Why You Should Stop Overusing Foley Catheters

Catheter-related infections begin in the ED and are avoidable if the tube is used only when necessary.

Seems that a lot of patients receive treatments that are not literature-defended in U.S. emergency departments. Much of this has occurred because these procedures are thought of as “routine,” and, as such are not challenged. Think of it – how many patients come in and get put on a monitor, have an IV started and get supplemental oxygen? Tens of thousands of patients daily. Yet, in many cases each of these procedures is unnecessary and unindicated.

According to a 2012 survey of about 1,200 hospitals conducted by the Emergency Department Benchmarking Alliance (EDBA), there were about 20 CTs done for every 100 ED patients. This number is close to the National Hospital Ambulatory Medical Care Survey (NHAMCS) (2010) results in which it is noted that 16% of ED patients received a CT scan (with a little less than half involving the head).

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Some of these excessive procedures cause unnecessary discomfort to patients while in the ED, others can cause harm and others are just a waste of time and money. Last Spring in EP Monthly two such procedures were covered – oxygen and IV fluids. Picking up this thread, we’ll cover some other procedures that are often performed without proper indications. This month we’ll look at Foley catheters.

Foley Catheters
The literature indicates that many Foley catheters started in the hospital are avoidable and that the emergency department has the dubious honor of being the place where most of these unnecessary catheters are ordered. There are a number of papers affirming this practice and encouraging the implementation of validated policies that can reduce the placement of unindicated catheters. Hospitals are especially interested in in this issue as catheters are often left in place long after insertion, leading to unnecessary urinary tract infections which can both increase a patient’s length of stay and not be paid for by Medicare. Here are some papers on unindicated Foley catheters.

The first study in this section looked at 375,235 ED patients in a national database and determined the frequency of Foley use and appropriateness (based on CDC guidelines). 2.8% of ED patients got a Foley (8.4% of admitted patients and 1.6% of discharged patients). A CDC-approved indication was NOT documented in 64% of the catheters placed in the ED. Frequency of use and use for appropriate indications did not significantly change over the 15 year period of this study.

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1. URINARY CATHETER USE AND APPROPRIATENESS IN U.S. EMERGENCY DEPARTMENTS, 1 995-2010 Schuur, J.D., et al, Acad Emerg Med 21(3):292, March 2014
BACKGROUND: Substantial focus has been placed on prevention of catheter-associated urinary tract infection, which has been reported to be the most prevalent hospital-acquired infection. Efforts have addressed avoidance of unnecessary urinary catheter placement and removal at the earliest appropriate time. The ED has been noted to be the source of half of all non-obstetric hospital admissions, and is the site of urinary catheter placement in many of these patients.
METHODS: The authors, coordinated at Brigham & Women’s Hospital in Boston, performed a retrospective cross sectional analysis of 375,235 adult ED visits included in the NHAMCS database for the period 1995-2010 to evaluate rates of urinary catheter placement and appropriateness of placement based on CDC guidelines.
RESULTS: Urinary catheters were placed in 2.8% of the ED visits, including 8.5% of admitted and 1.6% of discharged patients. A CDC-approved indication was not documented for 64% of the urinary catheters placed in the ED. There was no significant difference in yearly rates of urinary catheter placement in the ED from 1995 to 2010.
CONCLUSIONS: The total percentage of catheters placed in admitted ED patients was lower than previously reported in smaller studies, but there was no decrease in the use of urinary catheters for ED patients over the study period and a CDC-approved indication for appropriate catheter use was not documented for two-thirds of the urinary catheters placed in the ED. Targeting of catheter placement in the ED might represent a significant opportunity to reduce avoidable catheter-associated urinary tract infections. 34 references (jschuur@partners.org – no reprints) 9/14 – #16

A Michigan program to reduce Foley catheter-associated infections throughout the state’s hospital consisted of teaching appropriate use. Specifically, key practices included use of reminders or removal prompts and/or nurse-initiated discontinuation, use of alternatives to indwelling catheters, portable bladder ultrasound monitoring and protocols of insertion care and maintenance. When compared with other states the rates of catheter-induced infection in Michigan decreased by 25% vs 6% in other states.

2. PREVENTING CATHETER-ASSOCIATED URINARY TRACT INFECTION IN THE UNITED STATES: A NATIONAL COMPARATIVE STUDY Saint, S., et al, JAMA Intern Med 173(10):874, May 27, 2013
BACKGROUND: A statewide initiative was implemented in Michigan in 2007 (the Keystone Bladder Bundle Initiative) to reduce rates of catheter-associated urinary tract infections (CA-UTIs). Key practices include use of reminders or removal prompts and/or nurse-initiated discontinuation, use of alternatives to indwelling catheters, portable bladder ultrasound monitoring and protocols of insertion care and maintenance.
METHODS: The authors, coordinated at the University of Michigan, surveyed infection preventionists in 131 Michigan hospitals and a random sample of 566 non-Michigan hospitals to compare practices to prevent CA-UTI. They further queried data from the 2009 National Healthcare Safety Network (NHSN) to estimate standardized infection ratios (SIRs) for CA-UTI.
RESULTS: Responses were received from 69% and 79% of the non-Michigan and Michigan hospitals; 67% and 94% of responders, respectively, reported participation in a collaborative effort to reduce CA-UTI. On multivariate analysis, Michigan hospitals were more likely than non-Michigan hospitals to use portable bladder ultrasound monitoring (OR 2.02) and catheter reminders or stop orders and/or nurse initiated discontinuation (2.19). There were no significant differences between the groups in the use of condom catheters in men, aseptic insertion technique or intermittent catheterization. Based on NHSN data, from 2009 to 2010 CA-UTIs decreased by 25% in Michigan hospitals but by only about 6% in non-Michigan hospitals (corresponding SIRs 0.75 vs. 0.94).
CONCLUSIONS: More frequent use of selected practices to prevent CA-UTI and implementation of a “bladder bundle” initiative were associated with a greater reduction in these infections in Michigan than in hospitals outside of Michigan. 23 references (saint@med.umich.edu – no reprints) 11/13- #16

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This study looked at a single hospitals experience with Foley catheters started in the ED of admitted patients. 11.8% of admitted patients (538) had a Foley started in the ED. Nearly a third were placed without any of the institutional guidelines being present and in about half of these, there were no indications for the catheterizations documented at all. Female patients and those over 80 were particularly represented in the group getting noncompliant catheters.

3. 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.
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) 4/11 – #16

The following study focuses on an instructional program and monitoring plan to improve the appropriateness of Foley catheter use in 18 EDs. Indications for catheter insertion were developed and published by the CDC-P in 1992 and formed the basis for determining appropriateness. Bottom line — ED catheter use went down from 9% to 5.4% and appropriateness increased from 74% to 91%.

4. AVOIDING POTENTIAL HARM BY IMPROVING APPROPRIATENESS OF URINARY CATHETER USE IN 18 EMERGENCY DEPARTMENTS Fakih, M.G., et al, Ann Emerg Med 63(6):761, June 2014
BACKGROUND: Decisions regarding placement of urinary catheters in hospitalized patients are often made prior to admission while the patient is in the ED. Inappropriate placement of urinary catheters in the ED increases the risk of device-related infections in hospitalized patients.
METHODS: The authors, coordinated at Wayne State University and the Ascension Health System, examined the use of urinary catheters in 13,215 patients admitted through the ED to 18 facilities in the USA before, during and after implementation of institutional guidelines on urinary catheter placement based on CDC-P recommendations published in 2009. Emergency physician and nurse advocates were instructed to engage their colleagues to support the program and to suggest methods of avoiding catheterization.
RESULTS: The frequency of newly-placed urinary catheters in the ED decreased from 9.1% during a seven-day baseline period to 6.1% during a 14-day implementation period and 5.4% during a six-month post-implementation period. The appropriateness of catheter placement increased from 74% at baseline to 91.4% during the implementation period and remained at 91.8% post-implementation. Throughout the study periods, rates of appropriateness of catheter placement were 87.1% when catheterization was based on a physician order compared with 72.5% when catheters were placed without a physician order.
CONCLUSIONS: Implementation of an institutional guideline on urinary catheter placement in the ED was associated with a sustained reduction in the inappropriate use of these devices among patients who were admitted to the hospital. 26 references (mohamad.fakih@stjohn.org – no reprints) 11/14 – #18

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The overzealous use of Foley catheters in the ED is a fixable problem.  It takes agreement on the indications for use, preferably evidence-based, a period of staff education and subsequent monitoring.  Seems that if an ED can’t successfully tackle this problem, then we’ll never get a grip on such challenges as excessive CT use and more complex examples of overutilization.