Geriatrics Unit Reduces Catheter Use, Reports Fewer Deaths

Laird Harrison

May 25, 2016

LONG BEACH, California — A program to reduce urinary catheterization successfully reduced mortality in one Canadian geriatrics unit.

For the program, catheterization was aggressively tracked, information about catheters was provided in electronic health records order sets, and education on problems associated with catheterization was offered to providers treating patients in the acute care for elders unit at Sinai Health System.

"It's making the right thing the easy thing to do," Samir Sinha, MD, DPhil, director of geriatrics at Mount Sinai and the University Health Network Hospitals in Toronto, told Medscape Medical News.

Dr Sinha and one of his coauthors, Richard Norman, MD, from the University of Toronto, presented the finding here at the American Geriatrics Society 2016 Annual Scientific Meeting.

Up to 25% of inpatients are catheterized, and up to 52% of those catheterizations are unnecessary, Dr Norman reported.

Some physicians order catheterization because they think it will be easier than other ways of helping patients with toileting, he told Medscape Medical News. And some mistakenly believe that conditions such as cognitive impairment or restricted activity are indications for catheterization.

But catheters increase the risk for urinary tract infection, pressure ulcers, functional decline, discharge to a location other than home, prolonged hospital stays, and death. "Catheters are a single-point restraint," Dr Norman said. "Patients are stuck in bed. They can't get up and mobilize."

And about one-quarter of the time, providers forget that patients have catheters, he said.

In the United States, treatment for catheter-associated urinary tract infection is no longer reimbursed by Medicare, and the Centers for Medicare and Medicaid Services has set a goal to reduce these infections 25% by 2020, he reported.

To reduce the use of catheters, Dr Norman and his colleagues launched a two-phase program across the general internal medicine and surgical services at the hospital.

In February 2010, they put up posters about appropriate indications for catheterization, held small group staff meetings to discuss these indications, and tracked catheter insertions and removals on patient charts.

Then, in the spring of 2011, catheter indications were added to admission order lists in electronic health records, and representatives from nursing and allied health professions were educated to disseminate information.

Although physicians elsewhere have complained about the burden imposed by electronic health records, "there was no push-back" related to the addition of information about correct catheter use, Dr Sinha said.

"I think there is more cognitive burden when you don't have these order sets," he said.

"Holy Moly, My Patient Has a FOLEY!"

Staff meetings were held with all physicians, nurses, and allied health professionals to discuss catheterizations, and nurses attended an intensive 3.5-hour session on continence and catheters.

Empowering nurses to challenge catheter orders was one of the most effective parts of the program, said Dr Sinha.

Automatic orders for catheter removal in orthopedics patients after 2 days, unless contraindicated, began in June 2011. And catheter safety cross practice, in which nurses followed-up on every patient with a catheter, began in July 2011.

 
We virtually eliminated long-duration catheterization.
 

Posters with the headline "Holy Moly, My Patient has a FOLEY!" were placed in every bathroom stall, where hospital staff had ample time to review indications for catheters, associated risks, and ways they could take action to remove them, Dr Norman said.

A slide of the poster drew laughs from the audience, and one person asked if she could have copies to post in her own medical center.

Nurses were motivated to help their patients, but also saw that reducing catheter use was in their own self-interest. Patients who can move are better able to take care of themselves, Dr Sinha explained.

Almost 12% of the 24,499 patients admitted to the medicine, surgery, or geriatrics unit during the study period received catheters.

Two months after the catheterization-reduction program was implemented in the geriatrics unit, mean length of stay dropped from 13.8 days to 10.4 days (P = .032), and the number of days catheters remained in each patient dropped from 15.4 to 3.5 (P ≤ .01). "We virtually eliminated long-duration catheterization," Dr Norman reported.

Mortality dropped in all three units, but the decrease was significant only for the geriatrics unit (P = .029).

Table. Deaths per 1000 Admissions Among Catheterized Patients

Unit Before Intervention After Intervention
Medicine (n = 703) 82.5 74.1
Geriatrics (n = 341) 82.1 44.3
Surgery (n = 1889) 11.1 9.4

 

Rates of urinary tract infection also dropped, but the change was not significant, Dr Norman reported.

Other changes were introduced during the same period, said Dr Sinha. For example, efforts were made to reduce potentially inappropriate drug prescriptions and improve the treatment of constipation.

Although these factors could have influenced the mortality rate, the change in mortality corresponded very closely to the timing of the catheter campaign, said Dr Norman.

After the presentation, an audience member asked if any change in reimbursement could have affected the behavior of physicians.

Provider reimbursement was not affected by catheter use, Dr Norman explained.

Steps similar to these should be widely adopted, said session moderator Ellen Flaherty, PhD, from the Dartmouth Centers for Health and Aging in Lebanon, New Hampshire.

"I think absolutely targeting this to the United States makes a lot of sense," she told Medscape Medical News. "There is a different reimbursement structure, but the most important point is that it's the best for patients."

Dr Sinha, Dr Norman, and Dr Flaherty have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2016 Annual Scientific Meeting: Abstract P2. Presented May 19, 2016.

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