BERKELEY, CA (UroToday.com) - The Minneapolis Veterans Affairs Medical Center had a dedicated catheter nurse prospectively review the medical records of inpatients with Foley catheters. The study was a 16-month prospective surveillance of indwelling urinary catheter-associated complications in hospitalized veterans. The daily surveillance included Foley catheter related bacteria and trauma. During 6,513 surveyed Foley catheter days, urinalysis/urine culture was done in 407 patients, identifying 116 possible UTIs or 1.8% of Foley catheter days of which only 21, or 18%, involved clinical symptoms. The remaining 95 asymptomatic bacteriuria episodes accounted for 39 (70%) of 56 antimicrobial-treated possible UTIs.

The authors identified other catheter-related problems including 100 instances of GU trauma (1.5% of device days) with at least 1/3 of these leading to interventions such as cystoscopy. Other catheter-related problems included pain, gross hematuria, incidentally noted catheter migration, and overt mechanical trauma. Trauma events were characterized by injury type and resulting interventions. Categories include isolated hematuria, creation of false passage, accidental removal with balloon inflated, or misplacement of the Foley catheter, and ridging caused by an incompletely retracted catheter balloon at time of catheter removal.

The authors' analysis indicated that symptomatic UTIs only accounted for 0.3% of Foley catheter days, while catheter-related trauma requiring intervention was more common, accounting for 0.5% of Foley catheter days. This is article addresses other catheter-related problems, specifically GU trauma related to an indwelling catheter, something not well-documented in the medical literature but well-known in clinical practice.

Leuck AM, Wright D, Ellingson L, Kraemer L, Kuskowski MA, Johnson JR

Journal Citation: J Urol. 2012 May;187(5):1662-6
doi: 10.1016/j.juro.2011.12.113

PubMed Abstract
PMID: 22425122

BERKELEY, CA (UroToday.com) - This article discusses the use of suprapubic aspiration (SPA), the gold standard for obtaining uncontaminated urine specimens in young febrile children. Real time ultrasound has been shown to increase the success rate of SPA as it provides bladder location so that successful insertion of a needle for SPA can be performed.

The authors evaluated the use of the BladderScan (BVI9400, Verathon) to provide an automated measurement of bladder volume. There is no data on the success rate of SPA using this device. So 60 SPAs were observed over an 8-month period between 2009 and 2010, in a Melbourne, Australia tertiary referral center. The population audited in this report were children, age 0 to 24 months, presenting to the emergency department and requiring acute urine collection by SPA. Sixty (58% male) of an estimated 200 SPA procedures were observed and documented. The mean age of children undergoing SPA was five months. There were five children who had associated urologic abdominal comorbidities, including renal reflux, bifid kidney, hydronephrosis, hypospadias, and abdominal ventriculoperitoneal shunt. All patients in the study had SPA as an initial method of urine collection to diagnose or exclude urinary tract infection. The audit showed an overall success rate of 53% using the BladderScan. Success rate was high on patient readings of ≥ 20 ml compared with ≤ 20 ml.

They concluded that although the rates were lower than the success rates reported using conventional ultrasound, the BladderScan offers a more affordable and user-friendly alternative. Also, it can be useful in settings where retroperitoneal ultrasound is either not available or expertise in operating the device at all hours is limited.

Buntsma D, Stock A, Bevan C, Babl FE

Journal Citation: Emerg Med Australas. 2012 Dec;24(6):647-51
doi: 10.1111/1742-6723.12011

PubMed Abstract
PMID: 23216726

BERKELEY, CA (UroToday.com) - This article details the steps that the VA Medical Center in Ann Arbor, Michigan took in 2011 to encourage prompt removal in unnecessary urinary catheters. The intervention described consisted of 3 components:

  1. urinary management policy intended to prioritize prevention of UTIs,
  2. electronic urinary management in nursing “template,” and
  3. standardized catheter kits with presealed junctions to prevent introduction of bacteria to the system.

 

A nurse and physician were tasked with ensuring uniform implementation and achieving “buy-in” from staff. Catheter-use measures included the percentage of inpatients with Foley and percentage of catheters with inappropriate indication. 

Results indicated an absolute decrease of 3.1% in Foley catheter use. The catheter prevalence of medical units significantly decreased while prevalence in units did not. The percentage of inappropriate Foleys decreased overall, from 13.3% prior to intervention to 2.3% after the intervention.

Although the observed reduction in statistically significant, facility-wide reduction of Foley use was not. It was unclear why catheter prevalence was reduced in medical units without a corresponding UTI reduction.

This article does not add anything new to the literature except the use of a specific catheter kit, one that has a pre-sealed junction, not often discussed in other studies. This is an important practice as it assists with maintaining system sterility, thus reducing introduction of bacteria.

Miller BL, Krein SL, Fowler KE, Belanger K, Zawol D, Lyons A, Bye C, Rickelmann MA, Smith J, Chenoweth C, Saint S

Reference: Infect Control Hosp Epidemiol. 2013 Jun;34(6):631-3
doi: 10.1086/670624

PubMed Abstract
PMID: 23651896

 

BERKELEY, CA (UroToday.com) - The Agency for Healthcare Research & Quality (AHRQ) surveyed 398 hospitals to determine the effect of the 2008 non-payment policy of the Centers for Medicare and Medicaid services on catheter associated UTIs. They found that, overall, payment penalties have not shown significant effect in reducing CAUTI as there were no changes in CAUTIs among Medicare and other patients. Overall rates have been declining likely due to multiple factors including new clinical practices – but not necessarily due to payment or financial penalties.[1]

The article by Palmer and colleagues is a qualitative analysis looking at this impact. They conducted semi-structured interviews with 36 hospital infection prevention specialists (N=135) to ask them about their views on the CMS rule of “never” events. They found equivocal results on attitudes about the rule with different perspectives on the consequences of including CAUTIs in the policy. These infectious interventionists recognized the importance of CAUTI prevention, but they believe CAUTIs are less of a health risk in patients than other health-care associated infections. Several questioned the relevancy of targeting CAUTIs in the policy, as this type of infection was considered to be the lowest priority amongst hospital-acquired infections. Many felt this policy diverts resources away from other prevention activities (e.g. ventilator-associated pneumonia or Clostridium difficile). Many felt that CAUTIs may have a minimal financial impact on hospitals’ bottle lines. However, there were some who felt that the inclusion of CAUTIs in the policy made sense, because of the cost of antibiotics, length of stay, and risk of multidrug resistant infections.

So two main groups of themes were identified:

  • Concerns over significance of problem, opportunity costs, financial significance, incentives
  • Concerns about clinical organizational behaviors and limited defensive practice

This study was unique as it assessed the 2008 CMS CAUTI policy from the perspective of infectious preventionists. It is an in-depth analysis and shows that to change the culture within the hospital, as it relates to indwelling catheter use, there is a need to understand the attitudes and behaviors of the staff.

 

Reference:

  1. Lee GM, Kleinman K, Soumerai SB, Tse A, Cole D, Fridkin SK, Horan T, Platt R, Gay C, Kassler W, Goldmann DA, Jernigan J, Jha AK. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012 Oct 11;367(15):1428-37. doi: 10.1056/NEJMsa1202419

 

Palmer JA, Lee GM, Dutta-Linn MM, Wroe P, Hartmann CW

Reference: Urol Nurs. 2013 Jan-Feb;33(1):15-23
doi: 10.7257/1053-816X.2013.33.1.15

PubMed Abstract
PMID: 23556374

 

BERKELEY, CA (UroToday.com) - The practice of prescribing prophylactic antibiotics at the time an indwelling urinary catheter is removed is common, especially in urologic practice. This is a practice that I followed in the 1990s when removing a Foley catheter from patients in my home care practice as I was seeing a frail elder population who were at increased risk for developing a UTI. The theory behind this practice is that the antibiotic may reduce potential bacterial seeding from catheter biofilm or urine and reduce risk of UTI or urosepsis. But there is very little evidence-based research on the benefit of the administration of prophylactic antibiotics, when the catheter is removed, in preventing subsequent symptomatic urinary tract infection.

This article is a systematic review and analysis of studies published before November 2012, on antibiotic prophylaxis administered to prevent symptomatic UTI after removal of an indwelling urinary catheter (IUC). Catheters had been in place for a short period of time, less than 14 days. The authors wanted to determine whether antibiotics provided a benefit. As patients with an IUC have bacteriuria, catheter manipulation that occurs during removal might predispose the patient to an infection.

This meta-analysis was of 5 randomized controlled trials (RCTs), 1 unpublished RCT, and one non-randomized controlled study. Results were mixed, but the authors concluded that the evidence indicated an overall reduction in symptomatic urinary tract infection when antibiotic prophylaxis was given, with a risk ratio of 0.45, (95% confidence interval 0.28 to 0.72) compared with controls. But there was significant variation of duration of monitoring after IUC removal, ranging from about 4 days to 6 weeks. Also, various antimicrobial agents were used, and their duration of prophylaxis ranged from a single dose administration to 3-day-courses.

A concern is that this increase in the use of antibiotics may increase resistance in this patient population. So while clinicians must be careful about encouraging antibiotic use, this may be a beneficial option in at-risk populations.

Marschall J, Carpenter CR, Fowler S, Trautner BW; CDC Prevention Epicenters Program

Reference: BMJ. 2013 Jun 11;346:f3147
doi: 10.1136/bmj.f3147

PubMed Abstract
PMID: 23757735

 

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