CHAMP Foley Catheter Use Catherine E Du Beau

CHAMP Foley Catheter Use Catherine E. Du. Beau, 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. 2. 3. 4. 5. 6. Scope of the problem Rationale for targeting catheter use Appropriate indications for catheter use Catheter management Trouble-shooting failure to void 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 PAIN DELIRIUM FALLS

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. Morbidity 2. Quality 3. 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 careacquired infections • Illinois: Public Act 93 -0563, SB 59, 2003: mandates quarterly reporting of hospital infection rates, with yearly publishing by hospital • Consumers: Stop. Hospital. Infections. 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 stay IATROGENIC ILLNESS FUNCTIONAL DECLINE

Indications for using catheters There are only FOUR indications: 1. Inability to void 2. 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 • Coudé catheter 2. Inflate the balloon only after catheter 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 Meds: anticholinergic, Ca+ blkrs Sacral cord disease Neuropathy: DM, vit B 12 defic Constipation – Blocked outlet 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 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

Sacral Reflexes Clitoris Bulbocavernosus Reflex Anus Adapted from Geriatric Review Syllabus Urinary Incontinence slide set, American Geriatric Society, 2006 Anal wink

Pelvic Exam Cystocele Rectocele Photographs from: Abrams P, Cardozo L, Khoury S, Wein A, ed. Incontinence. 2 nd International Consultation on Incontinence. Plymouth UK: Health Publications Ltd, 2002; pp 381 -2.

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 clamp!) (never B. Insure adequate fluid intake (PO or IV) C. Monitor for 8 hours

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 < 100 (men) or <200 (women): done Higher PVR: re-insert, review causes of failure to void

Does the pt have a Foley? YES Why does pt have Foley? Does the pt still need Foley? NO Review the 4 indications Appropriate YES Medical reason for inability to void? Plan to D/C Foley Review PMHx, MAR, exam Inappropriate

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?