Emergency Nursing Education

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An 85 year old male with dementia…Brought to the ED from his skilled nursing facility

with a complaint of nonfunctioning PEG tube. In the initial assessment, the nurse notes the

patient was incontinent and placed a urinary catheter

The patient is admitted for a PEG change. Overnight the patient becomes more confused and pulls on his catheter leading to severe hematuria and requiring a urology evaluation.

Within 36 hours was febrile, with positive blood cultures, treated for CAUTI and requires a prolonged hospital stay.

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ObjectivesDescribe urinary catheter use with focus on

the emergency department (ED)Identify current evidence on prevention of

CAUTIsOutline nursing assessment of the ED patient

who may require urinary catheterizationList criteria for catheter placementReview communication necessary between

nurses and providers to facilitate appropriate clinical decision-making

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Urinary Catheter UtilizationAbout 15 - 25% of patients will have a

urinary catheter placed during their hospitalization.

Many are placed inED

ICU

OR

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Reducing CAUTIDetermine appropriate indicationAvoid use if no indicationSeek alternatives when possibleUse sterile technique for placementRemove as soon as possible

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Why we think putting in a catheter is a good idea – but it’s notPerception FactsFacilitates I/O measurement

Alternatives are available with less risk (e.g., urinals, daily weights)

Prevents falls from getting up to urinate

Increases risk to fall, especially in the confused patient

Protects skin in the incontinent patient

Increases risk of skin breakdown from immobility, muscle loss, and catheter-related trauma

Saves time for the bedside nurse

Extended LOS, infection complications, and other risks, it does not

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Indications for catheterizationPatient is critically ill and will require

accurate output measurementUrinary retention/obstruction

Bladder scanner or bedside ultrasound firstImmobilization needed for trauma or surgeryIncontinent with open sacral/perineal woundsEnd of life/hospiceChronic or existing catheter use

Re-evaluate need and discuss with provider

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“Not” indications for catheterizationSubstitute for frequent toiletingTo obtain a specimen if the patient can void

freelyPatient preferenceDementiaObesity

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Patients at high risk for inappropriate catheterization

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Reducing inappropriate placements reducesInfection ratesCostAntibiotics useLength of stayMorbidityPatient discomfort

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Communication with providersClear understanding of indicationsCommitment to nonmaleficence (doing no

harm)Patient focused care

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So, how does this affect the care of this patient?Brought to the ED from his SNF with a

complaint of nonfunctioning PEG tube. In the initial assessment, the nurse noted the patient being incontinent and placed a urinary catheterIncontinence is not an indication by itself for

catheter placement

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So, how does this affect the care of this patient?The patient was admitted for a PEG change.

Overnight the patient became more confused and pulled on his catheter leading to severe hematuria and requiring a urology evaluation.The agitated patient (possibly due to dementia)

is not a good candidate for catheter placement

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So, how does this affect the care of this patient?Within 36 hours was febrile, with positive

blood cultures, treated for CAUTI and required a prolonged hospital stay.This patient had no indications to place a

catheter; the suggestion is that placement of the catheter in the ED was a potential cause of infection. Patient stay is prolonged, patient develops a clinical problem he did not present with initially. This infection is potentially preventable.

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Another example…A 76-year-old woman admitted for

congestive heart failure…Urinary catheter placed and started on diuretics Condition improved; ready for discharge on 3rd dayNo urinary output for 5 hours after catheter

removalBladder scan showed 500 mL of urineStraight catheterization Observed overnight for symptom resolution

CAUTI ED slides, Fakih, 2012

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So, how does this affect the care of this patient?Urinary catheter placed and started on

diureticsAccurate I & O measurement can be a valid

indication for catheter placement for critically ill patients

Evaluate for need before placement

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So, how does this affect the care of this patient?Condition improved; ready for discharge on 3rd dayNo urinary output for 5 hours after catheter removalBladder scan showed 500 mL of urine

Not all patients with congestive heart failure require catheterization

Early removal may have prompted evaluation of urinary retention

Additional day of hospitalizationRisk for urosepsis

Explore alternatives for measuring I & ORemoval after initial diuresis to shorten exposureFrequent toiletingCommunicate with inpatient staff indication for

placement to assure timely removal17

Another example…

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So, how does this affect the care of this patient?Team felt the catheter would make her

more comfortableComfort is a myth

It may be convenient for the staff and the patient, but does not promote comfort, nor is it a safe indication

Some patients may request a catheter to avoid the need to get up. It is still an inappropriate reason

ConsequencesProlonged, unexpected hospitalization from

hospital-acquired CAUTIRisk for urosepsis

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The take homeReview indications for urinary catheter

placementDiscuss placement with providerCommunicate indications for placement with

inpatient staff for timely removalDo no harm

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Other indications for urinary catheter:Urinary retention/obstruction?

o Use bladder scanner firstImmobilization needed for trauma or surgery?Incontinent with open sacral/perineal wounds?End of life/hospice?Chronic or existing catheter use?

o Re-evaluate need and discuss with provider

 

Insert catheter and treat signs of shock:HypotensionDecreased cardiac output/functionDecreased renal functionHypovolemiaHemorrhage

Re-assess after intervention  

Do NOT insert

Explore alternatives

Still critically ill, requiring accurate output measurement?

Insert or maintain catheter Remove catheter

prior to admission

Is the patient critically ill and will require accurate output measurement?

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