Is that catheter needed? (Take 2)

When I paraphrased an article in Today’s Hospitalist by writing that physicians were “clueless” about which of their patients have urinary catheters, hospitalist Henryhbk rightly criticized me in the comments for a poor choice of words.

My intent was to remind patients that unfortunately they can’t assume their catheter is needed just because it’s in. That advice still stands, but in this post I’ve taken a fuller look at the sources cited in the article.

Henryhbk described a robust system for managing urinary catheterization in his hospital. It is reassuring and believable –but, at least according to these journal articles, it’s also atypical.

I went ahead and paid $15 for access to the article referred to in Today’s Hospitalist. (Systematic Review and Meta‐analysis: Reminder Systems to Reduce Catheter‐Associated Urinary Tract Infections and Urinary Catheter Use in Hospitalized Patients; Jennifer Meddings, Mary A. M. Rogers, Michelle Macy, and Sanjay Saint; Clinical Infectious Diseases 2010 51:5, 550-560.) Here are some relevant excerpts. I’ve bolded some key text.

From the introduction:

The greatest risk factor for [catheter-associated urinary tract infections] CAUTI is prolonged catheterization [5, 6]. Urinary catheters often are placed unnecessarily [7], remain in use without physician awareness [8], and are not removed promptly when no longer needed [7, 9]. Catheters also cause discomfort, restrict mobility, and delay hospital discharges [10–12]. Interventions that prompt removal of unnecessary catheters may therefore enhance patient safety. Yet a recent national study demonstrated that hospitals direct little attention to monitoring or reducing urinary catheter use [13], thus permitting many catheters to remain in place by default.

From the discussion

In most hospitals [32], 4 key steps are required in the life cycle of the urinary catheter before removal from the patient: (1) the physician recognizes that a urinary catheter is present; (2) the physician recognizes that the catheter is unnecessary; (3) the physician writes the order for catheter removal; and (4) the nurse removes the catheter in response to the physician order. In contrast, the catheter reminders and stop orders evaluated in this study have the potential to bypass several of these steps, leading to the routine and prompt removal of unnecessary catheters.

From the conclusion:

In summary, interventions to routinely prompt physicians or nurses to remove unnecessary urinary catheters significantly decrease the rate of CAUTI, and no evidence indicates that these interventions increase the need for recatheterization. Urinary catheter reminders and stop orders have the potential to improve patient safety by changing the default status of urinary catheters from persistent use to timely removal. Given the large burden of CAUTI, it is surprising that only ∼1 in 10 US hospitals use reminders or stop orders [13].

Reference [13] about the rate of reminder/stop order us is from 2008, so it’s fairly current.

Reference [8] from the introduction (Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med 2000; 109(6):476–480) is the original source for my “clueless” comment about whether physicians know about the presence of catheters. I didn’t feel like shelling out another $30 for this article, so I just looked up the abstract, which I’ve reprinted here (and again bolded certain parts). Keep in mind this article is 10 years old:

PURPOSE: Although infections associated with indwelling urinary catheters are common, costly, and morbid, the use of these catheters is unnecessary in more than one-third of patients. We sought to assess whether attending physicians, medical residents, and medical students are aware if their hospitalized patients have an indwelling urinary catheter, and whether physician awareness is associated with appropriate use of these catheters.

RESULTS: Among 288 physicians and students on 56 medical teams, 256 (89%) completed the survey. Of 469 patients, 117 (25%) had an indwelling catheter. There were a total of 319 provider-patient observations among these 117 patients. Overall, providers were unaware of catheterization for 88 (28%) of the 319 provider-patient observations. Unawareness rates by level of training were 21% for students, 22% for interns, 27% for residents, and 38% for attending physicians (P = 0.06). Catheter use was inappropriate in 36 (31%) of the 117 patients with a catheter. Providers were unaware of catheter use for 44 (41%) of the 108 provider-patient observations of patients who were inappropriately catheterized. Catheterization was more likely to be appropriate if respondents were aware of the catheter (odds ratio = 3.7; 95% confidence interval, 2.1 to 6.7, P <0.001).

CONCLUSION: Physicians are commonly unaware that their patients have an indwelling urinary catheter. Inappropriate catheters are more often “forgotten” than appropriate ones. System-wide interventions aimed at discontinuing unnecessary catheterization seem warranted.

September 17, 2010

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