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March/April 2012
Catheter Conundrum: Reducing Unnecessary PlacementBy Lindsey Getz The high risk of infection and other complications due to urinary catheterization suggests a need for physicians and hospitals to reevaluate their catheterization procedures. Studies have found that older patients tend to be at the highest risk of unnecessary catheterization and are also at a greater risk of complications from the procedure. In many settings, urinary catheters aren’t given much thought, but the potentially serious risks associated with them offer good reason for the catheterization process to not only be taken more seriously, but for medical staff to examine whether it’s necessary in each patient case. Urinary catheterization is a major risk factor for hospital-acquired infection, yet it seems urinary catheters are commonly placed inappropriately. This is a major concern but not given a tremendous amount of attention, perhaps because catheters are often, though inappropriately, considered routine. “Many people just think of the urinary catheter as just another part of being in a hospital, but studies have shown that a third or more of catheters are placed without appropriate indication,” says Sanjay Saint, MD, MPH, associate chief of medicine at the Ann Arbor VA Medical Center and a professor of medicine at the University of Michigan Medical School. “Urinary catheters can lead to infectious and noninfectious complications and should only be used when indicated.” The most common complications of urinary catheters are urinary tract infections (UTIs) and bloodstream infections, but Saint says there are important noninfectious complications that also need to be considered. “These would include pain due to the catheter, discomfort, and lack of mobility because it functions as a one-point restraint,” says Saint. “On top of that, there is a dehumanizing element to having a catheter put in your bladder. Anytime you have to be moved to a different location in the hospital for a procedure, the entire hospital community can see your urine. I don’t think the impact of that dehumanization should be underestimated.” Michi Yukawa, MD, MPH, an assistant professor of medicine in the geriatrics division of the University of California, San Francisco, says elder patients suffering from dementia may pull at the catheter and potentially injure themselves. “Patients with dementia may be confused as to why it’s there or even forget that it’s attached,” she says. “And even patients without dementia can forget about the catheter, which is a problem when it becomes a tripping hazard. They may start walking away and forget the Foley bag is hooked on to the bed. I’ve seen terrible things happen simply because a patient forgot they were attached to a catheter—bleeding or other injuries.” The fact that the catheter essentially tethers the patient to the bed also increases the risk of complications, says Mohamad Fakih, MD, MPH, medical director of infection prevention and control at St John Hospital and Medical Center in Detroit. “Increasing the patient’s immobility will also increase their risk of pressure ulcers or deconditioning,” he says. “These are things we don’t talk about much but are important for healthcare workers to remember.” Of course, infection is one of the greatest concerns. The risk of developing a UTI is time associated because the longer a patient has a catheter, the more likely it is that complications may arise. “Every day that the catheter is in, it increases the patient’s risk of developing a UTI by about 5%,” says Jennifer A. Meddings, MD, MSc, a hospitalist at the University of Michigan Health System. “Once a patient has had a catheter in place for about five to seven days, most already have bacteria present in their urine, and many of these patients soon develop the symptoms to qualify as a UTI,” she says. “Also, the hospital-acquired UTI is often not a simple infection to treat,” she adds. “The bacteria are more likely to be drug resistant, and the patient may need to be on powerful antibiotics that have their own set of risk factors associated with them. While taking these powerful antibiotics, the elderly are at high risk of getting C difficile, for instance. In other cases, the bladder infection may lead to a kidney infection or even spread to the blood.” Cases in which the infection spreads to the blood create the greatest risk of disability or death. “When an infection gets into the bloodstream, it’s associated with a lot of other serious complications,” says Meddings. “For the elderly, who may have some type of implant in the body, it can be particularly serious because that implant is also likely to be infected. An elderly patient may be admitted for a hip replacement, get an infection from prolonged use of a urinary catheter, wind up with a bloodstream infection, and ultimately have to have the hip implant replaced because it’s infected. It’s a scenario that most wouldn’t think about when utilizing what seems like a benign urinary catheter, but it is possible.” Catheter Placement The study also found that one-half of the female patients aged 80 or older who underwent catheterization did not meet institutional guidelines for the procedure. Patients aged 80 or older were also three times more likely to have an inappropriately placed urinary catheter. “It was striking that elderly women had a much higher chance of being inappropriately catheterized than men,” says Fakih. “While men can use a urinal, women would need a bed pan, and it’s possible this is one of the reasons they may be more likely to be unjustifiably catheterized.” ‘Forgotten’ Catheters There are certainly instances where a catheter is indicated, including cases of acute urinary retention, acute bladder outlet obstruction, the need for accurate measurements of urinary output, to assist in the healing of open wounds, to ensure strict immobilization during healing, or to improve comfort for end of life, if needed. Saint says, in many cases a catheter is initially justified, but the problem arises when it’s forgotten. “There are certainly many appropriate reasons where a catheter would be indicated,” he says. “But after a few days of hospitalization, the initial indication is no longer there. Still, once out of sight, the urinary catheter may be out of mind. A urinary exam is not part of a routine check, and it simply may be forgotten about. We’ve also found in our research that physicians aren’t always aware their patient has a catheter. It was placed by someone else, perhaps in the [emergency department], and the physician never even realizes it.” Catheters are commonly placed inappropriately based on a patient’s incontinence. Unless a patient has decubitus ulcers and there is concern about keeping him or her clean, incontinence is not a justified reason for catheterization, says Saint. “If the patient has urinary incontinence, there is the perception that it is more convenient for nurses to place a catheter rather than take the patient out of the bed several times a day to change bed sheets and clothing. But that is not an appropriate reason for a catheter.” Consider Alternatives “We also try scheduling toileting as a reminder to a patient that is retaining urine that they need to go to the bathroom,” says Yukawa. “If that doesn’t work, try the intermittent straight catheter before going directly to an indwelling catheter so that you’ve first exhausted other options.” To reduce the number of nonindicated catheters, medical teams need to start paying closer attention to catheterization use, which may require a change in thinking. “The medical team needs to start seeing the catheter as a risk for the patient,” says Fakih. “They need to stop looking at it as a benign procedure that can’t hurt the patient. Once we start looking at it in a different light—as something that can help a patient but has some serious risk associated with it—we start thinking twice about putting a catheter in and only do so in the cases where it’s indicated.” Altering the way catheters are placed may require procedural change. For instance, it is not easy to track catheters the way medications are tracked. And since catheters are under a patient’s bed sheets, they’re not easily seen. General Supplies One solution is to enforce a policy that patients should not be catheterized unless there is an order to do so. “When we looked at the unnecessary use of catheters, we frequently found there was never a physician order to put one in,” says Meddings. “There may have been a verbal order, but there was never a documented, written order.” Meddings, who was the lead author on a study published in the September 2010 issue of Clinical Infectious Diseases, found that using reminder systems could decrease catheter use and reduce catheter-associated urinary tract infections (CAUTIs). The study found that reminder systems prompting hospital staff to assess and remove catheters on a routine basis reduced the rate of CAUTIs by 52%. In recent years hospitals may be more invested in reducing catheter use via methods such as catheter reminder systems, considering CAUTIs were the first complication chosen for nonpayment by Medicare beginning in late 2008. While implementing reminder systems and developing new policies will help to reduce unnecessary catheter use, Saint says the changes are also socio-adaptive in nature, and those types of changes don’t occur easily. “The bottom line is that doctors and nurses can’t do this by themselves,” he says. “They’re going to need the leadership of their hospitals, nursing homes, or healthcare organizations to support the effort because these changes are not just technical; they’re socio-adaptive. Socio-adaptive fixes require an understanding of the culture and then modifying that culture so that the default is no longer to place the catheter but to think twice about whether it’s necessary.” Saint says that after many years of healthcare professionals thinking of catheters as routine, this won’t necessarily be simple. “But it’s a wonderful opportunity for healthcare workers to practice medical mindfulness,” he adds. “In a chaotic environment like a hospital, we do things in a reflexive manner and most are appropriate. The patient has low blood pressure, so we give fluids. The patient has an infection, so we give antibiotics. That makes sense. But when a patient is admitted, it doesn’t make sense to reflexively place a urinary catheter. The healthcare workers need to ask themselves every single time, ‘Does the patient really need this?’ And every new day that the catheter is still in place they need to ask, ‘Does it still need to be there?’ In many cases, they’ll find the answer is no.” — Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.
Physician Engagement for Catheter Awareness • Involve physicians as much as possible in planning, education, and implementation. Include physicians (eg, hospitalists, urologists, hospital epidemiologists, and infectious disease physicians) on your team. • Garner support of medical leadership (eg, chief of staff, chief medical officer). • Conduct education on, for example, the Centers for Medicare & Medicaid Services’ rule changes, proper indications, evidence supporting reducing catheter use, and evidence that physicians are often not aware that a patient has a catheter. • Periodically post catheter prevalence and CAUTI rates in a physician venue. • If you are part of a large healthcare system, influence and leverage system policies on physician practices. • Physicians-in-training, physician assistants, and nurse practitioners can also play a key role in CAUTI-related activities, depending on the hospital and the unit, thus the above strategies may also apply to these inpatient care providers. For more information and strategies, visit www.catheterout.org. — LG
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