Variation in the prevalence of urinary catheters: a profile of National Health Service patients in England

Adherence to Evidence-Based Guidelines and Implications When Designing Electronic Documentation for Urinary Catheters

AIM

The aim of this study was to investigate the point prevalence and the rate of adherence to evidence-based guidelines for patients who had indwelling urinary catheters in three Australian acute care hospitals.

DESIGN

A cross-sectional observational design was used.

METHODS

A multisite cross-sectional observational design was utilised in three acute hospitals across Australia. Data were collected from each site in a single day directly from observation of the patient, the bedside notes and medical records. The data collected included observations of clinical care and scrutiny of the documentation of the insertion details and catheter care using best practice guidelines.

RESULTS

Of the 1730 patients audited, 47% were female. The mean point prevalence of catheters in situ across three sites was 12.9%. Correct documentation compliance was reported to be, on average, 40%. Documentation was significantly better when a template was available to guide information recorded: this was regardless of whether it was hard copy or electronic. Overall, clinical care compliance with best practices was 77%. Of note for improvement was the fixing of the urinary catheter to the thigh in highly dependent patients.

CONCLUSION

It was identified that there is a need for improvement across all three sites: specifically regarding securement of the urinary catheter to the patient's thigh within the ICU. In addition, it was identified that there is a need for documentation of the urine bag change in ward areas. Documentation may be improved by incorporating templates into healthcare documentation systems in the future. Further work is needed to ensure nurses are aware of the adverse effects of urinary catheters and thus, the need to adhere to best practice guidelines.

PATIENT OR PUBLIC CONTRIBUTION

There has been no patient or public contribution.

REPORTING METHOD

We have adhered to the STROBE guidelines for reporting.

Measuring and improving the cradle-to-grave environmental performance of urological procedures

An urgent need for societal transformation exists to reduce the environmental impact of humanity, because environmental health affects human health. Health care causes ~5% of global greenhouse gas emissions and other substantial and ongoing environmental harms. Thus, health-care professionals and managers must lead ongoing efforts to improve the environmental performance of health systems. Life-cycle assessment (LCA) is a methodology that enables estimation of environmental impacts of products and processes. It models environmental effects from 'cradle' (raw material extraction) to 'grave' (end of useful life) and conventionally reports a range of different impact categories. LCA is a valuable tool when used appropriately. Maximizing its utility requires rational assumptions alongside careful consideration of system boundaries and data sources. Well-executed LCAs are detailed and transparently reported, enabling findings to be adapted or generalized to different settings. Attention should be given to modelling mitigation solutions in LCAs. This important step can guide health-care systems towards new and innovative solutions that embed progress towards international climate agreements. Many urological conditions are common, recurrent or chronic, requiring resource-intensive management with large associated environmental impacts. LCAs in urology have predominantly focussed on greenhouse gas emissions and have enabled identification of modifiable 'hotspots' including electricity use, travel, single-use items, irrigation, reprocessing and waste incineration. However, the methodological and reporting quality of published urology LCAs generally requires improvement and standardization. Health-care evaluation and commissioning frameworks that value LCA findings alongside clinical outcomes and cost could accelerate sustainable innovations. Rapid implementation strategies for known environmentally sustainable solutions are also needed.

Urinalysis is predictive for absence of urinary tract infection in men with and without catheters

OBJECTIVES

To determine accuracy of negative urinalysis (UA) for predicting negative urine culture and the absence of urinary tract infection (UTI), and optimal urine culture growth cutoff for UTI diagnosis in men with and without urinary catheters.

SUBJECTS AND METHODS

UAs with urine cultures within 1 week from adult men were identified and evaluated. Predictive values for the absence of UTI (absence of ≥1 of the following criteria: documentation of UTI diagnosis, antibiotic prescription, uropathogen presence on culture) were calculated.

RESULTS

In total, 22 883 UAs were included. Negative UA had a high predictive value for negative urine culture (0.95, 95% confidence interval [CI]: 0.94-0.95) and absence of UTI (0.99, CI: 0.99-0.995) in the overall cohort. Negative UA also had a high predictive value for negative urine culture (0.93, CI: 0.90-0.95) and absence of UTI (0.99, CI: 0.98-0.999) in those with indwelling urinary catheters. The traditional threshold of culture growth of 100 000 colony-forming units (CFU)/mL did not capture 22% of UTIs.

CONCLUSION

UA exhibits high predictive value for negative urine culture and absence of UTI in men, supporting a protocol wherein culture is only performed in the context of abnormal UA. The traditional 100 000 CFU/mL cut-off may have not captured a subset of UTI in the male population, and warrants further investigation.

Single-center, double-blind, randomized, placebo-controlled pilot study of Canoxidin® for prevention of catheter encrustation in patients with indwelling catheters

INTRODUCTION AND OBJECTIVES

Long-term use of an indwelling catheter is associated with complications such as catheter encrustation and infection. Canoxidin® is a novel oral treatment that can potentially prevent catheter encrustation, as it contains a urine acidifier and a combination of two crystallization inhibitors. This study aimed to evaluate the effects of Canoxidin® on catheter encrustation in patients with indwelling Foley catheters.

PATIENTS AND METHODS

This was a single-center, double-blind, randomized, placebo-controlled study. Neuro-urology patients aged ≥18 years with an indwelling catheter (urethral or suprapubic) were randomized to treatment consisting of either Canoxidin® or placebo for one month. Foley catheters (two per patient, one before treatment and one after treatment) were removed for analysis of the presence and degree of encrustation.

RESULTS

A total of 40 patients were enrolled and randomized, 28 of whom had analyzable catheters (13 assigned to Canoxidin® and 15 assigned to placebo). The patients had a mean age of 51.8 years, and eight (28.6%) were female. Two patients (13.3%) in the placebo group and eight patients (61.5%) in the Canoxidin® group experienced an improvement (less encrustation). There was a significant association between Canoxidin® and improvement (odds ratio: 10.4, 95% confidence interval: 1.6 to 66.9, P = 0.016). No adverse effects attributable to the treatment were reported.

CONCLUSIONS

The overall rate of catheter encrustation was high among those with indwelling Foley catheters. One-month treatment with Canoxidin® reduced the formation of these encrustations, with an excellent short-term safety profile.

Patient engagement to counter catheter-associated urinary tract infections with an app (PECCA): a multicentre, prospective, interrupted time-series and before-and-after study

BACKGROUND

The risk of urinary tract infections (UTIs) is increased by unnecessary placement and prolonged use of urinary catheters.

AIM

To assess whether inappropriate use of catheters and catheter-associated UTI were reduced through patient participation.

METHODS

In this multicentre, interrupted time-series and before-and-after study, we implemented a patient-centred app which provides catheter advice for patients, together with clinical lessons, feedback via e-mails and support rounds for staff members. Data on catheter use and infections were collected during a six-month baseline and a six-month intervention period on 13 wards in four hospitals in the Netherlands. Dutch Trial Register: NL7178.

FINDINGS

Between June 25th, 2018 and August 1st, 2019, 6556 patients were included in 24 point-prevalence surveys, 3285 (50%) at baseline and 3271 (50%) during the intervention. During the intervention 249 app users and a median of seven new app users per week were registered (interquartile range: 5.5-13.0). At baseline, inappropriate catheter use was registered for 175 (21.9%) out of 798 catheters, compared to 55 (7.0%) out of 786 during the intervention. Time-series analysis showed a non-significant decrease of inappropriate use of 5.8% (95% confidence interval: -3.76 to 15.45; P = 0.219), with an odds ratio of 0.27 (0.19-0.37; P < 0.001). Catheter-associated UTI decreased by 3.0% (1.3-4.6; P = 0.001), with odds ratio 0.541 (0.408-0.716; P < 0.001).

CONCLUSION

Although UTI significantly decreased after the implementation, patient participation did not significantly reduce the prevalence of inappropriate urinary catheter use. However, the inappropriate catheter reduction of 5.8% and an odds ratio of 0.27 suggest a positive trend. Patient participation appears to reduce CAUTI and could reduce other healthcare-associated infections.

Intermittent catheterisation

When an individual has voiding difficulties, the person may require a urinary catheter. Enabling the person to choose an appropriate method of catheterisation and supporting them can have an enormous impact on the individual's health and wellbeing. Indwelling urethral catheters are suitable for some people but for others they can affect a person's lifestyle and lead to depression. Intermittent catheterisation can work well for some people. Intermittent self-catheterisation has been used to manage urinary retention for over 3500 years. It remains the 'gold standard' in terms of bladder drainage, but it is under-used and indwelling catheters remain more common. This article examines the history of intermittent catheterisation, indications for self-catheterisation and how to support people to use self-catheterisation.

Safety and efficacy of fluoroscopy-guided urethral catheterization in case of failed blind or cystoscopy-assisted urethral catheterization

This retrospective study evaluated the safety and efficacy of fluoroscopy-guided urethral catheterization in patients who failed blind or cystoscopy-assisted urethral catheterization. We utilized our institutional database between January 2011 and March 2023, and patients with failed blind or cystoscopy-assisted urethral catheterization and subsequent fluoroscopy-guided urethral catheterization were included. A 5-Fr catheter was inserted into the urethral orifice, and the retrograde urethrography (RGU) was acquired. Subsequently, the operator attempted to pass a hydrophilic guidewire to the urethra. If the guidewire and guiding catheter could be successfully passed into the bladder, but the urethral catheter failed pass due to urethral stricture, the operator determined either attempted again with a reduced catheter diameter or performed balloon dilation according to their preference. Finally, an appropriately sized urethral catheter was selected, and an endhole was created using an 18-gauge needle. The catheter was then inserted over the wire to position the tip in the bladder lumen and ballooned to secure it. We reviewed patients' medical histories, the presence of hematuria, and RGU to determine urethral abnormalities. Procedure-related data were assessed. Study enrolled a total of 179 fluoroscopy-guided urethral catheterizations from 149 patients (all males; mean age, 73.3 ± 13.3 years). A total of 225 urethral strictures were confirmed in 141 patients, while eight patients had no strictures. Urethral rupture was confirmed in 62 patients, and hematuria occurred in 34 patients after blind or cystoscopy-assisted urethral catheterization failed. Technical and clinical success rates were 100%, and procedure-related complications were observed in four patients (2.2%). The mean time from request to urethral catheter insertion was 129.7 ± 127.8 min. The mean total fluoroscopy time was 3.5 ± 2.5 min and the mean total DAP was 25.4 ± 25.1 Gy cm2. Balloon dilation was performed in 77 patients. Total procedure time was 9.2 ± 7.6 min, and the mean procedure time without balloon dilation was 7.1 ± 5.7 min. Fluoroscopy-guided urethral catheterization is a safe and efficient alternative in patients where blind or cystoscopy-assisted urethral catheterization has failed or when cystoscopy-urethral catheterization cannot be performed.

External urinary catheter devices: A multisite project involving point prevalence

External urinary catheter devices used in hospitals can offer an alternative to indwelling urinary catheters. Prevalence and patient outcomes are not well understood. This multisite project involved point prevalence of device use in patients with labia on acute care units. All patients on included units with corresponding anatomy were observed for presence of device in addition to review of indication of use and chart audit. Device use was 28.8 %. Immobility was the leading indication, and most patients had severe dysfunction as to mobility. For most patients, level of mobility remained the same from admission to discharge. Many patients were either potentially physically able to mobilize out of bed to urinate or were likely continent. There was variation in suction setting and chart documentation. The project lacked a comparison group and collected limited patient information. Areas for future inquiry include prevalence and impact on mobility, continence, and skin integrity.

A comprehensive status update on modification of foley catheter to combat catheter-associated urinary tract infections and microbial biofilms

Present-day healthcare employs several types of invasive devices, including urinary catheters, to improve medical wellness, the clinical outcome of disease, and the quality of patient life. Among urinary catheters, the Foley catheter is most commonly used in patients for bladder drainage and collection of urine. Although such devices are very useful for patients who cannot empty their bladder for various reasons, they also expose patients to catheter-associated urinary tract infections (CAUTIs). Catheter provides an ideal surface for bacterial colonization and biofilm formation, resulting in persistent bacterial infection and severe complications. Hence, rigorous efforts have been made to develop catheters that harbour antimicrobial and anti-fouling properties to resist colonization by bacterial pathogens. In this regard, catheter modification by surface functionalization, impregnation, blending, or coating with antibiotics, bioactive compounds, and nanoformulations have proved to be effective in controlling biofilm formation. This review attempts to illustrate the complications associated with indwelling Foley catheters, primarily focussing on challenges in fighting CAUTI, catheter colonization, and biofilm formation. In this review, we also collate scientific literature on catheter modification using antibiotics, plant bioactive components, bacteriophages, nanoparticles, and studies demonstrating their efficacy through in vitro and in vivo testing.

Cost-effectiveness of a novel urethral catheter safety device in preventing catheterization injuries in the UK

AIMS

Intraurethral catheter balloon inflation is a substantial contributor to significant catheter-related urethral injury. A novel safety valve has been designed to prevent these balloon-inflation injuries. The purpose of this evaluation was to assess the cost-effectiveness of urethral catheterisation with the safety valve added to a Foley catheter versus the current standard of care (Foley catheter alone).

MATERIALS AND METHODS

The analysis was conducted from the UK public payer perspective on a hypothetical cohort of adults requiring transurethral catheterization. A decision tree was used to capture outcomes in the first 30 days following transurethral catheterization, followed by a Markov model to estimate outcomes over a person's remaining lifetime. Clinical outcomes included catheter balloon injuries [CBIs], associated short-term complications, urethral stricture disease, life years and QALYs. Health-economic outcomes included total costs, incremental cost-effectiveness ratio, net monetary benefit (NMB) and net health benefit.

RESULTS

Over a person's lifetime, the safety valve was predicted to reduce CBIs by 0.04 per person and CBI-related short-term complications by 0.03 per person, and nearly halve total costs. The safety valve was dominant, resulting in 0.02 QALYs gained and relative cost savings of £93.19 per person. Probabilistic sensitivity analysis indicated that the safety valve would be cost-saving in 97% of simulations run versus standard of care.

CONCLUSIONS

The addition of a novel safety valve aiming to prevent CBIs during transurethral catheterization to current standard of care was estimated to bring both clinical benefits and cost savings.

Effective Treatments of UTI—Is Intravesical Therapy the Future?

Urinary tract infection (UTI) afflicts millions of patients globally each year. While the majority of UTIs are successfully treated with orally administered antibiotics, the impact of oral antibiotics on the host microbiota is under close research scrutiny and the potential for dysbiosis is a cause for concern. Optimal treatment of UTI relies upon the selection of an agent which displays appropriate pharmacokinetic-pharmacodynamic (PK-PD) properties that will deliver appropriately high concentrations in the urinary tract after oral administration. Alternatively, high local concentrations of antibiotic at the urothelial surface can be achieved by direct instillation into the urinary tract. For antibiotics with the appropriate physicochemical properties, this can be of critical importance in cases for which an intracellular urothelial bacterial reservoir is suspected. In this review, we summarise the underpinning biopharmaceutical barriers to effective treatment of UTI and provide an overview of the evidence for the deployment of the intravesical administration route for antibiotics.

Need to clamp indwelling urinary catheters before removal after different durations: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to evaluate the effect of bladder training by clamping on bladder urethral function in patients with indwelling urinary catheters used for different durations.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

The UpToDate, Cochrane Library, OVID, PubMed, China National Knowledge Infrastructure, CINAHL and Embase were screened from 1 January 2000 to 28 February 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials (RCTs) or quasi-experimental designs comparing the efficacy of bladder training in patients with an indwelling urinary catheter by clamping or free drainage before urinary catheter removal were published in English or Chinese.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted the data and assessed the quality of studies. Continuous variables were analysed using mean difference and standardised mean difference (SMD) values with a 95% CI. Categorical variables were analysed using relative risk (RR) and 95% CI.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was urinary tract infection incidence, and secondary outcomes included hours to first voiding, incidence of urinary retention and recatheterisation and residual urine volume.

RESULTS

Seventeen papers (15 RCTs and 2 quasi-RCTs) comprising 3908 participants were included in the meta-analysis. The pooled results of the meta-analysis showed that the clamping group had a significantly higher risk of urinary tract infections (RR=1.47; 95% CI 1.26 to 1.72; p<0.00001) and a longer hour to first void (SMD=0.19; 95% CI 0.08 to 0.29; p=0.0004) compared with the free drainage group. Subgroup analysis of indwelling urinary catheter use durations of ≤7 days indicated that clamping significantly increased the risk of urinary tract infection (RR=1.69; 95% CI 1.42 to 2.02, p<0.00001) and lengthens the interval to first void (SMD=0.26, 95% CI 0.11 to 0.41, p=0.0008) compared with free drainage.

CONCLUSIONS

Bladder training by clamping indwelling urinary catheters increases the incidence of urinary tract infection and lengthens the hours to first void in patients with indwelling urinary catheters use durations of ≤7 days compared with the free drainage. However, the effect of clamping training on patients with an indwelling urinary catheter use duration of >7 days is unclear.

Regional variation in urinary catheter use in the Netherlands from 2012 to 2021: a population-based cohort

Objectives

Our aim was to evaluate trends and regional differences in the use of indwelling and intermittent urinary catheters in the community setting in the Netherlands from 2012 to 2021.

Design and methods

For this population-based cohort study, data on catheter use was collected from the Drug and Medical Devices Information System of the National Healthcare Institute of the Netherlands. This database contains information on the Dutch insured population, which was 100% of the total population in 2018. Users were divided into 12 provinces according to the Nomenclature of Territorial Units for Statistics codes. The number of catheter users was adjusted for the total population of the provinces by sex and age, and was expressed by users per 100,000 people. Negative binomial regression (NBR) was used to test for differences in clean intermittent catheter (CIC) and indwelling catheter (IDC) users across Dutch provinces.

Results

Between 2012 and 2021, IDC users increased by 44.6% from 41,619 to 60,172, and CIC users increased by 27.3% from 34,204 to 43,528. The greatest increases were mainly observed among IDC users over 85 years old and male CIC users over 65 years old. NBR showed significant differences for IDC and CIC users between the 12 provinces. CIC incidence was higher in Drenthe and Groningen (Northern Netherlands) compared to Zuid-Holland (Southern Netherlands). IDC incidence was higher in seven provinces dispersed throughout the Netherlands compared to Noord-Holland.

Conclusion

CIC and IDC users have continued to increase in recent years; this was especially observed among older men. In addition, there were regional differences in the number of CIC and IDC users; CIC was more prominent in the northern region of the Netherlands, and IDC varied between multiple provinces. Practice variation in urinary catheterization may result from patient population differences or healthcare provider preferences and their alignment with guidelines.

The presence of a urinary catheter is an important predictor of in-hospital mortality in internal medicine patients

RATIONALE AND OBJECTIVE

Mortality rates are used to assess the quality of hospital care after appropriate adjustment for case-mix. Urinary catheters are frequent in hospitalized adults and might be a marker of patient frailty and illness severity. However, we know of no attempts to estimate the predictive value of indwelling catheters for specific patient outcomes. The objective of the present study was to (a) identify the variables associated with the presence of a urinary catheter and (b) determine whether it predicts in-hospital mortality after adjustment for these variables.

METHODS

The study population included all acutely admitted adult patients in 2020 (exploratory cohort) and January-October 2021 (validation cohort) to internal medicine, cardiology and intensive care departments at the Laniado Hospital, a regional hospital with 400 beds in Israel. There were no exclusion criteria. The predictor variables were the presence of a urinary catheter on admission, age, gender, comorbidities and admission laboratory test results. We used bivariate and multivariate logistic regression to test the associations between the presence of a urinary catheter and mortality after adjustment for the remaining independent variables on admission.

RESULTS

The presence of a urinary catheter was associated with other independent variables. In 2020, the odds of in-hospital mortality in patients with a urinary catheter before and after adjustment for the remaining predictors were 14.3 (11.6-17.7) and 6.05 (4.78-7.65), respectively. Adding the presence of a urinary catheter to the prediction logistic regression model increased its c-statistic from 0.887 (0.880-0.894) to 0.907 (0.901-0.913). The results of the validation cohort reduplicated those of the exploratory cohort.

CONCLUSIONS

The presence of a urinary catheter on admission is an important and independent predictor of in-hospital mortality in acutely hospitalized adults in internal medicine departments.

A Prospective Multi-Institutional Evaluation of Iatrogenic Urethral Catheterization Injuries

OBJECTIVES

To perform a multi-institutional investigation of incidence and outcomes of urethral trauma sustained during attempted catheterization.

PATIENTS & METHODS

A prospective, multi-center study was conducted over a designated 3-4 month period, incorporating seven academic hospitals across the UK and Ireland. Cases of urethral trauma arising from attempted catheterization were recorded. Variables included sites of injury, management strategies and short-term clinical outcomes. The catheterization injury rate was calculated based on the estimated total number of catheterizations occurring in each center per month. Anonymised data were collated, evaluated and described.

RESULTS

Sixty-six urethral catheterization injuries were identified (7 centers; mean 3.43 months). The mean injury rate was 6.2 ± 3.8 per 1000 catheterizations (3.18-14.42/1000). All injured patients were male, mean age 76.1 ± 13.1 years. Urethral catheterization injuries occurred in multiple hospital/community settings, most commonly Emergency Departments (36%) and medical/surgical wards (30%). Urological intervention was required in 94.7% (54/57), with suprapubic catheterization required in 12.3% (n = 7). More than half of patients (55.56%) were discharged with an urethral catheter, fully or partially attributable to the urethral catheter injury. At least one further healthcare encounter on account of the injury was required for 90% of patients post-discharge.

CONCLUSIONS

This is the largest study of its kind and confirms that iatrogenic urethral trauma is a recurring medical error seen universally across institutions, healthcare systems and countries. In addition, urethral catheter injury results in significant patient morbidity with a substantial financial burden to healthcare services. Future innovation to improve the safety of urinary catheterization is warranted.

Revisiting the Frequency and Antimicrobial Resistance Patterns of Bacteria Implicated in Community Urinary Tract Infections

Urinary tract infections (UTIs) are one of the most common infectious diseases at the community level. The continue misuse of antimicrobials is leading to an increase in bacterial resistance, which is a worldwide problem. The objective of this work was to study the incidence and pattern of antimicrobial resistance of the main bacteria responsible for UTI in the community of central and northern Portugal, and establish an appropriate empirical treatment. The urine samples were collected in Avelab—Laboratório Médico de Análises Clínicas over a period of 5 years (2015−2019). The urine cultures were classified as positive when bacterial growth was equal to or higher than 105 CFU/mL, and only for these cases, an antimicrobial susceptibility test was performed. Of the 106,019 samples analyzed, 15,439 had a urinary infection. Urinary infections were more frequent in females (79.6%) than in males (20.4%), affecting more elderly patients (56.9%). Escherichia coli (70.1%) was the most frequent uropathogen, followed by Klebsiella pneumoniae (8.9%). The bacteria responsible for UTI varied according to the patient’s sex, with the greatest differences being observed for Enterococcus faecalis and Pseudomonas aeruginosa, these being more prevalent in men. In general, there was a growth in bacterial resistance as the age of the patients increased. The resistance of bacteria in male patients was, in most cases, statistically different (Chi-Square test, p < 0.05) from that observed for bacteria isolated from female patients, showing, in general, higher resistance in male patients. Although E. coli was the most responsible uropathogen for UTI, it was among the bacteria most susceptible to antibiotics. The isolates of K. pneumoniae, Proteus vulgaris and Enterobacter showed high resistance to the tested antimicrobials. The most common multidrug-resistant (MDR) bacteria implicated in UTI were K. pneumoniae (40.4%) and P. aeruginosa (34.7%), but E. coli, the most responsible bacteria for UTI, showed a MDR of 23.3%. When we compared our results with the results from 10 years ago for the same region, in general, an increase in bacterial resistance was observed. The results of this study confirmed that urinary tract infections are a very common illness, caused frequently by resistant uropathogens, for which the antibiotic resistance profile has varied over a short time, even within a specific region. This indicates that periodically monitoring the microbial resistance of each region is essential in order to select the best empirical antibiotic therapy against these infections, and prevent or decrease the resistance among uropathogenic strains.

Catheter valves: are they useful in supporting patients in a trial without catheter?

A trial without catheter (TWOC) is a common urological procedure undertaken to remove an indwelling urinary catheter when no longer clinically indicated. An appropriately trained practitioner should undertake a TWOC in a controlled environment to ensure that a further urinary retention does not occur. Indwelling urinary catheters are commonly used with a free drainage system such as a leg bag, which continually empties the bladder. This article examines the potential benefits of using a catheter valve as an alternative to free drainage, prior to undertaking a TWOC, to optimise clinical outcomes and patient experience. This article will guide nurses to increase their knowledge of catheter valves to promote person-centred informed decision-making.

Transurethral Catheterization in Early Training: The Impact of Peer-Led Mentorship

Introduction

Transurethral catheterization (TUC) is a common hospital procedure. According to the literature, junior doctors contribute to the majority of TUC-related injuries. Our aim is to evaluate the immediate and long-term impact of a short procedure-centric TUC workshop on junior doctor's confidence, procedural knowledge, and ability to identify potential complications of catheterization.

Materials and Methods

Intern doctors were invited to attend a one-hour workshop on TUC. A questionnaire was completed before and after the workshop. Three months later, the questionnaire was readministered to assess the workshop's long-term impact. The questionnaire consisted of three domains. A: experience, training, and confidence levels (using 5-point Likert scales), B: procedural knowledge (the highest possible score was 10 points), and C: identification of TUC-related complications (the highest possible score was 3 points).

Results

81 interns participated and reported a confidence level of 3.03 ± 1.05 in performing a straightforward TUC. Preworkshop domain B and domain C were 3.92 ± 1.63 and 1.75 ± 0.69 points, respectively. After the workshop, reported confidence levels improved to 3.71 + 1.02 (p < 0.05). Likewise, the scores in domains B and C increased significantly to 8.85 ± 1.40 (p < 0.005) and 2.65 ± 0.6 (p < 0.005), respectively. Three months later, the same parameters were evaluated, and confidence levels were higher than those of the preworkshop levels at 3.83 ± 0.77 (p < 0.05). The average domain B score was 7.85 ± 1.88 (p < 0.005), and domain C score was 2.69 ± 0.53 (p < 0.005). All scores reported after three months were significantly better than the preworkshop levels (p < 0.005), but there were no statistically significant differences when compared to the immediate postworkshop scores (p > 0.05).

Conclusion

Short peer-led TUC workshops positively impact intern doctors' confidence levels, procedural knowledge, and identifying complications.

Examining the challenges of hospital discharge for patients with a urinary catheter

BACKGROUND

Patient discharge between acute and secondary care will be viewed differently based on the stakeholder groups involved. Examining these different perceptions may help improve the discharge process and the patient journey from hospital to home.

AIMS

To determine the perceptions of community and hospital nursing staff regarding the challenges that exist with the general hospital discharge process for patients with a urinary catheter.

METHODS

A survey was created and sent to a wide range of acute and community nurses and the subscriber list of Journal of Community Nursing, Journal of General Practice Nursing and Wound Care Today.

FINDINGS

Compared with hospital staff, the opinions of community staff were more negative around the discharge process and post-discharge care and materials.

CONCLUSIONS

Results of this survey provide insight into the perceptions of nursing staff into general patient discharge for those with a urinary catheter and help identify the challenges that exist on the patient journey from hospital to home.

A review of techniques for difficult catheterisation and their costs

Objective:

Awareness of departmental expenditure gives surgeons the ability to make cost-effective decisions. We reviewed the available techniques for difficult catheterisation and assessed the cost of each method.

Methods:

A literature search was undertaken using EMBASE and Medline databases. Seven techniques for difficult catheterisation were identified, and a cost analysis was performed. All items required for a technique were costed per unit, including VAT, and can be referenced to the NHS supply chain.

Results:

Techniques were divided into three broad categories: simple urethral techniques – increased lubrication with different catheter sizes (£5.05) or types (£8.83 Tiemann tip, £10.65 Coude tip); complex urethral techniques – blind hydrophilic guidewire (£27.31), S-dilators (£244.62) and flexible cystoscopy (£38.78); and percutaneous techniques – suprapubic catheterisation (£117.38).

Conclusion:

This paper demonstrates a progression in cost and specialist input required when moving from simple urethral techniques to complex and percutaneous techniques. It is clear that clinicians should consider these cost implications and exhaust all simple techniques before moving to the more complex options. We would advocate the use of a national evidence-based difficult catheter algorithm to guide management based on both effectiveness and cost.

Level of evidence:

Not applicable.

Catheters at home: managing urinary catheters in the home environment

In England, there are some 90000 people with catheters in the community, and community nurses often have to manage catheter-related problems. This article looks at these common catheter problems found in the community, for example, blockage, infections and positioning problems. These problems were identified by a literature review and from the author's experience, from many years working in the community. It has been found that education, knowledge, empowerment and communication are vital factors affecting patients' ability to manager their catheters themselves. The article begins with a discussion about how patients can be involved in and manage many aspects of care for their own catheters. It goes on to talk about the common catheter-associated problems and how these can be avoided or addressed. It is hoped that better management of catheter-associated complications in the community settings can prevent unnecessary visits to the emergency department, which will save time and costs for the health service, as well as avoid the negative impact of these on patient lives.

Use of indwelling catheters and preventing catheter-associated urinary tract infections

Indwelling urinary catheters are considered an important healthcare intervention for many patients. However, these devices must be used with caution because they are associated with a risk of various potential complications such as catheter-associated urinary tract infections (CAUTIs), as well as a financial burden for healthcare organisations. This article outlines the various types of indwelling catheter that are available, explains the reasons for their use, and details the care required to prevent associated complications, particularly CAUTIs.

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.

Managing complications associated with the use of indwelling urinary catheters

The insertion of an indwelling urethral urinary catheter is an invasive procedure that is commonly undertaken in healthcare settings. However, there are several risks and potential complications associated with these devices, so their use should be avoided where possible. It is important that nurses are equipped with the necessary knowledge and skills not only to assess if a patient requires a catheter, but also to minimise the risk of associated complications and to understand how these can be managed. This article discusses some of the common complications that can occur with the use of indwelling urinary catheters, including: catheter-associated urinary tract infections; catheter blockages; encrustation; negative pressure; bladder spasm and trauma; and, in men, paraphimosis. It also explains the steps that nurses can take to reduce the risk of these complications and how to manage them effectively.

A prevalence survey of patients with indwelling urinary catheters on district nursing caseloads in the United Kingdom: The Community Urinary Catheter Management (CCaMa) Study

Background

Catheter-associated urinary tract infection (CAUTI) is common in both hospitals and the community.

Aim

To investigate the prevalence of indwelling urinary catheters on district nursing caseloads in the UK.

Methods

Participants were recruited through the Infection Prevention Society (IPS). An electronic survey was undertaken on a single day between November 2017 and January 2018. Data were analysed using descriptive statistics.

Findings

A total of 49,575 patients were included in the survey, of whom 5352 had an indwelling urinary catheter. This gave a point prevalence of 10.8% (95% confidence interval [CI] = 10.53-11.07), which varied between organisations, ranging from 2.36% (95% CI = 2.05-2.73) to 22.02% (95% CI = 20.12-24.05). Of catheters, 5% were newly placed (within four weeks). Of these, most (77%) had a documented indication for insertion. Only half of patients with a newly placed catheter had a plan for its removal. This varied between organisations in the range of 20%-96%. Only 13% of patients had a patient-held management plan or 'catheter passport' but these patients were significantly more likely to also have an active removal plan (28/36 [78%] vs. 106/231 [46%]; P < 0.0001). Alternative bladder management strategies had been considered for 70/267 (26%) patients.

Discussion

The management of patients with an indwelling urinary catheter represents a significant component of district nursing caseloads. Given the high proportion of newly catheterised patients without an active management plan for removal of the catheter, the establishment of an optimal management pathway should be the focus of future prevention efforts.

Inpatient healthcare-associated bloodstream infections in older people

This retrospective study describes inpatient healthcare-associated bloodstream infections (HABSI) in older adults and explores whether urinary catheters (presence/insertion/removal) were related to HABSI events. One hundred and sixty-seven HABSI events were identified, predominantly (124, 74%) with Gram-negative bacteria. HABSI was attributed to a urinary source in 110 patients (66%), with over half (63, 57%) of these associated with urinary catheters. Catheter-associated HABSI may be avoidable and potential preventative strategies are discussed.

Antimicrobial use in UK long-term care facilities: results of a point prevalence survey

BACKGROUND

The majority of people in long-term care facilities (LTCFs) are aged 65 years and older, and most of their care needs are provided by the LTCF staff. Provision of healthcare services for residents in LTCFs is variable and can result in disjointed care between carers and NHS healthcare professionals.

OBJECTIVES

Our aim was to understand the use of antibiotics in LTCFs across the UK and to identify potential gaps in knowledge and support for carers and residents when using antibiotics, in order to determine how community pharmacy teams can provide additional support.

METHODS

A point prevalence survey (PPS) was conducted by community pharmacists (n = 57) when they carried out visits to LTCFs across the UK between 13 November and 12 December 2017. Anonymized data were recorded electronically by the individual pharmacists.

RESULTS

Data were analysed for 17909 residents in 644 LTCFs across the UK. The mean proportion of residents on antibiotics on the day of the visit was as follows: 6.3% England (536 LTCFs), 7.6% Northern Ireland (35 LTCFs), 8.6% Wales (10 LTCFs) and 9.6% Scotland (63 LTCFs). The percentage of antibiotics prescribed for prophylactic use was 25.3%. Antibiotic-related training was reported as being available for staff in 6.8% of LTCFs and 7.1% of LTCFs reported use of a catheter passport scheme. Pharmacists conducting the PPS intervened during the survey for 9.5% of antibiotic prescription events; 53.4% of interventions were for clinical reasons and 32.2% were for administration reasons.

CONCLUSIONS

This survey identified high prophylactic use of antibiotics. There are opportunities for community pharmacy teams to improve antimicrobial stewardship in LTCF settings, including workforce education.

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.

Foundation Year 1 doctors’ experience and confidence in catheterisation: A multicentre survey

Objective:

This survey sought to review the experience gained by doctors during their first year of training and their confidence in performing this procedure.

Materials and methods:

All Foundation Year 1 doctors in three hospitals in Scotland were invited to complete an online survey towards the end of their first year of training. The survey asked participants about the number of catheterisations performed, confidence with this procedure and whether they had been signed off as competent.

Results:

In total, 149 doctors were invited to complete the questionnaire and 98 (65.8%) responded. At the time of survey completion, 97.9% and 93.6% of respondents were signed off as competent for male and female catheterisation respectively. A total of 55.7% had performed fewer than five catheterisations, 28.9% had performed 5–10 and 15.5% had performed more than 10. We found 25.8% were very confident about performing an average-difficulty catheterisation and 6.3% were very confident about performing an above-average difficulty catheterisation. Overall, 7.1% of respondents were very confident about changing a suprapubic catheter.

Conclusion:

Despite being deemed competent by the end of first year of training and meeting curriculum requirements, confidence levels in performing catheterisation remains low and many doctors do not have sufficient experience and confidence for daily practice.

Level of evidence:

2c

Epidemiology and health-economic burden of urinary-catheter-associated infection in English NHS hospitals: a probabilistic modelling study

BACKGROUND

Catheter-associated urinary tract infection (CAUTI) and bloodstream infection (CABSI) are leading causes of healthcare-associated infection in England's National Health Service (NHS), but health-economic evidence to inform investment in prevention is lacking.

AIMS

To quantify the health-economic burden and value of prevention of urinary-catheter-associated infection among adult inpatients admitted to NHS trusts in 2016/17.

METHODS

A decision-analytic model was developed to estimate the annual prevalence of CAUTI and CABSI, and their associated excess health burdens [quality-adjusted life-years (QALYs)] and economic costs (£ 2017). Patient-level datasets and literature were synthesized to estimate population structure, model parameters and associated uncertainty. Health and economic benefits of catheter prevention were estimated. Scenario and probabilistic sensitivity analyses were conducted.

FINDINGS

The model estimated 52,085 [95% uncertainty interval (UI) 42,967-61,360] CAUTIs and 7529 (UI 6857-8622) CABSIs, of which 38,084 (UI 30,236-46,541) and 2524 (UI 2319-2956) were hospital-onset infections, respectively. Catheter-associated infections incurred 45,717 (UI 18,115-74,662) excess bed-days, 1467 (UI 1337-1707) deaths and 10,471 (UI 4783-13,499) lost QALYs. Total direct hospital costs were estimated at £54.4M (UI £37.3-77.8M), with an additional £209.4M (UI £95.7-270.0M) in economic value of QALYs lost assuming a willingness-to-pay threshold of £20,000/QALY. Respectively, CABSI accounted for 47% (UI 32-67%) and 97% (UI 93-98%) of direct costs and QALYs lost. Every catheter prevented could save £30 (UI £20-44) in direct hospital costs and £112 (UI £52-146) in QALY value.

CONCLUSIONS

Hospital catheter prevention is poised to reap substantial health-economic gains, but community-oriented interventions are needed to target the large burden imposed by community-onset infection.

Chlorhexidine versus saline in reducing the risk of catheter associated urinary tract infection: A cost-effectiveness analysis

BACKGROUND

Catheter associated urinary tract infections are one of the most common infections acquired in hospital. A recent randomised control study demonstrated the benefit of using chlorhexidine (0.1%) for meatal cleaning prior to urinary catheter insertion, by reducing both catheter associated asymptomatic bacteriuria and infection. These findings raise the important question of whether a decision to switch from saline to chlorhexidine was likely to be cost-effective. The aim of this paper was to evaluate the cost-effectiveness of adopting routine use of chlorhexidine for meatal cleaning prior to urinary catheter insertion METHODS: The outcomes of this cost-effectiveness study are changes to health service costs in $AUD and changes to quality adjusted life years from a decision to adopt 0.1% chlorhexidine for meatal cleaning prior to urinary catheter insertion as compared to saline. Effectiveness outcomes for this study were taken from a 32 week stepped wedge randomised controlled study conducted in three Australian hospitals.

RESULTS

The changes in health costs from switching from saline to 0.1% chlorhexidine per 100,000 catheterisations would save hospitals AUD$387,909 per 100,000 catherisations, prevent 70 cases of catheter associated urinary tract infections, release 282 bed days and provide a small improvement in health benefits of 1.43 quality adjusted life years. Using a maximum willingness to pay for a marginal quality adjusted life year threshold of AUD$28,000 per 100,000 catherisations, suggests that adopting chlorhexidine would be cost effective and potentially cost-saving.

CONCLUSION

The findings from our work provide evidence to health system administrators and those responsible for drafting catheter associated urinary tract infections prevention guidelines that investing in switching from saline to chlorhexidine is not only clinically effective but also a sensible decision in the context of allocating finite healthcare resources.

Bacterial biofilm formation on indwelling urethral catheters

Urethral catheters are the most commonly deployed medical devices and used to manage a wide range of conditions in both hospital and community care settings. The use of long-term catheterization, where the catheter remains in place for a period >28 days remains common, and the care of these patients is often undermined by the acquisition of infections and formation of biofilms on catheter surfaces. Particular problems arise from colonization with urease-producing species such as Proteus mirabilis, which form unusual crystalline biofilms that encrust catheter surfaces and block urine flow. Encrustation and blockage often lead to a range of serious clinical complications and emergency hospital referrals in long-term catheterized patients. Here we review current understanding of bacterial biofilm formation on urethral catheters, with a focus on crystalline biofilm formation by P. mirabilis, as well as approaches that may be used to control biofilm formation on these devices. SIGNIFICANCE AND IMPACT OF THE STUDY: Urinary catheters are the most commonly used medical devices in many healthcare systems, but their use predisposes to infection and provide ideal conditions for bacterial biofilm formation. Patients managed by long-term urethral catheterization are particularly vulnerable to biofilm-related infections, with crystalline biofilm formation by urease producing species frequently leading to catheter blockage and other serious clinical complications. This review considers current knowledge regarding biofilm formation on urethral catheters, and possible strategies for their control.

Planning to halve Gram-negative bloodstream infection: getting to grips with healthcare-associated Escherichia coli bloodstream infection sources

BACKGROUND

A thorough understanding of the local sources, risks, and antibiotic resistance for Escherichia coli bloodstream infection (BSI) is required to focus prevention initiatives and therapy.

AIM

To review the sources and antibiotic resistance of healthcare-associated E. coli BSI.

METHODS

Sources and antibiotic resistance profiles of all 250 healthcare-associated (post 48 h) E. coli BSIs that occurred within our secondary and tertiary care hospital group from April 2014 to March 2017 were reviewed. Epidemiological associations with urinary source, gastrointestinal source, and febrile neutropenia-related BSIs were analysed using univariable and multivariable binary logistic regression models.

FINDINGS

E. coli BSIs increased 9% from 4.0 to 4.4 per 10,000 admissions comparing the 2014/15 and 2016/17 financial years. Eighty-nine cases (36%) had a urinary source; 30 (34%) of these were classified as urinary catheter-associated urinary tract infections (UTIs). Forty-five (18%) were related to febrile neutropenia, and 38 (15%) had a gastrointestinal source. Cases were rarely associated with surgical procedures (11, 4%) or indwelling vascular devices (seven, 3%). Female gender (odds ratio: 2.3; 95% confidence interval: 1.2-4.6) and older age (1.02; 1.00-1.05) were significantly associated with a urinary source. No significant associations were identified for gastrointestinal source or febrile neutropenia-related BSIs. Forty-seven percent of the isolates were resistant to ciprofloxacin, 37% to third-generation cephalosporins, and 22% to gentamicin.

CONCLUSION

The gastrointestinal tract and febrile neutropenia together accounted for one-third of E. coli BSI locally but were rare associations nationally. These sources need to be targeted locally to reduce an increasing trend of E. coli BSIs.

Use of Urinary Collection Devices in Community and Nursing Homes in Istria County

INTRODUCTION

This study is aimed at assessing the use of various types of urinary catheters, appropriateness of catheter placement and factors associated with antibiotic use in a population of chronically catheterized patients in Istria County.

MATERIALS AND METHODS

This cross-sectional study, conducted between March and June 2017 in Istria County, Croatia, was initiated through a network of general family medicine offices. Data were collected from general practitioners (GPs) and from medical managers in nursing homes. Participants were asked to review medical records of their patients and to complete a 10-item questionnaire designed to retrieve information on patients with urinary catheter.

RESULTS

All GPs in the county were surveyed. We identified 309 patients with urinary catheter: 216 men (70%) and 93 women (30%). The overall prevalence of individuals with urinary catheters was 0.18%: 4.7% in nursing home population and 0.1% among non-institutionalized adult population. Most common indication for catheterization was chronic urinary retention (52%). One hundred eighty-six patients (60.4%) reported antibiotic usage in the previous 3 months for treating urinary infection.

CONCLUSIONS

In Istria County, the prevalence of indwelling urinary catheters is highest in males, especially among patients in nursing homes. There is a need for focused education among GPs regarding urinary catheter maintenance and antibiotic prescription for suspected urinary tract infections.