What’s New in the Patient Safety World

November 2013 

Further Reducing Urinary Catheter Use



From a strictly numerical perspective we’ve probably done more columns on CAUTI’s and catheter complications than any other topic (see the links at the end of today’s column).


Much of the literature base on these topics comes from clinical researchers at the University of Michigan. Recently they’ve again done a series of very useful articles on urinary catheters. One is a meta-analysis of strategies and interventions to reduce unnecessary use of urinary catheters and other strategies to prevent CAUTI’s (Meddings 2013a). It highlights multiple interventions to both avoid initial placement of urinary catheters and strategies to promote prompt removal of catheters that are no longer necessary. These include making available guidelines for appropriate use of catheters and examples of inappropriate use, alternatives to indwelling catheters, use of paper or computerized reminder tools, automatic stop orders, nurse-empowered removal protocols, etc. and the article discusses potential pitfalls with the strategies. It has good discussions on implementation strategies and monitoring and feedback. It is a comprehensive review of the field with good statistics on success rates and a great bibliography.


Lead author of that first paper, Jennifer Meddings, also did an editorial with many of the same recommendations (Meddings 2013b) in commenting on a study reported by a group from The Netherlands (Janzen 2013). The latter study was a simple study that showed increasing physician awareness through educational sessions plus daily review of catheter necessity successfully reduced catheter duration, CAUTI’s and LOS. But Meddings’ editorial comments are even more helpful since they discuss the barriers and impediments one may encounter in various settings. She notes how pre-existing behavior (physician and nurse), communication patterns, and workflow issues are all important in choosing a strategy that will work best in your setting.


The last article, again from the University of Michigan group, is a systematic review and meta-analysis of the noninfectious complications of indwelling urinary catheters (Hollingsworth 2013). Our May 2012 What’s New in the Patient Safety World column “Foley Catheter Hazards” touched upon a few noninfectious complications of urinary catheters. This new meta-analysis, however, is more comprehensive than any previous individual studies on the topic. The authors find that noninfectious complications occur at least as frequently as CAUTI in patients with short-term catheterization and the rates are 4 times higher in those with long-term catheterization.


Some complications may be minor, like leakage of urine around the catheter. But others are more serious, including gross hematuria, urethral strictures and erosions, false passage, accidental removal, and catheter blockage. Long-term catheterizations and indwelling catheters in spinal cord-injured patients may also be associated with bladder calculi and bladder cancer. The meta-analysis provides lots of statistics on the reported frequencies of these complications, noting that considerable variation exists related to quality of the studies and sex differences in the reported populations.


The authors stress that the best way to avoid such complications is to avoid catheterization in the first place. However, recognizing that indwelling urinary catheters may be necessary in some cases, they also emphasize education and skill training for those inserting catheters.


They also point out that data on the costs of noninfectious complications is very scant at this time and should be a focus of future research.





Overall, these are a series of easy-to-read, practical recommendations on dealing with very common problems. Very informative work coming from the group at the forefront of improving patient safety related to urinary catheters.





Our other columns on urinary catheter-associated UTI’s:










Meddings J, Rogers MAM, Krein SL, et al. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 2013; Published Online First: 27 September 2013




Meddings J. Interventions to reduce urinary catheter use: it worked for them, but will it work for us? BMJ Qual Saf 2013; Published Online First: 19 September 2013




Janzen J, Buurman BM, Spanjaard L, et al. Reduction of unnecessary use of indwelling urinary catheters. BMJ Qual Saf bmjqs-2013-001908Published Online First: 6 June 2013




Hollingsworth JM, Rogers MAM, Krein SL, et al. Determining the Noninfectious Complications of Indwelling Urethral Catheters: A Systematic Review and Meta-analysis. Ann Intern Med 2013; 159(6): 401-410









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