Kristina Rebelo

March 24, 2009

March 24, 2009 (San Diego, California) — Inappropriate urinary catheterization in hospitalized patients is common but should not be used as a remedy for incontinence because it is significantly associated with urinary complaints and increased hospital length of stay, according to a poster presented here at the Society for Healthcare Epidemiology of America (SHEA) 19th Annual Scientific Meeting.

The research said inappropriate use has been identified as 1 of the risk factors for catheter-associated urinary tract infections, primarily the result of indwelling urinary catheters. To date, data on risk factors associated with this inappropriate use have been scarce.

Dr. Mark E. Rupp

"This study reinforces just how prevalent these devices are in modern hospitals and how frequently their use is unnecessary," said SHEA president Mark E. Rupp, MD, medical director, healthcare epidemiology/infection control professor, Section of Infectious Diseases, University of Nebraska Medical Center, in Omaha. He is the senior author of the study.

Convenience a Factor

Dr. Rupp told Medscape Infectious Diseases that "the number 1 reason for this is that people become complacent about them and they forget that they're in. Nurses may leave them in because they're convenient — nobody likes to change diapers or change bedding. If a patient has incontinence, this is 1 way to prevent them from soiling the bedding, but it puts the patient at risk of developing a urinary tract infection or something more severe, with the infection developing into bacteremia due to catheter-related infection."

Using electronic-data-capture methods, the University of Nebraska Medical Center researchers conducted a prospective study analyzing the medical records of 391 adult patients admitted to their medical center. Between October and December 2007, a total of 444 urinary-catheter-days were recorded among 123 patients with urinary-catheter use in a medical/surgical-care unit.

Their results indicated that 31.5% of patients had a urinary-catheter device at some point during their hospital stay. The most common indication for Foley-catheter use in this patient group was surgery or postoperative management (75%). Patient age was the only risk factor that was significantly associated with urinary-catheter use (P < .05).

No significant association was found between urinary-catheter use and outcome measures, such as mortality, intensive-care-unit admission, and readmission or culture-order rates. The study did find, however, that urinary-catheter use was significantly associated with urinary complaints, such as urinary frequency, hematuria, fever, and urinary tract infections (P < .05).

Dr. Rupp said that their study wasn't designed to closely examine outcome measures.

"Presumably, this could contribute to morbidity and mortality, but this was a very small study focused on establishing the extent of inappropriate catheter use and not the complications of that misuse — we looked at 123 patients, but to establish morbidity and mortality, we would need to have looked at literally thousands of episodes," said Dr. Rupp.

Study results indicated that 38.2% of patients with a urinary catheter had at least 1 day of inappropriate catheter use, and 32.9% of all catheter-days were regarded as unnecessary. Inappropriate catheter use was significantly associated with length of hospital stay and duration of catheterization (P < .05).

Other Methods Available

Dr. Rupp explained there are other ways incontinent patients can be cared for during hospitalization that do not involve the use of a catheter: "Diapers can be used, the patient can perhaps be more frequently reminded to use the restroom, or the urinal [or bedside commode] can be brought to them."

"There's even information to indicate that intermittent catheterization is less likely to cause infections than an indwelling catheter," Dr. Rupp added. "In other words, put someone on a schedule where you insert the tubing several times a day rather than permanently. For men, there's such a thing as a condom catheter. It fits over the penis using adhesive and collects the urine as it drains, rather than having a tube that goes into the bladder."

When asked if nurses would be able to make time for patient bladder surveillance, Dr. Rupp said that "they should have time, and if they don't, that's an indication that we need to increase our staffing ratios so we have enough people on the wards to care for our patients; we're working toward trying to establish that."

New Guidelines on Catheter Placement

Jennifer Meddings, MD, clinical lecturer at the University of Michigan Health System, in Ann Arbor, who presented 2 research posters at SHEA in the same clinical area, said that Dr. Rupp's conclusions did not surprise her.

"I would have been surprised at a different conclusion. We've known about this inappropriate catheter use for decades," said Dr. Meddings, who mentioned that new guidelines, by the Healthcare InfectionControl Practices Advisory Committee (HICPAC) of the US Centersfor Disease Control and Prevention, for catheter placement intended to provide evidence-based recommendations for preventing catheter-related infections are coming out in a few months.

"The new HICPAC [guidelines] will say that placing these catheters for convenience or incontinence is clearly inappropriate and will not be tolerated," she said. "Oftentimes, nurses will place catheters on their own without a physician's order; according to the studies, this happens in different settings in maybe 1 out of 3 cases [because] patients that may have difficulty getting out of bed or staff may not want to change the linens."

Dr. Meddings said that researchers in the area of catheter-related infections are hoping that the new Medicare regulations, where hospitals will no longer receive high payments for costs associated with treating patients for certain hospital-acquired infections, will cut inappropriate catheter use.

"The number 1 risk factor is prolonged placement and the first way to prevent infection is that patients don't get it if they don't need it," she said.

"We need to look at this from 2 perspectives: first, to minimize placement on the front end — who gets them in the first place; and second, to remove them once they've been in place," Dr. Meddings concluded. "It's a 2-pronged approach, when it goes in and when it comes out, and we need to look at both problems. Trying to solve 1 problem won't do it; we need to address both problems in a healthcare setting."

The study authors and Dr. Meddings have disclosed no relevant financial relationships.

Society for Healthcare Epidemiology of America (SHEA) 19th Annual Scientific Meeting: Poster 138. Presented March 20, 2009.