1. CHAMP Foley Catheter Use
Catherine E. DuBeau, M.D.
University of Chicago

2. 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
Elaborate the content of the bullet points: This slide describes the main learning objectives of this module. In order to meet these objectives, the module will use didactic content review and description of triggers for bedside teaching.

3. Outline Scope of the problem Rationale for targeting catheter use
Appropriate indications for catheter use
Catheter management
Trouble-shooting failure to void
Teaching triggers
Segue from previous slide and main point: Specific topics to be covered in the module. Link and elaborate the content of the bullet points: Self-explanatory

4. 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
Segue from previous slide and main point: As topics are discussed, those that link to other CHAMP modules will be highlighted in red, and >>>>>
PAULA/ALIZA – WILL OTHERS HAVE LINKS TO CHALK/CHALK EQUIVALENT? HOW SHOULD THIS BE STATED?

5. 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)
Segue from previous slide and main point:Urinary catheters are a well established, prevalent and morbid hazard of hospitalization. Link and elaborate the content of the bullet points: Repeated studies have described the prevalence of urinary catheters in hospital settings and directly linked their use to nosocomial infections, particularly urinary tract infections. Another hazards of catheters especially relevant to older patients is that they are restrictive and can in fact act as what has been called a “one point restraint.” They also lead to direct physical trauma, as listed.

6. Scope of the Problem Prevalent and morbid PAIN DELIRIUM FALLS
25% of hospitalized pts have a catheter
Cause 40% of nosocomial infections
Uncomfortable and restrictive (“one-point restraint”)
Urethral and meatal trauma
Segue from previous slide and main point: Catheter morbidity is linked to other hazards of hospitalization, including pain, delirium and falls. Learners should be directed to these other modules.
PAIN
DELIRIUM
FALLS

7. 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
Segue from previous slide and main point: Catheter morbidity is compounded by important systems issues in their use and management. Link and elaborate the content of the bullet points: Physicians are often unaware of which patients under their care have a catheter in place and this lack of knowledge contributes to inappropriate management. When it comes to caring for patients catheterized for inability to void (retention), internists usually have had little training or direct experience, and have to rely on urological consultation– which may help with specific problem solving but which doesn’t facilitate systems changes or learning.

8. Rationale for targeting catheters
Morbidity
Quality
Expense
Segue from previous slide and main point: The rationale for targeting cathetr management extends beyond morbidity and includes quality issues and expense.

9. Morbidity External 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
Segue from previous slide and main point: Morbidity associated with urinary catheters is extensive and not limited to indwelling catheters. Link and elaborate the content of the bullet points: As mentioned earlier, infection is a main morbidity from catheters. All patients have polymicrobial bacteriuria by 30 days of catheterization, and is present in many much earlier. This in turn results in UTI and fever, and also persistent upper track infection. UTIs with urea-splitting organisms such as Proteus species can lead to development of stones. Non-infectious complications included mechanical injury and discomfort which can lead to agitation.
External catheters are not necessarily safer or less morbid, and can also lead to bacteriuria and infection. In men, condom catheters can lead to penile injury, and if the catheter twists and obstructs it can cause urinary retention.

10. Morbidity DELIRIUM External 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
Segue from previous slide and main point: Morbidity associated with urinary catheters is extensive and not limited to indwelling catheters. Link and elaborate the content of the bullet points: As mentioned earlier, infection is a main morbidity from catheters. All patients have polymicrobial bacteriuria by 30 days of catheterization, and is present in many much earlier. This in turn results in UTI and fever, and also persistent upper track infection. UTIs with urea-splitting organisms such as Proteus species can lead to development of stones. Non-infectious complications included mechanical injury and discomfort which can lead to agitation.
External catheters are not necessarily safer or less morbid, and can also lead to bacteriuria and infection. In men, condom catheters can lead to penile injury, and if the catheter twists and obstructs it can cause urinary retention.
DELIRIUM

11. Morbidity
More people die from hospital-acquired infections than from auto accidents and homicides combined
Segue from previous slide and main point: Catheter-associated infections are not just morbid, but result in significant mortality.

12. Quality
Joint Commission Patient Safety requirement: reduce the risk of health care-acquired infections
Illinois: Public Act , SB 59, 2003: mandates quarterly reporting of hospital infection rates, with yearly publishing by hospital
Consumers: StopHospitalInfections.org
Segue from previous slide and main point: The second reason for targeting catheter use as a hazard of hospitalization is its prominence in important quality initiatives, especially in regard to the association between catheter use and infection. Link and elaborate the content of the bullet points: At the national level, JCAHO’s Patient Safety requirements put a significant emphasis on reducing the risk of health-care acquired infections, including catheter-associated UTIs. Individual states may have their own initiatives, such as Illinois, which mandates quarterly public reporting of hospital infection rates. And there are consumer-based initiatives, such as the group Stop Hospital Infections.

13. Expense Unnecessary equipment and labor costs
Hospital infections cost $5 billion annually
Longer length of stay
Segue from previous slide and main point: The third reason to target catheters for teaching and systems changes is the associated increase in hospitals expenses. Link and elaborate the content of the bullet points: Inappropriate or prolonged catheter use results in unnecessary equipment and labor costs. The associated infections add to the expense, and contribute to the $5 billion annual cost of nosocomial infections. Finally, catheter use has been associated with longer lengths of hosptial stay, further adding to costs.

14. Expense Unnecessary equipment and labor costs
Hospital infections cost $5 billion annually
Longer length of stay
Segue from previous slide and main point: The associated longer length of stay with catheter use is linked with other hazards of hospitalization for older patients, specifically iatrogenic illness and functional decline.
IATROGENIC ILLNESS FUNCTIONAL DECLINE

15. Indications for using catheters
There are only FOUR indications:
Inability to void
Incontinence AND
Open wounds needing protection
Terminal illness/palliative care
Monitor urine output AND patient unable to assist/comply
After anesthesia (short term only)
Segue from previous slide and main point: Given catheter morbidity and the high prevalence of inappropriate catheter use, it is imperative to know the appropriate indications for placing a catheter, of which there are only four. Link and elaborate the content of the bullet points: The indications are inability to void (urinary retention); incontinence but only with coexistent open wounds that in a location that requires protection from urine contamination, or in situations of terminal illness and palliative care, in which the patient chooses to have a catheter placed for convenience or inability to comfortably or easily toilet. The third reason is the need for strict monitoring of urine output, but only in those situations where the patients themselves are unable to assist with urine collections or comply with instructions. Finally, catheters are appropriate for short term use immediately after anesthesia when voiding may be impaired.

16. 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)
Segue from previous slide and main point: There are specific guidelines for management of appropriately placed catheters. Link and elaborate the content of the bullet points: All catheters should be managed with a closed drainage system. Long-term catheters should be changed when there is infection. The standard of practice is monthly changes, but this has not been well studied and catheters may be left in longer if there are no complications. A common problem is leakage of urine around the catheter. Although many respond by increasing catheter size, a small size catheter with a smaller balloon or decreasing balloon size by removing some fluid is preferable. Large balloons can irritate the bladder causing uninhibited contractions that cause the leakage. All patients with leakage around the catheter should be checked for UTI. If there is no infection and leakage continues despite changes in balloon size, other options are pyridium (100 mg tid – qid), which acts as a topical bladder anesthetic, or bladder relaxants (Detrol, Ditropan or similar agents). However, bladder relaxants should not be used in patients who are catheterized for urinary retention, as these agents will exacerbate and/or prolong the retention.

17. Trouble-shooting insertion
“Can’t pass”
Discomfort/spasm at sphincter:
Use lidocaine gel
Insert with slight ‘torque’ while patient exhales
Try larger catheter
Coudé catheter
Inflate the balloon only after catheter is inserted all the way in, up to the meatus
Segue from previous slide and main point: There are specific suggestions for proper catheter insertion and trouble-shooting difficulty passing a catheter. Link and elaborate the content of the bullet points: Often, the problem with difficulty passing a catheter (especially in men) is not urethral narrowing obstruction but pain and spasm at the level of the urethral sphincter. This can be overcome with insertion of lidocaine gel into the urethra before trying to pass the catheter, holding the penis upright (“anatomical position”), and a gentle push with a torque or twist while the patient exhales. With urethral narrowing, larger catheters are more likely to pass successfully, and/or a catheter with a Coude tip can be used. In all cases, the catheter should be inerted all the way into the bladder, ie with the hub all of the way to the meatus, before the balloon is inflated. Otherwise, one risks infalting the balloon within the urethra.

18. Trouble-shooting failure to void
Two basic reasons
Poor pump
Blocked outlet
Segue from previous slide and main point: The other major issue for trouble-shooting is why a patient has urinary retention or failure to void, for which there are only two basic causes. Link and elaborate the content of the bullet points: Bladders fail to empty because of either a “poor pump” (weak or nonexistent contractions) or there is blockage of the bladder outlet/urethra.

19. Trouble-shooting failure to void
Two basic reasons
Poor pump
Blocked outlet
Segue from previous slide and main point: The other major issue for trouble-shooting is why a patient has urinary retention or failure to void, for which there are only two basic causes. Link and elaborate the content of the bullet points: Bladders fail to empty because of either a “poor pump” (weak or nonexistent contractions) or there is blockage of the bladder outlet/urethra. The “action” of the bladder pump is driven by acetylcholine and calcium. Inhibiting these actions (click twice for animated red lines) with drugs such as anticholinergics and calcium channel blockers will result in poor pump performance. Sphincter closure is under the control of alpha adrenergic receptors. Stimulating these receptors, eg, with drugs such as the alpha agonists found in over-the-counter cold tablets (click for animated red line), will result in sphincter closure and outlet obstruction.
Pump action: Ach, Ca++
Sphincter closure: Alpha adrenergic

20. 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
Segue from previous slide and main point: The two basic reasons for failure to void have a straightforward differential diagnosis. Link and elaborate the content of the bullet points: Reasons for weak bladder contractions include:
Medications, specifically anticholinergics (which block muscarinic receptors responsible for bladder contraction) and calcium channel blockers (which relax bladder smooth muscle).
Disease or injury to the sacral spinal cord or conus, because the nerves mediating bladder contraction are at sacral levels S2-4
Peripheral neuropathies, as indicated
And constipation, which may set up reflex inhibition of bladder contraction
Reasons for bladder outlet obstruction include:
Benign and malignant prostate disease
Medications: alpha-blockers cause contraction of sphincter smooth muscle and can precipitate retention in men (especially if combined with anticholinergics, as in OTC cold tablets)
Neurological disease, specifically supra-sacral spinal cord injury, which results in reflex urethral sphincter contraction at the same time as bladder contraction, a condition called bladder-sphincter dyssynergia
In women, scarring from previous anti-incontinence surgery, or in some cases large cystocele or prolapse (which can kink and obstruct the urethra)
Constipation, from mechanical compression from the large rectal stool mass
Prostate disease
Meds: alpha-agonists
Neurological disease: dyssynergia
Women: scarring, cystocele
Constipation

21. Teaching Triggers
Segue from previous slide and main point: The next step is to apply this content in bedside teaching by recognizing and responding to specific situational triggers.

22. 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
Segue from previous slide and main point: The systems approach to appropriate catheter management and teaching begins with vigilance for catheter use in every patient. Link and elaborate the content of the bullet points: Knowing that physicians are unaware of the presence of a catheter in a third of their patients that have one, the first action step is assessing every patient at the bedside for the presence of a catheter, and emphazing/modeling the need to do so with housestaff. If a catheter is found, this becomes the trigger for the teaching appropriate indications for catheter use.

23. 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
Segue from previous slide and main point: Recall and review the main indications for appropriate use of catheters.

24. Action step 1: Look for catheter on every patient when at bedside
Trigger: Catheter found
“Why does this pt have a catheter?
Segue from previous slide and main point: Even if the housestaff know of catheter presence and report an appropriate indication for its use, further teaching can be done (Action step 2).
Appropriate indication
Action Step 2

25. Action step 2: “Does this patient still need the catheter?
Yes
Action step 3
Segue from previous slide and main point: This second action step is to ask whether the catheter is still needed or can be discontinued. Link and elaborate the content of the bullet points: If the catheter is still indicated, further teaching can follow from Action Step 3.

26. Action step 3: “Does this patient have a medical reason for inability to void?
A. Review MAR
B. Review medical history
Segue from previous slide and main point: With patients still have an appropriate indication for the catheter, the next teaching points are on the assessment of the medical reasons for failure to void. Link and elaborate the content of the bullet points: After describing the two main reasons for failure to void, steps to take with the team are 1) review the medicine administration record (MAR) for anticholinergics, calcium channel blockers, alpha agonists; 2) Review medical history for conditions associated with impaired bladder contraction or outlet obstruction, as discussed earlier; and 3) consider doing additional examination of sacral reflexes and pelvis (women) with the team, and reviewing whether or not a post voiding residual was done.
C. *Additional exam, Post voiding residual

27. Sacral Reflexes Clitoris Bulbocavernosus Reflex Anus Anal wink
Segue from previous slide and main point: Beside testing of sacral root reflexes is feasible and straightforward. Elaborate the content: There are two reflexes to test sacral levels S2-4, the anal wink and bulbocavernosus. For the anal wink, instruct the patient to relax his/her perineum, then lightly scratch along the side of the rectum. You should see the anus contract (“the wink”). Repeat on the other side. False-negative results can be due to the patient’s failing to relax. If the anal wink is negative, then the bulbocavernosus (BC) reflex can be done as a backup. The stimulus for the BC is to lightly squeeze the clitoris in a woman or the glans penis in a man; you are looking for the same reflex anal contraction as in the anal wink. If the BC is negative, it can be double-checked by palpation: insert a finger in the patient’s rectum, repeat the BC stimulus, and assess for anal contraction.
Anus
Anal wink
Adapted from Geriatric Review Syllabus Urinary Incontinence slide set, American Geriatric Society, 2006

28. Pelvic Exam Cystocele Rectocele
Segue from previous slide and main point: Bedside evaluation for pelvic prolapse in women can be done with a “split speculum” exam. Link and elaborate the content of the bullet points Separate the speculum and use only the bottom blade. First, insert the bottom blade and pull it down slightly to support the posterior vaginal wall. This will give you a good view of the urethra and anterior vaginal wall. Have the patient cough or strain.
In the left photo, note that the anterior vaginal wall prolapses into and through the vaginal introitus; this is a cystocele. Also note a small violaceous nodule at the urethral meatus—this is a urethral caruncle, a benign finding associated with vaginal atrophy. Note that the bottom of the tissues supporting the urethra are flat, and almost an inverted “U”; in women with intact pelvic support, these tissues would in fact be “U” shaped, and analogous to the musculofascial “hammock” that provides urethral support.
To assess the posterior vaginal wall, turn the single speculum blade around and use it to support the anterior wall. Again have the patient cough or strain. In the right-side photo, note bulging of the posterior wall, again just through the introitus. This is an example of a rectocele.
Cystocele
Rectocele
Photographs from: Abrams P, Cardozo L, Khoury S, Wein A, ed. Incontinence. 2nd International Consultation on Incontinence.
Plymouth UK: Health Publications Ltd, 2002; pp

29. Action step 2: “Does this patient still need the catheter?No
Action step 4
Segue from previous slide and main point: Another teaching opportunity arises when a patient with a catheter no longer has an appropriate indication for it.

30. Action step 4: Discontinue all catheters before discharge unless there is chronic retention
Segue from previous slide and main point: This teaching point is to discontinue all catheters before the patient is discharged, unless the patient remains with or has chronic retention.

31. Action step 4: Discontinue all catheters before discharge unless there is chronic retention
Segue from previous slide and main point: This teaching point is to discontinue all catheters before the patient is discharged, unless the patient remains with or has chronic retention.
TRANSITIONS OF CARE

32. A. Deflate balloon and remove catheter (never clamp!)
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
Segue from previous slide and main point: Specific steps should be followed when catheters are discontinued. Link and elaborate the content of the bullet points: Clamping the catheter before removal is not necessary and will only result in bladder overdistention which can prolong retention. During the voiding trial after catheter removal, patients must have sufficient fluid intake to insure an adequate urine output; if urine output is too low, then voiding may not be necessary. Patients should be monitored for 8 hrs after catheter removal; this can be facilitated by removing the catheter very early in the morning.

33. Action step 4: Discontinue all catheters
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
Segue from previous slide and main point: Completing the voiding trial after catheter removal. Link and elaborate the content of the bullet points: If after 8 hours the patient has not voided, reinsert the catheter to check bladder volume. If the volume is less than 200 ml, failure to void may be due to inadequate bladder volume. Therefore increase fluids and repeat voiding trial, as well as re-review the causes of failure to void to make sure none have been overlooked/insufficiently treated.
If the patient voids during the 8 hr period, check the PVR after the first void. If the PVR is less than 100 ml in men or 200 ml in women, voiding is satisfactory and the patient can continue without a catheter. If however the PVR is higher, then the catheter should be reinserted and causes of failure to void re-reviewed. Note that these PVR cut-off levels are empiric, and may be individualized. For example, if the PVR is 250 ml in a woman and good follow up is possible, then voiding symptoms and the PVR can be followed and re-assessed after discharge.
PVR < 100 (men) or <200 (women): done
Higher PVR: re-insert, review causes of failure to void

34. Does the pt have a Foley? Why does pt have Foley?
YES
Why does pt have Foley?
Review the 4 indications
Does the pt still need Foley?
Appropriate
Inappropriate NO
YES
Medical reason for inability to void?
Review PMHx, MAR, exam
Segue from previous slide and main point: This slide summarizes the action steps for bedside teaching about catheter use. Link and elaborate the content of the bullet points Separate the speculum and use only the bottom blade. First, insert the bottom blade and pull it down slightly to support the posterior vaginal wall. This will give you a good view of the urethra and anterior vaginal wall. Have the patient cough or strain.
Plan to D/C Foley

35. 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
Segue from previous slide and main point: After proceeding through the action steps, there will be some patients will need to leave the hospital with a catheter in place. Link and elaborate the content of the bullet points: Appropriate patients for discharge from the hospital with catheter in place are those who have failed a voiding trial and are otherwise ready for discharge; and patients who had a catheter placed for acute urinary retention who have not completed a full 7 days of bladder decomprssion. Such patients will need primary care, urology, and/or home nursing follow-up for monitoring symptoms and catheter problems and to conduct the voiding trial. Other issues for these patients in arranging transition for care include provision of a urine leg bag for daytime use and a large volume bedside bag for overnight; and family/caretaker instruction on catheter management and monitoring for symptoms of catheter complications and infection as listed.

36. 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
Segue from previous slide and main point: For either immediate or follow-up management, it is important to identify patients who should be referred to a urologist. Link and elaborate the content of the bullet points: In the inpatient setting, urology should be consulted when catheters insertion fails, or if a patient with a catheter develops large volume hematuria that fails to clear with irrigation. This is particularly important as large blood clots may block the catheter. Urology should also be consulted (usually for outpatient follow-up) for patients with unresolved urinary retention.

37. 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?
PAULA/ALIZA – KEEP THIS SLIDE FOR POGO-E? IF SO, HOW TO REFER PEOPLE TO APPROPRIATE TTW MATERIALS?