We’ve had a little hiatus in our ongoing discussions about CAUTI prevention but recently there has been renewed activity in the literature that has been quite interesting. Though we’ve done numerous columns on prevention of CAUTI’s, one of the questions we’re still often asked is “What are the appropriate indications for a urinary catheter?” and how were they determined.
Most of us have been using the indication criteria published by the CDC in 2009 (Gould 2009) as discussed in our June 9, 2009 Patient Safety Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”. That guideline provided a table listing appropriate indications for indwelling urethral catheters. Appropriate indications in the CDC guideline include:
Most importantly, that guideline stressed that indwelling urethral catheters should not be used for management of incontinence except under very unique circumstances. Nor should they be used just to obtain specimens for culture or diagnostic testing.
But even that guideline left lots of gray areas. For example, to some “critically ill patients” meant all ICU patients could have an indwelling catheter.
To address some of the many unanswered questions regarding appropriate use of urinary catheters, clinicians from the University of Michigan convened an expert panel and utilized the RAND/UCLA Appropriateness Method to come up with recommendations (Meddings 2015). And they went further than just indwelling urinary catheters, also making recommendations regarding external urinary catheters and intermittent straight catheters. The “Ann Arbor Criteria” recommendations apply to medical inpatients, not patients in the perioperative setting.
Appropriate indications for Foley catheters in the Ann Arbor Criteria are:
Inappropriate indications for Foley catheters in the Ann Arbor Criteria are:
The Ann Arbor Criteria paper includes examples that help clarify many of the above criteria.
Perhaps the biggest contribution of the Ann Arbor group work is recognition of the important discussion points that came up during the process. Competing patient safety goals is one recurrent theme we see in the battle to prevent CAUTI’s. The classic such conundrum is the incontinent patient who is at risk for skin breakdown or pressure ulcers. One important situation discussed in the Ann Arbor exercise was managing incontinence in patients with morbid obesity or severe edema in whom concerns about skin issues was important. Panelists recognized that not all hospitals have resources such as mechanical lifts that may be needed for turning and lifting such patients. Unexpected discussion took place regarding what to do in the patient with incontinence-related dermatitis. The panel ultimately decided that Foley catheters or intermittent sterile catheterization were inappropriate for any level of dermatitits but that external catheters might be appropriate for patients with moderate or severe incontinence-associated dermatitis.
One of the indications in the previous CDC guideline was “need for accurate measurements of urinary output in critically ill patients”. Unfortunately, that often meant that almost all patients in ICU’s got urinary catheters. The panelists in the Ann Arbor group uniformly agreed that should not be the case. They may be required in cases where monitoring urine volume hourly is critical for management. But there are usually other ways to assess urine output when it is needed on a daily rather than hourly basis. (Note also that in those who do need monitoring of hourly urine output an external catheter may be inappropriate because it only measures urine the bladder has spontaneously voided.)
The discussion also had some good advice about the need for a urology consultation before decisions regarding Foley catheter insertion or removal in certain circumstances. Specifically, consultation with a urologist should be considered before catheter use in the patient with prostatitis or those with recent urological procedures or urethral trauma.
Another really valuable contribution are the recommendations by the Ann Arbor group regarding indications for external urinary catheters and intermittent straight catheters.
Appropriate indications for external catheters in the Ann Arbor Criteria are:
Inappropriate indications for external catheters in the Ann Arbor Criteria are:
Appropriate indications for Intermittent Straight Catheterization in the Ann Arbor Criteria are:
Inappropriate indications for Intermittent Straight Catheterization in the Ann Arbor Criteria are:
One of the most valuable items in the Ann Arbor document is an example of an “ICU checklist for appropriateness of Foley catheter” (see Figure 4 in the Meddings article).
The Meddings paper notes how often the expert panel kept coming up with scenarios that needed further clarification. Another recent study interviewed nurses and physicians in the emergency department and acute medical wards of a large hospital to examine the thinking that went into decisions about indwelling urinary catheter placement (Murphy 2015). They also found that opinions varied considerably, most notably showing differing beliefs on when such catheters were appropriate for each clinical indication. They found that both patient and non-patient factors influenced decisions. These included clinical setting, resources, patient age and gender, and staff workload. Often decisions were difficult because of conflicting goals, as also noted in the Ann Arbor paper.
In an editorial accompanying the Murphy study, Krein and Saint (Krein 2015) separate CAUTI prevention interventions into the “socio-adaptive” and “technical” components. Socio-adaptive components include behavior change and unit culture whereas technical components include things like catheter reminders and stop orders. Of course, changing behavior and culture are much more difficult. Krein and Saint also take aim at one “indication” that has historically appeared on most catheter appropriateness criteria lists “for patient comfort and dignity in end-of-life situations”. They note that indwelling catheters are neither comfortable nor dignified. We couldn’t agree more. Our experience has been that use of this pseudo-indication is usually camouflage for the convenience of someone else.
As noted above, the “Ann Arbor Criteria” apply to medical inpatients, not patients in the perioperative setting. Of interest related to that is a study which showed the place of catheter insertion was an important risk factor for CAUTI and that the operating room was actually the safest place for catheter insertion (Barbadoro 2015). The authors felt that reflected the importance of hand hygiene and proper aseptic insertion techniques as crucial determinants in CAUTI prevention.
While there are no hard and fast criteria for which patients should have a Foley catheter inserted perioperatively, one needs to use common sense. Not all patients undergoing surgery need a catheter. At one hospital we looked at patients undergoing surgeries expected to be relatively short in duration (eg. laparoscopic cholecystectomy). One surgeon routinely used a Foley, three surgeons did not. Once the “outlier” surgeon realized the others did not use a Foley, he also ceased using Foleys for such cases. Factors to consider in deciding which patients in the OR need Foleys are expected case duration (and likelihood it might be extended by complications), expected volumes of fluid in and fluid out, and location of the surgical procedure on the body (eg urologic surgery or other surgery on contiguous structures of the genitourinary tract).
A few recent studies also addressed efforts to prevent CAUTI’s. One addressed CAUTI prevention in pediatric patients (Davis 2014). The researchers implemented a bundle of interventions including the following:
They found that their CAUTI prevention bundle was associated with a 50% reduction in the mean monthly CAUTI rate.
Another study looked at the impact of a computerized clinical decision support (CDS) intervention reducing the duration of urinary tract catheterizations (Baillie 2014). On the basis of the indication chosen, providers were alerted to reassess the need for the urinary catheter if it was not removed within the recommended time. They first used a stock reminder in their commercial electronic health record but found only 2% of reminders resulted in removal of Foley catheters. They then refined the reminder to have a more palatable user interface and found this resulted in a 15% catheter removal rate. Catheter utilization ratios and CAUTI rates also improved significantly over the duration of the project. We’ve always been big fans of using alerts to both avoid initial use of Foley catheters and prompt early removal of Foley catheters that were inserted. This study, however, points out the importance of the manner in which the alert is delivered.
And for those patients who do have indications for an indwelling urinary catheter, there are important considerations regarding catheter selection and drainage devices. A good summary of catheter types, balloon sizes, catheter lengths and other practical issues also has good suggestions about preparing patients for catheter removal (Yarde 2015).
Nursing home patients have a high prevalence of indwelling urinary catheters. Once again, faculty from the University of Michigan Medical School have led the charge in improving CAUTI rates in this population (Mody 2015). Actually the intervention was a multimodal targeted infection prevention program aimed at nursing home residents with indwelling urinary catheters and/or feeding tubes. The intervention consisted of preemptive barrier precautions (but not patient isolation), active surveillance for multi-drug resistant organisms and infections (with data feedback), and comprehensive staff education regarding infection prevention practices and hand hygiene. Nursing homes randomized to the intervention group were compared with those doing their own infection control programs. While much of the study was focused on reducing MDRO’s, at which it was successful, the impact on CAUTI prevention was striking. The reduction of almost 50% in rates of first CAUTI’s was attributed to reduced antibiotic usage, emphasis on hand hygiene, and education on appropriate catheter care and use.
Our other columns on urinary catheter-associated UTI’s:
Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. CDC HICPAC 2009
Meddings J, Saint S, Fowler KE, et al. The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method. Ann Intern Med 2015; 162(9_Supplement): S1-S34
Murphy C, Prieto J, Fader M. “It's easier to stick a tube in”: a qualitative study to understand clinicians’ individual decisions to place urinary catheters in acute medical care. BMJ Qual Saf 2015; Published online 11 June 2015
Krein SL, Saint S. What’s your excuse for Foley use? BMJ Quality & Safety Online First 2015; published on 1 June 2015
Barbadoro P, Labricciosa FM, Recanatini C, et al. Catheter-associated urinary tract infection: Role of the setting of catheter insertion. American Journal of Infection Control 2015; Published online: March 31, 2015
Davis KF, Colebaugh AM, Eithun BL, et al. Reducing Catheter-Associated Urinary Tract Infections: A Quality-Improvement Initiative. Pediatrics 2014; 134:3 e857-e864; published ahead of print August 11, 2014
Baillie CA, Epps M, Hanish A, et al. Usability and Impact of a Computerized Clinical Decision Support Intervention Designed to Reduce Urinary Catheter Utilization and Catheter-Associated Urinary Tract Infections. Infection Control & Hospital Epidemiology 2014; 35(9): 1147-1155
Yarde D. Managing indwelling urinary catheters in adult. Nursing Times 2015; 111(22): 12-13 May 27, 2015
Mody L, Krein SL, Saint S, et al. A Targeted Infection Prevention Intervention in Nursing Home Residents with Indwelling Devices: A Randomized Clinical Trial. JAMA Intern Med 2015; 175(5): 714-723
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