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Indwelling urinary cathetersare widely used in hospital-ized patients and can be anappropriate means of thera-

peutic management under specif-ic circumstances. However, manyindwelling urinary catheters areused without clear indications(Gokula, Hickner, & Smith, 2004;

Jain, Parada, David, & Smith,1995), thus putting patients at anunnecessary risk for complica-

tions during their hospitaliza-tion. Catheter-associated compli-cations include physical andpsychological discomfort to thepatient, bladder calculi, renalinflammation, and most fre-quently, catheter-associated uri-nary tract infections (CAUTI)(Gokula, Smith, & Hickner,2007). The development of CAUTI in older adults can resultin falls, delirium, and immobility(Hazelett, Tsai, Gareri, & Allen,

2006).

A Review of Strategies to

Decrease the Duration of IndwellingUrethral Catheters and PotentiallyReduce the Incidence of Catheter-Associated Urinary Tract Infections

Michael S. Bernard, Kathleen F. Hunter, and Katherine N. Moore

Michael S. Bernard, MN, RN(EC), NP- Adult, is a Nurse Practitioner, VON 360 Degree Nurse Practitioner-Led Clinic,Peterborough, Ontario, Canada.

Kathleen F. Hunter, PhD, RN, NP GNC(C),is an Assistant Professor, University of Alberta, Edmonton, Alberta, Canada.

Katherine N. Moore, PhD, RN, CCCN,is a Professor, University of Alberta,

Edmonton, Alberta, Canada.

Research

Urinary tract infections (UTIs)account for at least 35% of all hos-pital-acquired infections (Hart,2008), with 80% of those beingattributed to the use of indwellingcatheters (Gokula et al., 2007). Inaddition to the impact on qualityof life, CAUTIs place a financial

burden on the health care systemin terms of treatment and in-creased length of stay. The exactcost of CAUTI is difficult to calcu-late due to changes in clinical and

billing practices (Saint, 2000).

However, in the U.S., concern overcare costs resulting from a largelypreventable problem has resultedin changes to the Centers forMedicare & Medicaid Services’(CMS) reimbursement system,with hospitals no longer receivingadditional payment for CAUTIsthat were not present at the time of admission (Wald & Kramer, 2007).

In addition to financial cost,CAUTIs affect patient well-being.In a systematic review that exam-

ined the clinical and economic

© 2012 Society of Urologic Nurses and Associates

Bernard, M.S., Hunter, K.F., & Moore, K.N. (2012). A review of strategies todecrease the duration of indwelling urethral catheters and potentially reducethe incidence of catheter-associated urinary tract infections. Urologic Nursing, 32(1), 29-37.

The use of indwelling urinary catheters in hospitalized patients presents an increased risk of the development of complications, including catheter-associated urinary tract infection (CAUTI). With regard to the risk of developing a CAUTI,the greatest factor is the length of time the catheter is in situ. The aim of this arti- cle is to review the evidence on the prevention of CAUTI, particularly ways to ensure timely removal of indwelling catheters. Published studies evaluating inter-

ventions to reduce the duration of catheterization and CAUTI in hospitalized patients were retrieved. The research identified two types of strategies to reduce the duration of indwelling urinary catheters and the incidence of CAUTI: nurse- led interventions and informatics-led interventions, which included two subtypes: computerized interventions and chart reminders. Current evidence supports the use of nurse-led and informatics-led interventions to reduce the length of catheterizations and subsequently the incidence of CAUTI.

Key Words: Catheter-associated urinary tract infection (CAUTI),indwelling urinary catheters, informatics, hospital-acquiredinfections, bacteremia.

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consequences of bacteriuria fromcatheters, 3.6% of those withsymptomatic UTI also developed

bacteremia, and mortality from bacteremia can be as high as 10%(Saint, 2000). Although morbidi-ty and mortality rates are rela-tively low from CAUTIs com-pared to other hospital-acquiredinfections, the use of urinarycatheters in hospitalized patientsleads to a large cumulative risk

burden for mortality (Gouldet al., 2009). Potentially seriouscomplications associated withindwelling urethral catheters and

the possible development of CAUTI warrant efforts to restrictthe use of these devices by hav-ing clear indications for insertionand discontinuation.

Indications for Indwelling UrinaryCatheter Use

Indications for short-termcatheterization (less than 30 days)have been described by severalauthors (Gokula et al., 2007;

Gould et al., 2009; Hooton et al.,2010; Nazarko, 2008). Theseinclude a) urinary retention,

b) obstruction to the urinary tract,c) close monitoring of the urineoutput of critically ill patients,d) urinary incontinence that posesa risk to the patient because of Stage 3 or greater ulcer to thesacral area, and e) comfort care forterminally ill patients. Despitesuch recommendations andguidelines, catheters are often

placed for inappropriate or poorly

documented reasons (Gokulaet al., 2004; Jain et al., 1995;Munasinghe, Yazdani, Siddique,& Hafeez, 2001; Raffaele, Bianco,Aiello, & Pavia, 2008). Amonghospitalized patients, the rate of unnecessary urethral catheteriza-tion has been reported between21% and 50% (Gardam, Amihod,Orenstein, Consolacion, & Miller,1998; Gokula et al., 2004; Jainet al., 1995; Saint, 2000). Themajority of inappropriatelyplaced catheters are initiated andinserted in the emergency depart-ment (Gokula et al., 2007;

Munasinghe et al., 2001). Urinarycatheters are inserted without aphysician order in as many asone-third of patients, and even if an order is recorded, no docu-mented rationale is provided. Thelack of documented rationale wasidentified several years ago(Gardam et al., 1998) and remainsan ongoing problem (Gokula et al.,2004, 2007).

Individuals 65 years of age orolder are at increased risk for unnec-

essary catheterization (Gokula et al.,2007; Holroyd-Leduc et al., 2007;Saint, 2000), a concern given theirhigh risk of developing complica-tions, particularly infection. Norecent research has been publishedon decision making related to theuse of indwelling catheterization,

but historically, the increased usein older adults has been an attemptto manage bladder emptying inthose with cognitive impairment,incontinence, and decreased func-

tion in carrying out activities of

daily living (Hampton, 2006;Hazelett et al., 2006) or conven-ience to staff (Jain et al., 1995;Saint, Lipsky, Baker, McDonald, &Ossenkop, 1999). Anecdotal evi-dence and case studies suggest thatthese reasons may continue insome settings.

Whatever the reason for inser-tion, assessment of the continuedneed for an indwelling catheter isoften overlooked, and cathetersthen remain in situ without prop-er indications (Jain et al., 1995;Rabkin et al., 1998). Dingwalland McLafferty (2006) reported

that although nursing staff haveknowledge about proper andimproper indications for urinarycatheters and associated risk,they continue to use indwellingurinary catheters for reasons of personal preference and do notassess their continual use. Evenwith the best nursing care forthose with indwelling urinarycatheters, each day presents anincreasing risk for infection,ranging from 3% to 10% (Hooten

et al, 2010; Saint, Lipsky, &Goold, 2002). Strategies should be developed to ensure thatcatheters are used only whenindicated and only for as long asthey are needed. Thus, the pur-pose of this review was to evalu-ate the current literature forresearch-based strategies to re-duce catheter insertion timeand to review the effects of thesestrategies on the duration of catheterization and incidence of

CAUTIs.

Research Summary

Introduction

Prevention of catheter-associated urinary tract infections(CAUTIs) has become a major focus of health care providers,accrediting agencies, and reimbursement sources.

Purpose

Evaluate current literature for research-based strategies

to decrease the length of time of catheter placement, theeffects of strategies on the duration and removal of catheters,and the incidence of CAUTI.

Methods

A search of electronic databases using key words yield-ed 53 abstracts that were appraised. Only 9 research stud-ies focused on reducing the duration of catheter use andCAUTI incidence.

Findings

The available evidence supports nurse-led or informat-ics-led interventions for reducing the length of catheteriza-tions and incidence of CAUTI. However, no specific interven-tion was clearly superior than the others.

Conclusions

More evidence, particularly through randomized con-trolled trials, to determine the best method of ensuring time-ly removal of indwelling urinary catheters in all settings isrequired.

Level of Evidence – V

(Melnyk & Fineout-Overholt, 2011)

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Methods

A search of the electronicdatabases MEDLINE, CINAHL,Cochrane Database, Google, andGoogle Scholar was conducted.Grey literature (abstracts fromconferences or presentations)was also sought for the years

2000 to 2010 using GoogleScholar.

Search terms were indwel -ling urinary catheter*, Foley catheter*, and urinary catheter*,UTI , added UTI*, bacturia,

pyuria, CAUTI*, catheter ac -quired urinary tract infection,acute care, acute-care, tertiary care, tertiary-care, and hospital-ized . Fifty-three abstracts wereappraised, and only researchstudies that addressed acute-care

patients, the timely removal of catheters (removal once nolonger indicated), and the out-come measures of duration of indwelling urinary catheter andincidence of CAUTIs wereincluded. Of the 53 abstractsreviewed, 9 were relevant to theresearch questions.

Evidence Base for StrategiesTo Decrease IndwellingCatheter Use

Nine studies were found thatfocused on reducing the durationof catheter use, and subsequent-ly, the incidence of CAUTIs (seeTable 1). Most of these studiesinvolved reminder systems totrigger the review for continueduse of indwelling urinarycatheters. Two key interventionswere noted: nurse-led (Crouzetet al., 2007; Elpern et al., 2009;Fakih et al., 2008; Huang et al.,2004; Robinson et al., 2007) and

informatics-led with two sub-types – computerized reminders(Apisarnthanarak et al., 2007;Cornia, Amory, Fraser, Saint, &Lipsky, 2003; Topal et al., 2005)and chart reminders (Loeb et al.,2008).

Nurse-led interventions. Nurse-led interventions utilize nursingstaff (charge nurse, clinical nursespecialist, or staff nurses) to assess,after a set period of time, whetheran indwelling urinary catheter is

still indicated for the patient. This

leads to a decision to discontinueor continue the catheter throughcollaborative discussion with thephysician or use of a standingorder. Elpern et al. (2009) em-ployed a quasi-experimental de-sign in a medical intensive careunit (ICU) at Rush Medical Center

(Chicago), including all patientsadmitted with an indwelling uri-nary catheter or with an in-dwelling urinary catheter insert-ed during their stay. The initialphase of the intervention was theidentification of patients with anindwelling urinary catheter by amember of the nursing staff. On adaily basis, in consultation withthe staff nurses and with thephysician, the investigatorsdetermined whether there wereappropriate indications for thecontinuation of the patients’catheters as defined in a litera-ture review on the indications foruse. Data were collected over asix-month period with outcomemeasures, days of catheter use,and rates of CAUTI. The prospec-tive data were compared to retro-spective data from the 11-monthpre-study initiation. Results indi-cated that the active interventionof daily consultation and reviewof the need for a catheter signifi-

cantly reduced the number of indwelling urinary catheter daysper month as well as the numberof CAUTIs.

Taiwanese researchers Huanget al. (2004) also investigated anurse-led intervention to discon-tinue indwelling urinary cath-eters. Participants were recruitedfrom five ICUs: cardiovascular,coronary care, surgery, neuro-surgery, and medicine. A 12-month observational period was

followed by a 12-month interven-tion period. Those with in-dwelling urinary catheters wereidentified through the computer-ized order entry system. Allpatients who had indwelling uri-nary catheters were included inthe study. Indications for inser-tion and continuation of thecatheters were defined; the pri-mary intervention was a dailyreminder to physicians by nurs-ing staff to remove catheters five

days after insertion. Overall,

there was a consistent decreasein the duration of catheters insitu from 7.0 +1.1 days to 4.6 +0.7 days and a statistically signif-icant reduction in incidence of CAUTI from 11.5 + 3.1 to 8.3 +2.5 per 1000 catheters days.

A French research group

(Crouzet et al., 2007) conducted aquasi-experimental study of anurse-led intervention in severalnon-critical acute care units(neurosurgery, cardiovascularsurgery, orthopedic surgery, neu-rology, and geriatrics). Allpatients who had undergone uri-nary catheterization in hospitalwere included. The study tookplace over six months, with athree-month observational phaseand a three-month interventionphase. During the observationalphase, CAUTIs occurred ondays 5 and 6 of catheterization;thus, the target day for removalwas day 4. Although there wasno overall reduction in length of time that the catheters were insitu (8.4 vs. 6.7 days), there was astatistically significant reductionin CAUTI (12.8 vs. 1.8). Theauthors attribute the improve-ment to increased surveillance aswell as decreased catheter days.

Fakih et al. (2008) used a

quasi-experimental design thatmade use of pre-existing, nurse-led multidisciplinary rounds andinvolved 10 nursing units overthree phases (pre-intervention,intervention, and post-interven-tion). Each unit served as a con-trol and as part of the interven-tion for one period of time.Nursing staff were given educa-tion on indications for urinarycatheters based on recommenda-tions of the Centers for Disease

Control and Prevention (CDC)(Gould et al., 2009). If no indica-tions existed for catheterizationduring the daily rounds, thenurses contacted the physicianfor an order to discontinue thecatheter. There was a statisticallysignificant reduction in the num-

ber of urethral catheterizationdays and the percentage of unnecessary catheter days in theintervention phase of the study.Unfortunately, the authors report

that once the study was complet-

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ed, on a subsequent visit to the site, there was aregression to pre-intervention practice in the post-intervention phase. This emphasizes the need foron-going support of staff in practice changes.

Robinson et al. (2007) used a mixed retrospec-tive and prospective study design. Patient recordsfor a two-week period were reviewed retrospec-tively to identify those who had had indwelling

urinary catheters. For many patients in this study,no appropriate reason could be identified, andmany developed CAUTIs. In the two-weekprospective arm, the charge nurses identifiedpatients without a clear indication for a catheter.The authors concluded that the charge nurses’active interventions in requesting discontinuationof unneeded catheters resulted in a 67% reduc-tion in the number of days of catheter use and a26% reduction in the number of CAUTIs whencompared to the results from the retrospectivearm.

Informatics-led interventions. Informatics-ledinterventions make use of technological informa-tion systems, including computerized, order-entrysystems that automatically prompt health carepractitioners to take action with regard to a speci-fied and defined intervention. Two studies werefound that described two types of order-entry sys-tems. The first was a computerized order-entryand charting system that prompted health careworkers to assess and reassess the indications forthe use of indwelling urinary catheters (Topol etal., 2003). The second involved recording the useof catheters in a computerized database, similar tomedication entry orders with automatic stoporders (Apisarnthanarak et al., 2007; Cornia et al.,

2003).Computerized interventions. Topal et al.

(2005) used the computerized order-entry andcharting system in four general medicine units atan acute care hospital in Connecticut. They useda quasi-experimental design over three collectioncycles, pre-intervention and intervention at twopoints, each of which was 53 days in duration. Ineach cycle, the researchers measured and record-ed the use of antimicrobials, the incidence of CAUTIs, and the duration of catheterization. Theintervention phase included two separate strate-gies. The first was to enter the indications for the

catheter being ordered into a computerized sys-tem in the emergency department and then send-ing these orders with the indications to the admit-ting doctors. The admitting doctors were thenprompted to choose one of three orders for thecontinuation of the indwelling urinary catheter:a) to discontinue the catheter, b) to maintain thecatheter for an additional 48 hours, and c) to leavethe catheter in place. The second strategy was toallow the nurses to discontinue catheters that nolonger had an indication based on their assess-ment and a standing order. Nursing staff receivededucation sessions on the indications forindwelling urinary catheters use, alternatives, and

T a b l e 1 .

S t u d i e s t h a t F o c u s e d o n t h e D u r a t i o n o f C a t h e t e r U s e w i t h N u r s i n g - L e d

I n t e r v e n t i o n s ( c o n t i n u e d )

A u t h o r / Y e a r

M e t h

o d s

P a r t i c i p a n t s

I n t e r v e n t i o n s

O u t c o m e s

C o m m e n t s

R o b i n s o n e t a l . , 2 0 0 7

M i x e d r e t r o s p e

c t i v e a n d

p r o s p e c t i v e d e s i g n .

T w o - w e e k n e e d s

a s s e s s m e n t f o l l o w e d b y a

t w o - w e e k p r o s p e c t i v e s t u d y .

P a t i e n t s w h o h a d u r i n a r y

c a t h e t e r s i n p l a c e o r p

l a c e d

o n a m e d i c a l u n i t a n d

a

s u r g i c a l u n i t .

T h e c h a r g e n u r s e i d e n t i f i e d

p a t i e n t s w i t h i n a p p r o p r i a t e

i n d w e l l i n g u r i n a r y c a t h e t e r s .

N u r s e s r e q u e s t e d a n o r d e r

f o r d i s c o n t i n u a t i o n o f u r i n a r y

c a t h e t e r s i f t h e y h a d n o c l e a r

i n d i c a t i o n b a s e d o n a p a s t

l i t e r a t u r e r e v i e w o n t h e

i n d i c a t i o n s f o r u s e .

P a t i e n t s w h o d e v e l o p e d U T I

s y m p t o m s a f t e r t h e

i n t e r v e n t i o n d e c r e a s e d f r o m

4 0 % t o 1 3 . 3 % .

N u m b e r o f d a y s c a t h e t e r s

w e r e i n p l a c e d e c r e a s e d

f r o m

a m e a n o f 8 . 5 7 ( 1 t o

3 6 ) t o 4 . 5 ( 1 t o 1 3 ) d a y s .

T h e f r e q u e n c y o f t h e

i n t e r v

e n t i o n i s n o t d e s c r i b e d .

H u a n g e t a l . , 2 0 0 4

T i m e - s e q u e n c e

n o n r a n d o m i z e d i n t e r v e n t i o n

s t u d y .

1 2 - m o n t h r e t r o

s p e c t i v e

o b s e r v a t i o n a l p

e r i o d t h r o u g h

c h a r t r e v i e w f o l l o w e d b y a

1 2 - m o n t h p r o s p e c t i v e

p e r i o d .

A l l p a t i e n t s a d m i t t e d w

i t h a n

i n d w e l l i n g u r i n a r y c a t h

e t e r o r

w h o h a d a c a t h e t e r p l a c e d ,

d u r i n g t h e s t u d y p e r i o d s .

D a i l y r e m i n d e r s t o p h y s i c i a n

f r o m

t h e n u r s i n g s t a f f t o

o b t a i n a n o r d e r f o r r e m o v a l

a f t e r f i v e d a y s o f i n s e r t i o n

t h a t w e r e n o l o n g e r

n e c e s s a r y .

C A U T I i n c i d e n c e d e c r e a s e d

f r o m

1 1 . 5 ± 3 . 1 t o 8 . 3 ± 2 . 5

p e r 1 0 0 0 c a t h e t e r d a y s

( p

= 0 . 0 0 9 ) .

D u r a t i o n o f c a t h e t e r i z a t i o n

d e c r e a s e d f r o m

7 . 0 + 1 . 1

d a y s t o 4 . 6 + 0 . 7 d a y s

( p

< 0 . 0 0 1 ) .

U n n e

c e s s a r y c a t h e t e r i z a t i o n

w a s n o t d e s c r i b e d .

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bladder scanning after removal toensure that patients were not inretention. The interventionsresulted in a 42% reduction inthe duration of catheterization,and follow up at one yearrevealed a 79% reduction in theduration of catheterization.

Cornia et al. (2003) utilized aquasi-experimental design todetermine the effect of a comput-erized reminder system on thelength of catheterization. Thestudy focused on patients admit-ted to medical and cardiovascu-lar wards at a city hospital inSeattle. They conducted thestudy on two floors, each of which contained a set of wards.One floor and its wards served asthe intervention group, and theother served as the control group.The intervention included acomputerized order-entry systemthat required the physician toindicate the rationale for initiat-ing catheters and after three days,added daily reminders to deter-mine whether the catheters werestill warranted. On the controlward, catheters were initiated aswritten orders, with no remindersystem. The number of days of catheterization between the twointervention and control units, as

well as the number of UTIs, werecompared after the first day of catheterization. The authorsreported a statistically significantreduction in the number of catheterization days from 8 to 5compared to the control ward.However, they did not find a sig-nificant reduction in the rate of CAUTI. A lack of blinding on thecontrol unit (knowing they werepart of a research study) mayhave changed practice so that

infection rates were reduced.In an inner-city hospital inThailand, Apirsarnthanarak et al.(2007) tested the computerizedorder-entry system to reduceindwelling urinary catheter use.The authors used pre- and post-measures to evaluate the efficacyof a program that focused on nurs-es’ reminders to physicians toorder the removal of unnecessarycatheters. The intervention was adaily reminder to the nurses onthe computerized order-entry sys-

tem to identify patients withcatheters that had been in place formore than three days and then tonotify the attending physicians if catheters were not indicated. Thenurses had been previously edu-cated on what constituted appro-priate indications based on the

authors’ review of the literature.The primary outcome measurewas the development of CAUTI,which the authors compared attwo points in time: pre-interven-tion and intervention. There was asignificant reduction in the num-

ber of catheter-utilization days,with a mean reduction from 11 to3 days, as well as a significantreduction in CAUTIs (see Table 2).

Chart reminders. In a ran-domized controlled trial in threeacute care hospitals in Ontario,where all patients had in-dwelling urinary catheters, Loebet al. (2008) utilized automaticstop orders through the medica-tion order-entry system. Subjectswere assigned either to a groupwith automatic stop orders or to acontrol group for which the cur-rent practice was maintained.The intervention consisted of anautomatic pre-written stop orderin the intervention group’s chartsto discontinue the use of the

catheter if there was no longer anindication for its use. Nursingstaff were required to select anindication if they wished tomaintain the indwelling urinarycatheter. The indications for useincluded urinary obstruction,neurogenic bladder, urinary re-tention, urological surgery, fluidchallenge for acute renal failure,open sacral wound for inconti-nent patients, and urinary incon-tinence in terminally ill patients.

There was a significant reductionin the number of days of catheteruse and a significant decrease inthe number of CAUTIs in theintervention group (see Table 3).

Discussion

The purpose of this reviewwas to discuss the currentresearch on strategies for timelyremoval of indwelling urethralcatheters and to assess the strate-gies on effectiveness and impact

on incidence of CAUTI. Only ninestudies were found that addressedthe topic. The available evidencesupports nurse-led or chartreminders to stimulate consistentdaily assessment of the continu-ing need for a catheter and toremove it as soon as possible.

Among the current studies, onlyone (Loeb et al., 2008) was a ran-domized controlled trial. Theexperimental design was possible

because of the unique computer-ized charting system in the studysetting, which allowed the easyidentification and randomizationof their participants. In the otherstudies, randomization into twogroups was not feasible becausethe nature of the interventionsmade it possible to carry them outonly in an entire hospital unit.

Another factor that reducedthe quality of the studies – ex-cluding those of Apisarnthanaraket al. (2007), Cornia et al. (2003),and Loeb et al. (2008) – was thelack of reported confidence inter-vals (CIs), which made it difficultto judge the precision of the sta-tistics, making the results lessreliable as predictors of the effec-tiveness of the interventions.

The studies took place acrossseveral settings: critical care

(Apisarnthanarak et al., 2007;Elpern et al., 2009; Loeb et al.,2008), medicine (Cornia et al.,2003; Fakih et al., 2008; Huanget al., 2004; Topal et al., 2005), andsurgical units (Crouzet et al., 2007;Robinson et al., 2007). Four coun-tries were represented: Canada(Loeb et al., 2008), France (Crouzetet al., 2007), the United States(Cornia et al., 2003; Elpern et al.,2009; Fakih et al., 2008; Huanget al., 2004; Robinson et al., 2007;

Topal et al., 2005), and Thailand(Apisarnthanarak et al., 2007). Thepotential differences in health carepractices and education in thesesettings could affect the generaliz-ability of the results. Moreover, allinterventions, whether nurse-ledor informatics-led, demonstrated asignificant reduction in the dura-tion of catheterization. However,practice change may be limited toparticular settings because of resource issues. For example, to beimplemented, an intervention that

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catheters in all settings. The cur-rent studies identify both nurse-led and informatics-led interven-tions as successful in reducingthe length of catheterizations,and subsequently, the incidenceof CAUTI. Research into the bar-riers of translating knowledge

about CAUTI into practice may be important in application of these interventions.

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