6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.
“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”
Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.
John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.
“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”
Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”
7: Diabetic patients require extra attention.
“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”
8: Practice good antibiotic stewardship.
After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.
“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”
Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”
“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”
9: Determine whether the patient can be seen as an outpatient.
Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.
“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”
One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.
