Optimal catheter management: The easiest and most effective means to prevent CAUTI is to limit the use of urinary catheters to clearly identified medical indications (see Table 1, above). However, as simple as this prevention practice may sound, studies have demonstrated that as many as 20% of patients have indwelling catheters initially placed for unjustified or even unknown medical indications.8 Additionally, continued catheter use is inappropriate in one-third to one-half of all catheter days.9 These data confirm misuse and overuse of indwelling urinary catheters in the hospital setting is common.
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In 1981, the Centers for Disease Control and Prevention (CDC) recognized the importance of addressing this situation and published a guideline to aid prevention of CAUTIs.10 The CDC urged the limitation of catheter use to a carefully selected patient population. Furthermore, the report strongly stressed the importance of catheter removal as soon as possible and advised against the use of catheters solely for the convenience of healthcare workers.
Evidence-based techniques for insertion and catheter care also were outlined in the guideline (see Table 2, p. 31). However, these recommendations have been poorly implemented, likely due to the competing priorities of providers and the difficulty operationalizing the guidelines. Additionally, evidence from the intervening 25 years has not yet been incorporated into the guideline, although a revision currently is underway.
Until that revision is complete, the Joanna Briggs Institute guideline published in 2001 addresses some of the same management techniques and incorporates newer evidence.11 Of note, practices that have been discredited due to contradictory evidence include aggressive meatal cleaning, bladder irrigation, and the application of antimicrobial agents in the drainage bag.12
Strategies to reduce unnecessary catheter days: One of the remediable reasons for catheter misuse lies in the fact physicians often are unaware of the presence of an indwelling catheter in their hospitalized patients.
Saint, et al., showed physicians were unaware of catheterization in 28% of their patients and that attending physicians were less conscious of a patient’s catheter status than residents, interns, or medical students.13 Further, the “forgotten” catheters were more likely to be unnecessary than those remembered by the healthcare team.
This information has prompted the use of various computer-based and multidisciplinary feedback protocols to readdress and re-evaluate the need for continued catheterization in a patient. For example, a study at the VAMC Puget Sound demonstrated that having a computerized order protocol for urinary catheters significantly increased the rate of documentation as well as decreased the duration of catheterization by an average of three days.14
Similar interventions to encourage early catheter removal have included daily reminders from nursing staff, allowing a nurse to discontinue catheter use independent of a physician’s order, and feedback in which nursing staff is educated about the incidence of UTI.15-17 All these relatively simple interventions showed significant improvement in the catheter removal rate and incidence of CAUTIs as well as documented cost savings.
Alternatives to indwelling catheters: In addition to efforts to decrease catheter days, alternatives to the indwelling catheters also should be explored. One such alternative method is intermittent catheterization.
Several studies in postoperative patients with hip fractures have demonstrated that the development of UTI is lower with intermittent catheterization when compared with indwelling catheterization.18 Nevertheless, since the risk of bacteriuria is 1% to 3% per episode of catheterization, after a few weeks the majority of patients will have bacteriuria. However, as the bulk of this bacteriuria often is asymptomatic, intermittent catheterization may still be an improvement. This is particularly true in postoperative patients undergoing rehabilitation and those patients only requiring catheterization for a limited number of days.