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Urinary Catheter Use in the Hospitalized Patient

Urinary Catheter Use in the Hospitalized Patient. Jeannette Guerrasio, MD Heidi Wald, MD Jeanie Youngwerth, MD Ethan Cumbler, MD 2008. Goals. To optimize the use of urinary catheters, while decreasing the risks

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Urinary Catheter Use in the Hospitalized Patient

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  1. Urinary Catheter Use in the Hospitalized Patient Jeannette Guerrasio, MD Heidi Wald, MD Jeanie Youngwerth, MD Ethan Cumbler, MD 2008

  2. Goals • To optimize the use of urinary catheters, while decreasing the risks • To provide a model on the approach to the hospitalized patient with urinary incontinence

  3. Objectives • Explore the indications for indwelling urinary catheters • Identify risks associated with use • Review of urinary incontinence • Prevent urinary incontinence in the hospital • Understand the treatment of urinary incontinence • Know alternatives to indwelling foley catheters

  4. Urinary catheters • 24 million catheters are used in the United States per year • Approximately 25% of hospital patients have an indwelling urinary catheter • Initial insertion was unjustified in 21% and that continued catheter use accounted for half of the hospital days patients were catheterized Saint S, et al. Am J Med. 2000;109:476-80. Weinstein JW, et al. Infect Control Hosp Epidemiol. 1999;20:543-8. Jain P, et al. Arch Intern Med. 1995;155:1425-9.

  5. Indications for Urinary Catheters • Relieving urinary obstruction • Drainage of neurogenic bladder with retention • Monitoring output in critically ill patients • Pressure ulcers • Severe cases of macrohematuria or pyuria • Urogenital or adjacent surgery Wong, ES and Hooten TM. CDC Guidelines for the prevention of catheter associated UTI, www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html Inelmen EM, et al. 2007;62(10):18-22.

  6. Abuses • Routine placement • Forget to remove when no longer indicated • Patient’s request* • Patients with limited mobility or pain • Dementia • Shortage of nursing staff/increased staff demands * It is always important involve patients in decision making, which includes discussing the risks and benefits and making decisions together. Saint S, et al. Am J Med 2000;109:476-480. Jain P, et al. Arch Intern Med. 1995;155(13):1425-1429.

  7. Abuses • Routine placement • Forget to remove when no longer indicated • Patient’s request • Patients with limited mobility or pain • Dementia • Shortage of nursing staff/increased staff demands  INCONTINENCE

  8. Physicians May Not Be Aware of Catheter Presence • Physicians unaware of the presence of a urinary catheter: • Medical Students in 21% of cases • Interns- 22% • Residents- 27% • Attendings- 38% 1/3 of the catheters inappropriate in this study Saint S, et al. Am J Med 2000;109:476-480

  9. Harm • Urinary tract infections represent 40% of all nosocomial infections - • Catheters are implicated in 8 out of 10 case • 1 million cases of hospital acquired UTIs • Risk increases with length of use • Bacteriurea incidence of 3-10% each day • Cost >$400 million annually in US • Increased LOS and resource utilization • Complications: bacteremia, sepsis, prosthetic infections, death Haley RW et al. Am J Epidermiol 1985;121(2):159-167. Saint S. Am J Control. 2000;28(1):68-75. Jarvis WR. Infect Control Hosp Epidemiol. 1996;17(8):552-557. Lo, E et al. Infect Control Hosp Epidem.iol2008;29(1)S41-50.

  10. Harm • Discomfort • 42% report discomfort • 48% reported pain • 61% reported restricted activities of daily living • Falls • One more tether on which to trip Saint S, et al. J Am Geriatr Soc. 1999;47: 1453-7.

  11. Harm The one-point restraint… • Additional Risk • Bleeding • Damage or rupture of urethra • Obstruction of urine • Retained foreign body Inelmen EM, Sergi G, Enzi G. Geriatrics. 2007;62(10):18-22.

  12. New Legislation As of October 1, 2008: • The Centers for Medicare and Medicaid modified the Inpatient Prospective Payment System • Hospital acquired UTIs will not be reimbursed Centers for Medicare and Medicaid Services. Medicare program: changes to the hospital inpatient prospective payment systems and fiscal year 2008. Fed Regist. 2007;72(162):47129-48175.

  13. Alternatives to the indwelling catheter • Consider these options: • Incontinence garments (diapers) • patients prefer over catheters • Condom catheters • lower rates of UTI, death; less discomfort • Incontinence bed pads • Intermittent catheters Palese A, et al. J Wound, Ostomy & Continence Nursing. 2007;34(6):649-54. Saint S, et al. J Am Geriatr Soc. 2006;54:1055-1061 Pfisterer MH,et al J Am Geriatr Soc. 2007;55(12):2016-22.

  14. If you must… • Indicate the start and stop date, with initial order for indwelling catheters • Goal: Removal within 48 hours! … of note, while silver alloy catheters decrease bacteriuria, they have not been shown to decrease symptomatic infection, asymptomatic infection, or bloodstream infections. Johnson, JR, et al. Ann Intern Med. 2006;144:116-127. Niel-Wiese, BS et al. J Hosp Infect. 2002;52:81-87. Srinivasan, A et al. Infect Control Hosp Epidemiol. 2006:27:38-43.

  15. WORKSHOP • Lets examine the patients on service. • How many of them had a urinary catheter placed in the ED or during hospitalization? • Of those who had a urinary catheter placed, what was the reason? • Are there any less invasive solutions to the reason the catheter was placed?

  16. Preventing Misuse and Complications • Know the types and causes of urinary incontinence • Discuss an approach to the prevention • Treatment of urinary problems in the hospital

  17. Urinary Incontinence • Among hospitalized patients, up to 34% of incontinence may represent a new diagnosis • Direct healthcare costs $16 billion • Indirect healthcare costs $26 billion • Significant psychological impact - isolating, increases rates of depression, increases care giver burden • Increase the chance that a patient will be d/c’d to a facility Palese A, et al. J Wound, Ostomy & Continence Nursing. 2007;34(6):649-54. Wilson MG. Clinics in Geriatric Medicine. 2004;20(3).

  18. Urinary Incontinence • 4 Types • Urge • Stress • Overflow • Mixed DuBeau, C. Clinical presentation and diagnosis of urinary incontinence. Up-to-date. 2008. DuBeau, C. Treatment of urinary incontinence. Up-to-date. 2008.

  19. Urinary Incontinence • Urge • Most common cause • Associated with largest urinary volume with the void • Can not inhibit urination when they get the desire to urinate • i.e. sound of running water, keys trying to unlock the door

  20. Urinary Incontinence • Stress • Increased intra-abdominal pressure and a compromised sphincter • Small volumes of urine • Occurs with cough, sneeze, valsalva, bending

  21. Urinary IncontinenceOverflow • Neuropathic • The result of poor autonomic innervation, can be seen with diabetes mellitus • Post void residual >200mL • Obstructive (lower urinary tract problem) • Slow urinary stream, urine intermittency, hesitancy, straining, high post-void residual • Most common in men with BPH • Functional • Cognitive impairment • Physical limitations

  22. WORKSHOP • How many patients had pre-existing problems with urinary incontinence? • How many were you aware of this? • How many patients are having difficulty with incontinence in the hospital? • What barriers do the patients identify?

  23. WORKSHOP • Ask all patients on service the following three questions: • Before this hospitalization do you ever have problems holding your urine? • Have you had problems with incontinence of urine here in the hospital? • What makes it difficult for you to get to the bathroom in time here in the hospital?

  24. Approach to Prevention/Treatment • Review medications • Improve patients’ mobility • Compensate for impaired cognition • Address underlying co-morbidities • ? Pharmacologic therapy • alpha blocker (terazosin for BPH with overflow incontinence) • anti-muscarinic medications (oxybutynin for urge incontinence)

  25. Review Medication List • List a few medications that cause sedation and/or delirium Types of medication: • Anticholinergics and narcotics reduce bladder emptying • urinary retention and overflow incontinence • Cholinergics worsen bladder hyperactivity • Urge

  26. Review Medication List • Medications that cause sedation or delirium • Decrease ability to sense full bladder • Decrease their ability to communicate need for toileting

  27. Review Medication Lists Dosing schedules • Some medications increase the need to urinate at night (diuretics),when the patients’ mobility or level of consciousness is diminished • Consider changing the times medications are administered

  28. Patient Mobility • Reduce barriers to mobility • Remove tether, such as telemetry and pulse oximetry when no longer indicated • Provide oxygen tubing that is sufficient length to reach to the toilet • Move furniture, bed rails, and cords that impede the path to the bathroom • Early physical therapy to maintain strength and coordination for toileting

  29. Patient Mobility Critical factor in the hospital • If weakness or slow gait speed: • Provide urinals and commodes • Make walking aids easily accessible • If limited by pain: • optimize pain regimen Wyman J et al. Nurs Res 1993:42:270-5.

  30. Reduced cognition • Should only cause incontinence in late-stage dementia and severe brain or spinal cord injury • Treat any underlying psychiatric disorder that my contribute: psychosis, anxiety • Methods to overcome cognitive deficit: • Timed voiding (voiding prompts) Gammack, JK. Clinics in Geriatric Medicine 2004;20(3) .

  31. Address Underlying Co-morbidities • Constipation causes urge and overflow incontinence • Bowel regimen • Urinary tract infections can exacerbate urge incontinence • check a u/a, simple and inexpensive • Coughs cause stress incontinence • Anti-tussive

  32. Address Underlying Comorbidities • Diabetes Mellitus- • autonomic neuropathy • polyurea • Improve glycemic control • BPH causes overflow incontinence • Check a bladder scan • Review the medication list for anticholinergic medication • Consider selective peripheral alpha blocker (tamsulosin)

  33. Treatment Review* • Overflow incontinence • Functional • Prompted voiding • Neurogenic • Press down on abdomen while voiding to increase intraabdominal pressure • Parasympathomimetic: bethanechol • Intermittent catherization • Obstructive: BPH • Avoid caffeine, avoid anticholinergics • Alpha-agonists: selective preferred • 5-Alpha reductase inhibitors: finasteride* • Saw palmetto* • ?TURP* *indicates a therapy not generally used by the hospital physician

  34. Treatment Review* • Stress incontinence • Kegel exercises* • Weight loss* • Pharmacotherapy & surgery* - poor success rates • Urge incontinence • Anticholinergic medications: oxybutinin and tolterodine • Biofeedback: consciously try to suppress the desire to urinate* • Calcium channel antagonists inhibit detrusor muscle contraction, consider if +HTN • Electrical stimulation or sacraneuromodulation* *indicates a therapy not generally used by the hospital physician

  35. Summary • Indwelling urinary catheters are overused, in frequency and duration • They are not without risk • The hospital will lose revenue for catheter related UTIs • Our goal is to prevent the usage of catheters by: • Preventing and treating urinary incontinence • Consider alternatives • Ordering catheters with start and stop times, or removal <48hrs

  36. Workshop • Education of staff on appropriate use of urinary catheters will help decrease un-needed indwelling catheters. • power and persistence of this intervention limited • What systems changes can you envision that could reduce catheter use?

  37. References (in order of appearance) Saint S, Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, Bernstein SJ, Lipsky BA, Hofer TP. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109:476-80. Weinstein JW, Mazon D, Pantelick E, Reagen-Cirincione P, Dembry LM, Hierholzer WJ Jr. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity Infect Control Hosp Epidemiol. 1999;20:543-8. Jain P, Parada J, David A, Smith L. Overuse of the indwelling urinary tract catheter in hospitalized medical patients Arch Intern Med. 1995;155:1425-9. Wong ES, Hooten TM. CDC Guidelines for the prevention of catheter associated UTI, www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html Inelmen EM, Sergi G, Enzi G. When are indwelling urinary catheters appropriate in elderly patients? Geriatrics. 2007;62(10):18-22. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate: a new need for vital statistics. Am J Epidermiol 1985;121(2):159-167. Saint S. Clinical and economic consequences of nosocomial-related bacteriuria. Am J Control. 2000;28(1):68-75Jarvis WR. Selected aspects of nosocomial infections: morbidity, mortality, cost and prevention. Infect Control Hosp Epidemiol. 1996;17(8):552-557. Lo E, Nicolle L, Classen D, Arias K, Podgorny K, Anderson DJ, Burstin H, Calfee DP, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control and Hosp Epidem. 2008;29(1)S41-50. Saint S, Lipsky BA, Baker PD, McDonald LL, Ossenkop K. Urinary catheters: what type do men and their nurses prefer? J Am Geriatr Soc. 1999;47: 1453-7. Centers for Medicare and Medicaid Services. Medicare program: changes to the hospital inpatient prospective payment systems and fiscal year 2008. Fed Regist. 2007;72(162):47129-48175. Palese A, Regattin L, Venuti F, Innocenti A, Benaglio C, Cunico L, Saiani L. Incontinence pad use in patients admitted to medical wards: an Italian multicenter prospective cohort study. J Wound, Ostomy & Continence Nursing. 2007;34(6):649-54. Saint S, Kaufman SR, Rogers MAM, Baker PD, Ossenkop K, Lipsky BA. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc. 2006;54:1055-1061 Pfisterer MH, Johnson TM, Jenetzky E, Hauer K, Oster P. Geriatric patients’ preferences for treatment of urinary incontinence: study of hospitalized, cognitively competent adults aged 80 and older. J Am Geriatr Soc. 2007:55(12):2016-22. Johnson JR, Kuskowski MA, Wilt TJ. Ann Intern Med. 2006;144:116-127. Niel-Wiese BS, Arend SM, van den Brock, PJ. Is there evidence for recommending silver-coated urinary catheter guidelines. J Hosp Infect. 2002;52:81-87. Srinivasan A, Karchmer T, Richards A, Song X, Perl T. A prospective trial of a novel, silicone-based, silver-coated Foley catheter for the prevention of nosocomial urinary tract infection. Infect Control Hosp Epidemiol. 2006:27:38-43. Wilson MG. Geriatrics Incontinence. Clinics in Geriatric Medicine. 2004;20(3). DuBeau C. Clinical presentation and diagnosis of urinary incontinence. Up-to-date. 2008. DuBeau C. Treatment of urinary incontinence. Up-to-date. 2008. Gammack JK. Urinary incontinence in the frail elder. Clinics in Geriatric Medicine 2004;20(3) . Wyman J, Elswick RK, Ory MG, Wilson MS, Fantl, JA. Influence of functional urological, and environmental characteristics on urinary incontinence in community-dwelling older women. Nurs Res 1993:42:270-5.

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