Inappropriate use of urinary catheters among hospitalized elderly patients: Clinician awareness is key

Urinary and double incontinence in older women with hip fracture - risk of death and predictors of incident symptoms among survivors in a 1-year prospective cohort study

OBJECTIVES

To investigate the association of urinary incontinence (UI) and double incontinence (DI, concurrent UI and fecal incontinence) with one-year mortality among older female hip fracture patients and to identify predictors of incident UI and DI.

DESIGN

A prospective cohort study SETTING AND SUBJECTS: 1,468 female patients aged ≥ 65 treated for their first hip fracture during the period 2007-2019 METHODS: Continence status was elicited at baseline and one-year post-fracture. Age- and multivariable-adjusted Cox proportional hazards and multinomial logistic regression models were used to determine the associations of incontinence with one-year mortality and to examine the associations of baseline predictors with incident UI and DI respectively.

RESULTS

Of the women with no incontinence, UI and DI, 78 (13%), 159 (23%) and 60 (34%), died during follow-up. UI (HR 1.72, 95% CI 1.31-2.26) and DI (HR 2.61, 95% CI 1.86-3.66) were associated with mortality after adjusting for age. These associations lost their predictive power in multivariable analysis while age over 90, living in an institution, impaired mobility, poor nutrition, polypharmacy, and late removal of urinary catheter remained associated with mortality. Of continent women, 128 (21%) developed UI and 23 (4%) DI during follow-up. In multivariable analysis, impaired mobility was associated with incident UI (OR 2.56, 95% CI 1.48-4.44) and DI (OR 4.82, 95% CI 1.70-13.7), as well as living in an institution (OR 3.44, 95% CI 1.56-7.61 and OR 3.90, 95% CI 1.17-13.0).

CONCLUSIONS AND IMPLICATIONS

Underlying vulnerability likely explains differences in mortality between continence groups and development of incident UI and DI.

Reducing urinary catheter use in geriatric patients - results of a single-center champion-led intervention

BACKGROUND

Indwelling urinary tract catheters (UTC) are a well-known risk factor for urinary tract infections (UTI). Because geriatric patients are at high risk of infection, an intervention with a focus on appropriate and minimal UTC use was introduced in 4 acute care geriatric wards.

METHODS

Between 11/2018 and 1/2020, unit-based data on UTC use and nosocomial UTI was collected in accordance with the methods of the German national surveillance system KISS. From 6/2019 to 1/2020, a champion-led intervention was implemented which focused on: (i) feedback of surveillance data, (ii) education and training in aseptic UTC insertion and maintenance, (iii) HCW's daily assessment of UTC necessity based on a checklist and (iv) timely removal of unnecessary UTCs. UTC use, incidence, and incidence densities for catheter-associated UTI (CAUTI) were calculated before and during the intervention. In addition, we analyzed adherence to a scheduled daily assessment of UTC necessity. Rate ratios (RR) with 95% confidence intervals (95%CI) were calculated. Differences based on the quality of checklist completion were evaluated using the Kruskal Wallis test.

RESULTS

We analyzed the data of 3,564 patients with a total 53,954 patient days, 9,208 UTC days, and 61 CAUTI. Surveillance data showed a significant decrease in the pooled UTC utilization rate from 19.1/100 patient days to 15.2/100 patient days (RR = 0.80, 95%CI 0.77-0.83, p < 0.001). CAUTI per 100 patients dropped from 2.07 to 1.40 (RR = 0.68, 95%CI 0.41-1.12, p = 0.1279). Overall, 373 patients received a UTC during the intervention. Of those patients 351 patients had an UTC ≥ 2 days. The analysis of these patients showed that 186 patients (53%) received a checklist as part of their chart for daily evaluation of UTC necessity. 43 (23.1%) of the completed checklists were of good quality; 143 (76.9%) were of poor quality. Patients in the group whose checklists were of good quality had fewer UTC days (median 7 UTC days IQR (3-11)) than patients whose checklists were of poor quality (11 UTC days IQR (6-16), p = 0.001).

CONCLUSION

We conclude that a champion-led, surveillance-based intervention reduces the use of UTC among geriatric patients. Further research is needed to determine to what extent the use of checklists in daily medical UTC assessment affects the prevention of CAUTI. The fact that patients whose checklists were completed well had fewer UTC days should encourage a conscientious and thorough daily review of the need for UTC.

Factors associated with urinary and double incontinence in a geriatric post-hip fracture assessment in older women

BACKGROUND

Incontinence and hip fractures are common in older people, especially women, and associated with multiple adverse effects. Incontinence is a risk factor for falls.

AIMS

We aimed to investigate the prevalence of urinary (UI) and double incontinence (DI, concurrent UI and faecal incontinence), and to identify factors associated with UI and DI 6 months post-fracture.

METHODS

A prospective real-life cohort study was conducted consisting of 910 women aged ≥ 65 who were treated for their first hip fracture in Seinäjoki Central Hospital, Finland, between May 2008 and April 2018. Continence status was elicited at baseline and 6 months postoperatively at our geriatric outpatient clinic where all participants underwent a multidisciplinary comprehensive geriatric assessment (CGA) consisting of an evaluation of cognition, nutrition, mood, mobility, and functional ability.

RESULTS

At baseline, 47% of the patients were continent, 45% had UI and 8% had DI, and at follow up, 38%, 52%, and 11%, respectively. The mean age of the patients was 82.7 ± 6.8. Both UI and DI were associated with functional disability and other factors related to frailty. The associations were particularly prominent for patients with DI who also had the worst performance in the domains of CGA. We identified several modifiable risk factors: depressive mood (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.16-2.84) and constipation (OR 1.48, 95% CI 1.02-2.13) associated with UI and, late removal of urinary catheter (OR 2.33, 95% CI 1.31-4.14), impaired mobility (OR 2.08, 95% CI 1.05-4.15), and poor nutrition (OR 2.31, 95% CI 1.11-4.79) associated with DI.

CONCLUSIONS

This study demonstrates a high prevalence of UI and DI in older women with hip fracture and modifiable risk factors, which should be targeted in orthogeriatric management and secondary falls prevention. Patients with DI were found to be an especially vulnerable group.

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.

Prevalence and predictors of continence containment products and catheter use in an acute hospital: A cross-sectional study

Although incontinence is common in hospital, the prevalence and predictors of continence aid use (continence wear and catheters) are poorly described. A one-day cross-sectional study was conducted in a large university hospital assessing consecutive inpatients (≥55) for their pre-admission and current use of continence aids. Barthel Index, Clinical Frailty Scale and Charlson Co-morbidity scores were recorded. Appropriateness was defined by local guidelines. 355 inpatients, median age 75±17 years, were included; 53% were male. Continence aid use was high; prevalence was 46% increasing to 58% for those ≥75. All-in-one pads were the most common, an overall prevalence of 31%. Older age, lower Barthel and higher frailty scores were associated with continence aid use in multivariate analysis. Inappropriate use of aids was high at 45% with older age being the only independent predictor. Continence aids are often used inappropriately during hospitalisation by older patients. Concerted efforts are required to address this issue.

Predictors of long length of hospital stay among elders admitted with seizures in a tertiary centre: a prospective study

OBJECTIVE

Population ageing is a global phenomenon, and life expectancy in Brazil is growing fast. Epilepsy is the third most important chronic neurological disorder, and its incidence is higher among elderly patients than in any other segment of the population. The prevalence of epilepsy is greater among inpatients than in the general population and it is related to long length of hospital stay (LOS), which is associated with hospital mortality and higher healthcare costs. Despite these facts, reports of elderly inpatients admitted with seizures and associated outcomes are scarce. To identify predictors of long LOS among elderly inpatients admitted with seizures.

METHODS

We prospectively enrolled elders admitted with epileptic seizures or who experienced seizures throughout hospitalization between November 2015 and August 2019. We analysed demographic data, neurological disorders, clinical comorbidities, and seizure features to identify risk factors.

RESULTS

The median LOS was 11 days, with an interquartile range (IQR) of 5-21 days. The frequency of long LOS (defined as a period of hospitalization ≥12 days) was 47%. Multivariate analysis showed there was an exponential increase in long LOS if a patient showed any of the following conditions: intensive care unit (ICU) admission (OR=4.562), urinary tract infection (OR=3.402), movement disorder (OR=5.656), early seizure recurrence (OR=2.090), and sepsis (OR=4.014).

CONCLUSION

Long LOS was common among elderly patients admitted with seizures, and most predictors of long LOS found in this cohort might be avoidable; these findings should be confirmed with further research.

Reducing catheter-associated urinary tract infections: a systematic review of barriers and facilitators and strategic behavioural analysis of interventions

Background

Reducing the need for antibiotics is crucial in addressing the global threat of antimicrobial resistance. Catheter-associated urinary tract infection (CAUTI) is one of the most frequent device-related infections that may be amenable to prevention. Interventions implemented nationally in England target behaviours related to catheter insertion, maintenance and removal, but the extent to which they target barriers to and facilitators of these behaviours is unclear.

This strategic behavioural analysis applied behavioural science frameworks to (i) identify barriers to and facilitators of behaviours that lead to CAUTI (CAUTI-related behaviours) in primary, community and secondary care and nursing homes; (ii) describe the content of nationally adopted interventions; and (iii) assess the extent to which intervention content is theoretically congruent with barriers and facilitators.

Methods

A mixed-methods, three-phased study: (1) systematic review of 25 studies to identify (i) behaviours relevant to CAUTI and (ii) barriers to and facilitators of CAUTI-related behaviours, classified using the COM-B model and Theoretical Domains Framework (TDF); (2) content analysis of nationally adopted CAUTI interventions in England identified through stakeholder consultation, classified using the Behaviour Change Wheel (BCW) and Behaviour Change Techniques Taxonomy (BCTTv1); and (3) findings from 1 and 2 were linked using matrices linking COM-B and TDF to BCW/BCTTv1 in order to signpost to intervention design and refinement.

Results

The most frequently reported barriers to and facilitators of CAUTI-related behaviours related to ‘environmental context and resources’; ‘knowledge’; ‘beliefs about consequences’; ‘social influences’; ‘memory, attention and decision processes’; and ‘social professional role and identity.’

Eleven interventions aiming to reduce CAUTI were identifed. Interventions were primarily guidelines and included on average 2.3 intervention functions (1–5) and six BCTs (2–11), most frequently ‘education’, ‘training’ and ‘enablement.’ The most frequently used BCT was ‘information about health consequences’ which was used in almost all interventions. Social professional role and identity and environmental context and resources were targeted least frequently with potentially relevant BCTs.

Conclusions

Interventions incorporated half the potentially relevant content to target identifed barriers to and facilitators of CAUTI-related behaviours. There were missed opportunities for intervention as most focus on shaping knowledge rather than addressing motivational, social and environmental influences. This study suggests that targeting motivational, social and environmental influences may lead to more effective intervention design and refinement.

Inappropriate initial urinary catheter placement among older Chinese hospital inpatients: An observational study

AIM

The aim of this study is to evaluate incidences of inappropriate initial urinary catheter placements within an older inpatient cohort.

METHODS

A total of 200 inpatients that received urinary catheterizations within 24 hours of admission were recruited for this observational study. The key demographic and clinical factors were recorded. Adverse outcomes were assessed by examining incidences of catheter-associated urinary tract infection (CAUTI) during hospitalization, after transfer to skilled nursing facilities, second, duration of hospital stay and by scoring changes on the Katz Index of Independence in Activities of Daily Living. Correlative relationships between demographic data and clinical factors with adverse outcomes were analyzed.

RESULTS

Inappropriate initial urinary catheterization in our cohort was approximately 39%. This was associated with elevated Charlson comorbidity index scores and increased dependency, with correlations to medical diagnosis. We also observed that the primary rationale for the procedure (inappropriate catheterization) was for neurogenic bladder (where intermittent catheterization was indicated) and in 'convenience-of-care' catheterizations. Inappropriate catheter placement was ultimately associated with an elevated CAUTI at point of discharge, with transfers to skilled nursing facilities and also with an increased duration of hospital stay.

CONCLUSIONS

Inappropriate catheter placement was prevalence in southwestern China and associated with adverse outcomes.

Point prevalence survey of indwelling urinary catheter use and appropriateness in patients living at home and receiving a community nursing service in Ireland

BACKGROUND

Indwelling urinary catheters (IUC) are reported as the most common indwelling device in hospitals and residential/care home settings.

AIM

The aim of this study was to assess the prevalence and appropriateness of IUCs in people living at home and receiving a community nursing service.

METHODS

An IUC self-report questionnaire was sent to 66 community nurses in one community care area. A second questionnaire was completed by the researcher on each patient (n = 80) identified by the community nurses. Data were analysed using descriptive statistics and the chi-square test was used to test associations between patient demographics, catheter changes and nurses documentation.

RESULTS

The self-report questionnaire was completed by 46 of the 52 areas (88% response rate). The overall prevalence of IUCs was 1.9% with a higher prevalence among men (70%) and in the over-85-years age group (31%). The mean age was 76 years (age range = 34-98 years) and duration of use was approximately four years. Routine IUC changes were carried out by community nurses (52%), in the acute hospital (25%) or by general practitioners (20%) and the type of catheter influenced person/location of catheter changes (P = 0.001).

DISCUSSION

This study adds to the understanding of IUCs in patients at home and is the first to investigate if the IUC is appropriate in this setting. It prompted a review of current guidance and development of standard documentation for IUC management locally to ensure that the IUC in use is appropriate. It also suggests that there is a need for internationally accepted, appropriate indications for long-term IUC use to facilitate consistency and allow comparison across studies in future.

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.

Hospitalization-associated disability in older adults with valvular heart disease: incidence, risk factors and its association with care processes

BACKGROUND

The aim of this study was to determine the incidence and recovery of hospitalisation-associated disability (HAD), the associated risk factors, and the link with care processes in patients aged 70 years or older hospitalised with valvular heart disease (VHD).

METHODS

Prospective cohort study performed on the cardiology and cardiac surgery units of University Hospitals Leuven, Belgium. HAD was defined as the loss of independence to complete one of the Activities of Daily Living (ADLs) between hospital admission and discharge. Recovery of HAD at 30 days post hospital discharge was achieved when patients recovered their baseline ADL status (2 weeks before hospital admission) (ClinicalTrials.gov: NCT02572999).

RESULTS

Eighty patients were enrolled in the study, 77 completed the assessment at discharge and 62 responded at 30 days follow-up. Forty patients (51.9%) developed HAD; 18 of them (45.0%) recovered their baseline ADL status. The risk of HAD increased when patients were physically restrained (relative risk (RR) 1.73, 95% confidence interval (CI) 1.20-2.49), had indwelling catheters (RR 1.80, 95% CI 0.85-3.80) and received preventive pressure ulcer measures (RR 1.71, 95% CI 1.07-2.74). Patients with HAD had longer hospital stays (+3 days, p = .011) and longer use of indwelling catheters (+2 days, p = .024).

CONCLUSION

Half of the older adults with VHD developed HAD. The results indicate a potential association between HAD and care processes, which could be used as quality measures and intervention targets. Validation in larger cohort studies is recommended.

Treated-and-released urinary catheterization in the emergency department by sex

BACKGROUND

The prevalence and difference in likely indications of urinary catheterization (UC) in treated-and-released emergency department (ED) visits between men and women are currently unknown.

METHODS

This was a cross-sectional analysis using the 2013 National Emergency Department Sample for all treated-and-released visits in persons aged ≥18 years. The prevalence of conditions associated with UC visits in men and women were identified. A hierarchical ranking was used to categorize diagnosis codes identified during ED visits into clinically meaningful categories to assess conditions for UC.

RESULTS

In 2013, there were 87,797,062 treated-and-released ED visits in adults. The rate of UC in treated-and-released ED visits in adults was 4.3 per 1,000 visits, with 6.5 per 1,000 visits in men and 2.7 per 1,000 visits in women. Using the hierarchal ranking, a higher proportion of UC visits in men were coded for acute urinary retention, and a higher proportion of UC visits in women were coded for neurologic, cognitive, and psychiatric conditions.

CONCLUSIONS

The rate of UC in treated-and-released ED visits was higher in men than women, and UC rate increased with age. The heterogeneity of conditions coded in UC visits in women compared with men may suggest more potentially avoidable UC in women in the treated-and-released ED population. If confirmed, this would suggest opportunities for quality improvement in the ED to prevent overutilization of urinary catheters.

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.