Download Incontinence

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

To provide a model on the approach to the
hospitalized patient with urinary
incontinence
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
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.
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.
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.
Abuses






Routine placement
Forget to remove when no longer indicated
Patient’s request
Patients with limited
mobility or pain
 INCONTINENCE
Dementia
Shortage of nursing
staff/increased staff demands
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
Harm

Urinary tract infections represent 40% of all nosocomial
infections 

1 million cases of hospital acquired UTIs



Catheters are implicated in 8 out of 10 case
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.
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.
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.
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.
Alternatives to the indwelling
catheter

Consider these options:

Incontinence garments (diapers)


Condom catheters



patients prefer over 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.
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.
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?
Preventing Misuse and
Complications
1.
2.
3.
Know the types and causes of urinary
incontinence
Discuss an approach to the prevention
Treatment of urinary problems in the
hospital
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).
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.
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
Urinary Incontinence

Stress



Increased intra-abdominal pressure and a
compromised sphincter
Small volumes of urine
Occurs with cough, sneeze, valsalva, bending
Urinary Incontinence
Overflow

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

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?
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?
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)
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
Review Medication List

Medications that cause sedation or
delirium


Decrease ability to sense full bladder
Decrease their ability to communicate need
for toileting
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
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
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.
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) .
Address Underlying
Co-morbidities

Constipation causes urge and overflow
incontinence


Urinary tract infections can exacerbate
urge incontinence


Bowel regimen
check a u/a, simple and inexpensive
Coughs cause stress incontinence

Anti-tussive
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)
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
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
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
Workshop

Education of staff on appropriate use of
urinary catheters will help decrease unneeded indwelling catheters.


power and persistence of this intervention limited
What systems changes can you envision
that could reduce catheter use?
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;54:10551061
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.