUTI levels being carried out in adult ICUs by

implementing eight components adopted in patient

care (Al-Hameed Fahad, Ahmed Gulam , Al-Saedi

Asim & Al-Hameed Faisal, 2018)

The results of the research discussed above show

that the CAUTI of care bundle can prevent and

reduce CAUTI so that it can help nurses to improve

effective and efficient health services for patients.

This Systematic review recommends that the

CAUTI bundle can significantly reduce CAUTI

incidence and become the basis for the study of the

effect of the CAUTI bundle in Indonesia.

ACKNOWLEDGEMENTS

We would like to acknowledge Diponegoro

University in supporting this work.

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