Early Removal of Indwelling Urinary Catheter in Adult Patients

Abstract 

Catheter-associated urinary tract infections (CAUTI) are preventable by limiting urinary catheter use. This research paper takes an in-depth look at the relationship that exists between early removal of indwelling urinary catheter (UC) and lower prevalence of CAUTI. A systemic review of literature is used to provide reliable data on UC removal. The research addresses the significance of the afore-mentioned topic in clinical practice. It provides background information on indwelling catheter use. Results indicate that early removal of indwelling catheter reduces risks of CAUTI. The PICO framework formulates the research question for analyzing key concepts needed to complete this study

Significance 

Urinary Tract Infection accounts for 36% of all healthcare-associated infections (HAI) (Parker et al., 2017). It affects an estimated 449,334 adults per year, incurring the US government a total of $749 per admission (Meddings et al., 2014). About 12% to 16% of all hospital inpatients and ICU patients receive an indwelling urinary catheter (Parker et al., 2017). Research from Cadth Rapid Response Report indicates that indwelling catheters are inappropriate for patients experiencing discomfort, obesity, urinary obstructions, and upper-extremity impairment (Lachance & Grobelna, 2019). However, certain situations are clear indicators for catheter use including management of immobilized patients, increasing comfort in end of life care and hourly urine measurement for critically ill patients (Lachance & Grobelna, 2019). The US is taking stringent measures to eradicate CAUTI through non-payment by Medicare as of October 2008 (Meddings et al., 2014). Such efforts have not reduced CAUTI rates seeing that 26893 cases were recorded in 2016 in acute care hospitals. CAUTI is highly associated with increased length of hospitalization, mortality, and morbidity. Standard care of indwelling catheters is resource-intensive (Clarke et al., 2019). Costs can be minimized through early removal if placement of an indwelling catheter is deemed unavoidable (Kranz et al., 2020). The ensuing discussion explores evidence that suggests that early removal of indwelling catheters reduces risk of CAUTI more than standard care.

Background 

Urinary catheters can be external, internal (indwelling, urethral) or suprapubic (Lachance & Grobelna, 2019). External catheters are placed on the outside of the body and are less invasive compared to indwelling catheters, which are inserted through transurethral prostatectomy (Lachance & Grobelna, 2019). Considering indwelling urinary catheters are the most common form of short-term bladder drainage, patients suffering from chronic urinary retention undergo catheterizations on a scheduled basis. Long-term usage of indwelling catheters exposes patients to urethral trauma, catheter encrustation, urethral or perineal irritation, and compromised mobility (Parker et al., 2017). CAUTI risks are further increased by lack of resources to facilitate constant catheter care and minimal nurse support for such conditions (Clarke et al., 2019). Physicians initiate strategies prompting the removal of an indwelling catheter that is no longer needed. Kranz et al. (2020) assert that 41% of physicians in the USA lack prior information on whether a patient under their care was catheterized. Essentially, applying interventions that facilitate early removal of indwelling catheters can alleviate risks of CAUTI.

In critical urinary cases, insertion of an indwelling catheter is the only viable solution. To reduce prevalence of CAUTI, the 2017 and 2018 NICE guidelines provide integral instructions in handling urethral catheters (Lachance & Grobelna, 2019). The 2018 NICE guidelines suggest prescription of antibiotic prophylaxis drugs to prevent and manage CAUTI infections (Lachance & Grobelna, 2019). It also recognizes that antibiotic drugs can disrupt current patient health outcomes and recommends that physicians remove the catheter as soon as possible. In situations where complete removal is not possible, the guidelines recommend changing catheters for hospitalized adults within seven days of initial placement (Lachance & Grobelna, 2019). Meddings et al. (2014) suggest that the most effective strategy to handle standardized care is creating a catheter reminder checklists, which alert nurses and physicians that the catheter is still in place. However, Meddings et al. (2014) reiterate that these reminders can be easy to ignore or miss when healthcare providers are in stressful situations.

The next type of intervention, in cases where physicians miss a reminder, is a “stop order.” Stop orders require that catheters be removed after a set period. The physician can only reinsert the catheter through an order renewal. Clarke et al. (2019) contend that stop orders are useful for reducing the duration of catheter placement allowing for early removal. This approach requires continuous documentation and education of bedside nurses and physicians in addressing catheter removal (Clarke et al., 2019). Meddings et al. (2014) identify two barriers in the implementation of early removal protocols, which include active resisters who avoid change in practice and mid-level executives who cut costs by delaying interventions. Hospitals can avoid unnecessary costs of administering antibiotics by strictly implementing early removal policies (Clarke et al., 2019).

My PICO question is: In hospitalized adult patients (P), does early removal of indwelling urinary catheter (I), decrease the risk of CAUTI (O), as compared to standard care of indwelling urinary catheter (C)?Nurses must commit to applying interventions that negate insertion of unnecessary indwelling catheters and early removal to minimize risks of CAUTI. Maximizing early removal of indwelling catheters requires that nurse-initiated removal protocols be adhered to professionally.

References

Clarke, K., Hall, C., Wiley, Z., Tejedor, S. C., Kim, J., Reif, L., Jacob, J. (2019). Catheter-Associated Urinary Tract Infections in Adults: Diagnosis, Treatment, and Prevention. Journal of Hospital Medicine , E2-E5. http://doi.org/10.12788/jhm.3292 

Kranz, J., Schmidt, S., Wagenlehner, F., & Schneidewind, L. (2020). Catheter-Associated Urinary Tract Infections in Adult Patients: Preventive Strategies and Treatment Options. Deutsches Ärzteblatt International , 117(6), 83-88. http://doi.org/10.3238/arztebl.2020.0083 

Lachance, C., & Grobelna, A. (2019). Management of Patients with Long-Term Indwelling Urinary Catheters: A Reviewof Guidelines. CADTH , 1-25.

Meddings, J., Rogers, M., Krein, S., Fakih, M., Olmsted, R., & Saint, S. (2014). Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Quality & Safety , 23(4), 277–289. http://doi.org/10.1136/bmjqs-2012-001774 

Parker, V., Giles, M., Graham, L., Suthers, B., Watts, W., O’Brien, T., & Searles, A. (2017). Avoiding inappropriate urinary catheter use and catheter-associated urinary tract infection (CAUTI): a pre-post control intervention study. BMC Health Services Research , 17(314), 1-9. https://doi.org/10.1186/s12913-017-2268-2 

Appendix I: PICO Table 

PICO Question: In hospitalized adult patients, does early removal of indwelling urinary catheters decrease the risk of CAUTI, as compared to standard care of indwelling urinary catheter?