Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

March 2022

Urinary Catheter Reinsertion

In our many columns on CAUTI’s (catheter-associated urinary tract infections) there is one topic we have seldom discussed – reinsertion of urinary catheters. A recent study by researchers at Henry Ford Hospital (Jamil 2022) brought that issue to our attention.

While we have focused efforts on avoiding urinary catheters that don’t meet criteria, Jamil et al. point out that it is estimated 25%-45% of adult patients will have an indwelling urinary catheter inserted at some point during their hospitalization, with rates as high as 89% for patients within the ICU. And we’ve also focused efforts on prompt removal of those catheters once they no longer meet criteria for continued use. But what happens once we remove those catheters?

The researchers developed a post-catheter removal bladder management protocol referred to as the Urinary Catheter Alleviation Navigator Protocol (UCANP) and piloted this protocol on four units, a neuro-intensive care unit, 2 neurosurgical and/or neurologic step-down units, and a neurosurgical and/or neurologic general practice unit.

The protocol: After catheter removal, a post-void residual (PVR) was obtained if a spontaneous void occurred within the first 4 hours. Patients with a PVR ≤ 100 mL “graduated” from the post-catheter removal management protocol. Patients with a PVR ≥ 400 mL were initiated on the intermittent catherization pathway. Patients with a PVR between 100 and 400 mL were monitored with repeat bladder scans every 4 hours and followed the protocol suggested pathway depending on the repeat bladder scan volumes. Patients who did not spontaneously void within 4 hours or had a PVR ≥ 400 mL were started on the intermittent catherization pathway. Patients would undergo nurse-conducted intermittent catherization for 48 hours. If they were unable to void spontaneously by that time, the primary medical and nursing team would evaluate the patient’s cognitive and physical ability, family support status, post-discharge location (home vs skilled nursing center, long term acute care center, sub-acute rehab center etc.), and ability to continue self or care-assisted intermittent catherization after discharge.

After implementation of the protocol, the reinsertion rate of 16% was compared to 21% and 27% in the pre-pilot cohort and another historical cohort, respectively. The mean number of catheter days was significantly lower during the protocol period (1.4 days) compared to the pre-pilot (5.6 days) and other historical (9.5 days) cohorts (P = .006). Rates of CAUTI’s were 0.6% during the pilot, compared to 1.2% in the pre-pilot cohort and 1.7% in the other historical cohort. Investigated in a larger patient population would be required to assess statistical significance regarding reduction in CAUTI’s.

Successful implementation of the protocol looks like it drew upon many of the success factors from the Michigan Keystone Project. All medical personnel (physicians, nurses, nursing assistants) were provided educational material and instructions on the outlined protocol. Comprehensive Unit-Based Safety Program (CUSP) principles were used and debriefings were held every 3 weeks by clinical leadership. The EMR was used for both order entry and tracking of patients, with reminders and instructions for nursing staff about next steps in the protocol.

We think this is an exciting study. If it results in reductions in catheter days of this magnitude in other populations and settings, we’d expect a significant reduction in CAUTI’s.

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”

· June 30, 2015 “What Are Appropriate Indications for Urinary Catheters?”

· December 2015 “CAUTI Prevention Tools”

· July 2016 “Holy Moly, My Patient has a FOLEY!”

· December 2016 “The Joint Commission NPSG for CAUTI’s”

· April 3, 2018 “Cost of a CAUTI”

· September 25, 2018 “Foley Follies”

· April 30, 2019 “Reducing Unnecessary Urine Cultures”

· March 2, 2021 “Barriers to Timely Catheter Removal”

References:

Jamil ML, Wurst H, Robinson P, et al. Urinary catheter alleviation navigator protocol (UCANP): Overview of protocol and review of initial experience. AJIC 2022; 50(1): 81-85

https://www.ajicjournal.org/article/S0196-6553(21)00459-4/fulltext

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