Rick Bukata: The High Cost of ‘Convenience Caths’

Emergency physicians need to lead the charge on halting unnecessary urinary catheterizations, for the sake of patient safety and the bottom line.

Emergency physicians need to lead the charge on halting unnecessary urinary catheterizations, for the sake of patient safety and the bottom line. 

The emergency department is one of the biggest, if not the biggest, source of unnecessary urinary catheterizations. The problem is straightforward – they cause urinary infections. Medicare told the hospitals in 2008 that any urinary catheter-induced infection that extends the length of stay beyond that for the primary diagnosis will not be compensated. Bottom line – the hospitals eat the extra costs and the patients often get an unnecessary UTI.

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Emergency departments need to take a proactive approach to limit both the patient’s and the hospital’s risks associated with unnecessary urinary catheters. There are a number of recent papers that describe the problem and the solutions.

Who are the patients most likely at risk – elderly women. The first paper notes a 12% catheterization rate for 4,521 patients admitted through the ED (astonishing!!) and a third were placed without any of the hospital’s institutional guidelines and in a sixth there was no apparent reason for catheterization. Female gender and an age of 80 or older were risk factors for noncompliance (half the women age 80 or older did not have an indication per institutional guidelines). The mean age of patients who had a catheter placed without an indication was 71. The astonishing thing about this study – these were the results after an attempted intervention to decrease unindicated catheterizations.

The urinary catheter guidelines for the ED were a combination of CDC (1981) recommendations and hospital-derived consensus recommendations. They were surprisingly generous:

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• Urinary flow obstruction
• Neurogenic bladder
• Urologic procedure
• Urine output monitoring
• Emergency surgery
• Incontinence with sacral decubiti
• Hospice comfort or palliative care
• Acute hip fracture
• Severe hypoxia
• Unconsciousness
• Acute mental status changes with severe agitation
• Pelvic ultrasound if emergent or patient unable to drin.

Conspicuously absent are indications related to nursing convenience. For example, many EDs routinely put catheters into CHF patients given IV diuretics – a no-no unless other criteria are met.

URINARY CATHETERS IN THE EMERGENCY DEPARTMENT: VERY ELDERLY WOMEN ARE AT HIGH RISK FOR UNNECESSARY UTILIZATION,
Fakih, M.G., et al, Am J Infect Contr 38(9):683, November 2010

BACKGROUND: Urinary catheters, which are frequently placed in the ED, are the most common source of hospital-acquired urinary tract infection (UTI). Because catheter-associated UTI in hospitalized patients is believed to be avoidable, the Centers for Medicare and Medicaid Services discontinued reimbursement for these infections in 2008.

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METHODS: This implicit chart review study, from Wayne State University, evaluated factors associated with noncompliance with institutional guidelines for urinary catheter placement in the ED in 4,521 patients admitted through the ED over three four-week periods, including one from before, one directly after, and one three months after an educational intervention for residents focused on these guidelines.

RESULTS: A urinary catheter was placed in the ED in 538 patients (11.8%). Nearly one-third of the catheters (30.3%) were placed without any of the indications noted on the institutional guidelines, and in about one-sixth of cases there was no apparent reason for catheterization. On multivariate analysis that adjusted for potential confounders, independent predictors of the likelihood of noncompliance with institutional guidelines included female patient gender (odds ratio [OR] 1.88) and an age of 80 or older (OR 2.89).

CONCLUSIONS: Even including patients seen up to a year after dissemination of institutional guidelines for urinary catheterization in patients hospitalized via the ED, there was no guideline-relevant indication for nearly a third of the catheters placed in this study. Very elderly patients and women each appear to be at increased risk for inappropriate urinary catheterization in the ED. 27 references (mohamad.fakih@stjohn.org – no reprints)
Copyright 2011 by Emergency Medical Abstracts – All Rights Reserved 4/11 – #16

Another study by the same authors, again looking at care at the ED of St. John Hospital and Medical Center in Detroit (over 100,000 ED visits per year) found, not surprisingly, that instructing physicians and not nurses regarding the institutional policies concerning catheterizations was only modestly effective – catheterizations for admitted patients went from 15% to 11%. Importantly, a physician order was only documented in half the cases (at least in outpatients, lack of a physician order precludes charging for the procedure and equipment). Clearly, to attempt to successfully reduce unindicated catheterizations a department-wide effort is required where everybody knows the indications and performance is monitored.

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EFFECT OF ESTABLISHING GUIDELINES ON APPROPRIATE URINARY CATHETER PLACEMENT,
Fakih, M.G., et al, Acad Emerg Med 17:337, March 2010

BACKGROUND: Urinary tract infections (UTI) account for more than one-third of hospital-acquired infections and are in large part related to urinary catheterization. CMS has targeted in-hospital catheter-associated UTI as a non-reimbursable condition. The ED might be an ideal setting in which to reduce unnecessary urinary catheterization in patients being hospitalized.

METHODS: This study, from Wayne State University in Detroit, examined the effect of ED-specific guidelines for urinary catheterization, when admission is planned, on overall rates of urinary catheter placement in the ED, and on unindicated catheterization. The guidelines were presented to attending physicians and residents (but not nurses), who also got a pocket card listing appropriate indications for catheterization, and an ED physician champion promoted adherence to the guidelines.

RESULTS: Rates of urinary catheterization in the ED for patients being admitted decreased from 14.9% pre-intervention to 10.6% post intervention. There was a documented physician order for the catheter for only 47% of the patients who were catheterized, and an appropriate indication was documented in about three-fourths of these cases, compared with only about half the cases for which no physician order was present. The likelihood of an appropriate indication increased after the intervention (to 82.2% of cases, from 72.6% of cases pre-intervention).

CONCLUSIONS: Education of physicians regarding guidelines for urinary catheterization was associated with some reduction in ED catheter placement for admitted patients, but education of physicians alone might not be sufficient. 9 references (mohamad.fakih@stjohn.org for reprints)
Click here for abstract in PubMed
Copyright 2010 by Emergency Medical Abstracts – All Rights Reserved 7/10 – #20

An initiative to limit inappropriate catheterizations needs to be hospitalwide and not limited to the ED. Certainly, although the ED is a major offender, the problem is widespread. The following paper found that 32% of ca
theter-days were considered inappropriate in the inpatient setting. A nurse-led initiative substantially decreased the number of inappropriate catheter days and the incidence of catheter-associated infections went from 4.7 per 1,000 catheter days to 0 – remarkable. Their criteria for catheterization were:

• Urinary tract obstruction
• Urinary retention
• Patient undergoing a prolonged procedure (over two hours)
• Recent surgical or invasive procedure
• Epidural catheter in place
• Frequent monitoring of urinary output (every 1-2 hours)
• Deep sedation / paralysis
• Stage III or IV skin ulcers
• Surgical repair of decubitus
• Movement intolerance due to terminal illness or severe impairment

Inappropriate indications were:

• Incontinence without any of the above indications
• Diuresis
• Frequent, non-essential determination of urinary output
• Nurse’s concern about patient’s discomfort
• Diarrhea without any of the above indications
• Patient’s preference

As can be seen, the two sets of criteria differ considerably and they reflect the need for developing some consensus at individual hospitals if progress in this area is to be expected.

REDUCING USE OF INDWELLING URINARY CATHETERS AND ASSOCIATED URINARY TRACT INFECTIONS
Elpern, E.H., et al, Am J Crit Care 18(6):535, November 2009

BACKGROUND: Urinary tract infections (UTIs) are the most common nosocomial infection in the ICU setting. Unnecessary use of indwelling urinary catheters is an important source of these infections.

METHODS: Prompted by awareness of an elevated rate of catheter-associated UTIs in their medical ICU, the authors, from Rush University Medical Center in Chicago, examined the effect of a nurse- led intervention to reduce unnecessary use of indwelling urinary catheters in this setting. The intervention consisted of identification of ten literature-based indications for appropriate use of indwelling urinary catheters and daily monitoring of appropriateness of catheter use in the ICU with recommendations to discontinue use if patients no longer met appropriateness criteria.

RESULTS: During the six-month intervention, 337 patients had indwelling urinary catheters for a total of 1,432 days, and catheter use was considered inappropriate in 32% of these catheter days (11% of catheter days in an analysis restricted to patients with catheters in place for 24 hours or more). With the intervention, the mean number of urinary catheter days was reduced from 311.7 per month during the eleven months prior to the intervention to 238.6 per month, and the number of catheter-associated UTIs was reduced from 4.7 per 1000 device days to 0 in 1,432 device days.

CONCLUSIONS: Implementation of a nurse-led low-technology intervention in the medical ICU of this inner city academic medical center was associated with a reduction in the use of indwelling urinary catheters and catheter-associated UTIs. 24 references (reprints@aacn.org for reprints)
Copyright 2010 by Primary Care Medical Abstracts – All Rights Reserved 4/10 – #16

The last article is an overview of an ED project to limit unindicated catheterizations as well as assuring that the catheterizations that did occur had the least risk of precipitating infections. This article would be a good one to get and model a program after.

STRATEGIES TO PREVENT URINARY TRACT INFECTION FROM URINARY CATHETER INSERTION IN THE EMERGENCY DEPARTMENT
Parnell, K., et al, J Emerg Nurs 36(6):546, November 2010
Placement of an indwelling urinary catheter is the source of 80% of urinary tract infections (UTIs) in hospitalized patients. Catheter-associated UTIs are listed by CMS as a preventable and, thus, non-reimbursable hospital-acquired condition. The authors, from University Health Care System in Augusta, GA, report on a project developed to educate ED staff on methods of preventing catheter-associated UTIs. The program was based on CDC guidelines and the policies of University Hospital. Components included proper hand hygiene, perineal cleansing, catheter insertion technique and proper anchoring, collection of urine specimens via the catheter, catheter management, troubleshooting and documentation to include assessment of the color, clarity and characteristics of urine at the time of insertion to facilitate later identification of problems. Participation in the instructional program was mandatory, and was conducted during regular working hours. The program included PowerPoint and poster presentations, and team mannequin-based practice sessions with feedback. Healthcare workers in the ED were also provided with handouts listing best practices, CDC guidelines and University policies. Development of the program resulted in implementation of new practices in the ED. The cost of the project, which essentially included supplies, totaled $153. Of 62 participants who attended the instructional sessions, 51 returned post-participation surveys. All of the respondents noted that participation in the project contributed to their knowledge and competency with regard to urinary catheter insertion and UTIs. No information was presented regarding the effects of the program on the occurrence of catheter-associated UTIs. 7 references (Kimberlyp93@comcast.net – no reprints) (no PMID available)
Copyright 2011 by Emergency Medical Abstracts – All Rights Reserved 7/11 – #17

The bottom line –
The ED nurses and physicians should collaborate to address this challenge. There are a substantial number of other studies that make it clear that this is a universal problem and that relatively simple strategies can be effective in improving care for patients and limiting costs for the hospital. Having the ED be the instigator for a hospital-wide effort to decrease unnecessary urinary catheterizations has got to get serious brownie points from the hospital administration and patients will benefit as well.