Catheter Misuse and Overuse

The problem has serious consequences and has proven difficult to solve

Common, convenient, reassuring. Also uncomfortable, easily forgotten—and often unnecessary. In brief, a bundle of contradictions.

I’m talking about urinary catheters.?

Internal urinary catheters help patients during and after surgery and, for some, become part of day-to-day life. It is difficult to overstate how common they are: by some estimates, close to a quarter of patients in US hospitals are fitted with a catheter.1

This would not be a problem if not for the complications associated with these devices, notably catheter-associated urinary tract infections (CAUTI), paraphimosis, and urethral stricture.1 CAUTIs alone can lead to such serious complications as sepsis and endocarditis. Approximately 13,000 US deaths per year have been linked to health-care-associated UTIs,2 and a UK model estimated an annual excess of 45,000 bed days and 10,000 lost QALYs from CAUTIs.3

Given their prevalence and morbidity, it comes as no surprise that CAUTIs have been on payers’ radar. They were one of the first hospital-acquired conditions selected for non-payment by Medicare in 2008 and have since been targeted for complete elimination.? This has proved more challenging than anticipated.

The search for solutions

Hospitals sometimes aggregate CAUTI prevention strategies into a composite set of interventions colloquially known as “bladder bundles.”? These bundles may include bladder ultrasound to identify situations that don’t warrant a catheter, improving clinical skill in catheter placement, catheter restriction and removal protocols, and education. These items sound good on paper but require a lot of resources. Perhaps more importantly, the entrenched use of catheters among doctors and nurses can lead to therapeutic inertia and resistance to change.

Even when hospitals implement targeted strategies to change practice, results may disappoint. In 2018, one center reported on an intervention called SafetyLEAP, adopted in the center’s internal medicine wards to decrease catheter use. The catheter point prevalence did indeed drop from 22% to 13%, but the ratio of catheter days to patient days declined only modestly (0.14 to 0.12) and the rate of CAUTI remained unchanged.?

Another study reported in the same year, involved over 1,000 patients in a tertiary care center. The institution implemented a multipronged program that required a physician to specify a “reason to continue catheterization” if the catheter had been in for 48 hours after surgery. Despite near-perfect adherence to the intervention, CAUTI rates didn’t budge.?

Compounding the problem, clinical guidelines on appropriate catheter use can be quite vague. As an example, the CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections recommends using urinary catheters in operative patients “only as necessary, rather than routinely” and leaving them in place “only as long as needed”—but leaves the definitions of “necessary” and “as needed” in the air.? Such tentative language may lead clinicians to define “unnecessary catheter use” too conservatively, thus keeping CAUTI levels higher than they need to be.

Outside the box

The term “thinking outside the box,” while a cliché in business circles, has literal significance in this case. Rather than continually chasing the magic catheter protocol that will finally change CAUTI outcomes, hospital personnel have an opportunity to “cut CAUTI off at the roots” by replacing internal with external catheters. Not only do external devices reduce the risk of CAUTI, but patients appreciate their simplicity and convenience.?

It goes without saying that not all external catheters are created equal. In my next installment, I’ll talk about two features that make my favorite one stand out.

References

1. Gunjan G et al. Urinary catheterization from benefits to hapless situations and a call for preventive measures. J Family Med Prim Care 2016;5:539.
2. Letica-Kriegel AS et al. Identifying the risk factors for catheter-associated urinary tract infections: a large cross-sectional study of six hospitals. BMJ Open 2019;9:e022137.
3. Smith DRM et al. Epidemiology and health-economic burden of urinary-catheter-associated infection in English NHS hospitals: a probabilistic modelling study. J Hosp Infect 2019;103:44-54.?
4. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates. Fed Regist 2008;73:48473–91.
5. Meddings J et al. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Quality & Safety 2014;23:277.
6. Wooler KR et al. A pre and post-intervention study to reduce unnecessary urinary catheter use on general internal medicine wards of a large academic health science center. BMC Health Serv Res 2018;18:642.
7. Kaplan JA. Near-perfect compliance with SCIP Inf-9 had no effect on catheter utilization or urinary tract infections at an academic medical center. Am J Surg 2018;215:23.
8. CDC 2009 Summary of Recommendations: Guideline for Prevention of Catheter-Associated Urinary Tract Infections. https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html?