CHAMP Foley Catheter Use

1. CHAMPFoley Catheter Use Catherine E. DuBeau, M.D. University of Chicago

2. Learning Objectives • Name short and long term risks of catheterization • Differentiate the medical reasons for incomplete voiding • Analyze catheter management problems • Perform bedside evaluation of need for catheter and construct plan for catheter removal

3. Outline • Scope of the problem • Rationale for targeting catheter use • Appropriate indications for catheter use • Catheter management • Trouble-shooting failure to void • Teaching triggers

4. Emphases and Links Text will be repeated in YELLOW to indicate links to other CHAMP modules Further content in CHALK will be listed at the end

5. Scope of the Problem • Prevalent and morbid • 25% of hospitalized pts have a catheter • Cause of 40% of nosocomial infections • Uncomfortable and restrictive (“one-point restraint”) • Urethral and meatal trauma (traumatic hypospadius in men, patulous meatus in women, scarring, bleeding)

6. Scope of the Problem • Prevalent and morbid • 25% of hospitalized pts have a catheter • Cause 40% of nosocomial infections • Uncomfortable and restrictive (“one-point restraint”) • Urethral and meatal trauma PAIN DELIRIUM FALLS

7. Scope of the Problem • Often an “invisible” problem • Hospital MDs unaware of catheter use in about 1/3 of their catheterized patients • Being unaware associated with inappropriate use and longer catheterization periods • Internists have little training in the medical reasons for failure to void • Resulting Urology consults don’t always lead to mutual satisfaction/learning

8. Rationale for targeting catheters • Morbidity • Quality • Expense

9. Indwelling Polymicrobial bacteriuria (universal at 30 days) Fever (1/100 pt-days) Chronic pyelo Bladder and renal stones Urethral and meatal injury Agitation External Bacteriuria and infection Penile cellulitis and necrosis Urinary retention Morbidity

10. Indwelling Polymicrobial bacteriuria (universal at 30 days) Fever (1/100 pt-days) Chronic pyelo Bladder and renal stones Urethral and meatal injury Agitation External Bacteriuria and infection Penile cellulitis and necrosis Urinary retention Morbidity DELIRIUM

11. Morbidity More people die from hospital-acquired infections than from auto accidents and homicides combined

12. Quality • Joint Commission Patient Safety requirement: reduce the risk of health care-acquired infections • Illinois: Public Act 93-0563, SB 59, 2003: mandates quarterly reporting of hospital infection rates, with yearly publishing by hospital • Consumers: StopHospitalInfections.org

13. Expense • Unnecessary equipment and labor costs • Hospital infections cost $5 billion annually • Longer length of stay

14. Expense • Unnecessary equipment and labor costs • Hospital infections cost $5 billion annually • Longer length of stay IATROGENIC ILLNESS FUNCTIONAL DECLINE

15. Indications for using catheters There are only FOUR indications: • Inability to void • Incontinence AND • Open wounds needing protection • Terminal illness/palliative care • Monitor urine output AND patient unable to assist/comply • After anesthesia (short term only)

16. Catheter management • Closed drainage systems • Changing • Any acute infection • Monthly for chronic catheter • Leakage around catheter • Balloon too big (size or inflation) • Infection • Bladder spasm: consider pyridium or bladder relaxant, eg. Detrol or Ditropan (but only if catheter indication is not retention)

17. Trouble-shooting insertion • “Can’t pass” • Discomfort/spasm at sphincter: • Use lidocaine gel • Insert with slight ‘torque’ while patient exhales • Try larger catheter • Coudécatheter • Inflate the balloon only after catheter is inserted all the way in, up to the meatus

18. Trouble-shooting failure to void • Two basic reasons • Poor pump • Blocked outlet

19. Trouble-shooting failure to void • Two basic reasons • Poor pump • Blocked outlet Pump action: Ach, Ca++ Sphincter closure: Alpha adrenergic

20. Trouble-shooting failure to void • Two basic reasons • Poor pump • Blocked outlet Meds: anticholinergic, Ca+ blkrs Sacral cord disease Neuropathy: DM, vit B12 defic Constipation Prostate disease Meds: alpha-agonists Neurological disease: dyssynergia Women: scarring, cystocele Constipation

21. Teaching Triggers

22. Action step 1: Look for catheter on every patient when at bedside Trigger: Catheter found “Why does this pt have a catheter? Unsure/inappropriate indication: Review indications

23. Action step 1: Look for catheter on every patient when at bedside Trigger: Catheter found “Why does this pt have a catheter? Review indications: 1. Inability to void 2. Incontinent with wounds/palliative care 3. Monitor output 4. Post anesthesia

24. Action step 1: Look for catheter on every patient when at bedside Trigger: Catheter found “Why does this pt have a catheter? Action Step 2 Appropriate indication

25. Action step 2: “Does this patient still need the catheter? Yes Action step 3

26. A.Review MAR Action step 3: “Does this patient have a medical reason for inability to void? B. Review medical history C. *Additional exam, Post voiding residual

27. Sacral Reflexes Clitoris Bulbocavernosus Reflex Anus Anal wink Adapted from Geriatric Review Syllabus Urinary Incontinence slide set, American Geriatric Society, 2006

28. Pelvic Exam Cystocele Rectocele Photographs from: Abrams P, Cardozo L, Khoury S, Wein A, ed. Incontinence. 2nd International Consultation on Incontinence. Plymouth UK: Health Publications Ltd, 2002; pp 381-2.

29. Action step 2: “Does this patient still need the catheter? No Action step 4

30. Action step 4: Discontinue all catheters before discharge unless there is chronic retention

31. Action step 4: Discontinue all catheters before discharge unless there is chronic retention TRANSITIONS OF CARE

32. A. Deflate balloon and remove catheter (never clamp!) Action step 4: Discontinue all catheters B. Insure adequate fluid intake (PO or IV) C. Monitor for 8 hours

33. D. If no void, reinsert catheter and note volume. If < 200, increase fluids and repeat trial. Review causes of failure to void. Action step 4: Discontinue all catheters E. If voids, check PVR PVR < 100 (men) or <200 (women): done Higher PVR: re-insert, review causes of failure to void

34. Does the pt have a Foley? YES Why does pt have Foley? Review the 4 indications Does the pt still need Foley? Appropriate Inappropriate NO YES Medical reason for inability to void? Review PMHx, MAR, exam Plan to D/C Foley

35. Who to discharge with a catheter • Patients with retention who fail voiding trials • Patients who have not completed at least 7 days of decompression for new retention (they will need PCP, GU, and/or VNA follow-up to do and monitor voiding trial) • Transitions of care: • Leg bag for day & large bag for night, or large bag alone • Family instruction re: emptying bag; changing bags (if necessary); using straps to secure catheter (and leg bag) to leg; monitoring for output, hematuria, fever, SP pain; importance of adequate fluids

36. When to refer to Urology • Failure to insert catheter even after trying earlier suggestions • Large volume hematuria that does not clear with 3-way irrigation • If you have treated medical reasons for failure to void and pt still has retention, then outpatient referral to Urology

37. Using Foleys to Teach Practice-Based Learning: Going Beyond Content • What is the team’s practice and how can we learn from it? • PLAN to focus on Foleys for a teaching session/rounds • DO a “census audit”, based on triggers: • How many patients have a Foley? • Of these, how many did the team know about? • How many have a correct indication? • STUDY the results • Share tally results with team and discuss implications and the practice-based learning process • ACT: how can we improve Foley care? Repeat audit?