Indwelling urinary catheters in acute care: A step-by-step clinical pathway for nurses

Abstract

The Centers for Disease Control and Prevention (CDC) estimates that 1 of every 10 to 20 patients hospitalized in the United States develops a healthcare-associated infection (HAI). Urinary tract infection (UTI), a type of HAI, accounts for approximately 32% of infections reported by acute care hospitals and approximately 18% to 25% of all nosocomial bacteremia. The majority of hospital-associated UTIs are caused by instrumentation of the urinary tract, mainly from an indwelling urinary catheter (IUC). Catheter-associated urinary tract infections (CAUTIs) can result in increased morbidity, mortality, hospital cost, and length of stay.

Infection prevention and control efforts have long been focused on monitoring and preventing HAIs, but prevention has recently emerged as a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, and others. The Joint Commission on Accreditation of Healthcare Organizations (The Joint Commission) has approved a new National Patient Safety Goal for 2012 for CAUTIs, which will be applicable to hospital and critical access hospital accreditation programs.

Hospital staffs, particularly nursing staffs, are developing clinical pathways for removal of IUCs and for bladder monitoring, to ensure patient safety and evidence-based practice (EBP) at a lower cost. This is a review of current IUC indications and use, complications associated with an IUC, types of catheters and details "best practices" for catheter management and prevention of CAUTIs. This article provides methods and a step-by-step clinical pathway for removing these catheters that will improve patient care and safety, while reducing associated costs.

Current Use of an Indwelling Urinary Catheter

An IUC is a hollow but flexible tube that is usually inserted and managed by nurses.  It remains in place through the use of an inflated balloon to secure its place in the bladder.  The end of the catheter is attached to a drainage bag that collects urine. (See Figure 1).  
Catheters are used in both men and women in all care settings, but the acute care setting uses IUCs more than any other medical device.  Catheters are invasive devices, which in many instances, are placed unnecessary, remain in without provider awareness, and are not removed when no longer needed.

At least 15% to 25% of patients may have an IUC inserted sometime during their hospital stay, with most only used for the short-term (defined as < 30 days).  Prevalence is greater in high acuity patient units, with critical care and intensive care units having the highest prevalence.  CAUTIs can lead to increased length of stays, mortality rates, and ultimately higher hospital costs.  Approximately 560,000 cases of CAUTIs are reported yearly to the CDC.  The cornerstone of any CAUTI prevention program would be to remove the IUC as soon as possible.

A common reason for inappropriately and prolonged IUC use is that physicians forget, or were never aware of the presence of the catheter. These forgotten catheters often remain in place until either a catheter-related complication occurs or the patient’s discharge is imminent.  However, these forgotten catheters are becoming a financial liability for hospitals.  The cost of treating a single episode of a CAUTI in a hospital varies from $980 to $2,900, depending on the presence of associated bacteremia.  According to the CDC, the total expense of these infections is $450,000,000 per year in the United States.

In many cases, these catheters are inappropriately used and remain in place for too long.  This inappropriate use has been equated to a “one-point restraint,” because like a restraint, catheters can cause functional impairment, discomfort, and pressure ulcers. 

Indications for Use of an Indwelling Urinary Catheter

There are several reasons why IUCs are inappropriately used in patients including:

• As a substitute for nursing care of the patient with urinary incontinence.
• As a means of obtaining urine for culture or other diagnostic tests when the patient cannot voluntarily void.
• For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc).

Non-patient-related reasons for inappropriate IUC use include staff ignorance of published recommendations, physician uncertainty about the patient’s medical course, and convenience of hospital staff.  Appropriate indications have been developed and include the following:

• Acute urinary retention and urethral obstruction and bladder cannot be drained by intermittent catheterization
• For accurate measurements of urinary output in critically ill patients
• To assist in the healing of open sacral or perineal pressure ulcers ( Stage III or IV) that are not healing because of urine leakage
• To improve patient comfort for end of life care
•  Perioperative use for selected surgical procedures:
  • Urologic surgeries or other surgeries on organs of the genitourinary tract
  • Anticipated prolonged duration of surgery  
  • Operative patients with urinary incontinence
  • Need for intra-operative hemodynamic monitoring.

Catheter Size and Material

When selecting a specific catheter, staff should consider several factors such as: length of time the catheter will remain in place, patient comfort, presence of latex sensitivity or allergy, ease of insertion and removal, ability to reduce the complications such as urethral and bladder tissue damage, and ability to resist colonization by biofilms, microorganisms, and encrustation.  The different material used for catheters are outlined in Table 1.  Nurses should determine the reason for catheter use (e.g. post-surgical bladder drainage) and risk factors (e.g. need to use a curved or Coudé-tip in a man with an enlarged prostate) before deciding on the most appropriate one.  Part of that selection includes determining a certain catheter size or catheter tip configuration (see Table 2).  

Understanding CAUTIs and Other Adverse Events

An IUC is associated with many adverse events, perhaps the most harmful and frequent complication of these devices is a CAUTI.   Urology defines a CAUTI as an infection of the urinary tract caused as a result of bacteria moving through or migrating around the IUC and infecting the bladder and urethral mucosa.  CAUTIs are considered to be complicated infections, because normal host defense mechanisms are compromised by the presence of a foreign body.  Although frequently asymptomatic, up to one-third of patients with catheter-associated bacteriuria will develop symptoms of a CAUTI, especially if the catheter remains in place long-term (defined as > 30 days).  These CAUTIs are usually caused by biofilms, a collection of microorganisms that colonize the internal catheter lumen and drainage bag.  They can block the catheter and lead to sepsis. The only way to eradicate them is by changing the system or removing the IUC.  The length of time IUCs remain in situ is directly related to increases in CAUTIs.  Antimicrobial therapy is only transiently effective if the catheter remains in place.

In addition to the length of time the IUC is in place, there are other risk factors for development of a CAUTI, including improper catheter insertion techniques, female gender, older age, compromised immune system, and co-morbid conditions (e.g. diabetes, renal dysfunction).  Other contributing factors to the development of a CAUTI are non-evidence-based nursing care practices for managing catheters.  Procedures such as care of the catheter, drainage tube and bag, and others, are routinely performed by nurses, are not supported by research and, in many cases, have been shown to contribute to the development of a CAUTI.   The fact that nurses are not following specific practices to prevent CAUTIs was shown in a survey distributed to both nonfederal and federal U.S. hospitals about prevention of hospital-acquired UTIs and other device-associated infections.  Additionally noted in this study, only 9% of hospitals reported using an IUC stop-order or reminder, only 14% used condom catheters in appropriate men, and only about 30% used a portable bladder ultrasound scanner, a noninvasive method for determining post-void residual urine volumes (PVR).  In those patients with an IUC, following the “Do’s and Don’ts” of good nursing practices outlined in Table 3 can prevent associated complications, including CAUTIs. These recommendations are based on the most current evidence-based clinical practice guideline (EBCPG).

Regulations Concerning Use of an IUC in Hospitals

Monitoring HAIs and comparison of CAUTI rates have become a national requirement.    The National Healthcare Safety Network (NHSN) of the Center for Disease Control and Prevention is a performance measurement system devoted to tracking HAIs. The NHSH created the National Nosocomial Infection Surveillance (NNIS) system, a national database that benchmarks infection rates of similar hospitals.  CMS has implemented regulations that include a financial incentive for hospitals to remove IUCs as soon as possible, thus preventing associated complications, specifically CAUTIs.  One of the eight costly and sometimes deadly preventable hospital-acquired conditions identified by Centers for Medicare and Medicaid Services (CMS) is a CAUTI.  CMS will no longer reimburse hospitals the costs associated with CAUTIs.

Hospitals are developing care pathways for removal of these catheters and step-by-step bladder monitoring.  Figure 2 is a Step-by-Step clinical pathway that was developed by this author to guide nursing staff in IUC removal and to ensure bladder monitoring so as to prevent unnecessary catheterizations.  

The CDC HICPAC EBCPG on prevention of CAUTIs emphasizes quality improvement initiatives and provides suggestions for implementation.  HICPAC has estimated that up to 69% of hospital-acquired CAUTIs may be prevented by implementation of an evidence-based prevention program.  Although patients who have IUCs in place long term will most certainly develop a CAUTI, evidence suggests that certain interventions can reduce the incidence of CAUTIs in patients who have IUCs in place for short-term duration.  These interventions include educating physician and nursing staff on indications and evidence-based care of the IUC to prevent infection.  Hospitals must be proactive in: 1) instituting hospital-wide administrative interventions, 2) implementing quality improvement programs, 3) putting in place physician reminder systems and automatic stop orders, 4) developing nurse-driven protocols, 5) limiting post-surgical patient use, and 7) providing portable bladder volume ultrasound devices (e.g. BladderScan® bladder volume instruments) on nursing units to assess adequate bladder emptying.  In hospitals, it is strongly recommended that an organization-wide program be implemented to monitor catheter use so that IUCs that are no longer necessary are promptly removed. There is evidence that a nurse–driven surveillance team is necessary and Figure 2 is an excellent example of a nurse-driven clinical process. 

Alternative Methods of Bladder Management

Applying infection control–based catheter practices may enhance patient safety while decreasing catheter related costs. One practice method is the use of the BladderScan® when assessing bladder volume and need for catheterization.  Other practices that may decrease CAUTIs include:

1) using IUCs only when necessary,

2) removing catheters when no longer needed via the use of various reminder systems,

3) using silver alloy or antimicrobial catheters in patients at highest risk of infection,

4) using external (or condom-style) catheters as appropriate for men,

5) ongoing use of a portable bladder volume ultrasound to detect residual urine amounts,

6) maintaining aseptic insertion technique, and

7) using alternatives to IUCs, (e.g. intermittent catheterization) to manage urinary retention.  Hospital medical and nursing staff will need to implement alternative bladder management strategies.

Hospital staff should develop a protocol, similar to the Step-by-Step clinical pathway outlined in Figure 2 that provides guidance for nursing staff to successfully remove an IUC.  This pathway emphasizes the need for non-invasive monitoring of bladder volume. Bladder monitoring should not be performed with repeat catheterizations, but through the use of non-invasive technology (e.g., portable bladder volume ultrasound instrument) to avoid unnecessary catheterizations and to prevent infections of the urinary tract. Non-invasive portable bladder volume ultrasound devices have been used for over two decades to monitor for  urinary retention and have been advocated by many, to reduce the need for catheterization.  A portable bladder volume ultrasound accurately measures urine volume and is a nurse-friendly device. Additionally, these “scanners” have been found to reduce the number of intermittent catheterizations and to perhaps even decrease the risk of UTI.

Conclusions

Best practices for use of IUCs are the only way to promote safe patient care while avoiding unnecessary costs from catheter associated UTIs.  Nurses play a key role in ensuring IUC monitoring and care.  Once an IUC is removed, non-invasive bladder monitoring is the best nursing practice.

References:

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Table 1

Types of Catheter Material

Table 2

 IUC Size and Tips

Size:

• Catheter diameter sizes are determined by the outer circumference and measured in Charrière (Ch or CH) also know as French Gauge (Fr).
  • Range is 6–18 Fr with each French unit equaling 0.33 mm in diameter.
  • The size of the catheter is marked at the inflation channel as well as with an (international) color code (e.g. 14 Fr is green, 16 Fr is orange)
  • Smallest catheter size is recommended (14 Fr to 16 Fr)
• Inner lumen of the catheter varies quite a lot between different catheter materials (e.g. latex and a silicone catheter), so inserting a larger size catheter does not necessarily ensure a wider drainage.
• Use of large-size catheters (>18 Fr or larger) may cause:
  • erosion of the bladder neck and urethral mucosa
  • urethral stricture formation
  • inadequate drainage of peri-urethral gland secretions, causing a buildup of secretions that may lead to irritation and infection.

Catheter Tips:

• Standard tip of the catheter is round with two drainage eyes. For routine catheterization, a straight-tipped catheter is recommended.
• Coudé-tip catheter, or Tiemann catheter which is angled upward at the tip and may be preferred as it allows easy passage in men with an enlarged prostate or urethral stricture.
  

Table 3

 "Dos" and "Do Nots" of Nursing Management of IUCs

Do’s:

Conduct daily evaluation of need and implement quality improvement programs.

• Early removal of the catheter using a reminder or nurse-initiated (e.g. automatic “stop orders”) removal protocol appears warranted.
• Use non-invasive BladderScan® to as part of bladder monitoring

Adhere to general infection control principles including

• Hand hygiene - most important factor in preventing nosocomial infections.
• Aseptic catheter insertion
• Wear disposable gloves when handling any part of the catheter system.

Bladder ultrasound use protocol in place to avoid unnecessary catheterizations Proper catheter insertion techniques

• Minimize urethral trauma during insertion by using generous amounts of sterile lubricant along the entire catheter (especially in male patients).
• Hold the penis in a near vertical insertion position when catheterizing a male patient.

Ensure proper catheter maintenance and care

• Secure or anchor catheter to prevent excessive tension on the catheter, which can lead to urethral trauma and tears.
• Ensure an unobstructed urine flow by preventing any kinks or loops from occurring in the catheter and tubing.
• Empty the drainage bag at least every 4 to 6 hours or when urine in the drainage bag reaches 400 ml to avoid migration of bacteria up the lumen of the catheter system. Empty the bag prior to transporting the patient.
• Separate graduated containers for each patient and each patient drain. With multiple drainage devices for one patient, keep drainage devices on opposite sides of the bed and keep drainage devices in semi-private rooms on opposite sides of the room.
• Consider changing the catheter before obtaining a specimen for culture as cultures obtained through the old catheter may be inaccurate.
• Consider changing the entire catheter and system if infection or obstruction occurs.

Encourage adequate fluid intake (approximately 30ml/kg/day with a 1,500 ml/day minimum or as indicated based on the patient’s medical condition).

Do Not’s:

Avoid performing rigorous, frequent cleansing of the catheter entry site (meatus or suprapubic) and do not use antiseptics for routine cleansing, rather just wash the catheter entry site daily with soap and water daily or after fecal contamination. Do not disconnect the catheter from the drainage bag for any reason.

• Consider the use of pre-connected catheter seal may prevent disconnection.

Do not clamp the catheter or drainage tube.

Do not perform routine cultures in the absence of infection because all chronically catheterized individuals have bacteria and the organisms change frequently (about one to two times per month).

Urine cultures should only be obtained if the patient demonstrates clinical symptoms of a UTI.

Do not give the asymptomatic patient antibiotics and antimicrobials as a UTI prevention strategy.

Do not perform bladder or catheter irrigation unless medically necessary (e.g. tissue/blood clots obstructing drainage). If catheter patency is questioned or occlusion is suspected, scan the bladder to assess urine volume.

Figure 1

Components of an IUC System

Figure 2

Step-by-Step Care Clinical Pathway for IUC Removal

Authored by:

Diane K. Newman, DNP FAAN BCB-PMD

Adjunct Associate Professor of Urology in Surgery,

Perelman School of Medicine, University of Pennsylvania

Philadelphia, Pennsylvania

Copyright © 2012 Verathon Inc.