Patient Safety Tip of the Week
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
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:
- Acute urinary retention
or obstruction
- Need for accurate
measurements of urinary output in critically ill patients
- Selective use in
perioperative patients
- To assist in healing of
open sacral or perineal wounds in incontinent patients
- Patients requiring
prolonged immobilization (eg. potentially
unstable thoracic or lumbar spine)
- To improve comfort for
end-of-life care if needed
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:
- Acute urinary retention
without bladder outlet obstruction
- Acute urinary retention
with bladder outlet obstruction due to noninfectious, nontraumatic
diagnosis
- Chronic urinary retention
with bladder outlet obstruction
- Stage III or IV or unstageable pressure ulcers or similarly severe wounds
of other types that cannot be kept clear of urinary incontinence despite
wound care and other urinary management strategies
- Urinary incontinence in
patients for whom nurses find it difficult to provide skin care despite
other urinary management strategies and available resources, such as lift
teams and mechanical lift devices
- Hourly measurement of
urine volume required to provide treatment
- Daily (not hourly)
measurement of urine volume that is required to provide treatment and cannot
be assessed by other volume and urine collection strategies
- Single 24-h urine sample
for diagnostic test that cannot be obtained by other urine collection
strategies
- Reduce acute, severe pain
with movement when other urine management strategies are difficult
- Improvement in comfort
when urine collection by catheter addresses patient and family goals in a
dying patient
- Management of gross
hematuria with blood clots in urine
- Clinical condition for
which ISC or external catheter would be appropriate but placement by
experienced nurse or physician was difficult or patient for whom bladder
emptying was inadequate with nonindwelling
strategies during this admission
Inappropriate
indications for Foley catheters in the Ann Arbor Criteria are:
- Urinary incontinence when
nurses can turn/provide skin care with available resources, including
patients with intact skin, incontinence-associated dermatitis, pressure
ulcers stages I and II, and closed deep-tissue injury
- Routine use of Foley
catheter in ICU without an appropriate indication
- Foley placement to reduce
risk for falls by minimizing the need to get up to urinate
- Post-void residual urine
volume assessment
- Random or 24-h urine
sample collection for sterile or nonsterile
specimens if possible by other collection strategies
- Patient or family request
when no expected difficulties managing urine otherwise in nondying patient, including during patient transport
- Patient ordered for “bed rest” without strict immobility requirement
- Foley catheter placement
for convenience of urinary management in patient during transport for
tests and procedures
- Preventing urinary tract
infection in patient with fecal incontinence or diarrhea or management of
frequent, painful urination in patients with urinary tract infection
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:
- Stage III or IV or unstageable pressure ulcers or similarly severe wounds
of other types that cannot be kept clear of urinary incontinence despite wound
care and other urinary management strategies
- Moderate to severe
incontinence-associated dermatitis that cannot be kept clear of urine
despite other urinary management strategies
- Urinary incontinence in
patients for whom nurses find difficult to provide skin care despite other
urinary management strategies and available resources (such as lift teams
and mechanical lift devices)
- Daily (not hourly)
measurement of urine volume that is required to provide treatment and
cannot be assessed by other volume§ and urine collection strategies
- Single 24-h or random
sterile or nonsterile urine sample for diagnostic
test that cannot be obtained by other urine collection strategies
- Reduction in acute,
severe pain with movement when other urine management strategies are
difficult (eg. unrepaired fracture)
- Patient request for
external catheter to manage urinary incontinence while hospitalized
- Improvement in comfort
when urine collection by catheter addresses patient and family goals in a
dying patient
Inappropriate
indications for external catheters in the Ann Arbor Criteria are:
- Any use in an
uncooperative patient expected to frequently manipulate catheters because
of such behavior issues as delirium and dementia
- Any type of urinary
retention
- Hourly measurement of
urine volume
- Urinary incontinence in
patients with intact skin when nurses can turn/provide skin care with
available resources when the patient has not requested the external
catheter
- Routine use in ICU
without an appropriate indication
- External catheter
placement to reduce risk for falls by minimizing the need to get up to
urinate
- Post-void residual urine
volume assessment
- 24-h or random sample
collection for sterile or nonsterile specimens
if possible by noncatheter collection strategies
- Catheter placement for
convenience of urinary management in patient during transport for tests
and procedures
- Patient or family
request when there are no expected difficulties managing urine by commode,
urinal, or bedpan in nondying patient
- To prevent urinary tract
infection in patient with fecal incontinence or diarrhea or to manage
frequent, painful urination in patients with urinary tract infection
Appropriate
indications for Intermittent Straight Catheterization in the Ann Arbor Criteria
are:
- Acute urinary retention
without bladder outlet obstruction, if bladder can be emptied adequately
by a maximum frequency of ISC every 4 hours
- Acute urinary retention
with bladder outlet obstruction due to noninfectious, nontraumatic
diagnosis
- Chronic urinary
retention with or without bladder outlet obstruction
- Stage III or IV or unstageable pressure ulcers or similarly severe wounds
of other types that cannot be kept clear of urinary incontinence despite wound
care and other urinary management strategies if ISC is adequate to manage
the type of incontinence (i.e. overflow)
- Urinary incontinence
that is treated and can be managed by ISC (i.e. overflow incontinence)
- Urine volume
measurements (not hourly) or sample collections in patients using ISC for
urinary retention/obstruction or overflow incontinence
- Random urine sample collection
for sterile or nonsterile specimens if
impossible by other collection strategies
- Management of urine in
patients with strict temporary immobility if ISC does not require
excessive movement
- Post-void residual urine
volume assessment if bladder scanner is unavailable or inadequate and more
detail than suprapubic fullness is needed
Inappropriate
indications for Intermittent Straight Catheterization in the Ann Arbor Criteria
are:
- Hourly measurement of
urine volume required to provide treatment
- Random urine sample
collection for sterile or nonsterile samples if
possible by other strategies
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:
- placing an indwelling
urinary catheter only when there was an approved indication for its usage
- inserting urinary
catheters using aseptic technique and an insertion checklist
- maintaining urinary
catheters based on principles of asepsis and positioning the patient and
collection device to assist in urine drainage
- reviewing urinary
catheter necessity daily and removing promptly when the indications are no
longer met
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:
- May
8, 2007 Tip of the Week “Doctor,
when do I get this red rubber hose removed?”
- January
8, 2008 Tip of the Week “Urinary
Catheter-Associated Infections”
- April 2008 What’s New in
the Patient Safety World column “More
on Nosocomial UTI’s”
- June
24, 2008 Tip of the Week “Urinary
Catheter-Related UTI’s: Bladder Bundles”
- April
21, 2009 Tip of the Week “Still
Futzing with Foleys?”
- June
9, 2009 Tip of the Week “CDC
Update to the Guideline for Prevention of CAUTI”
- March 2010 “IDSA
CAUTI Guidelines”
- February
2011 What’s New in the Patient Safety World
column “Catheters
Not Needed in C-Sections?”
- January 2012 “CAUTI’s
Still Get No Respect”
- May 2012 “Foley
Catheter Hazards”
- November 2012 “CAUTI
Conundrum”
- December 18, 2012 “Unintended
Consequences of the CAUTI Measure?”
- January 2013 “Silver-Coated
Urinary Catheters Don’t Reduce CAUTI’s”
- June 2013 “Barriers
to CAUTI Prevention”
- November 2013 “Further
Reducing Urinary Catheter Use”
- June 2014 “Updated
HAI Prevention Guidelines from SHEA/IDSA”
References:
Gould CV, Umscheid CA, Agarwal RK,
et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections
2009. CDC HICPAC 2009
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
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
http://annals.org/article.aspx?articleid=2280677
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
http://qualitysafety.bmj.com/content/early/2015/05/19/bmjqs-2015-004114.short?g=w_qs_ahead_tab
Krein SL, Saint S. What’s your
excuse for Foley use? BMJ Quality &
Safety Online First 2015; published on 1 June 2015
http://qualitysafety.bmj.com/content/early/2015/06/01/bmjqs-2015-004376.full.pdf+html
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
http://www.ajicjournal.org/article/S0196-6553%2815%2900107-8/abstract
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
http://pediatrics.aappublications.org/content/early/2014/08/06/peds.2013-3470
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
http://archinte.jamanetwork.com/article.aspx?articleid=2195118&resultClick=3
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