“Incontinence Isn’t Enough”

I recently wrote “How To Be a Urethra Whisperer”. I then ended up at a local chapter of my state nursing association, where one of our board members, an educator on a med-surg floor, pointed out that new guidelines are really changing how and when we use indwelling catheters. I was interested, because as I pointed out in my post, I put in a lot of catheters. She told me that because of the new emphasis on avoiding hospital-acquired infections, our hospital has whole new order sets that have to be evaluated and renewed daily for continuation of indwelling urinary catheters. The criteria were fairly narrow. She said, “incontinence isn’t enough.” (That reminded me of my ICU days when I would wake up a sleepy resident to ask for a Foley order and he would say, “Is this for you or for the patient?” meaning was it for my convenience.)

I have noticed that our new Foley packaging includes a big orange piece of paper that says “PLEASE CONSIDER WHETHER THIS CATHETER IS NECESSARY” or some such. I investigated. I knew that hospitals are going to be nailed for hospital acquired infections, and indwelling urinary catheters are a huge culprit, but I dug around a little more.

Turns out that infections from urinary catheters are the most common infections that patients get in hospitals, and despite campaigns to increase hand hygiene, perineal care, and aseptic technique, the infection rates are not getting any better. Therefore, the drive is to use fewer urinary catheters to begin with (Jim Kling, “Protocol Reduces Use of Urinary Catheters, Infections,” Medscape Medical News, April 3, 2011, accessed at http://www.medscape.com/viewarticle/743452; free account required to view).

See also “Facts About Foleys” here. Notably:

• “38% of indwelling urinary catheters inserted in the hospital have no justifiable medical indication.”
• “The risk of developing a catheter associated urinary tract infection increases by 5% for every day the catheter is in place. Long term use (over 28 days) has a 100% infection rate.”
• “Each catheter associated urinary tract infection (CAUTI) costs a hospital approximately $3,383 to treat plus up to 4.6 additional hospital days.”

The “no justifiable medical indication” grabbed my attention because it related to my colleague’s comment that “incontinence isn’t enough” and also to that long-ago resident who would ask if the Foley was for me or for the patient. What are justifiable medical conditions? Late-stage pressure ulcers, surgical hip fractures, and so on. Not weakness or a desire not to keep getting up to use the commode (I hear my nursing instructors droning in my head “no one ever got better lying around in bed!”).

This strikes me as a minefield. What of the patient who is too weak to get up but does not meet the criteria for a Foley and therefore lies in urine and develops pressure ulcers? Then she will meet criteria, only she will have two hospital-acquired issues that are expensive and painful.

Nevertheless, nurses already have a role in the fight against catheter-associated urinary tract infections. We can question orders for them that don’t seem appropriate: especially since order sets involve checking boxes more often than not, physicians may just reflexively check the box and be happy you pointed it out. We can educate patients on the pros and cons. They always have the right to refuse. We can, of course, be as meticulous as possible about our sterile technique and follow-up peri care, and we can ensure that catheters are removed as soon as possible.

I have a feeling that urinary catheters are on their way out except in surgery or strange cases such as neurogenic bladder. Until then, they’re going to cost hospitals a lot of money, and it will fall mostly on nurses to help soften the blow. We need to educate ourselves, our colleagues, and our patients about these infections and ways to avoid urinary catheter use.