Doctor, when do I get this red rubber hose removed?”). Then we saw further reductions once we began to use clinical decision support built into our electronic medical records. Other useful measures have included daily A major step was when clinicians from the University of Michigan (Meddings 2015) published appropriateness criteria for urinary catheters June 30, 2015 Patient Safety Tip of the Week “What Are Appropriate Indications for Urinary Catheters?”). After that, more hospitals began auditing practices to ensure that catheter use was in line with appropriateness.May 8, 2007 Tip of the Week “
But CAUTI’s haven’t disappeared. In fact, the latest AHRQ data on hospital acquired conditions show that CAUTI’s actually increased in recent years
Doctor, when do I get this red rubber hose removed?” and our July 2016 What's New in the Patient Safety World column “”). This is when, unbeknownst to the attending physician, his/her patient has a Foley catheter inserted during the evening or night and its presence is not readily recognized.And the bane of those practicing in the hospital is the “surprise” Foley catheter (see our Patient Safety Tip of the Week for May 8, 2007 “
Our June 2013 What's New in the Patient Safety World column “Barriers to CAUTI Prevention” highlighted the barriers to implementation of best practices to prevent CAUTI’s seen in the highly successful Keystone initiative in Michigan to prevent CAUTI’s (Krein 2013). Not surprising was lack of buy-in from physicians and nurses, or insertion of the catheter in the ER. A surprising barrier, however, was requests from patient or family for the catheter.
While many guidelines and protocols call for timely postoperative removal of urinary catheters placed prior to surgical procedures, there has been a lack of guidelines to help determine in which procedures a catheter is needed at all. We recall working with a small hospital that had only two general surgeons. One routinely used a urinary catheter during appendectomies, the other did not. Once we pointed out the discrepancy, the other surgeon realized he did not need a catheter when doing a routine appendectomy.
Now, the Michigan group (Meddings 2018) has again come to the rescue! They have developed guidelines for patients undergoing general and orthopedic surgery. Procedural appropriateness ratings for catheters were summarized for clinical use into three groups:
Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures. You’ll have to go to the article itself for details about the individual procedures. But the first category (no need for a catheter) includes things like laparoscopic cholecystectomy, open appendectomy, most hernia repairs, and unilateral knee and hip procedures. Examples of procedures where removal of the catheter before the patient leaves the OR include bilateral hip and knee procedures, hip replacement revision surgery, and several bariatric procedures. Lastly, the category where catheter use for at least one post-op day is appropriate includes procedures like colectomies and abdominoperineal resections.
In view of the above study, you have even more reason to ensure appropriate use of urinary catheters. We hope that you’ll implement the many interventions we’ve discussed in detail in our numerous columns listed below and mentioned briefly at the beginning of today’s column. Recently, one hospital system implemented many of those interventions in a serial fashion and achieved excellent results (
Our other columns on urinary catheter-associated UTI’s:
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
Saint S, Trakutner BW, Fowler KE, et al. A Multicenter Study of Patient-Reported Infectious and Noninfectious Complications Associated With Indwelling Urethral Catheters. JAMA Intern Med 2018; Published online July 2, 2018.