Earlier in June, the Premier Safety Institute® of the Premier hospital alliance issued a bulletin calling for the removal of unnecessary urinary catheters to prevent catheter-associated urinary tract infections (CAUTIs). Is it all that easy? While The Joint Commission has added CAUTIs as a National Patient Safety Goal for 2012 and the Department of Health and Human Services has publicized its goal of reducing CAUTIs by 25 percent by 2013, it is not entirely clear how such ambitious goals will be met. Regardless, it will undoubtedly take not just the attention of nursing management, but rather an entire team's dedication. The patient and the patient's family caregivers or spokespersons have to be a part of that team.
It's simply not enough to issue an edict to "kick the catheter habit." There are clearly established reasons for inserting an indwelling urinary catheter, defined in the literature as follows1:
• acute urinary retention or obstruction, to prevent permanent distention of the bladder and life-threatening damage to the kidneys
• incontinence at the end of a patient's life, in which the patient is immobile or lacks cognizance
• a patient with a perineal wound
• the need for critical monitoring of urinary output affecting the care of an incontinent patient
• perioperative circumstances, the broadest of all categories and thus reasons for judgment in decision-making.
We must not overlook the fact that hospitalized patients, on average, are typically sicker and more frail than they were just a decade ago because the healthier patients are discharged more quickly or having same-day procedures in outpatient clinics altogether. Those remaining hospitalized are often already in compromised health with multiple co-morbidities and not only less able to fight infection, they are also vulnerable to injuries from falls while disoriented and often heavily medicated.
Patients falling while trying to use the toilet are more likely to sustain an injury than those falling elsewhere in the hospital, a study at Barnes-Jewish Hospital in St. Louis found2. But in-hospital elimination falls do not necessarily occur in the bathroom. They can occur in the bathroom, on the way from the bed to the bathroom or at bedside commodes placed next to patients' beds. Nurses and family members might establish a regular schedule of assisted trips to the bathroom for patients at high risk of falling, but even the assistance requires special training. Researchers also found that patients who would normally use a walker or a cane outside the hospital frequently weren't using one when they fell. While CAUTIs add an estimated $320 million to the cost of healthcare, falls cost our country $19 billion3 and are the number one cause of death from injury in the Medicare age population.
Yes, a team approach can reduce CAUTIs, and this has been demonstrated, by examining every facet of bladder management and educating every member of the team, including patients and family members4. In the case of geriatric patients, there are specific issues associated with the misuse of indwelling urinary catheters, not the least of which are urethral trauma and delirium triggered by the catheter insertion itself. Involved family members need to understand when a catheter is indeed necessary and when it can be the source of injury or subsequent infection itself. They need to question, both nurses and doctors, on the rationale and the duration of the catheter whose placement introduces a pathway to infection in the body. The risk of infection increases every day a catheter is indwelling. It is appropriate to discuss openly the alternatives. And we all need to remember that removal of a catheter requires skill and patience by the provider to avoid injury and infection, as much as its insertion, if not more.
Let's make the hospital safer in every way, for everyone. Get on the team to make it happen. That includes you!
Nancy Muller, PhD
1Lo E, Nicolle L, Classen D, et al. Strategies to prevent catheter-associated urinary tract infections in actue care hospitals. Infection Control Hospital Epidemiology October 2008; Suppl 1: S41-50.
2Hitcho EB, Krauss MJ, Birge S, Dunagan WC, Fischer I, Johnson S, Nast PA, Costantinou E, Fraser VJ. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. Journal of General Internal Medicine, July 2004.
3Stevens JA, Corso PS, Finkelstein EA, Miller TR.The costs of fatal and nonfatal falls among older adults. Injury Prevention December 2006:290-295.
4 Garman L. June 28, 2011. Team approach reduces urinary tract infections in rehab patients , accessed on June 30, 2011, from http://www.eurekalert.org/pub_releases/2011-06/afpi-tar062411.php
Published On: July 01, 2011