CHAMP CHAMP Hazard of Hospitalization:Hazard of Hospitalization:Foley CathetersFoley Catheters

Catherine E. DuBeau, M.D.Catherine E. DuBeau, M.D.

Professor of MedicineProfessor of Medicine

University of Massachusetts University of Massachusetts Medical SchoolMedical School

Worcester, MAWorcester, MA

Learning ObjectivesLearning Objectives

• Name short and long term risks of Name short and long term risks of catheterizationcatheterization

• Differentiate the medical reasons for Differentiate the medical reasons for incomplete voidingincomplete voiding

• Analyze catheter management problemsAnalyze catheter management problems• Perform bedside evaluation of the need Perform bedside evaluation of the need

for a catheter and construct plan for for a catheter and construct plan for catheter removalcatheter removal

OutlineOutline

1.1. Scope of the problemScope of the problem

2.2. Rationale for targeting catheter useRationale for targeting catheter use

3.3. Appropriate indications for catheter Appropriate indications for catheter useuse

4.4. Catheter managementCatheter management

5.5. Trouble-shooting failure to voidTrouble-shooting failure to void

6.6. Teaching triggersTeaching triggers

Emphases and LinksEmphases and Links

Text will be repeated in RED to indicate links to other CHAMP modules

Scope of the ProblemScope of the Problem

• Prevalent and morbidPrevalent and morbid– 25% of hospitalized pts have a catheter25% of hospitalized pts have a catheter– Cause of 40% of nosocomial infectionsCause of 40% of nosocomial infections– Uncomfortable and restrictive (“one-Uncomfortable and restrictive (“one-

point restraint”)point restraint”)– Urethral and meatal trauma (traumatic Urethral and meatal trauma (traumatic

hypospadius in men, patulous meatus hypospadius in men, patulous meatus in women, scarring, bleeding) in women, scarring, bleeding)

Scope of the ProblemScope of the Problem

• Prevalent and morbidPrevalent and morbid– 25% of hospitalized pts have a 25% of hospitalized pts have a

cathetercatheter– Cause 40% of nosocomial infectionsCause 40% of nosocomial infections– Uncomfortable and restrictive (“one-Uncomfortable and restrictive (“one-

point restraint”)point restraint”)– Urethral and meatal traumaUrethral and meatal trauma

PAINDELIRIUMFALLS

Scope of the ProblemScope of the Problem

• Often an “invisible” problemOften an “invisible” problem– Hospital MDs unaware of catheter use in Hospital MDs unaware of catheter use in

about 1/3 of their catheterized patientsabout 1/3 of their catheterized patients– Being unaware associated with inappropriate Being unaware associated with inappropriate

use and longer catheterization periodsuse and longer catheterization periods

• Internists have little training in the Internists have little training in the medical reasons for failure to voidmedical reasons for failure to void

• Resulting Urology consults don’t always Resulting Urology consults don’t always lead to mutual satisfaction/learninglead to mutual satisfaction/learning

Quality and SafetyQuality and Safety

• Catheter-associated urinary tract infection Catheter-associated urinary tract infection (CAUTI) is a target of the 2009 HHS Action (CAUTI) is a target of the 2009 HHS Action Plan to reduce Healthcare Associated Plan to reduce Healthcare Associated Infections (HAIs)Infections (HAIs)– Emphasized need to implement “best practices” Emphasized need to implement “best practices”

in the prevention of CAUTI, especially reducing in the prevention of CAUTI, especially reducing unecessary and prolonged catheterizationunecessary and prolonged catheterization

• CMS - CAUTI is a “never event” that is not CMS - CAUTI is a “never event” that is not reimbursedreimbursed

• CDC Healthcare Infection Control Practices CDC Healthcare Infection Control Practices Committee (HICPAC) – New 2010 Guidelines Committee (HICPAC) – New 2010 Guidelines on CAUTI preventionon CAUTI prevention

Rationale for targeting Rationale for targeting catheterscatheters

1.1. MorbidityMorbidity

2.2. QualityQuality

3.3. ExpenseExpense

MorbidityMorbidity

• IndwellingIndwelling– Polymicrobial Polymicrobial

bacteriuria bacteriuria (universal at 30 (universal at 30 days)days)

– Fever (1/100 pt-Fever (1/100 pt-days)days)

– Chronic pyeloChronic pyelo– Bladder and renal Bladder and renal

stonesstones– Urethral and Urethral and

meatal injurymeatal injury– AgitationAgitation

• ExternalExternal– Bacteriuria and Bacteriuria and

infectioninfection– Penile cellulitis and Penile cellulitis and

necrosisnecrosis– Urinary retentionUrinary retention

MorbidityMorbidity

• IndwellingIndwelling– Polymicrobial Polymicrobial

bacteriuria bacteriuria (universal at 30 (universal at 30 days)days)

– Fever (1/100 pt-Fever (1/100 pt-days)days)

– Chronic pyeloChronic pyelo– Bladder and renal Bladder and renal

stonesstones– Urethral and meatal Urethral and meatal

injuryinjury– AgitationAgitation

• ExternalExternal– Bacteriuria and Bacteriuria and

infectioninfection– Penile cellulitis and Penile cellulitis and

necrosisnecrosis– Urinary retentionUrinary retention

DELIRIUM

MorbidityMorbidity

More people die from hospital-acquired More people die from hospital-acquired infections than from auto accidents infections than from auto accidents and homicides and homicides combinedcombined

ExpenseExpense

• Unnecessary equipment and labor Unnecessary equipment and labor costscosts

• Hospital infections cost $5 billion Hospital infections cost $5 billion annuallyannually

• Longer length of stayLonger length of stay

ExpenseExpense

• Unnecessary equipment and labor Unnecessary equipment and labor costscosts

• Hospital infections cost $5 billion Hospital infections cost $5 billion annuallyannually

• Longer length of stayLonger length of stayIATROGENIC ILLNESS FUNCTIONAL DECLINE

Indications for using a catheterIndications for using a catheter

From CDC Guideline for prevention of CAUTI, From CDC Guideline for prevention of CAUTI, 2009 Update2009 Update

1.1. Acute retention or bladder outlet Acute retention or bladder outlet obstructionobstruction

2.2. Need for accurate I/O’sNeed for accurate I/O’s3.3. Assist in healing of open sacral ulcersAssist in healing of open sacral ulcers4.4. Provide comfort at end of lifeProvide comfort at end of life5.5. Peri-op in specific circumstances – GU Peri-op in specific circumstances – GU

surgery, prolonged surgery (intra-op use surgery, prolonged surgery (intra-op use only), intra-op I/O monitoring, required only), intra-op I/O monitoring, required prolonged immobilization (e.g., trauma, prolonged immobilization (e.g., trauma, unstable spine)unstable spine)

Catheter managementCatheter management

• Closed drainage systems with unobstructed Closed drainage systems with unobstructed flowflow

• Changing: base on clinical indicationChanging: base on clinical indication– Infection or breach of closed drainage systemInfection or breach of closed drainage system– ObstructionObstruction– Changing at fixed intervals not recommended.Changing at fixed intervals not recommended.

• Leakage around catheterLeakage around catheter– Balloon too big (size or inflation)Balloon too big (size or inflation)– InfectionInfection– Bladder spasm: consider pyridium; if no Bladder spasm: consider pyridium; if no

underlying obstruction or inability to void, underlying obstruction or inability to void, consider trial antimuscarinic bladder relaxant, consider trial antimuscarinic bladder relaxant, eg tolterodineeg tolterodine

Trouble-shooting insertionTrouble-shooting insertion

1. “Can’t pass”• Discomfort/spasm at sphincter:

• Use lidocaine gel• Insert with slight ‘torque’ while patient

exhales• Try larger catheter• Coudécatheter

2. Inflate the balloon only aftercatheter is inserted all the way in, up to the meatus

Trouble-shooting failure to voidTrouble-shooting failure to void(full or partial retention)(full or partial retention)

• Two basic reasonsTwo basic reasons– Poor pumpPoor pump– Blocked outletBlocked outlet

Trouble-shooting failure to Trouble-shooting failure to voidvoid

• Two basic reasonsTwo basic reasons– Poor pumpPoor pump– Blocked outletBlocked outlet

Pump action: Ach, Ca++

Sphincter closure: Alpha adrenergic

Trouble-shooting failure to Trouble-shooting failure to voidvoid

• Two basic reasonsTwo basic reasons– Poor pumpPoor pump

– Blocked outlet Blocked outlet

Meds: anticholinergic, Ca+ blockers, opiates

Sacral cord disease

Neuropathy: DM, B12 defic

ConstipationProstate disease

Meds: alpha-agonists

Neurological disease: dyssynergia

Women: scarring, cystocele

Constipation

Teaching TriggersTeaching Triggers

Action step 1: Look for catheter on Action step 1: Look for catheter on every patient when at bedsideevery patient when at bedside

Trigger: Catheter found

“Why does this pt have a catheter?

Review indications

Action step 1: Look for catheter on Action step 1: Look for catheter on every patient when at bedsideevery patient when at bedside

Trigger: Catheter found

“Why does this pt have a catheter?

Review indications:1. Inability to void

2. Sacral ulcer

3. Palliative care

4. Monitor output

5. Appropriate peri-op reason

Action step 1: Look for catheter on Action step 1: Look for catheter on every patient when at bedsideevery patient when at bedside

Trigger: Catheter found

“Why does this pt have a catheter?

Appropriate indication Action Step 2

Action step 2: “Does this patient still need the catheter?

Yes Action step 3

Action step 3: “Does this patient have a medical reason for inability to void?

A.A. Review MARReview MAR

B. Review medical historyB. Review medical history

C. *Additional exam, PVRC. *Additional exam, PVR

Anus

Clitoris

Anal wink

Bulbocavernosus

Sacral ReflexesSacral Reflexes

Adapted from Geriatric Review Syllabus Urinary Incontinence slide set, American Geriatric Society, 2006

Cystocele

RectocelePhotographs from: Abrams P, Cardozo L, Khoury S, Wein A, ed. Incontinence. 2nd International Consultation on Incontinence.

Plymouth UK: Health Publications Ltd, 2002; pp 381-2.

Pelvic ExamPelvic Exam

Action step 2: “Does this patient still need the catheter?

No Action step 4

Action step 4: Discontinue all Action step 4: Discontinue all catheters before discharge unless catheters before discharge unless there is chronic retentionthere is chronic retention

Action step 4: Discontinue all Action step 4: Discontinue all catheters before discharge unless catheters before discharge unless there is chronic retentionthere is chronic retention

TRANSITIONS OF CARE

Action step 4: Discontinue all catheters

A. Deflate balloon and remove A. Deflate balloon and remove catheter catheter ((never clamp!)never clamp!)

B. Insure adequate fluid intake (PO B. Insure adequate fluid intake (PO or or IV)IV)

C. Monitor for 8 hoursC. Monitor for 8 hours

D. If no void, reinsert catheter and note D. If no void, reinsert catheter and note volume. If < 200, increase fluids and volume. If < 200, increase fluids and repeat trial. Review causes of failure to repeat trial. Review causes of failure to void.void.

E. If voids, check PVRE. If voids, check PVR

PVR < 100 (men) or <200 (women): done

Higher PVR: re-insert, review causes of failure to void

Action step 4: Discontinue all catheters

1. Does the pt have a Foley?

Why does pt have Foley?

2. Does the pt still need Foley?

3. Medical reason for inability to void?

YES

Review 5 indications

InappropriateAppropriate

YES

Review PMHx, MAR, PE

4. Plans to D/C Foley

NO

Who to discharge Who to discharge withwith a a cathetercatheter

• Patients with retention who fail voiding trialsPatients with retention who fail voiding trials• Patients who have not completed at least 7 Patients who have not completed at least 7

days of decompression for new retention days of decompression for new retention (they will need PCP, GU, and/or VNA follow-(they will need PCP, GU, and/or VNA follow-up to do and monitor voiding trial)up to do and monitor voiding trial)

• Transitions of care:Transitions of care:– Leg bag for day & large bag for night, or large bag aloneLeg bag for day & large bag for night, or large bag alone– Family instruction re: emptying bag; changing bags (if Family instruction re: emptying bag; changing bags (if

necess); using straps to secure catheter (and leg bag) to necess); using straps to secure catheter (and leg bag) to leg; monitoring for output, hematuria, fever, SP pain; leg; monitoring for output, hematuria, fever, SP pain; importance of adequate fluidsimportance of adequate fluids

When to refer to UrologyWhen to refer to Urology

• Failure to insert catheter even after Failure to insert catheter even after trying earlier suggestionstrying earlier suggestions

• Large volume hematuria that does Large volume hematuria that does not clear with 3-way irrigationnot clear with 3-way irrigation

• If you have treated medical reasons If you have treated medical reasons for failure to void and pt still with for failure to void and pt still with retention, make retention, make outpatientoutpatient referral to referral to GUGU

Using Foleys to Teach Practice-Using Foleys to Teach Practice-Based Learning: Going Beyond Based Learning: Going Beyond ContentContent

• What is the team’s practice and how can What is the team’s practice and how can we learn from it?we learn from it?– PLANPLAN to focus on Foleys for a teaching to focus on Foleys for a teaching

session/roundssession/rounds– DODO a “ a “census auditcensus audit”, based on triggers:”, based on triggers:

• How many patients have a Foley?How many patients have a Foley?• Of these, how many did the team know about?Of these, how many did the team know about?• How many have a correct indication?How many have a correct indication?

– STUDYSTUDY the results the results• Share tally results with team and discuss Share tally results with team and discuss

implications and the implications and the processprocess

– ACTACT: how can we improve Foley care? : how can we improve Foley care? Repeat audit?Repeat audit?

Using Foleys to Teach Prevention Using Foleys to Teach Prevention of HAIsof HAIs

• Evidence-based catheter care to prevent Evidence-based catheter care to prevent CAUTI – CAUTI – “ABCDE”“ABCDE”– AAdherence to general infection control principlesdherence to general infection control principles

– BBladder ultrasound may help avoid ladder ultrasound may help avoid catheterizationcatheterization

– CCondom catheters or other alternatives (eg, ondom catheters or other alternatives (eg, intermittent catheterization) should be intermittent catheterization) should be considered in appropriate ptsconsidered in appropriate pts

– DDo not use an indwelling catheter unless you o not use an indwelling catheter unless you mustmust

– EEarly removal of the catheter using a reminder arly removal of the catheter using a reminder or nurse-initiated removal protocolor nurse-initiated removal protocol

Saint S et al. Joint Comm J Qual Pt Safety 2009; 35:449