Initial inappropriate urinary catheters use in a tertiary-care center: incidence, risk factors, and outcomes

Urinary Tract Infection Prevention and Treatment

Urinary tract infections are the most common bacterial infections encountered by health care professionals. In women, the lifetime incidence of urinary tract infections may be up to 40% to 50%, of whom a further 40% may have recurrent infections. Urinary tract infections are associated with significant morbidity and potential mortality-they may be complicated by frequent recurrences, kidney damage, sepsis, and preterm birth, as well as collateral damage of antimicrobial use, which includes Clostridium difficile colitis and selection of drug-resistant organisms. There are personal costs such as reduced quality of life in patients affected by recurrent urinary tract infections, and societal impacts resulting from absenteeism and health care costs. In this review, we discuss the definitions and classifications, pathogenesis, and current principles of management and prevention of urinary tract infections. Semin Nephrol 43:x-xx © 2023 Elsevier Inc. All rights reserved.

Inappropriate urinary catheterisation: a review of the prevalence, risk factors and measures to reduce incidence

Urinary tract infections (UTIs) comprise the second most common type of healthcare-associated infections, with up to 80% of UTIs caused by indwelling urinary catheters. Current research suggests that the best way to prevent catheter-associated UTIs (CAUTIs) is to reduce unnecessary catheterisation. Few reviews have focused on the prevalence, risk factors and preventive measures for inappropriate catheterisation. This article, consequently, sought to evaluate the current evidence on the prevalence, risk factors and measures that can be taken to prevent inappropriate urinary catheterisation.

Bladder Care in Palliative Care Inpatients: A Prospective Dual Site Cohort Study

Background: Urinary catheterization is often undertaken to relieve distressing bladder symptoms in palliative care.

Objective: The primary aim of this study was to determine the incidence of, and clinical indications that predispose patients admitted to palliative care units to, urinary catheterization. The secondary aims were to determine causal factors, including the type of malignancy, antecedent medications, and duration of admission in these patients.

Methods: This was a prospective observational dual site cohort study in palliative care inpatients. Univariate categorical chi-square analysis was performed to compare patients with and without urinary catheterization, and to identify risk factors associated with urinary catheter use.

Results: The incidence of catheterization in this cohort was 41% (43/104) and urinary retention (63%) was the most common cause. Agitation (47%) and urinary incontinence (70%) were common symptoms in those catheterized. Medications that were significantly associated with the need for urinary catheterization were benzodiazepines (p < 0.01) and antipsychotics (p = 0.01). All measures that define poor functional status were found to be significant (p < 0.01). Patients with prolonged hospitalization of greater than three weeks were catheterized more frequently (p = 0.017). The majority of patients catheterized (79%) were admitted for terminal care.

Conclusions: The high incidence of urinary catheterization highlights the need for good bladder care for all patients in the palliative care setting. Patients with risk factors include the use of antipsychotics and benzodiazepines, declining functional status and prolonged hospital admission are more likely to be catheterized.

Does my patient really need this at admission? Seven opportunities for improving value in patient care during their hospitalization

INTRODUCTION

Besides the main treatment for their disease, hospital patients receive multiple care measures which include venous lines (VL), urinary catheters (UC), dietary restrictions (DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF). In many cases these practices are of low value.

METHODS

We analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients). We used different methodologies to identify low-value clinical practices.

RESULTS

BR or DR at admission were recommended in 37% (32-44) and 24% (19-30) of the patients respectively. In 81% (71-87) and 33% (21-45) of the cases this restriction was deemed unnecessary. Ninety-six percent (92-98) had VL and 25% (19-32) UC. VL were not used in 10% (6-12), UC had no indications for insertion in 21% (11-35) and for maintenance in 31% (12-46) patients. Fifty-seven percent (49-64) of the patients were administered VTP and 69% (62-76) were prescribed SUP. Twenty-two percent (15-31) of patients with VTP and 52% (43-60) with SUP had no indication. Chronic anticoagulation for AF was interrupted in 65% (53-75) with BAF was prescribed in 38% (25-52) of them. An intervention to reduce low-value care supporting clinical practices addressed only to the Internal Medicine Wards showed very poor results.

CONCLUSION

These results demonstrate that there is ample room for reduction of low-value care. Interventions to implement clinical guidelines at admissions should be addressed to cover the entire admission process, from the emergency room to the ward. Partial approaches are discouraged.

Age-dependent morbidity and mortality outcomes after surgical aortic valve replacement

OBJECTIVES

This study addressed the assumption of increased morbidity and mortality after surgical aortic valve replacement in patients older than 80 years with severe aortic stenosis.

METHODS

This prospective study was performed in consecutive patients referred for aortic valve replacement. The age-dependent change in cognitive and physical function, quality of life and rehospitalization and complication rates during the following year and 5-year all-cause mortality were documented.

RESULTS

A total of 351 patients underwent surgical aortic valve replacement. The death risk at 5 years was 10%, 20% and 34% in patients aged <70 years, 70-79 years and ≥80 years, respectively. Patients aged 70-79 years and ≥80 years had a hazard ratio of 1.88 [95% confidence interval (95% CI) 0.92-3.83, P = 0.08] and 2.90 [95% CI 1.42-5.92, P = 0.003] for mortality, respectively, when compared with patients aged <70 years. The length of stay and rehospitalization rate during the following year were similar between the groups. Patients ≥80 years of age experienced more delirium and infections, whereas the risks of new pacemaker, transient ischaemic attack (TIA) or stroke, myocardial infarction and heart failure were comparable between the age groups. All groups exhibited reduced New York Heart Association class, improved physical quality of life and unchanged mental scores without any clinically significant Mini Mental Status reduction.

CONCLUSIONS

Elderly patients (≥80 years of age) have important gains in health measures and satisfactory 5-year survival with an acceptable complications rate during the year following surgery. Active respiratory mobilization and the removal of an indwelling urethra catheter can prevent adverse effects, and measures should be taken to prevent delirium and confusion in elderly patients.

Clinical trial registration

clinicaltrials.gov (NCT 01794832).

Contextual Barriers to Communication Between Physicians and Nurses About Appropriate Catheter Use

BACKGROUND

Indwelling urinary and vascular catheters are a common cause of health care-associated infections. Interventions designed to reduce catheter use can be ineffective if they are not integrated into the workflow and communication streams of busy clinicians.

OBJECTIVES

To characterize communication barriers between physicians and nurses and to understand how these barriers affect appropriate use and removal of indwelling urinary and vascular catheters.

METHODS

Individual and small-group semistructured interviews were conducted with physicians and nurses in a progressive care unit of an academic hospital. Common themes were identified, analyzed, and then organized using a conceptual framework of contextual barriers to communication: organizational, cognitive, and social complexity.

RESULTS

Several barriers to communication between physicians and nurses contributed to inappropriate use and delayed removal of catheters. Workflow misalignment between clinicians was a barrier associated with organizational complexity, issues with electronic medical records and pagers were associated with cognitive complexity, and strained relationships between clinicians and rigid hierarchies were associated with social complexity.

CONCLUSIONS

Communication is contextual, and improving physician-nurse communication about appropriate catheter use may require innovations that address the identified contextual barriers.

Factors associated with long-term urinary catheterisation and its impact on urinary tract infection among older people in the community: a population-based observational study in a city in Japan

OBJECTIVES

This study aimed to identify factors associated with long-term urinary catheterisation (LTUC) in community-dwelling older adults and to evaluate the risk of urinary tract infection (UTI) among people with LTUC.

DESIGN

Population-based observational study.

SETTING

Medical and long-term care insurance claims data from one municipality in Japan.

PARTICIPANTS

People aged ≥75 years living at home who used medical services between October 2012 and September 2013 (n=32 617).

OUTCOME MEASURES

(1) Use of LTUC, defined as urinary catheterisation for at least two consecutive months, to identify factors associated with LTUC and (2) the incidence of UTI, defined as a recorded diagnosis of UTI and prescription of antibiotics, in people with and without LTUC.

RESULTS

The 1-year prevalence of LTUC was 0.44% (143/32 617). Multivariable logistic regression analysis showed that the male sex, older age, higher comorbidity score, previous history of hospitalisation with in-hospital use of urinary catheters and high long-term care need level were independently associated with LTUC. The incidence rate of UTI was 33.8 and 4.7 per 100 person-years in people with and without LTUC, respectively. According to multivariable Poisson regression analysis, LTUC was independently associated with UTI (adjusted rate ratio 2.58, 95% CI 1.68 to 3.96). Propensity score-matched analysis yielded a similar result (rate ratio 2.41, 95% CI 1.45 to 4.00).

CONCLUSIONS

We identified several factors associated with LTUC in the community, and LTUC was independently associated with the incidence of UTI.

Advances and Challenges in the Diagnosis and Treatment of Urinary Tract Infections: the Need for Diagnostic Stewardship

PURPOSE OF REVIEW

Urinary tract infections (UTIs), including catheter-associated UTIs, are among the most common bacterial infections in both inpatient and outpatient settings. Diagnosis of true UTI remains a clinical challenge, and excessive antimicrobial treatment of asymptomatic bacteriuria (ASB) or contaminated urine cultures is common.

RECENT FINDINGS

Challenges with the appropriate diagnosis of UTIs include the lack of specific signs and symptoms, no definitive diagnostic criteria, high incidence of ASB, contamination of samples, and frequent lack of indications for ordering urine cultures. Promising interventions include education and feedback, indication requirements when ordering cultures, and use of reflex culture policies that limit urine cultures. Antimicrobial and diagnostic stewardship interventions can work synergistically to decrease ordering of urine cultures without clear indication and prevent excessive antimicrobial administration in patients without clearly defined UTI.

Efficacy of bladder irrigation in preventing urinary tract infections associated with short-term catheterization in comatose patients: A randomized controlled clinical trial

BACKGROUND

Bladder irrigation can be performed to prevent catheter-associated urinary tract infections (CAUTI), but its efficacy has been not reported in short-term indwelling urinary catheterization. This clinical trial aimed to examine the efficacy of bladder irrigation with normal saline solution in preventing CAUTI in comatose patients admitted to intensive care units.

MATERIALS AND METHODS

Eligible patients were randomized to the experimental group or control group. The experimental group received daily bladder irrigation with 450 cc sterile normal saline, in 3 150-mL doses, for 3 consecutive days. Data on signs of CAUTI, including urine culture, axillary body temperature (primary outcomes), and other urine and blood parameters (secondary outcomes) were obtained at baseline and 5 days later.

RESULTS

Results of group comparisons and logistic regression analysis that controlled for fluid intake showed that the risk of CAUTI decreased by 99% in the experimental group compared with the control group (odds ratio, 0.01; P < .001). Additional findings indicated a decrease in axillary body temperature and improvements in urine appearance, urinary red cells and white cells, and erythrocyte sedimentation rates and white-cell counts in the blood following bladder irrigation.

CONCLUSION

Daily bladder irrigation with normal saline during 3 days demonstrated efficacy in preventing CAUTI in comatose patients.

The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are the most common healthcare-acquired condition. The attributable cost of CAUTIs is frequently cited to be approximately $1,000. However, there is a paucity of recent literature that confirms this estimate. The purpose of this study was to perform a systematic review of the literature that estimates the attributable cost of CAUTIs in the United States.

METHODS

A systematic review was conducted using Pubmed. Studies conducted between the years 2000 and 2017, conducted at a facility within the United States, and that used novel patient-level cost data were included. Attributable cost estimates were adjusted for inflation to 2016 U.S. dollars using the medical care component of the Consumer Price Index.

RESULTS

Only 4 articles met our inclusion criteria. Adjusted to 2016 U.S. dollars, the attributable costs of a CAUTI as reported in these studies were: $876 (inpatient cost to the hospital for additional diagnostic tests and medications); $1,764 (inpatient cost to Medicare for non-intensive care unit [ICU] patients); $7,670 (inpatient and outpatient costs to Medicare); $8,398 (inpatient cost to the hospital for pediatric patients); and $10,197 (inpatient cost to Medicare for ICU patients).

CONCLUSIONS

The cost of a CAUTI ranges widely depending on population, patient acuity, and cost perspective. Attributable costs likely exceed $1,000. Additional research is needed to assess the full economic effect of CAUTIs.

Routine Indwelling Urethral Catheterization in Acute Heart Failure Patients Is Associated With Increased Urinary Tract Complications Without Improved Heart Failure Outcomes

BACKGROUND

Indwelling urethral catheters (IUC) are routinely inserted for the purpose of monitoring urine output in patients with acute heart failure (AHF). The benefit of IUC in patients capable of complying with urine collection protocols is unclear, and IUC carry multiple risks. This study describes the impact of IUC on AHF treatment.Methods and Results:A total of 540 records were retrospectively analyzed. After exclusion criteria were applied, 316 patients were propensity matched to establish groups of 100 AHF patients who either did (IUC(+)) or did not receive an IUC (IUC(-)) upon admission. Hospital length of stay (9 vs. 7 days), in-hospital urinary complications (24 vs. 5%), and 1-year urinary tract infection rate (17 vs. 6%; HR, 3.145; 95% CI: 1.240-7.978) were significantly higher in the IUC(+) group (P<0.05 for all). There were no differences in 30-day rehospitalization (6 vs. 6%; HR, 0.981; 95% CI: 0.318-3.058; P=0.986) or major adverse cardiac/cerebrovascular events at 1 year (37 vs. 32%, HR, 1.070; 95% CI: 0.636-1.799; P=0.798).

CONCLUSIONS

Based on this retrospective analysis, the routine use of IUC may increase length of stay and UTI complications in AHF patients without reducing the risk for major cardiovascular and cerebrovascular events or 30-day rehospitalization rate.

Dynamic changes in the appropriateness of urinary catheter use among hospitalized older patients in the emergency department

Objectives

To investigate incidence, rationales, related factors and outcomes for changing from appropriate catheter placement to inappropriate use among hospitalized older patients in the emergency department.

Methods

A secondary analysis was adopted from a longitudinal study that was designed to follow the lifecycle of the urinary catheter among hospitalized older patients. Patients aged 65 and older with a urinary catheter that had been placed in the emergency department were included. Demographic factors, present health conditions, conditional factors of catheter placement, and rationales for daily urinary catheter use were collected from the original data. Inappropriate urinary catheter days were evaluated as an outcome.

Results

Appropriate urinary catheters were placed in the emergency department in 117 of the 156 patients (75%). Of these patients, 77 patients (65.8%) experienced a change from appropriate placement to inappropriate use, with a mean duration of 2.88±1.56 days. The common rationales were post-operation for hip fracture (36.3%) and no longer needing to monitor urine output (27.2%). A hierarchical regression model shows that a change from appropriate catheter placement to inappropriate use was associated with a diagnosis of urinary tract infection (OR = 0.15; 95% CI = 0.03–0.77; p = 0.02) and no record of the indication for catheter placement (OR = 4.76; 95% CI = 1.20–18.90; p = 0.02), and all variables together explained 35.9% of the variance. In addition, a change from appropriate placement to inappropriate use was further associated with prolonging inappropriate catheter-days (β = 5.34; 95% CI: 3.72–6.97; p <0.001).

Conclusions

The study highlights a considerable percentage of change from appropriate placement to inappropriate use. Efforts to construct reminder intervention, to improve the record of catheter placement and continued attention to catheter use are necessary to reduce inappropriate urinary catheter use.

Gender differences in inappropriate use of urinary catheters among hospitalized older patients

This study investigated the incidence, rationales, and associated factors of inappropriate urinary catheter use among hospitalized older patients by gender. A longitudinal study of 321 patients with urinary catheter was conducted. Demographic factors, present health factors, urinary catheter factors, and indications of catheter use were collected. A total of 53.7% of urinary catheter-days were inappropriate. For both men and women, there was no significant difference in the incidence and common rationales of inappropriate use. Women, however, have another associated factor with inappropriate use. More tailored alternatives are needed for women to increase comfort to avoid inappropriate catheter use.

Current status of indwelling urinary catheter utilization and catheter-associated urinary tract infection throughout hospital wards in Korea: A multicenter prospective observational study

To evaluate the frequency and appropriateness of indwelling urinary catheters (IUC) use and the incidence of catheter-associated urinary tract infections (CA-UTI), and explore the risk factors for CA-UTI in hospitals as a whole, we conducted a study. This study was divided into two parts; a point-prevalence study on Dec 12^th 2012 and a prospective cohort study from Dec 13^th 2012 to Jan 9^th 2013 were performed in six hospitals in Korea. All hospitalized patients with newly-placed IUCs were enrolled and monitored weekly for 28 days after IUC placement. In the point-prevalence study, the IUCs were present in median 14.9/100 hospitalized patients (1Q 14, 3Q 16) across the six hospitals. In the prospective cohort study, the median IUC-days per patient was 5 (1Q 3, 3Q 10) and the median CA-UTI prevalence per 1,000 catheter days was 1.9 (1Q 0.7, 3Q 3.8) with significant inter-hospital variation. The proportion of patients with inappropriate IUC maintenance increased with number of IUC-days (8.5% on day 7, 9.4% on day 14, 16.3% on day 21, and 23.1% on day 28). Urinary output monitoring (23/36, 63.9%) was the most common indication for inappropriate use after 1 week of ICU placement. In multivariate analysis, IUC-days was significantly associated with the development of CA-UTI (odds ratio 1.122, 95% confidence interval 1.074–1.173, P< 0.001). IUC-days and CA-UTI rates vary between hospitals. IUC-days is a risk factor for CA-UTI, and is correlated with inappropriate use.

Inappropriate urinary catheter reinsertion in hospitalized older patients

BACKGROUND

We investigated the incidence and rationale for inappropriate reinsertion of urinary catheters and elucidated whether reinsertion is an independent predictor of adverse outcomes.

METHODS

A longitudinal study was adopted. Patients aged ≥65 years with urinary catheters placed within 24 hours of hospitalization were enrolled. Data collection, including demographic variables and health conditions, was conducted within 48 hours after admission. Patients with catheters in place were followed-up every day. If the patient had catheter reinsertion, the reinsertion information was reviewed from medical records. Adverse outcomes were collected at discharge.

RESULTS

A total of 321 patients were enrolled. Urinary catheters were reinserted in 66 patients (20.6%), with 95 reinsertions; 49.5% of catheter reinsertions were found to be inappropriate. "No evident reason for urinary catheter use" was the most common rationale for inappropriate reinsertion. Inappropriate reinsertion was found to be a significant predictor for prolonged length of hospital stay, development of catheter-associated urinary tract infections and catheter-related complications, and decline in activities of daily living.

CONCLUSIONS

This study indicates a considerable percentage of inappropriate urinary catheter reinsertions in hospitalized older patients. Inappropriate reinsertion was significantly associated with worsening outcomes. Efforts to improve appropriateness of reinsertion and setting clinical policies for catheterization are necessary to reduce the high rate of inappropriate reinsertion.

The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method

Interventions to reduce urinary catheter use involve lists of "appropriate" indications developed from limited evidence without substantial multidisciplinary input. Implementing these lists, however, is challenging given broad interpretation of indications, such as "critical illness." To refine criteria for appropriate catheter use-defined as use in which benefits outweigh risks-the RAND/UCLA Appropriateness Method was applied. After reviewing the literature, a 15-member multidisciplinary panel of physicians, nurses, and specialists in infection prevention rated scenarios for catheter use as appropriate, inappropriate, or of uncertain appropriateness by using a standardized, multiround rating process. The appropriateness of Foley catheters, intermittent straight catheters (ISCs), and external condom catheters for hospitalized adults on medical services was assessed in 299 scenarios, including urinary retention, incontinence, wounds, urine volume measurement, urine sample collection, and comfort. The scenarios included patient-specific issues, such as difficulty turning and catheter placement challenges. The panel rated 105 Foley scenarios (43 appropriate, 48 inappropriate, 14 uncertain), 97 ISC scenarios (15 appropriate, 66 inappropriate, 16 uncertain), and 97 external catheter scenarios (30 appropriate, 51 inappropriate, 16 uncertain). The refined criteria clarify that Foley catheters are appropriate for measuring and collecting urine only when fluid status or urine cannot be assessed by other means; specify that patients in the intensive care unit (ICU) need specific medical indications for catheters because ICU location alone is not an appropriate indication; and recognize that Foley and external catheters may be pragmatically appropriate to manage urinary incontinence in select patients. These new appropriateness criteria can inform large-scale collaborative and bedside efforts to reduce inappropriate urinary catheter use.

Novel low-resource intervention reduces urinary catheter use and associated urinary tract infections: role of outcome measure bias?

BACKGROUND

Previous interventions targeting nosocomial urinary tract infections have reduced catheterization and infections, but they require significant resources and may be susceptible to misclassification and surveillance bias. We sought to determine the effectiveness of a novel intervention at reducing catheterization and infections while exploring the potential for bias.

METHODS

We conducted a prospective study of a brief monthly in-person educational intervention focusing on appropriate urinary catheter use.

RESULTS

We studied 1,335 patients (13,753 patient days) on 1 control and 1 intervention ward. After the intervention, the device utilization rate was significantly reduced, with a relative risk of 0.49 (95% confidence interval [CI], 0.32-0.76; P = .001) versus 1.02 (95% CI, 0.58-1.82; P = .93) for controls. Both wards demonstrated a reduction in catheter-associated infections after intervention, with an intervention relative risk of 0.42 (95% CI, 0.16-1.08; P = .07) and 0.51 (95% CI, 0.22-1.20; P = .12) for controls. There was no change in the rate of all nosocomial urine infections, with an intervention relative risk of 0.79 (95% CI, 0.38-1.65; P = .53) and 0.89 (95% CI, 0.48-1.67; P = .72) for controls.

CONCLUSION

Our study demonstrates that our novel educational intervention significantly reduces urinary catheter use in hospitalized patients. The trend towards reduced catheter-associated infections after intervention, coupled with the absence of an improvement in all nosocomial infections supports a potential role of misclassification bias. We suggest that future prospective investigations explore this phenomenon using more robust outcome measures.

Knowledge and attitude of doctors and nurses regarding indication for catheterization and prevention of catheter-associated urinary tract infection in a tertiary care hospital

Background and Aims:

Catheter-associated urinary tract infection (CAUTI) is one of the most common health care acquired infection encountered in clinical practice. The present study was planned to assess the knowledge and attitude of health care providers regarding the indications for catheterization and methods of preventing CAUTI.

Methods:

A prospective questionnaire-based survey was done from March 2011 to August 2011. A structured questionnaire comprising of 41 items related to demographic details of the respondents, their knowledge regarding indications for catheterization and methods of preventing CAUTI was given to 54 doctors and 105 nurses. The response was evaluated for statistical correlation using a computer software.

Results:

The mean years of experience of the respondents in the health care setup was 6.8 years. Only 57% of the respondents could identify all the measures for prevention of CAUTI. The knowledge regarding the indication for catheterization though suboptimal was significantly better amongst the doctors as compared to nurses.

Conclusion:

The knowledge regarding indication and preventive measures was suboptimal in our study group. There is a tremendous scope of improvement in catheterization practices in our hospital and education induced intervention would be the most appropriate effort toward reducing the incidence of CAUTI.

Development of antibacterial coating on silicone surface via chlorhexidine-loaded nanospheres

Urinary tract infections (UTIs) are the most common type of hospital-acquired infection which cause significant morbidity and mortality. Antibacterial urinary devices to prevent UTIs are in great demand, while the problem of releasing antibacterials is still limited by duration of antibacterial release and hinders their clinical applications. This study investigated a new approach to sustain release of chlorhexidine (CHX) from urinary devices by coating of chlorhexidine-loaded nanospheres (CHX-NPs) on the surface. CHX-NPs were prepared by high-pressure emulsification-solvent evaporation technique that provided the size of nanospheres at 198.8 nm and the drug loading content at 5.6%. These nanospheres were spray-coated on silicone surface with reproducible and predictable amount of CHX. Release studies conducted in artificial urine to mimic in vivo condition showed that suitable dose of CHX was released in a sustained manner within a couple of weeks. Additionally, CHX-NPs showed antibacterial activity against common bacteria causing UTIs up to 15 days, which is threefold longer than that of physical mixing between CHX and polymer. Results from this study suggest possible applications of CHX-NPs in coating the surface of ureteral-relating devices for sustained antibacterial release.

Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm

Preventing catheter-associated urinary tract infection (CAUTI) remains a significant challenge for US hospitals. The "On the CUSP: Stop CAUTI" initiative represents the single largest national effort (involving >950 hospitals) to mitigate urinary catheter risk. The program brings together key organizations to assist state hospital associations and hospitals by providing education and coaching support, addressing both the technical aspects of preventing CAUTI and CAUTI-specific socio-adaptive challenges. At the local level, engaging health care workers, from physicians and nurses to other ancillary services, is critical. This includes (1) making the importance of addressing CAUTI stakeholder specific, (2) ensuring support from leaders of essential disciplines, (3) underscoring the importance of the collaborative nature of CAUTI prevention, and (4) identifying champions within the organization to lead and be accountable for the work. Sustainability is ensured by integrating the process into the health care worker's daily routine activities.

Inappropriate use of urinary catheters in patients admitted to medical wards in a university hospital

INTRODUCTION

The prevalence and predisposing factors were determined for inappropriate urinary catheterization (UC) among inpatients in medical wards.

METHODS

A cross-sectional study was conducted including all patients aged ≥ 18 years admitted to medical wards in a 1300-bed tertiary-care centre, and who had a urinary catheter in place on the day of the survey.

RESULTS

Of 380 patients observed, 46 (12.1%) had a urinary catheter in place. Twelve of them (26.1%) were inappropriately catheterized. The most common indication for inappropriate UC was urine output monitoring in a cooperative, non-critically ill patient. Inappropriateness was associated with increased age, poor functional status, urinary incontinence, dementia, and admission from a long-term care facility.

CONCLUSIONS

Further educational efforts should be focused on improving catheterization prescribing practices by physicians.

Appropriate use of indwelling urethra catheters in hospitalized patients: results of a multicentre prevalence study

BACKGROUND

Although indwelling urethra catheterization is a medical intervention with well-defined risks, studies show that approximately 14-38% of the indwelling urethra catheters (IUCs) are placed without a specific medical indication. In this paper we describe the prevalence of IUCs, including their inappropriate use in the Netherlands. We also determine factors associated with inappropriate use of IUCs in hospitalized patients.

METHODS

In 28 Dutch hospitals, prevalence surveys were performed biannually in 2009 and 2010 within the PREZIES-network. All patients admitted to a participating hospital and who had an IUC in place at the day of the survey were included. Pre-determined criteria were used to categorize the indication for catheterization as appropriate or inappropriate.

RESULTS

A total of 14,252 patients was included and 3020 (21.2%) of them had an IUC (range hospitals 13.4-27.3). Initial catheter placement was inappropriate in 5.2% of patients and 7.5% patients had an inappropriate indication at the day of the survey. In multivariate analyses inappropriate catheter use at the time of placement was associated with female sex, older age, admission on a non-intensive care ward, and not having had surgery. Inappropriate catheter use at the time of survey showed comparable associated factors.

CONCLUSIONS

Although lower than in many other countries, inappropriate use of IUC is present in Dutch hospitals. To reduce the inappropriate use of IUCs, recommended components of care (bundle for UTI), including daily revision and registration of the indication for catheterization, should be introduced for all patients with an IUC. Additionally, an education and awareness campaign about appropriate indications for IUC should be available.

Inappropriate use of urinary catheters: a prospective observational study

BACKGROUND

Despite the well-recognized role of urinary catheters in nosocomial urinary tract infections, data on risk factors associated with inappropriate urinary catheter use are scarce.

METHODS

A prospective review of electronic medical records of 436 patients admitted to an adult medical-surgical unit between October and December 2007 was performed to examine the appropriateness of urinary catheter use.

RESULTS

The use of 157 urinary catheters in 144 patients was observed. A total of 557 urinary catheter-days were recorded in these patients, of which 175 (31.4%) were found to be inappropriate based on the study criteria. The total number of catheters used and the total duration of catheterization were risk factors for inappropriate urinary catheter use (P < .05). Inappropriate catheter use was not associated with such adverse events as mortality, readmission, intensive care unit admission, catheter complications, or urine culture rates, but was associated with a trend toward longer duration of hospitalization.

CONCLUSIONS

Significant rates of inappropriate urinary catheter use and a trend toward longer duration of hospitalization with inappropriate catheter use were observed. These findings underscore the importance of establishing guidelines and effective policy implementation for the appropriate use of urinary catheters in hospitalized patients.

Will more restrictive indications decrease rates of urinary catheterisation? An historical comparative study

OBJECTIVES

To determine if more restrictive indications for urinary catheterisation reinforced by daily chart review will lower catheterisation rates.

DESIGN

An historical comparative observational study.

SETTING

An internal medicine department in a regional hospital in Israel.

PARTICIPANTS

The authors compared 882 patients hospitalised after a change in policy to an historical cohort of 690 hospitalised patients. Exclusions included patients less than age 30 and those with bladder outlet obstruction.

INTERVENTION

Emergency and internal medicine department physicians received instruction on a more restricted urinary catheterisation policy. During daily chart rounds, admissions were discussed with an emphasis on the appropriateness of all new urinary catheter insertions.

MAIN OUTCOME MEASURES

The primary outcome measure was catheterisation rate by admission diagnosis. Secondary outcome measures were the need for post-admission in hospital catheterisations and the rate of indwelling catheters 14 or more days after discharge.

RESULTS

There was a reduction in catheterisation rate in patients with congestive heart failure from 30/106 (29.3%) to 3/107 (2.8%) (p<0.001), in patients with an admission diagnosis of fever unable to provide a urine sample for culture from 35/132 (26.5%) to 12/153 (7.8%) (p<0.001) and in patients admitted for palliative care from 51.7% (15/29) to 12.0% (3/25) (p=0.002). The overall rate of catheterisation decreased from 17.5% (121/690) to 6.6% (58/882) (p<0.001). There was only one indicated catheterisation after admission due to the change in policy, and the proportion of patients discharged with catheters decreased.

CONCLUSION

The use of more restrictive indications for urinary catheterisation along with daily chart rounds can reduce the rate of urinary catheterisation in an internal medicine department without adverse consequences.

Preventing catheter-associated urinary tract infection in the zero-tolerance era

BACKGROUND

Catheter-associated urinary tract infection (CAUTI) is one of the most common health care‒associated infections in the critical care setting.

METHODS

A quasi-experimental study involving multiple interventions to reduce the incidence of CAUTI was conducted in a medical-surgical intensive care unit (ICU) and in 2 step-down units (SDUs). Between June 2005 and December 2007 (phase 1), we implemented some Centers for Disease Control and Prevention‒recommended evidence-based practices. Between January 2008 and July 2010 (phase 2), we intervened to improve compliance with these practices at the same time that performance monitoring was being done at the bedside, and we implemented the Institute for Healthcare Improvement's bladder bundle for all ICU and SDU patients requiring urinary catheters.

RESULTS

There was a statistically significant reduction in the rate of CAUTI in the ICU, from 7.6 per 1,000 catheter-days (95% confidence interval [CI], 6.6-8.6) before the intervention to 5.0 per 1,000 catheter-days (95% CI, 4.2-5.8; P < .001) after the intervention. There also was a statistically significant reduction in the rate of CAUTI in the SDUs, from 15.3 per 1,000 catheter-days (95% CI, 13.9-16.6) before the intervention to 12.9 per 1,000 catheter-days (95% CI, 11.6-14.2) after the intervention (P = .014).

CONCLUSION

Our findings suggest that reducing CAUTI rates in the ICU setting is a complex process that involves multiple performance measures and interventions that can be applied to SDU settings as well.

Uso excessivo do cateter vesical em pacientes internados em enfermarias de hospital universitário

Este estudo de corte incluiu 254 pacientes adultos que usaram cateter vesical (CV) durante a hospitalização em enfermarias de um hospital universitário. Foram avaliados: utilização do cateter, indicação, tempo de permanência, densidade de infecção urinária, mortalidade e permanência hospitalar. Durante o período de estudo, 14% dos pacientes internados usaram CV, totalizando 1.735 CV-dia. Em 23% dos casos, o procedimento não foi prescrito, nem sua indicação foi documentada. O tempo médio de uso do CV foi de 6,8 dias. Entre os pacientes clínicos, a indicação do CV foi inadequada em 29%; o tempo de permanência foi considerado inadequado em 49% dos pacientes clínicos e em 66,9% dos pacientes cirúrgicos. Pacientes com uso inadequado do CV tiveram mais infecção do trato urinário (RR 1,86 IC95% 1,4 a 3,04) e maior tempo de permanência hospitalar (11,9 e 8,9 dias, p=0,002). O estudo permitiu identificar no processo assistencial falhas potencialmente modificáveis e importantes para a prevenção da infecção do trato urinário por cateter vesical.

Urinary catheterization in medical wards

Aims:

The study aims to determine the: 1. frequency of inappropriate catheterization in medical wards and the reasons for doing it. 2. various risk factors associated with inappropriate catheterization, catheter associated urinary tract infections (CAUTI) and bacterial colonization on Foley's catheters (BCFC).

Settings and Design:

Hospital-based prospective study.

Materials and Methods:

One hundred and twenty five patients admitted consecutively in the medical wards of a tertiary care hospital, who underwent catheterization with a Foley's catheter, at admission, have been included in the study. Patient profiles were evaluated using the following parameters: age, sex, diagnosis, functional status, mental status, indication, duration and place of catheterization, development of BCFC and CAUTI.

Statistical tests used:

Chi-square test.

Results:

Thirty-six out of 125 (28.8%) patients included were inappropriately catheterized. BCFC developed in 52.8% and 22.4% were diagnosed with a CAUTI. The most frequent indication for inappropriate catheterization was urinary incontinence without significant skin breakdown (27.8%). The risk factors for inappropriate catheterization were female sex (RR=1.29, 95% CI=0.99, 1.69, P<0.05) and catheterization in the emergency (RR=0.74, 95% CI=0.61, 0.90, P<0.05). The risk factors for developing a BCFC were age>60 years (RR=0.65, 95% CI=0.48, 0.89, P<0.05), non-ambulatory functional status (RR=0.57, 95% CI=0.39, 0.84, P<0.01), catheterization in the emergency (RR=2.01, 95% CI=1.17, 3.46, P<0.01) and duration of catheterization>3 days (RR=0.62, 95% CI=0.43, 0.89, P<0.01). The risk factors for acquiring a CAUTI were age>60 years (RR=0.47, 95% CI=0.25, 0.90, P<0.05), impaired mental status (RR=0.37, 95% CI=0.18, 0.77, P<0.01) and duration of catheterization>3 days (RR=0.24, 95% CI=0.10, 0.58, P<0.01).

Conclusions:

Inappropriate catheterization is highly prevalent in medical wards, especially in patients with urinary incontinence. The patients catheterized in the medical emergency and female patients in particular are at high risk. Careful attention to these factors can reduce the frequency of inappropriate catheterization and unnecessary morbidity.

The effect of urinary bladder catheterization on patient care in an internal medicine department

INTRODUCTION

Recommendations for urinary catheterization in newly hospitalized patients are inconsistent and unclear.

METHODS

The authors studied prospectively consecutive patients who were catheterized in an internal medicine department over a 3-month period, with follow-up for 6 months or until the catheter was removed. Patient records were reviewed to determine if catheterization was definitely not indicated by commonly accepted criteria. After chart review, a category of possibly not indicated was defined as having no demonstrable effect on patient care.

RESULTS

There were 17.7% patients (122/691) catheterized during their admission. According to accepted criteria, definite inappropriate catheterization occurred in 18 patients (14.7%). There were an additional 69 patients (56.6%) with unclear clinical benefits, hospitalized because of fever, acute congestive heart failure, a cerebral vascular accident or respiratory insufficiency due to exacerbation of chronic obstructive lung disease. During hospitalization, attempts to remove the catheter failed in 13 patients, 4 of who remained with the catheter permanently, complicated by urosepsis in 1 patient.

CONCLUSION

Over 50% of the patients had acceptable indications for catheterization but no demonstrable benefit from the procedure. In such patients, the uncertain benefits of catheterization should be balanced by potential complications. Additional studies are warranted to determine the effect of acute urinary catheterization on patient care.

Hospital epidemiology and infection control in acute-care settings

Health care-associated infections (HAIs) have become more common as medical care has grown more complex and patients have become more complicated. HAIs are associated with significant morbidity, mortality, and cost. Growing rates of HAIs alongside evidence suggesting that active surveillance and infection control practices can prevent HAIs led to the development of hospital epidemiology and infection control programs. The role for infection control programs has grown and continues to grow as rates of antimicrobial resistance rise and HAIs lead to increasing risks to patients and expanding health care costs. In this review, we summarize the history of the development of hospital epidemiology and infection control, common HAIs and the pathogens causing them, and the structure and role of a hospital epidemiology and infection control program.

Urinary catheters in the emergency department: very elderly women are at high risk for unnecessary utilization

BACKGROUND

Many of the urinary catheters (UCs) placed in the emergency department (ED) might not be necessary. We evaluated compliance with our institutional UC utilization guidelines and assessed factors influencing utilization.

METHODS

We conducted a 12-week retrospective observational study evaluating UC utilization in all admissions from the ED. Data included reason for placement, presence of a physician's order for placement, resident physician involvement, and patient age and sex.

RESULTS

Out of 4521 patients evaluated, 532 (11.8%) had a UC placed. Of these UCs, 371 (69.7%) were indicated, and 312 (58.6%) had a physician's order documented. The mean age of the patients who had a UC placed without an indication was 71.3 ± 18.8 years, that of patients with an indication was 60.0 ± 22.4 years (P < .0001), and that of patients who did not have a UC placed was 56.2 ± 22.6 years (P < .0001). Half of the women aged ≥80 years who had a UC placed did not have an indication according to our institutional guidelines. Multivariate logistic regression showed that women were 1.9 times more likely than men, and those age ≥80 years were 2.9 times more likely than those age ≤50 years, to have a UC placed without an indication.

CONCLUSION

Very elderly women are at high risk for inappropriate UC utilization in the ED. Interventions are needed to address this vulnerable population.

Clinical and cost effectiveness of urethral catheterisation: a review

Reducing the number of catheter-associated urinary tract infections (CAUTI) in the National Health Service (NHS) has the potential for large cost savings. This review identifies factors which affect the incidence rate of CAUTI, as well as the need for further studies investigating cost-effectiveness, particularly in the areas of silver alloy catheters and education.

Internet survey of Foley catheter practices and knowledge among Minnesota nurses

BACKGROUND

Although nurses insert and care for many Foley catheters, little is known about nurses' attitudes and knowledge regarding indications for catheter use or methods to prevent catheter-associated urinary tract infection (CAUTI).

METHODS

An Internet-based survey was sent to a random sample of registered nurses (RNs) in Minnesota. The survey contained demographic questions and 5-point Likert-scale questions regarding indications for Foley catheter placement and effectiveness of various interventions for preventing CAUTI.

RESULTS

Nurses perceived early catheter removal as the most effective intervention to prevent CAUTI (mean score, 4.5; range 1-5). Compared with other RNs, those reporting additional catheter education were more likely to rate interventions to prevent CAUTI as effective, regardless of whether the interventions actually reduce the incidence of symptomatic CAUTI or asymptomatic bacteriuria/funguria. Intensive care unit RNs were significantly more likely than other RNs to endorse that a Foley catheter was indicated for any given clinical scenario and to endorse antimicrobial-coated catheters as effective in preventing CAUTI. Most respondents reported no institutional guidance regarding catheterization.

CONCLUSION

Although the surveyed Minnesota RNs demonstrated high-level awareness of the utility of early Foley catheter removal for preventing CAUTI, other aspects of their catheter-related knowledge were concerning. Improving these deficits may help improve catheter-related practice.

Reducing use of indwelling urinary catheters and associated urinary tract infections

BACKGROUND

Use of indwelling urinary catheters can lead to complications, most commonly catheter-associated urinary tract infections. Duration of catheterization is the major risk factor. These infections can result in sepsis, prolonged hospitalization, additional hospital costs, and mortality.

OBJECTIVES

To implement and evaluate the efficacy of an intervention to reduce catheter-associated urinary tract infections in a medical intensive care unit by decreasing use of urinary catheters.

METHODS

Indications for continuing urinary catheterization with indwelling devices were developed by unit clinicians. For a 6-month intervention period, patients in a medical intensive care unit who had indwelling urinary catheters were evaluated daily by using criteria for appropriate catheter continuance. Recommendations were made to discontinue indwelling urinary catheters in patients who did not meet the criteria. Days of use of a urinary catheter and rates of catheter-associated urinary tract infections during the intervention were compared with those of the preceding 11 months.

RESULTS

During the study period, 337 patients had a total of 1432 days of urinary catheterization. With use of guidelines, duration of use was significantly reduced to a mean of 238.6 d/mo from the previous rate of 311.7 d/mo. The number of catheter-associated urinary tract infections per 1000 days of use was a mean of 4.7/mo before the intervention and zero during the 6-month intervention period.

CONCLUSIONS

Implementation of an intervention to judge appropriateness of indwelling urinary catheters may result in significant reductions in duration of catheterization and occurrences of catheter-associated urinary tract infections.