CHAMPFoley Catheter Use

Catherine E. DuBeau, M.D.

University of Chicago

Learning Objectives

• Name short and long term risks of catheterization

• Differentiate the medical reasons for incomplete voiding

• Analyze catheter management problems

• Perform bedside evaluation of need for catheter and construct plan for catheter removal

Outline

1. Scope of the problem2. Rationale for targeting catheter

use3. Appropriate indications for

catheter use4. Catheter management5. Trouble-shooting failure to void6. Teaching triggers

Emphases and Links

Text will be repeated in YELLOW to indicate links to other CHAMP modules

Further content in CHALK will be listed at the end

Scope of the Problem

• Prevalent and morbid– 25% of hospitalized pts have a catheter– Cause of 40% of nosocomial infections– Uncomfortable and restrictive (“one-point

restraint”)– Urethral and meatal trauma (traumatic

hypospadius in men, patulous meatus in women, scarring, bleeding)

Scope of the Problem

• Prevalent and morbid– 25% of hospitalized pts have a

catheter– Cause 40% of nosocomial infections– Uncomfortable and restrictive (“one-

point restraint”)– Urethral and meatal trauma

PAINDELIRIUMFALLS

Scope of the Problem

• Often an “invisible” problem– Hospital MDs unaware of catheter use in

about 1/3 of their catheterized patients– Being unaware associated with

inappropriate use and longer catheterization periods

• Internists have little training in the medical reasons for failure to void

• Resulting Urology consults don’t always lead to mutual satisfaction/learning

Rationale for targeting catheters

1. Morbidity2. Quality3. Expense

Morbidity

• Indwelling– Polymicrobial

bacteriuria (universal at 30 days)

– Fever (1/100 pt-days)– Chronic pyelo– Bladder and renal

stones– Urethral and meatal

injury– Agitation

• External– Bacteriuria and

infection– Penile cellulitis and

necrosis– Urinary retention

Morbidity

• Indwelling– Polymicrobial

bacteriuria (universal at 30 days)

– Fever (1/100 pt-days)– Chronic pyelo– Bladder and renal

stones– Urethral and meatal

injury– Agitation

• External– Bacteriuria and

infection– Penile cellulitis and

necrosis– Urinary retention

DELIRIUM

Morbidity

More people die from hospital-acquired infections than from auto accidents and homicides combined

Quality

• Joint Commission Patient Safety requirement: reduce the risk of health care-acquired infections

• Illinois: Public Act 93-0563, SB 59, 2003: mandates quarterly reporting of hospital infection rates, with yearly publishing by hospital

• Consumers: StopHospitalInfections.org

Expense

• Unnecessary equipment and labor costs

• Hospital infections cost $5 billion annually

• Longer length of stay

Expense

• Unnecessary equipment and labor costs

• Hospital infections cost $5 billion annually

• Longer length of stayIATROGENIC ILLNESS FUNCTIONAL DECLINE

Indications for using catheters

There are only FOUR indications:1. Inability to void2. Incontinence AND

• Open wounds needing protection• Terminal illness/palliative care

3. Monitor urine output AND patient unable to assist/comply

4. After anesthesia (short term only)

Catheter management

• Closed drainage systems• Changing

– Any acute infection– Monthly for chronic catheter

• Leakage around catheter– Balloon too big (size or inflation)– Infection– Bladder spasm: consider pyridium or bladder

relaxant, eg. Detrol or Ditropan (but only if catheter indication is not retention)

Trouble-shooting insertion

1. “Can’t pass”• Discomfort/spasm at sphincter:

• Use lidocaine gel• Insert with slight ‘torque’ while patient

exhales• Try larger catheter• Coudécatheter

2. Inflate the balloon only aftercatheter is inserted all the way in, up to the meatus

Trouble-shooting failure to void

• Two basic reasons– Poor pump– Blocked outlet

Trouble-shooting failure to void

• Two basic reasons– Poor pump– Blocked outlet

Pump action: Ach, Ca++

Sphincter closure: Alpha adrenergic

Trouble-shooting failure to void

• Two basic reasons– Poor pump

– Blocked outlet

Meds: anticholinergic, Ca+ blkrs

Sacral cord disease

Neuropathy: DM, vit B12 defic

Constipation

Prostate disease

Meds: alpha-agonists

Neurological disease: dyssynergia

Women: scarring, cystocele

Constipation

Teaching Triggers

Action step 1: Look for catheter on every patient when at bedside

Trigger: Catheter found

“Why does this pt have a catheter?

Unsure/inappropriate indication:

Review indications

Action step 1: Look for catheter on every patient when at bedside

Trigger: Catheter found

“Why does this pt have a catheter?

Review indications:1. Inability to void

2. Incontinent with wounds/palliative care

3. Monitor output

4. Post anesthesia

Action step 1: Look for catheter on every patient when at bedside

Trigger: Catheter found

“Why does this pt have a catheter?

Appropriate indication Action Step 2

Action step 2: “Does this patient Action step 2: “Does this patient still need the catheter?still need the catheter?

Yes Action step 3

Action step 3: “Does this patient have a medical reason for inability to void?

A. Review MAR

B. Review medical history

C. *Additional exam, Post voiding residual

Anus

Clitoris

Anal wink

Bulbocavernosus Reflex

Sacral Reflexes

Adapted from Geriatric Review Syllabus Urinary Incontinence slide set, American Geriatric Society, 2006

Cystocele

RectocelePhotographs from: Abrams P, Cardozo L, Khoury S, Wein A, ed. Incontinence. 2nd International Consultation on Incontinence.

Plymouth UK: Health Publications Ltd, 2002; pp 381-2.

Pelvic Exam

Action step 2: “Does this patient still need the catheter?

No Action step 4

Action step 4: Discontinue all catheters before discharge unless there is chronic retention

Action step 4: Discontinue all catheters before discharge unless there is chronic retention

TRANSITIONS OF CARE

Action step 4: Discontinue all catheters

A. Deflate balloon and remove catheter (never clamp!)

B. Insure adequate fluid intake (PO or IV)

C. Monitor for 8 hours

D. If no void, reinsert catheter and note volume. If < 200, increase fluids and repeat trial. Review causes of failure to void.

E. If voids, check PVR

PVR < 100 (men) or <200 (women): done

Higher PVR: re-insert, review causes of failure to void

Action step 4: Discontinue all catheters

Does the pt have a Foley?

Why does pt have Foley?

Does the pt still need Foley?

Medical reason for inability to void?

YES

Review the 4 indications

InappropriateAppropriate

YES

Review PMHx, MAR, exam

Plan to D/C Foley

NO

Who to discharge with a catheter

• Patients with retention who fail voiding trials

• Patients who have not completed at least 7 days of decompression for new retention (they will need PCP, GU, and/or VNA follow-up to do and monitor voiding trial)

• Transitions of care:– Leg bag for day & large bag for night, or large bag alone– Family instruction re: emptying bag; changing bags (if

necessary); using straps to secure catheter (and leg bag) to leg; monitoring for output, hematuria, fever, SP pain; importance of adequate fluids

When to refer to Urology

• Failure to insert catheter even after trying earlier suggestions

• Large volume hematuria that does not clear with 3-way irrigation

• If you have treated medical reasons for failure to void and pt still has retention, then outpatient referral to Urology

Using Foleys to Teach Practice-Based Learning: Going Beyond Content

• What is the team’s practice and how can we learn from it?– PLAN to focus on Foleys for a teaching

session/rounds– DO a “census audit”, based on triggers:

• How many patients have a Foley?• Of these, how many did the team know about?• How many have a correct indication?

– STUDY the results• Share tally results with team and discuss implications

and the practice-based learning process

– ACT: how can we improve Foley care? Repeat audit?