champ foley catheter use catherine e. dubeau, m.d. university of chicago
TRANSCRIPT
CHAMPFoley Catheter Use
Catherine E. DuBeau, M.D.
University of Chicago
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
Outline
1. Scope of the problem2. Rationale for targeting catheter
use3. Appropriate indications for
catheter use4. Catheter management5. Trouble-shooting failure to void6. Teaching triggers
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
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)
Scope of the Problem
• Prevalent and morbid– 25% of hospitalized pts have a
catheter– Cause 40% of nosocomial infections– Uncomfortable and restrictive (“one-
point restraint”)– Urethral and meatal trauma
PAINDELIRIUMFALLS
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
Rationale for targeting catheters
1. Morbidity2. Quality3. Expense
Morbidity
• 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
Morbidity
• 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
DELIRIUM
Morbidity
More people die from hospital-acquired infections than from auto accidents and homicides combined
Quality
• Joint Commission Patient Safety requirement: reduce the risk of health care-acquired infections
• Illinois: Public Act 93-0563, SB 59, 2003: mandates quarterly reporting of hospital infection rates, with yearly publishing by hospital
• Consumers: StopHospitalInfections.org
Expense
• Unnecessary equipment and labor costs
• Hospital infections cost $5 billion annually
• Longer length of stay
Expense
• Unnecessary equipment and labor costs
• Hospital infections cost $5 billion annually
• Longer length of stayIATROGENIC ILLNESS FUNCTIONAL DECLINE
Indications for using catheters
There are only FOUR indications:1. Inability to void2. Incontinence AND
• Open wounds needing protection• Terminal illness/palliative care
3. Monitor urine output AND patient unable to assist/comply
4. After anesthesia (short term only)
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)
Trouble-shooting insertion
1. “Can’t pass”• Discomfort/spasm at sphincter:
• Use lidocaine gel• Insert with slight ‘torque’ while patient
exhales• Try larger catheter• Coudécatheter
2. Inflate the balloon only aftercatheter is inserted all the way in, up to the meatus
Trouble-shooting failure to void
• Two basic reasons– Poor pump– Blocked outlet
Trouble-shooting failure to void
• Two basic reasons– Poor pump– Blocked outlet
Pump action: Ach, Ca++
Sphincter closure: Alpha adrenergic
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
Prostate disease
Meds: alpha-agonists
Neurological disease: dyssynergia
Women: scarring, cystocele
Constipation
Teaching Triggers
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
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
Action step 1: Look for catheter on every patient when at bedside
Trigger: Catheter found
“Why does this pt have a catheter?
Appropriate indication Action Step 2
Action step 2: “Does this patient Action step 2: “Does this patient still need the catheter?still need the catheter?
Yes Action step 3
Action step 3: “Does this patient have a medical reason for inability to void?
A. Review MAR
B. Review medical history
C. *Additional exam, Post voiding residual
Anus
Clitoris
Anal wink
Bulbocavernosus Reflex
Sacral Reflexes
Adapted from Geriatric Review Syllabus Urinary Incontinence slide set, American Geriatric Society, 2006
Cystocele
RectocelePhotographs from: Abrams P, Cardozo L, Khoury S, Wein A, ed. Incontinence. 2nd International Consultation on Incontinence.
Plymouth UK: Health Publications Ltd, 2002; pp 381-2.
Pelvic Exam
Action step 2: “Does this patient still need the catheter?
No Action step 4
Action step 4: Discontinue all catheters before discharge unless there is chronic retention
Action step 4: Discontinue all catheters before discharge unless there is chronic retention
TRANSITIONS OF CARE
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
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
PVR < 100 (men) or <200 (women): done
Higher PVR: re-insert, review causes of failure to void
Action step 4: Discontinue all catheters
Does the pt have a Foley?
Why does pt have Foley?
Does the pt still need Foley?
Medical reason for inability to void?
YES
Review the 4 indications
InappropriateAppropriate
YES
Review PMHx, MAR, exam
Plan to D/C Foley
NO
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
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
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?