The Relationship of Indwelling Urinary Catheters to Death, Length of Hospital Stay, Functional Decline, and Nursing Home Admission in Hospitalized Older Medical Patients

Effectiveness of the T-Control catheter: A study protocol

Background

Foley catheters have been subject to limited development in the last few decades. They fulfil their basic function of draining urine from the bladder but cause other associated problems. T-Control is a new silicone Foley catheter with an integrated fluid control valve whose design aims to reduce the risks associated with bladder catheterisation by a multifactorial approach. The general purpose of this study is to evaluate the effectiveness and cost-effectiveness of the T-Control catheter versus the Foley-type catheter in patients with Acute Urine Retention (AUR).

Study design

This is a pragmatic, open, multicentre, controlled clinical trial with random allocation to the T-Control catheter or a conventional Foley-type catheter in patients with AUR.

Endpoints

The magnitude of infections will be analysed as a primary endpoint. While as secondary endpoint, the following will be analysed: rate of symptomatic and asymptomatic infections; days free of infection; quality of life-related to self-perceived health; indication of associated antibiotic treatments; determination of biofilm; number of catheter-related adverse events; use of each type of catheterisation's healthcare resources; level of satisfaction and workload of health professionals and acceptability of the T-Control device as well as the patient experience.

Patients and methods

Eligible patients are male adults aged ≥50 years, with AUR and with an indication of bladder catheterisation for at least 2 weeks. The estimated sample size is 50 patients. Patient follow-up includes both the time of catheter insertion and its removal or change 2 weeks later, plus 2 weeks after this time when the patient will be called for an in-depth interview.

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.

A novel intervention to reduce noninfectious and infectious complications associated with indwelling urethral catheters in hospitalized older patients: a quasi-experimental study

BACKGROUND

Indwelling urethral catheters are widely used in clinical settings. Catheter-associated urinary tract infection has been recognized as a common adverse event in older patients. However, noninfectious complications are almost 5 times as common as infectious complications, and insufficient attention has been given to noninfectious complications. Given this importance, a novel intervention related to removing unnecessary catheters in a timely manner to promote, after removal, the recovery of self-voiding function is herein developed to reduce infectious and noninfectious complications associated with indwelling urethral catheters in hospitalized older patients.

METHODS

A quasi-experimental study design was adopted. Patients aged 65 and older who had a urinary catheter placed within 24 h of hospital admission were included. All patients were allocated into either an intervention group, in which the novel intervention developed in the study was implemented, or a control group, who received care as usual. The outcomes of this study were to evaluate whether the novel intervention reduced the incidence of the following: catheter-associated urinary tract infections, catheter-associated noninfectious complications, decline in activities of daily living, and new nursing home admissions.

RESULTS

Of 106 hospitalized older patients who consented to participate, 92 completed follow-up until discharge, including 49 in the control group and 43 in the intervention group. The patients in the intervention group were significantly older than those in the control group [83.72 ± 9.18 vs. 80.26 ± 7.66, p = 0.038], and no differences were found between the groups in other demographics or present health conditions. Multivariable logistic regression analysis showed that the control group was more likely to develop noninfectious complications [adjusted odds ratio: 3.01, 95% confidence interval: 1.32-6.81] and a decline in ADLs [adjusted odds ratio: 11.20, 95% confidence interval: 3.68-34.00].

CONCLUSIONS

A novel intervention can be effective as a means of reducing noninfectious complications associated with indwelling urethral catheters in hospitalized older patients. This approach will help to standardize urethral catheter care, and it highlights the fact that health care professionals can play a crucial role in preventing harm from urethral catheters.

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.

Does Urinary Catheterization Affect the Quality of Death in Patients with Advanced Cancer? A Secondary Analysis of Multicenter Prospective Cohort Study

Background: Patients with life-limiting illnesses frequently experience urinary difficulties, and urinary catheterization is one of the interventions for managing them. However, evidence supporting the effects of urinary catheters on the quality of death (QoD) is lacking in this population. Objectives: To investigate whether urinary catheterization affects QoD in patients with advanced cancer in palliative care units. Design: A secondary analysis of a multicenter, prospective cohort study. Setting/Subjects: The study enrolled consecutive patients with advanced cancer admitted to palliative care units in Japan between January and December 2017. Those who were not catheterized on admission and who died while in a palliative care unit were analyzed. Measurements: QoD was evaluated at death using the Good Death Scale (GDS). Results: Of 885 patients, 297 (33.6%) were catheterized during their palliative care unit stay. Females and patients with a long palliative care unit stay were more likely to be catheterized. In inverse probability-weighted propensity score analysis, patients with urinary catheterization during their palliative care unit stay had higher total GDS scores than those without catheterization (coefficient 0.410, 95% confidence interval 0.068-0.752). In subgroup analyses stratified by sex, age, and length of palliative care unit stay, urinary catheterization was associated with higher total GDS scores in patients younger than 65 years of age and those who died after a palliative care unit stay of 21 days or fewer. Conclusions: This study suggested that urinary catheterization during a palliative care unit stay may have a positive impact on overall QoD in patients with advanced cancer. This study was registered in the UMIN Clinical Trials Registry (UMIN000025457).

A Smart Diaper System Using Bluetooth and Smartphones to Automatically Detect Urination and Volume of Voiding: Prospective Observational Pilot Study in an Acute Care Hospital

Background

Caregivers of patients who wear conventional diapers are required to check for voiding every hour because prolonged wearing of wet diapers causes health problems including diaper dermatitis and urinary tract infections. However, frequent checking is labor intensive and disturbs patients’ and caregivers’ sleep. Furthermore, assessing patients’ urine output with diapers in an acute care setting is difficult. Recently, a smart diaper system with wetness detection technology was developed to solve these issues.

Objective

We aimed to evaluate the applicability of the smart diaper system for urinary detection, its accuracy in measuring voiding volume, and its effect on incontinence-associated dermatitis (IAD) occurrence in an acute care hospital.

Methods

This prospective, observational, single-arm pilot study was conducted at a single tertiary hospital. We recruited 35 participants aged ≥50 years who were wearing diapers due to incontinence between August and November 2020. When the smart diaper becomes wet, the smart diaper system notifies the caregiver to change the diaper and measures voiding volume automatically. Caregivers were instructed to record the weight of wet diapers on frequency volume charts (FVCs). We determined the voiding detection rate of the smart diaper system and compared the urine volume as automatically calculated by the smart diaper system with the volume recorded on FVCs. Agreement between the two measurements was estimated using a Bland-Altman plot. We also checked for the occurrence or aggravation of IAD and bed sores.

Results

A total of 30 participants completed the protocol and 390 episodes of urination were recorded. There were 108 records (27.7%) on both the FVCs and the smart diaper system, 258 (66.2%) on the FVCs alone, 18 (4.6%) on the smart diaper system alone, and 6 (1.5%) on the FVCs with sensing device lost. The detection rate of the smart diaper system was 32.8% (126/384). When analyzing records concurrently listed in both the FVCs and the smart diaper system, linear regression showed a strong correlation between the two measurements (R²=0.88, P<.001). The Bland-Altman assessment showed good agreement between the two measurements, with a mean difference of –4.2 mL and 95% limits of agreement of –96.7 mL and 88.3 mL. New occurrence and aggravation of IAD and bed sores were not observed. Bed sores improved in one participant.

Conclusions

The smart diaper system showed acceptable accuracy for measuring urine volume and it could replace conventional FVCs in acute setting hospitals. Furthermore, the smart diaper system has the potential advantage of preventing IAD development and bed sore worsening. However, the detection rate of the smart diaper system was lower than expected. Detection rate polarization among participants was observed, and improvements in the user interface and convenience are needed for older individuals who are unfamiliar with the smart diaper system.

Risk Factors and Outcomes of Postoperative Catheter-Associated Urinary Tract Infection in Colorectal Surgery Patients: A Retrospective Cohort Study

Introduction

Catheter-associated urinary tract infection (CAUTI) is a relatively common cause of postoperative morbidity in colorectal surgery patients. It has been associated with increased length of stay and mortality.

Methods

We performed a retrospective cohort study of 620 colorectal surgeries to assess the prevalence of CAUTI and its relationship with preoperative and operative factors. We also sought to identify its association with postoperative outcomes.

Results

We found that CAUTI occurred in 20.6% of colorectal procedures. We found that CAUTI was associated with older patient age, female gender, higher BMI, higher American Society of Anesthesiologists (ASA) classification, lower hemoglobin, higher creatinine, lower albumin, urgent procedures, bilateral ureteric stent placement, usage of double-J (DJ) stents, postoperative abdominal sepsis, and perioperative steroid usage. CAUTI was also associated with the presence of underlying medical conditions such as hypertension, ischemic heart disease, chronic kidney disease, cerebrovascular disease, and diabetes. With regards to postoperative outcomes, it was associated with postoperative stroke, myocardial infarction, prolonged length of stay, Intensive care unit stay, and mortality.

Conclusion

CAUTI remains a significant cause of morbidity in colorectal patients. Our patient population had a significantly higher risk of CAUTI compared to other series. Though sometimes labelled a minor postoperative complication, its occurrence is associated with other more significant postoperative complications, including death.

Differences among institutions in the prevalence of and indications for urinary catheterization of advanced cancer patients at palliative care units: A multicenter prospective cohort study (EASED)

BACKGROUND

Studies on the appropriate use of urinary catheters for cancer patients at the end of life are limited.

AIM

To clarify the differences among institutions in the prevalence of and indications for urinary catheterization of advanced cancer patients at palliative care units.

DESIGN

Pre-planned secondary analysis of a multicenter, prospective cohort study; East-Asian collaborative cross-cultural Study to Elucidate the Dying process (EASED).

SETTING/PARTICIPANTS

This study enrolled consecutive advanced cancer patients admitted to palliative care units between January and December 2017. The final study group comprised 1212 patients from 21 institutions throughout Japan.

RESULTS

Out of the 1212 patients, 380 (31.4%; 95% confidence interval, 28.7%-34.0%) underwent urinary catheterization during their palliative care unit stay, and the prevalence of urinary catheterization in patients who died at palliative care units by institution ranged from 0.0% to 55.4%. When the 21 participating institutions were equally divided into three groups according to the institutional prevalence of catheterization, patients with difficulty in moving safely, exhaustion on movement, and restlessness or agitation were more likely to be catheterized in institutions with a high prevalence of catheterization than in those with a low or moderate prevalence (p < 0.008, p = 0.008, and p < 0.008, respectively).

CONCLUSION

This study revealed that the institutional prevalence of urinary catheterization in advanced cancer patients at palliative care units widely varied. Further studies are needed to establish the appropriate use of urinary catheters, especially in patients with difficulty in moving safely, exhaustion on movement, and restlessness or agitation.

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.

Incidence of and Risk Factors for Postoperative Urinary Tract Infection After Abdominal and Vaginal Colpopexy

OBJECTIVE

The aims of the study were to determine the rate of urinary tract infection (UTI) in women undergoing colpopexy and to evaluate risk factors and timing for postoperative UTI.

METHODS

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2017. Patients were grouped into those with and without UTI. Pairwise analysis between groups was performed using χ2 and Fisher exact test. Multivariable logistic regression was used to identify independent predictors of UTI.

RESULTS

Of 23,097 women who underwent colpopexy, 1079 (4.7%) experienced a postoperative UTI. Urinary tract infection was most frequently diagnosed in the second week after surgery (38.2%), compared with week 1 (19.9%), 3 (22.8%), and 4 (19.1%) (P < 0.001). Patients diagnosed with a UTI were more likely to have insulin-dependent diabetes (2.8% vs 1.7%, P = 0.006), coagulopathy (1.3% vs 0.7%, P = 0.04), and chronic steroid use (2.7% vs 1.8%, P = 0.004). Patients with a UTI versus those without a UTI were more likely to have undergone an intraperitoneal or extraperitoneal vaginal colpopexy (37.8% vs 30.5%, P < 0.001) and (29.8% vs 25.6%, P = 0.003), respectively, and more likely to undergo combined anterior and posterior colporrhaphy (17.1% vs 12.2%, P < 0.001). After logistic regression, intraoperative cystotomy repair (adjusted odds ratio = 2.93, 95% confidence interval = 1.54-5.59) was the most significant risk factor.

CONCLUSIONS

Postoperative UTI after colpopexy occurred less frequently than previously reported. Vaginal colpopexy is associated with a higher risk of UTI than abdominal or laparoscopic colpopexy.

Indwelling medical device use and sepsis risk at a health professional shortage area hospital: Possible interaction with length of hospitalization

BACKGROUND

We aimed to identify risk factors for sepsis diagnosis and possible interaction with length of hospital stay (LOS) among inpatients at a rural Health Professional Shortage Area hospital.

METHODS

This case-control study examined 600 adult patients (300 cases and 300 controls) admitted to a rural health system in North Carolina between 2012 and 2018. Case selection was based on assignment of ICD-9-CM diagnostic codes for sepsis. Controls were patients with a medical diagnosis other than sepsis during the observational period. Logistic regression was used to model sepsis diagnosis as a function of indwelling medical device use and stratified by LOS.

RESULTS

Indwelling medical device use preadmission and postadmission were significantly associated with increased risk of sepsis diagnosis among patients with extended hospital stays (LOS ≥ 5 days) (odds ratio [OR] = 5.51; 95% confidence interval [CI] = 1.95-15.62; P = .001 and OR = 3.28; 95% CI = 1.24-8.68; P = .017, respectively). Among patients with LOS <5 days, association with sepsis diagnosis was only significant for indwelling medical device use preadmission (OR = 9.61; 95% CI = 3.68-25.08; P < .0001).

CONCLUSIONS

Indwelling medical device use was significantly associated with increased risk of sepsis diagnosis and the risk was higher with longer hospitalization.

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.

Improving urinary catheterisation practices in a rural hospital in Ontario

INTRODUCTION

A urinary catheter constitutes a one-point patient restraint, can induce deconditioning and may lead to patient mortality. An audit performed at Winchester District Memorial Hospital revealed that 20% of patients had a urinary catheter, of whom 31% did not meet the criteria for catheterisation. The main objective of this study was to use the Influencer Change Model and the Choosing Wisely Canada toolkit to create a bundle of interventions that would reduce the unnecessary use of urinary catheters in hospitalised patients.

METHODS

In a rural teaching hospital, a time-series quasi-experiment was employed to decrease inappropriate use of urinary catheters. Both the Choosing Wisely Canada toolkit for appropriate use of urinary catheters and the Influencer change management approach were used to create effective interventions.

RESULTS

This study revealed that there was no improvement in appropriate urinary catheter use during Plan-Do-Study-Act (PDSA) cycle 1. There was gradual improvement during PDSA cycle 2, with the percentage of inappropriate urinary catheter use dropping from an initial 31% before any interventions to less than 5% by the end of this study.

DISCUSSION/CONCLUSION

This study aimed to reduce the inappropriate use of urinary catheters in a rural hospital with limited resources. The findings indicate that by using a change model, such as the Influencer Change Model, it is possible to promote better patient care through empowering healthcare staff to implement accepted protocols more stringently and thereby to decrease the inappropriate use of urinary catheters to 0%.

Emergency Department Interventions and Their Effect on Delirium's Natural Course: The Folly May be in the Foley

BACKGROUND

Delirium frequently affects older emergency department (ED) patients and has been associated with accelerated cognitive and functional decline, increased length of stay (LOS), and higher in- and out-of-hospital mortality.

OBJECTIVES

Care provided in the ED may have downstream effects on delirium duration during hospitalization. This study aimed to identify the modifiable factors of ED care associated with delirium duration in patients admitted to the hospital through the ED.

MATERIALS AND METHODS

This prospective cohort study enrolled ED patients who were 65 years and older and admitted to the hospital. Delirium was determined in the ED and during the first 7 days of hospitalization using the modified Brief Confusion Assessment Method. All delirious patients and a random selection (17%) of nondelirious patients were also enrolled. ED LOS, opioid administration, benzodiazepine administration, anticholinergic medication administration, and bladder catheter placement were obtained by medical record review. Multivariable proportional odds logistic regression was performed to determine if each of the factors was associated with delirium duration after adjusting for age, dementia, baseline function, comorbidity burden, severity of illness, nursing home residence, and central nervous system insult.

RESULTS

A total of 228 patients were enrolled. ED bladder catheter placement was significantly associated (adjusted proportional odds ratio = 3.1, 95% confidence interval: 1.3 to 7.4) with increased delirium duration after adjusting for confounders. ED LOS, opioid administration, benzodiazepine administration, and anticholinergic burden, however, were not.

CONCLUSIONS

ED bladder catheter placement was significantly associated with delirium duration and may present an opportunity for intervention.

Association between High Proportions of Seriously Mentally Ill Nursing Home Residents and the Quality of Resident Care

OBJECTIVES

To examine the association between the quality of care delivered to nursing home residents with and without a serious mental illness (SMI) and the proportion of nursing home residents with SMI.

DESIGN

Instrumental variable study. Relative distance to the nearest nursing home with a high proportion of SMI residents was used to account for potential selection of patients between high- and low-SMI facilities. Data were obtained from the 2006-2010 Minimum Data Set assessments linked with Medicare claims and nursing home information from the Online Survey, Certification, and Reporting database.

SETTING

Nursing homes with high (defined as at least 10% of a facility's population having an SMI diagnosis) and low proportions of SMI residents.

PARTICIPANTS

A total of 58 571 Medicare nursing residents with an SMI diagnosis (ie, schizophrenia or bipolar disorder) and 558 699 individuals without an SMI diagnosis who were admitted to the same nursing homes.

MEASUREMENTS

Outcomes were nursing home quality measures: (1) use of physical restraints, (2) any hospitalization in the last 3 months, (3) use of an indwelling catheter, (4) use of a feeding tube, and (5) presence of pressure ulcer(s).

RESULTS

For individuals with SMI, admission to a high-SMI facility was associated with a 3.7 percentage point (95% confidence interval [CI] = 1.4-6.0) increase in the probability of feeding tube use relative to individuals admitted to a low-SMI facility. Among individuals without SMI, admission to a high-SMI facility was associated with a 1.7 percentage point increase in the probability of catheter use (95 CI = .03-3.47), a 3.8 percentage point increase in the probability of being hospitalized (95% CI = 2.16-5.44), and a 2.1 percentage point increase in the probability of having a feeding tube (95% CI = .43-3.74).

CONCLUSION

Admission to nursing homes with high concentrations of residents with SMI is associated with worse outcomes for both residents with and without SMI. J Am Geriatr Soc 67:2346-2352, 2019.

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.

Delirium and Dementia

Approximately 35% to 37% of older emergency department (ED) patients will have delirium or dementia, which can negatively affect safe and appropriate clinical care. This article describes the epidemiology of delirium and dementia in the ED and how it affects clinical care and patient outcomes. Screening for delirium and dementia in the context of the busy ED environment, as well as their diagnostic evaluation and management, is discussed.

The Acute Care for Elders Unit Model of Care

Older patients are at risk for loss of self-care abilities during the course of an acute medical illness that results in hospitalization. The Acute Care for Elders (ACE) Unit is a continuous quality improvement model of care designed to prevent the patient's loss of independence from admission to discharge in the performance of activities of daily living (hospital-associated disability). The ACE unit intervention includes principles of a prepared environment that encourages safe patient self-care, a set of clinical guidelines for bedside care by nurses and other health professionals to prevent patient disability and restore self-care lost by the acute illness, and planning for transitions of care and medical care. By applying a structured process, an interdisciplinary team completes a geriatric assessment, follows clinical guidelines, and initiates plans for care transitions in concert with the patient and family. Three randomized clinical trials and systematic reviews of ACE or related interventions demonstrate reduced functional disability among patients, reduced risk of nursing home admission, and lower costs of hospitalization. ACE principles could improve elderly care in any acute setting. The aim of this commentary is to describe the ACE model and the basis of its effectiveness.

Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences

IMPORTANCE

Hospital-at-home (HaH) care provides acute hospital-level care in a patient's home as a substitute for traditional inpatient care. In September 2017, the Physician-Focused Payment Model Technical Advisory Committee recommended implementation of an alternative payment model for a new model of HaH that bundles the acute episode with 30 days of postacute transitional care.

OBJECTIVE

To report outcomes of this new payment model for HaH care.

DESIGN, SETTING, AND PARTICIPANTS

Case-control study of HaH care patients with a concurrent control group of hospital inpatients recruited from emergency departments (EDs) and residences in New York City from November 18, 2014, to August 31, 2017. HaH patients were 18 years or older with fee-for-service Medicare and acute medical illness requiring inpatient-level care. Control patients met HaH eligibility but refused participation or were seen in the ED when a HaH admission could not be initiated.

EXPOSURES

HaH care or inpatient care.

MAIN OUTCOMES AND MEASURES

Primary outcomes were acute period length of stay (LOS), all-cause 30-day hospital readmissions and ED visits, admissions to skilled nursing facilities (SNFs), referral to a certified home health care agency, and patient experiences with care. Analyses accounted for nonrandom selection using inverse probability weighting.

RESULTS

Among the 507 patients enrolled (mean [SD] age, 74.6 [15.7] years; 68.6% women), data were available on all patients 30 days postdischarge. HaH patients (n = 295) were older than controls (n = 212) and more likely to have a preacute functional impairment. HaH patients had shorter LOS (3.2 days vs 5.5 days; difference, -2.3 days; 95% CI, -1.8 to -2.7 days; weighted P < .001); lower rates of readmissions (8.6% [25] vs 15.6% [32]; difference, -7.0%; 95% CI, -12.9% to -1.1%; weighted P < .001), ED revisits (5.8% [17] vs 11.7% [24]; difference, -5.9%; 95% CI, -11.0% to -0.7%; weighted P < .001), and SNF admissions (1.7% [5] vs 10.4% [22]; difference, -8.7%; 95% CI, -13.0% to -4.3%; weighted P < .001); and were also more likely to rate their hospital care highly (68.8% [119] vs 45.3% [67]; difference, 23.5%; 95% CI, 12.9% to 34.1%; weighted P < .001). There were no differences in referrals to certified home health agencies.

CONCLUSIONS AND RELEVANCE

HaH care bundled with a 30-day postacute transitional care episode was associated with better patient outcomes and ratings of care compared with inpatient hospitalization. This model warrants consideration for addition to Medicare's current portfolio of shared savings programs.

The Impact of Dementia Special Care Units on Quality of Care: An Instrumental Variables Analysis

OBJECTIVE

To compare the quality of care following admission to a nursing home (NH) with and without a dementia special care unit (SCU) for residents with dementia.

DATA SOURCES/STUDY SETTING

National resident-level minimum dataset assessments (MDS) 2005-2010 merged with Medicare claims and provider-level data from the Online Survey, Certification, and Reporting database.

STUDY DESIGN

We employ an instrumental variable approach to address the endogeneity of selection into an SCU facility controlling for a range of individual-level covariates. We use "differential distance" to a nursing home with and without an SCU as our instrument.

DATA COLLECTION/EXTRACTION METHODS

Minimum dataset assessments performed at NH admission and every quarter thereafter.

PRINCIPAL FINDINGS

Admission to a facility with an SCU led to a reduction in inappropriate antipsychotics (-9.7 percent), physical restraints (-9.6 percent), pressure ulcers (-3.3 percent), feeding tubes (-8.3 percent), and hospitalizations (-14.7 percent). We found no impact on the use of indwelling urinary catheters. Results held in sensitivity analyses that accounted for the share of SCU beds and the facilities' overall quality.

CONCLUSIONS

Facilities with an SCU provide better quality of care as measured by several validated quality indicators. Given the aging population, policies to promote the expansion and use of dementia SCUs may be warranted.

Predicting the length of hospital stay of post-acute care patients in Taiwan using the Chinese version of the continuity assessment record and evaluation item set

Background

The Chinese version of the Continuity Assessment Record and Evaluation (CARE-C) item set was developed to facilitate the assessment of post-acute care (PAC) patients in Taiwan. Considering that the length of hospital stay (LOS) has a significant effect on the total healthcare cost, determining whether the CARE-C scores could predict the LOS of PAC patients is of great interest to the PAC providers.

Methods

This prospective trial included PAC patients with stroke or central nervous system injuries. The demographic data and CARE-C scores were collected after admission and before discharge. A multivariable stepwise linear regression model was used to identify the predictors of the LOS using age, sex, tube placement status, CARE-C component scores at admission, and score differences between admission and discharge as independent variables.

Results

This study included 178 patients (66 women and 112 men), with a mean age of 61.9 ± 15.6 years. Indwelling urinary catheter placement status at admission (β = 0.241, p = 0.002) was a positive predictor of the LOS, whereas age (β = −0.189, p = 0.010), core transfer subscale score at admission (β = −0.176, p = 0.020), and difference in continence subscale score (β = −0.203, p = 0.008) were negative predictors of the LOS. The model explained 14% of the total variance.

Conclusions

Indwelling urinary catheter placement status at admission, age, core transfer subscale score at admission, and difference in the CARE-C continence subscale score were identified as predictors of the LOS. The explanatory power of these predictors might be limited due to the regulations of Taiwan’s National Health Insurance.

[Recurrent and catheter-associated urinary tract infections : Prophylaxis and prevention]

Urinay tract infection (UTI) as one of the most frequent bacterial infections in humans is of utmost relevance. Because of the rising prevalence of antimicrobial resistance, urinalysis should always include urine culture and a resistogram in order to avoid an unspecific selection and overuse of antibiotics. Prevention of recurrent UTI must first of all rule out predisposing uropathogenic conditions. Nowadays, a great variety of drugs, behavioral, and supportive treatment options can effectively minimize UTI recurrence. The growing importance of vaccines (immunotherapy), probiotics (lactobacilli), and standardized herbal preparations meets the need of reducing antibiotic use and the development of antimicrobial resistance. Around 80% of all nosocomial UTIs (nUTIs) are associated with indwelling urinary catheters. It is estimated that up to 70% of all nUTIs occurring in Germany may be avoided by using appropriate preventative measures. Therefore, profound knowledge about the basics of catheter-associated nUTIs and the correct management of urinary catheters are of utmost individual and socioeconomic importance.

Altered Mental Status and Delirium

Older patients who present to the emergency department frequently have acute or chronic alterations of their mental status, including their level of consciousness and cognition. Recognizing both acute and chronic changes in cognition are important for emergency physicians. Delirium is an acute change in attention, awareness, and cognition. Numerous life-threatening conditions can cause delirium; therefore, prompt recognition and treatment are critical. The authors discuss an organized approach that can lead to a prompt diagnosis within the time constraints of the emergency department.

De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study

BACKGROUND

Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25-50%, and to evaluate the affecting factors of our de-implementation strategy.

METHODS

In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated.

DISCUSSION

This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications.

TRIAL REGISTRATION

Dutch trial registry: NTR6015 . Registered 9 August 2016.

Trial without a Catheter Programme Improves Urological Management for Retention of Urine after Hip Fracture Surgery

Background

Acute retention of urine (AROU) is commonly occurred in patients with geriatric hip fractures after surgeries. It is common that the catheters cannot be weaned off after insertion.

Objectives

We compared an approach using unified Trial Without Catheter (TWOC) protocol with non-unified management plans in patients with retention of urine after hip fracture surgery, to compare these approaches in terms of (1) rate of successful catheter removal, (2) duration required for successful catheter removal, (3) number of episodes of urinary tract infection, and (4) length of hospital stay.

Methods

We conducted a retrospective cohort study of 250 patients who failed to wean off a urinary catheter. 140 out of 1349 patients between December 2012 and September 2014 formed the intervention group (treated with unified TWOC protocol), and 110 out of 1193 patients between July 2006 and December 2008 were the control group (treated with different AROU management approaches). The efficiency and effectiveness of the urological management in both groups were compared.

Results

As expected, the rate of successful TWOC was higher in intervention group (before discharge, 68.6% versus 38.2%; after discharge, 20.0% versus 18.2%, overall, 88.6% versus 56.4%). Despite trial of weaning off urinary catheters, 16 patients in intervention group and 8 patients in control group failed with permanent catheter required. Forty patients in control group were discharged with permanently catheters without a trial of TWOC.

Conclusion

The TWOC program provides structured and standardized urological management for patients suffered from AROU after geriatric hip fracture surgeries. To reiterate, indwelling urethral catheters must not be placed permanently without carrying out urological assessment in patients with geriatric hip fractures.

Urethral catheters and medical malpractice: a legal database review from 1965 to 2015

Background

Urethral catheters (UCs) are commonly used in medicine and are associated with complications such as urinary tract infections (UTIs) and trauma. Given UC complications and their ubiquitous usage in healthcare, there is a potential for liability risk. We aim to explore litigation involving UC-related complications.

Methods

The LexisNexis legal database was queried for all state and federal cases from January 1965 through October 2015 using the terms “urethral catheter” or “Foley catheter” in combination with “medical malpractice”, “negligence”, “medical error”, and “trauma”. Each case was reviewed for reported medical characteristics and legal aspects, including the outcome of the case.

Results

Our search yielded 29 cases. Urologists were the most common providers cited as defendants (21%), all of whom were successful in their defense. The most common malpractice claim was for traumatic insertion (48%). Pain was the most common type of damage claimed by plaintiffs (28%), followed by UTI (24%). Nineteen (66%) cases favored defendants, while 10 (34%) cases favored the plaintiffs, of which 2 (7%) were settled out of the court. In settled cases, the mean settlement received by plaintiffs was $55,750 (range, $25,000–$86,500). The mean award to plaintiffs for cases determined by the court was $112,991 (range, $4,000–$325,000).

Conclusions

Despite widespread usage of UC over a 50-year period, lawsuits centered on UC misuse are rare at the state and federal court levels. Of litigated cases, urologists are commonly involved yet have successful defenses.

Decreased glomerular filtration rate estimated by 2009 CKD-EPI equation predicts mortality in older hip fracture population

OBJECTIVE

We examined estimated glomerular filtration rate using the Chronic Kidney Disease Epidemiology equation (eGFRCDK-EPI), removal of urinary catheter during hospitalization and polypharmacy as predictors of mortality in older hip fracture patients.

METHODS

Population-based prospective data were collected on 1425 consecutive hip fracture patients aged ≥65 years. Outcome was mortality at one year. Independent variables were age, sex, body mass index, fracture type, American Society of Anesthesiology score, delay to surgery, urinary catheter removal during acute hospitalization, eGFRCDK-EPI, number of daily medications, diagnosis of memory disorder, prefracture mobility and living arrangements.

RESULTS

Of the 1425 patients, 567 (40%) had renal dysfunction on admission, 526 (37%) had their urinary catheters removed during hospitalization and 1177 (83%) were taking ≥4 medications regularly before the fracture. In the multivariate analyses with the Cox proportional hazards model adjusted simultaneously for all the independent variables, eGFRCDK-EPI 30-44ml/min/1.73m(2) (HR 1.91, 95% CI 1.44-2.52) and <30ml/min/1.73m(2) (HR 1.95, 95% CI 1.36-2.78), non-removal of the urinary catheter (HR 1.45, 95% CI 1.12-1.88) and large number of daily medications (4-10 HR 1.81, 95% CI 1.78-2.79, >10 HR 2.21, 95% CI 1.38-3.54) were associated with mortality.

CONCLUSIONS

In older hip fracture patients, moderate to severe level renal dysfunction measured by eGFRCDK-EPI, non-removal of urinary catheter before discharge and polypharmacy increase mortality after hip fracture. Careful assessment of renal function and medications and following the care protocols on urinary catheter removal are essential in the care of geriatric hip fracture patients.

Urinary tract infection after surgery for colorectal malignancy: risk factors and complications

BACKGROUND

Over 4% of patients undergoing colorectal surgery develop postoperative urinary tract infection (UTI).

METHODS

Using 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program data for 47,781 patients, we examined independent risk factors and complications associated with UTI using multivariate logistic regression.

RESULTS

Independent predictors of UTI included female sex (odds ratio [OR] 1.705, 95% confidence interval [CI] 1.508 to 1.928), open procedure (OR 1.419, 95% CI 1.240 to 1.624), rectal procedure (OR 1.267, 95% CI 1.105 to 1.453), age greater than 65 years (OR 1.322, 95% CI 1.151 to 1.519), nonindependent functional status (OR 1.609, 95% CI 1.299 to 1.993), steroid use (OR 1.524, 95% CI 1.116 to 2.080), higher anesthesia class, and longer operative time. Patients with UTI had longer hospital stays (7 vs 12 days), higher reoperation rates (11.9% vs 5.1%), and higher 30-day mortality (3.3% vs 1.7%). Postoperative UTI correlated with other complications, including sepsis, surgical site infections, and pulmonary embolism (P < .001).

CONCLUSIONS

Postoperative UTI in colorectal surgery patients correlates with increased morbidity and mortality. Patients who contract postoperative UTI may be more likely to develop multiple complications.

Pre- and perioperative predictors of changes in mobility and living arrangements after hip fracture--a population-based study

PURPOSE OF THE RESEARCH

Examining pre- and perioperative predictors of changes in mobility and living arrangements after hip fracture.

MATERIALS AND METHODS

Population-based prospective data were collected on 1027 hip fracture patients aged ≥65. The outcomes were decreased vs. same or improved mobility level and need for more supported vs. same or less supported living arrangements 1 year after hip fracture. The independent variables were age, gender, body mass index, American Society of Anesthesiologists score, diagnosis of memory disorder, mobility level and living arrangements, fracture type, delay to surgery and urinary catheter removal during acute hospitalization.

THE PRINCIPAL RESULTS

Multivariate logistic regression analysis revealed the prefracture mobility level of walking outdoors (OR=0.47, 95% CI 0.30-0.75) or indoors (OR=0.25, 95% CI 0.09-0.72) assisted to be associated with a smaller decrease in mobility level. Non-independent mobility level (OR=2.74, 95% CI 1.70-4.41) was associated with the need of more supported living arrangements. Living in assisted living accommodations (OR=0.23, 95% CI 0.12-0.44) was associated with less need for more supported living arrangements. Removal of the urinary catheter showed a protective association on both decline in mobility level (OR=0.45; 95% CI 0.29-0.70) and moving to a more supported living arrangement(OR=0.49,95% CI 0.31-0.77.

MAJOR CONCLUSIONS

Worsening of mobility was significant for independent mobilizers. Prefracture impaired mobility was associated with the need of more supported living arrangements. Living in an assisted living accommodation protected against institutionalization. The findings emphasize the importance of a prompt removal of the urinary catheter after hip fracture.

Reducing inappropriate urinary catheter use: quality care initiatives

Healthcare-acquired urinary infection presents a substantial burden for patients and the healthcare system. Urinary tract infections have not gained the same level of media attention as other healthcare-associated infections, yet interventions to reduce urinary catheter use are one of the top ten recommended patient safety strategies. To improve practice around urinary catheter placement and removal requires interventions to change the expectations and habits of nurses, medical teams and patients regarding the need for a urinary catheter. In the authors' trust, a redesign of the existing urinary catheter device record was undertaken to help avoid unnecessary placement of catheters, and resulted in a reduction of urinary catheters in situ longer than 48 hours. Other strategies included implementation of catheter rounds in a high-usage area, and credit-card-sized education cards. A catheter 'passport' was introduced for patients discharged with a catheter to ensure information for insertion and ongoing use were effectively communicated.

Preventable Iatrogenic Disability in Elderly Patients During Hospitalization

BACKGROUND

In older patients, hospitalization is often associated with new or worsening disability. This hospitalization-associated disability may be explained in part by the cumulative effect of aging, frailty, comorbidities, and illnesses that led to hospitalization but may also result from health care management issues and the hospital environment. Our objective was to determine the frequency, causes, and the preventability of disability induced by the processes of care or "iatrogenic disability."

METHODS

A total of 503 patients, aged 75 years and older, hospitalized in the 105 medical and surgical units of Toulouse University Hospital between October 2011 and March 2012, with a minimal length of stay of 2 days, were included. Hospitalization-associated disability was defined as a loss of 0.5 points or more in the Katz Activity of Daily Living Score between the time of hospital admission and discharge. To determine the iatrogenic component of hospitalization-associated disability, an expert panel in geriatric medicine reviewed each medical chart using a standardized record review and identified precipitating iatrogenic adverse events resulting in functional decline.

RESULTS

Incidence of iatrogenic disability was 11.9% (95% confidence interval, 9.2%-15.1%). Of the 60 cases of iatrogenic disability, 49 (81.7%, 95% confidence interval, 69.6%-90.5%) were judged to be potentially preventable. The most common health management issues identified in patients with preventable iatrogenic disability were low mobilization [by excessive bed rest (26.5%) and lack of physical therapist intervention (55.1%)], overuse of diapers (49.0%), and transurethral urinary catheterization (30.6%).

CONCLUSIONS

The present study suggests that a significant proportion of hospitalization-associated disability may be induced by iatrogenic events, and that most of them are potentially preventable. Health care professionals need to be educated on the specific needs of elderly hospitalized patients and should consider hospitalization-associated disability as an outcome of care.

Upcoming rules and benchmarks concerning the monitoring of and the payment for surgical infections

There has been a good deal of dialogue about pay for performance and linking outcomes with reimbursement, especially given the recent national health care legislation. Many such concerns are caused by upcoming changes that have been outlined in the Affordable Care Act. This article discusses these upcoming changes and reviews some of the literature that supports them, specifically those related to surgical infections. Likewise, the lack of support for some of these changes in the academic literature is discussed. Finally, some of the proposed key benchmarks and the methodologies behind the design of those benchmarks are discussed.

Quality and innovations for caring hospitalized older persons in the unites States

Older persons are occasionally acutely ill and their hospitalizations frequently end up with complications and adverse outcomes. Medicare from U.S. federal government's payment resource for older persons is facing financial strain. Medicare highlights both cost-saving and high quality of care while older persons are hospitalized. Several health policy changes were initiated to achieve Medicare's goals. In response to Medicare's health policy changes, U.S. hospital environments have been changed and these resulted in hospital quality measurements' improvement. American seniors are facing the challenges during and around their hospital care. Several innovative measures are suggested to overcome these challenges.

The care of older adults in hospital: if it's common sense why isn't it common practice?

AIMS AND OBJECTIVES

To present three converging myths that underlie the perception that nursing care for older persons in hospital is simple in comparison with its actual complexity.

BACKGROUND

Literature provides strong evidence indicating that the myths we discuss inherently arise from ageism, the social value of older patients and the economic burden of being an older patient in hospital. These powerful social discourses promote harm to older patients. Harm emerges from both the omission of gerontological nursing knowledge and skill and the commission of acts that unintentionally harm. A corresponding ethical challenge results for acute care nurses.

DESIGN

A discursive paper.

METHODS

We illuminate gerontological issues by discussing three myths. In myth one, we detail four clusters of distinguishing characteristics in older hospitalised people. In the second myth, we challenge the idea that the role of the acute care hospital is to attend only to acute medical concerns. Finally, in the third myth, we address the issue of incorporating functional assessment into the acute care nursing assessment. We argue that functional assessment is poorly integrated and becomes acceptable only as long as the medical regimen is managed appropriately.

CONCLUSION

Safe quality care in hospital for older adults requires a hybrid practice that integrates acute care specialty knowledge with gerontological nursing knowledge and skill. Clinical reasoning that integrates this type of nursing knowledge can prevent harm.

RELEVANCE TO CLINICAL PRACTICE

Integrating key elements of acute care nursing specialty knowledge with gerontological nursing principles aids to prevent the omission of care that is known to be harmful to older people. Conversely, the commission of gerontologically sensitive acute care can enhance safety and promote quality care in hospital.

A Model of Risk Reduction for Older Adults Vulnerable to Nursing Home Placement

Because of the cost of nursing home care and desire of older adults to stay in their homes, it is important for health care providers to understand the factors that place older adults at risk for nursing home placement. This integrative review of 12 years of research, as published in 148 articles, explores the risk factors for nursing home placement of older adults. Using the framework of the vulnerable populations conceptual model developed by Flaskerud and Winslow (1998), we explored factors related to resource availability, relative risks, and health status. Important factors include socioeconomic status, having a caregiver, the availability and use of home- and community-based support services, race, acute illness particularly if hospitalization is required, medications, dementia, multiple chronic conditions, functional disability, and falls. Few intervention studies were identified. Development of evidence-based interventions and creation of policies to address modifiable risk factors are important next steps.

Predictors of postoperative urinary retention after colorectal surgery

BACKGROUND

National quality initiatives have mandated the earlier removal of urinary catheters after surgery to decrease urinary tract infection rates. A potential unintended consequence is an increased postoperative urinary retention rate.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors for postoperative urinary retention after colorectal surgery.

DESIGN

This was a prospective observational study.

SETTINGS

A colorectal unit within a single institution was the setting for this study.

PATIENTS

Adults undergoing elective colorectal operations were included.

INTERVENTIONS

Urinary catheters were removed on postoperative day 1 for patients undergoing abdominal operations, and on day 3 for patients undergoing pelvic operations. Postvoid residual and retention volumes were measured.

MAIN OUTCOME MEASURES

The primary outcomes measured were urinary retention and urinary tract infection.

RESULTS

The overall urinary retention rate was 22.4% (22.8% in the abdominal group, 21.9% in the pelvic group) and was associated with longer operative time and increased perioperative fluid administration. Mean operative time for those with retention was 2.8 hours and, for those without retention, the mean operative time 2.2 hours (abdominal group 2 hours vs 1.4 hours, pelvic group 3.9 hours vs 3.1 hours, p ≤ 0.02). Patients with retention received a mean of 2.7L during the operation, whereas patients without retention received 1.8L (abdominal group 1.9L vs 1.4L, pelvic group 3.6L vs 2.2L, p < 0.01). In the abdominal group, patients with and without retention also received different fluid volumes on postoperative days 1 (2.2L vs 1.7L, p = 0.004) and 2 (1.6L vs 1L, p = 0.05). Laparoscopic abdominal group had a 40% retention rate in comparison with 12% in the open abdominal group (p = 0.004). Age, sex, preoperative radiation therapy, preoperative prostatism, preoperative diagnosis, and level of anastomosis were not associated with retention. The urinary tract infection rate was 4.9%.

LIMITATION

The lack of documentation of preoperative urinary function was a limitation of this study.

CONCLUSIONS

The practice of earlier urinary catheter removal must be balanced with operative time and fluid volume to avoid high urinary retention rates. Also important is increased vigilance for the early detection of retention.

The effect of poststroke delirium on short-term outcomes of elderly patients undergoing rehabilitation

OBJECTIVES

Delirium is a common poststroke complication, but its prevalence and effect in rehabilitation settings is unknown. We retrospectively assessed the prevalence of delirium in elderly patients undergoing poststroke rehabilitation and its association with short-term outcomes.

METHODS

All patients (aged ≥65 years) admitted to the Department of Rehabilitation between November 2007 and October 2011 after a recent stroke were screened for delirium. Delirium was diagnosed using the confusion assessment method. Multiple logistic regressions were used to evaluate the association between delirium, institutionalization, and inhospital death, while multiple linear regressions were used for the association between delirium and functional recovery, defined in 3 different ways which include (1) measuring the relative functional gain of the Barthel index (BI-RFG); (2) the change in Barthel index (BI) walking subscore from admission to discharge; and (3) the change in Tinetti score from admission to discharge.

RESULTS

In all, 58 (33%) patients of the total 176 patients were consecutively admitted to our department with delirium. After adjustment for potential confounders, poststroke delirium (PSD) was an independent predictor of institutionalization (odds ratio [OR] = 7.23; 95% confidence interval [CI] = 4.79 to 10.91; P ≤ .0003) and inhospital death (OR = 4.26; 95% CI = 1.15 to 15.81; P = .03); PSD was not a predictor of functional recovery at discharge, neither using the BI-RFG (P = .96) nor using the change from admission to discharge of both the BI walking subscore (P = .57) and the Tinetti score (P = .61) as outcome measures.

CONCLUSIONS

In elderly patients undergoing poststroke rehabilitation, delirium is an independent predictor of institutionalization and inhospital death, but it does not affect functional recovery.

Altered mental status in older patients in the emergency department

Altered mental status is a common chief compliant among older patients in the emergency department (ED). Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute changes in mental status the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.

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.