Our May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?” talked about the problem of urinary tract infections related to unnecessary urinary catheters. We had noted a large number of patients had Foley catheters in place for inadequate medical reasons. So 16 years ago, we established “catheter rounds” and began putting a brightly-colored sticker on the order sheets of all patients with a Foley catheter, requiring the physician to indicate the reason for the Foley catheter and the expected duration of its use. Catheter use dropped about 50%!
Over the years, we’ve recommended the systems hospitals put in place can be low-tech or hi-tech. The simple colored sticker alert mentioned above was very effective. Adding lines for indication and duration to pre-printed order sheets can also be effective. For those facilities fortunate enough to have computerized physician order entry, add a new pop-up screen with these questions any time someone orders a Foley catheter.
But we’ve always been amazed at how often we get to go into a hospital and still make this remarkably simple recommendation! Very few hospitals pay attention to this simple intervention that reduces both patient morbidity and hospital cost.
Now, for the first time, the scope of this problem has been studied on a national basis. Sanjay Saint, M.D. and colleagues at the University of Michigan just published Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study (1) in the January issue of Clinical Infectious Diseases. They mailed written surveys to over 700 US hospitals and had an excellent response rate of over 70%. They found that 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and only 9% used catheter reminders. VA hospitals were more likely than non-VA hospitals to use portable bladder scanners, condom catheters, and suprapubic catheters but non-VA hospitals were more likely to use antimicrobial urinary catheters.
Our August 21, 2007 Tip of the Week “Costly Complications About to Become Costlier” alerted facilities to the fact that, as of October 2008, CMS/Medicare will no longer pay hospitals for catheter-associated UTI’s. So having a good system in place to prevent this complication is essential. Nosocomial UTI’s, still the most common nosocomial infection, are not only a safety issue for patients but they are also very costly to hospitals. The average additional cost for patients who develop nosocomial UTI’s is about $2000-3000 due to increased length of stay and increased antibiotic and supply needs. So establishing systems to prevent unnecessary Foley use is not only good for your patient safety program, it is also very cost-effective.
The system you put in place should have both a pre-emptive component and a surveillance component. As above, the pre-emptive component can be either low-tech or hi-tech. The simple colored sticker alert mentioned above was very effective. Adding lines for indication and duration to pre-printed order sheets can also be effective. If you have computerized physician order entry (CPOE), add a new pop-up screen with these questions any time someone orders a Foley catheter.
Beware of unintended consequences, though. Your policy should not be so restrictive that patients who truly do need a Foley catheter are made uncomfortable. Alternatives to Foley catheters may include condom catheters or intermittent catheterization. And, as Saint et al. point out, use of portable bladder scanners may reduce the need for any kind of catheter in the first place. And, if the patient does require a urinary catheter, consider using an antimicrobial one.
The second component of your system is the surveillance
component. That means assessing all patients with urinary catheters to see if
they still need them. We routinely look for unnecessary catheters during
patient safety “walk rounds” and so should you. However, you need a system in
place so they are looked for on a daily basis. Make this activity a “checklist”
item on nursing rounds or teaching rounds. Also, if your hospital uses a
barcode system to track inventory, adapt that system to alert you to every
patient to whom a catheter was attached.
Be sure to include monitoring and measuring in your QI activities because the initial Hawthorne effect of implementing such a system often fades with time.
And, as pointed out by Dr. Saint and his colleagues, educating your patients to question why they need or still need a catheter should be part of your patient-oriented patient safety program.
Saint S, Kowalski CP, Kaufman SR, et al. Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study. Clinical Infectious Diseases 2008; 46:243–250
Update: See also our April 2008 What’s New in the Patient Safety World column “More Neonatal Incubator Fires, More on Nosocomial UTI’s, More on 1000-Fold Heparin Overdoses” and our Patient Safety Tip of the week for June 24, 2008 “Urinary Catheter-Related UTI’s: Bladder Bundles” and our April 21, 2009 Patient Safety Tip of the Week “Still Futzing with Foleys?” and our June 9, 2009 Patient Safety Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”.