Indwelling Urinary Catheters: Pattern of Use in a Public Tertiary-level Australian Hospital

Karina So, MN(NP), Grad. Dip., H. Ed., MACH; David Habashy, MBBS; Breda Doyle, RN, ICU, BHA; Lewis Chan, FRACS, DDU

Disclosures

Urol Nurs. 2014;34(2):69-73. 

In This Article

Abstract and Introduction

Abstract

An audit of charts from patients identified as having an indwelling urinary catheter (IDC) was conducted in a 450-bed, tertiary level hospital (Concord Repatriation General Hospital) in Australia. Documentation of relevant information regarding IDC in the medical record included indication for catheterization, insertion and removal dates, use of antibiotics, place of insertion, designation of inserter, catheter type, availability of IDC kits, and use of catheter fixation devices.

Introduction

Catheter-associated bacteriuria is the most common hospital-acquired infection worldwide (Tambyah, 2004), and urinary tract infection (UTI) accounts for up to 40% of hospital-acquired infections (HAI) in the United States (U.S.) (Cardo et al., 2004). A 1988 hospital survey conducted in Australia showed that symptomatic hospital-acquired UTI was the second most common HAI nationally (McLaws, Gold, King, Irwig, & Berry, 1988), this being the most recent nationwide audit conducted in Australia (Reeda, Gorrieb, & Spelman, 2003; Richards & Russo, 2007). The majority of these UTIs are associated with the use of an indwelling urinary catheter (IDC) (Dailly, 2012; Hooton et al., 2010; World Health Organization [WHO], 2002). A more recent study that was undertaken in the Australian state of Victoria showed that catheter-associated UTI (CAUTI) was the third most common preventable hospital-acquired complication, with the two most common being pressure sores followed by in-hospital falls (McNair, Jackson, & Borovnicar, 2010).

Data collected in the U.S. show that at any given time, between 14% and 25% of patients in the hospital setting will have an IDC, up to half of which can be inappropriate (Apisarnthanarak et al., 2007; Dailly, 2012; Saint et al., 2000). The same was found in an audit performed on two general medical wards in a tertiary hospital in the Australian city of Melbourne (Harley, Yeo, Stuart, & Dendle, 2011). If these data are reflective of the general Australian practice, then there is much room for improvement. Up until now, the most effective means of reducing the rate of hospital-acquired UTI is to reduce the use and/or duration of urinary catheterization (Lo et al., 2008). With each day that a urinary catheter is in-situ, the risk of developing bacteriuria is between 3% to 8% (Hooton et al., 2010; Lo et al., 2008).

Urethral catheterization is the most commonly used form of urinary catheterization. When an IDC is inserted, there are multiple levels at which bacteria can be introduced into the otherwise sterile bladder. A break in the aseptic technique, inoculation with organisms that normally reside peri-urethrally, interruption of normal flow of urine through the urethra, the presence of a foreign body-mucous membrane interface for the tracking of bacteria, and the formation of bio-films are all mechanisms through which a UTI and its associated complications can occur. The risk of inoculation with multi-resistant organisms that harbour in the hospital environment (Swartz, 1994) and the injudicious use of antibiotics for asymptomatic bacteriuria are all possible consequences of what is perhaps initially perceived as a benign intervention. The aim is to ensure that IDCs are used only when needed and for the shortest time necessary.

Several interventions have been suggested in an attempt to achieve this aim. These interventions have ranged from the simple education of doctors and nurses to complex changes of policies affecting whole hospital funding. As an illustration of the former, Gokula, Smith, and Hickner (2007) conducted an audit of IDC use in their local hospital. After observing that a large proportion of IDCs were inserted in their emergency department, they decided to run education sessions for doctors and nurses regarding the use of IDCs, including indications and risks associated with use and other reasonable alternatives, as well as implementation of a checklist to clarify the indication for IDC insertion. The intervention resulted in an almost 80% reduction in the number of IDCs inserted in that emergency department. An intervention illustrating the other end of the spectrum involved a decision made by the Centers for Medicare and Medicaid Services (CMS) to withhold funding to hospitals for the costs incurred for the treatment of a preventable complication (for example, the development of a UTI and/or urosepsis after the inappropriate use of an IDC) (Wald & Kramer, 2007).

In Australia, hospital policies contain recommendations regarding appropriate indications for catheter insertion; however, the final decision as to whether or not to insert an IDC is left up to the treating clinician, and there is no system in place to ensure policies are being followed. While it is not the intention of the authors to suggest that a "policing" of urinary catheters would be appropriate, it would be quite reasonable to admit we are at a loss as to how urinary catheters are being used in the general hospital setting, including all of critical care, medical, and surgical wards. There is no published literature on how IDCs are being used within Australian hospitals, and for this reason, we conducted an audit of urinary catheter use in our hospital (Concord Repatri a tion General Hospital [CRGH]). The purpose of the audit was to describe the use of IDCs in CRGH and to use results as a method of quality improvement for our hospital.

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