In our April 21, 2009 Patient Safety Tip of the Week “Guideline for Prevention of Catheter-Associated Urinary Tract Infection 2008” has been made available through the Premier Patient Safety Institute website. But don’t worry, you don’t have to read the entire document! It comes with an excellent executive summary which contains all the key elements you’ll need. This is a great guideline that provides useful recommendations about the indications for indwelling urethral catheters, the proper insertion and care of them, alternatives to indwelling urethral catheters, and help in setting up the quality improvement systems you need to help your facilities avoid CAUTI’s. The bulk of the 322 pages is made up of appendices related to the evidence base, a great resource for those who need further insights into the recommendations in the guideline.” we noted that the legitimate indications for indwelling urethral catheters would be clarified in the upcoming release of new CDC/HICPAC guidelines. Well, a draft of the 322-page “
You’ll recall that the original CDC guideline was published in 1981 and had not been updated officially since that time.
Most importantly, the guideline stresses 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. The guideline provides a table listing appropriate indications for indwelling urethral catheters. Appropriate indications include:
The recommendations on indications for indwelling urethral catheters are particularly useful when it comes to the OR. In our April 21 column we noted that perioperative use of indwelling urethral catheters remains a significant problem in most hospitals. The guidelines stresses that indwelling urethral catheters should not be used routinely in operative patients, but rather only when necessary. Legitimate perioperative indications include those cases where prolonged duration is anticipated, those where intraoperative monitoring of urinary output is needed, and those where it is anticipated there will be large volumes of fluid infused or diuretics used. They may also be used in incontinent patients during the surgery period. And, of course, they may be used during urologic surgery or surgery on structures contiguous with the G-U tract. If there is a legitimate indication for perioperative use of a indwelling urethral catheter, the catheter should be removed as soon as possible (preferably within 24 hours). If used perioperatively, there should be specific protocols established to guide appropriate evaluation and consideration for removal of the catheters.
In our April 21 column we noted that one of the problems with failure to remove indwelling urethral catheters postoperatively may be that the OR IT systems are often poorly integrated with the other hospital IT systems. The other problem is that multiple handoffs occur in the perioperative patient. They typically go from a med/surg floor (or pre-op intake area) to the OR, then to the PACU or recovery room, then back to a med/surg floor or ICU. We strongly recommend that your structured handoff tools include a specific item related to indwelling urethral catheters.
The section on alternatives to indwelling urethral catheter use is also excellent. It discusses use of condom catheters in male patients and has an extensive discussion about use of intermittent catheterization, both “clean” and “sterile” types. Those of us who are neurologists have used clean intermittent catheterization in many patients for many years and continue to be amazed at how infrequently UTI’s occur when used properly. In the hospital, however, sterile technique and equipment should be used. The guideline recommends use of a portable ultrasound device (by appropriately trained personnel) to assess urine volume so as to avoid unnecessary intermittent catheter insertions.
The section on proper techniques for urinary catheter insertion include discussions on proper training of personnel, hand hygiene before and after catheter insertion, sterile equipment, aseptic technique, use of lubricant jelly, proper securing of the catheter to prevent movement and urethral traction, and use of the smallest bore catheter possible. Our comment: use a checklist, just like you would if you were inserting a central line.
Not included in the guideline, but worth noting if it applies to your facilities, is a recent UK National Patient Safety Agency Rapid Response Report “Female urinary catheters causing trauma to adult males”. This report notes numerous instances where shorter “female” catheters, when used in male patients, may result in pain, hematuria, retention, and penile swelling.
The section on urinary catheter maintenance focuses on maintaining sterile continuously closed drainage and unobstructed flow of urine (in the correct direction, of course). And they detail how to appropriately get samples for culture or diagnostic testing.
Some of the best advice in this guideline are the things not to do. This includes advice that you should not arbitrarily change catheters or drainage bags at fixed intervals and should not use systemic antibiotics routinely to prevent CAUTI’s. Bladder irrigation should be avoided unless obstruction is suspected. And antimicrobials need not be instilled in either the bladder or the drainage bags and antiseptic lubricants need not be routinely used. The guideline also notes that silver-alloy catheters or antibiotic-coated catheters need not be routinely used. And catheterized patients should not be screened routinely for asymptomatic bacteruria. They also discuss considerations that are still subject to future research.
The section on monitoring, surveillance, and quality improvement is excellent. They suggest use of a system of alerts and reminders to identify those patients with indwelling urethral catheters and need for continued catheterization and development of protocols for nurse-directed removal of unnecessary catheters. They also suggest procedure-specific protocols for perioperative management and protocols for postoperative urinary retention. Lastly, they discuss the role of administration in providing appropriate guidance and leadership, education and training, supplies and a system for documentation and surveillance. Use of feedback, both to individual providers and units, is highly recommended.
Going back to our April 21, 2009 Patient Safety Tip of the Week “Still Futzing with Foleys?” we again offer the following suggestion: treat the Foley catheter like a drug! Have it ordered through your CPOE or medication ordering system. That column lists out some of the potential benefits of using such a system.
And don’t forget our other columns on urinary catheter-associated UTI’s:
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). DRAFT Guideline for Prevention of Catheter-Associated Urinary Tract Infection 2008. CDC. http://www.premierinc.com/quality-safety/tools-services/safety/topics/guidelines/downloads/cauti_GuidelineApx_June09.pdf
National Patient Safety Agency (UK). Rapid Response Report. Female urinary catheters causing trauma to adult males. NPSA Reference: NPSA/2009/RRR002. 30 April 2009