October 22, 2012

Catheter Conundrum: Reducing Unnecessary Placement
By Lindsey Getz
For The Record
Vol. 24 No. 19 P. 22

The high risk of infection and other complications due to urinary catheterization suggests a need for physicians and hospitals to reevaluate their procedures.

In many healthcare 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. Despite urinary catheterization being a major risk factor for hospital-acquired infection, it seems urinary catheters are commonly placed inappropriately.

“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,” Saint says. “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,” Meddings says. “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
Catheters are commonly placed when patients are admitted through the emergency department, but in many cases those catheters are unwarranted. In a study published in the November 2010 issue of the American Journal of Infection Control, researchers found in 30% of cases there was no reason for catheter placement. “When we examined why the catheters were placed, there was no clear reason in a significant number of cases,” Fakih says. “It wasn’t even a case of whether it was appropriate or not—there was no defined reason at all.”

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 also were 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,” Fakih says. “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
Saint says in general, older patients are at higher risk of inappropriate catheterization because they may be less likely to advocate for themselves. “Elderly patients are often less likely to question the catheter or may possibly not even have the mental capacity to question it,” Saint says. “That’s a concern because the elderly are more likely to have a bad outcome from a hospital-acquired infection due to other comorbidities.”

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, Saint says. “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
Before opting for a catheter, experts suggest that medical professionals consider the alternatives, including a bedside commode, a urinal, or continence garments to manage incontinence. “Some patients may require a catheter, but it doesn’t have to be an indwelling catheter, which is associated with the highest risk of infection because it’s in place 24 hours a day and a slimy layer of protein forms that bacteria can grow on, called a biofilm,” Meddings explains. “If it’s only for short-term use, a straight catheter procedure can be used. This prevents the biofilm from forming. Male patients may also use an external condom catheter.”

“We also try scheduling toileting as a reminder to a patient that is retaining urine that they need to go to the bathroom,” Yukawa says. “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,” Fakih says. “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
“This has a lot to do with hospital supply traditions,” Meddings says. “In most hospitals, it’s impossible to know which patients have catheters unless you physically walk to the patient’s bed and look under the sheet. Part of the reason is that catheter supplies are part of the general care supplies used in the hospital and are not assigned to any one patient. Therefore, a nurse or a physician can put in a catheter without it ever really being tracked. The only place it’s closely tracked is in the operating room, but most are not placed there. This is one of the large barriers to overcome. Hospitals need to implement a strategy to track or monitor catheter use with the goal of making doctors more aware of which patients have them—and whether they’re indicated.”

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,” Meddings says. “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.