Straight Catheter Vs. Retention Catheter Ashley Bach, Paige Stevens, Charlsie Wolfe Auburn University of Montgomery

Case Study Nurses working labor & delivery have been arguing over the use of the straight in and out catheters Vs. the use of retention Foley catheters for patients who have difficulty voiding after receiving epidurals for pain management during labor. Many of the nurses are adamant that the straight in and out is effective in managing difficulty with voiding, while others believe the Indwelling Foley catheter is best.

Synopsis of Clinical Problem Presented in Case Study Lack of agreement because of deficit knowledge about which form of catheterization will best serve the client The need to define our terms Statistical data detailing the incidence of urinary tract infections placed in women who have been administered an epidural

Purpose & Goals of Study Purpose – Safest and most effective in relieving urinary retention Goal – To relieve urinary retention without any catheter-associated urinary tract infection

Purpose of Epidural To manage pain during childbirth The analgesic effects blunt the sensation of a full bladder and the need to empty it A massively over-distended bladder can lead to long-term damage, which is the need for catheterization (Doyle & Birtch, 2011)

Indwelling/Retention Catheter Can be left in the bladder from either a short or extended period of time (A.D.A.M., 2011). Inserted through the urethra and anchored in the urinary bladder using a balloon mechanism Urine is collected in a bag, which is periodically emptied, outside the patient Indications for use include: inability to void, urinary incontinence, post-surgery urinary retention, and various other disorders

Intermittent/Straight Catheter Inserted in order to facilitate the flow of urine and then removed immediately following voiding of the bladder (A.D.A.M., 2011). Indicated for patients for are temporary unable to void by themselves but need to empty their bladder

Targeted Resources Database at the Auburn Montgomery Library CINAHL Plus and Medline Plus Both contained journal articles which are professionally reviewed & considered trustworthy Able to combine key terms “catheter” “UTI” and “epidural” for article recommendations Also limited our search to the last 10 years

Evidence Search Table 1: PPAARE PPAARE Component Case Example Problem: Nurses lack education regarding which catheter is most efficacious and safe to use in patients who experience difficulty voiding related to epidural use during or after labor and delivery. Nurses use both types of catheter and argue about which one is the best. The patient: those females between the ages of twenty and thirty, who have received an epidural during natural labor and delivery and have been subjected to the use of a catheter, either indwelling or straight in-and-out, because of difficulty voiding. 25 year old female who has received both an epidural and a urinary catheter after delivery. Action: nurses insert an indwelling catheter into a patient who has received an epidural during labor and delivery. Insertion of an indwelling catheter Alternate action: nurses insert a straight in-and-out catheter into a patient who has received an epidural during labor and delivery. Insertion of a straight-in-and-out catheter Patient’s result: the patient shall be relieved of full bladder with the use of the safest possible type of catheter. Reduce the incidence of UTI’s in patients who receive catheterization during or after labor and delivery by using the safest type Level of evidence: systematic reviews preferred, case studies, controlled studies acceptable. Highest possible

Table 2:Evidence Grid Quantitative Studies: Quantitative studies we chose to include in our citations all evaluated the incidence of UTIs that resulted from catheter use after administration of an epidural They used meta-analysis, which is a combination of many trial results. It is a method designed to increase the reliability of research by combining and analyzing the results of all known trials of the same produce or experiments on the same subjects Evron, et al. was chosen because it was a highly regarded study by his peers, most of whom used his study in their meta-analysis Qualitative Study: Hidaka and Callister examined the feelings of women with regard to their birthing and epidural experience Although interesting, this study was not relevant to the collection of data pertaining to the incidence of UTIs as a result of administration of an epidural and subsequent catheter use, or to the question of which type of catheter was most efficacious

Relevant Evidence Relevant evidence suggested that any catheter use increased the incidence of urinary tract infections, regardless if it is used during or after labor & delivery (Jansen, Gibson, Bowles, & Leach, 2013). As the length of time the catheter remains in place, the risk of infection increases (Srinivas, 2009) Vast majority of quantitative information suggests that the use of intermittent catheterization offers benefits to the patient both in reduction of UTI’s and subsequent ability to void naturally (Doyle & Birtch, 2011)

Evidence Appraisal Quantitative Study: Evron, S., Dimitrochenko, V., Khazin, V., Sherman, A., Sadan, O., Boaz, M., & Ezri, T. (2009). All the authors work with medical groups that are associated with anesthesia, nursing and obstetrics. There are no conflict of interest. No source of funding Purpose clearly stated Hypotheses and variables are in alignment and identifiable in the study Article defined population Inclusive and exclusive criteria were clearly described Randomized, prospective, and single-blinded trial Protocol was described thoroughly and appropriate for the study Holon Medical Center Institutional Human Investigation Committee approved the protocol Patient’s written and informed consent were obtained prior to the start of the study Data collection was consistent with each participant Findings were explained Conclusion followed from the purpose, answer the question of which catheter was more efficacious.

Evidence Appraisal Qualitative Study: Hidaka, R., Callister, L.C. (2012). All the authors are affiliated with medical groups and have no vested interest in the outcome of the study No stated funding source, thus making it questionable Purpose is stated clearly Intent is clearly stated and phenomenon being investigated is identifiable Population is identifiable Rational for approach is given Sample method was explained Data collection protocol was a limitation due to unexplained attempts to ensure confidentiality and anonymity of the participants Participants’ experiences were described thoroughly Interrelationships were established by women who had experienced birth and utilized an epidural during the process Theory was constructed based on their reported experiences Findings were presented in a understandable manner and quotations were utilized to support the findings The researcher thoroughly explained their interpretation of the findings

Course of Action Recommendations: Use of intermittent catheterization over indwelling catheter use Educating nurses with regard to the decreased risk of hospital-acquired UTIs when intermittent instead of indwelling catheterization is implemented Hospital protocol should be changed accordingly Follow-up studies should be implemented Successful outcomes will be measured in terms of number of women who underwent an epidural and who had to subsequently utilize a catheter in order to void but did not contract a UTI Successful outcomes will be measured by nurses demonstrating knowledge concerning use of intermittent versus indwelling catheter use.

Conclusion Intermittent catheterization is preferred because of lower incidence of hospital-acquired UTIs related to their use. Provider education should be given. Hospital protocol should be changed so that the first-line policy is that of intermittent sue over indwelling catheters.\ Recommendation sent to thirteen hospitals across lower Alabama Six hospitals participated in the study, implementing our recommended protocol Data was submitted after two years Three hundred women participated Women Ages between 19 and 39 Gave birth vaginally and elected to receive epidurals, and subsequently required catheterization Variables: occupation, race, education level, height, weight of mother and baby, and duration of labor The results were compared to a corresponding number of women form the nonparticipating hospitals Results: 30% reduction in UTIs were experienced by women who used intermittent rather than continuous catheterization when compared to women form the previous two years, in participating hospitals. 40% fewer UTIs were experienced by women in participating hospitals, who utilized intermittent catheterization, as compared to women in non-participating hospitals, where the first-line solution was indwelling catheterization.

Conclusion Based on this data, we consider our recommendation to be the one that decreases the incidence of hospital-acquired UTI’s as a result of catheterization following epidural administration.

A. D. A. M. , Inc. (2011). Urinary catheters A.D.A.M., Inc. (2011). Urinary catheters. Medline Plus Medical Encyclopedia. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003981.htm DeSevo, M. R., & Semeraro, P. (2010). Urinary catheterization during epidural anesthesia. Nursing for Women's Health, 14(1), 12-13. doi: 10.1111/j.1751-4862010.01502.x Doyle, P. M., & Birtch, L., (2011). Urine elimination in pregnancy: indications for catheterization. British Journal of Midwifery, 556. Evron, S., Dimitrochenko, V., Khazin, V., Sherman, A., Sadan, O., Boaz, M., & Ezri, T. (2009). The effect of intermittent versus continuous bladder catheterization on labor duration and postpartum urinary retention and infection: a randomized trial. Journal of Clinical Anesthesia, 570. doi:10.1016/j.jclinane.2008.06.009  Jansen, L., Gibson, M., Bowles, B. C., & Leach, J. (2013). First do no harm: interventions during childbirth. The Journal of Perinatal Education, 22(2), 83-92. Retrieved from http://dx.doi.org/10.1891/1058-1243.22.2.83  Srinivas, S. (2009). Intermittent versus continuous bladder catheterization during labor: does it matter? Journal of Clinical Anesthesia, 20, 565-566. doi:10.1016/j.jclinane.2008.11.001  Hidaka, R., Callister, L.C. (2012). Giving birth with epidural analgesia: the experience of first-time mothers. The Journal of Perinatal Education, 21(1), 24-25, Retrieved from http://dx.doi.org/10.1891/1058-1243.21.1.24 References