Development of an evidence-based protocol for reduction of indwelling urinary catheter usage

MedSurg Nursing, June, 2007 by Sherry Robinson, Laurie Allen, Mary R. Barnes, Tammy A. Berry, Teresa A. Foster, Lisa A. Friedrich, Jennifer M. Holmes, Sandra Mercer, Dee Plunkett, Charlene M. Vollmer, Tina Weitzel

For many years, long-term care has been attuned to the problems associated with indwelling urinary catheters (Gammack, 2003; Newman, 2006). Use of catheters has been limited to residents with very specific problems, such as urinary retention or Stage III and IV pressure ulcers on the coccyx. The Nurses Improving Care to Health System Elderly (NICHE) group at a large tertiary care hospital in central Illinois questioned the frequent use of urinary catheters in hospital care. Why should urinary catheters be limited in long-term care, but no limitations exist in acute care? Wouldn't urinary catheters cause similar problems regardless of the setting?

To address the issue, the NICHE group developed an evidence-based protocol to enable the timely removal of unnecessary indwelling urinary catheters. Members proposed that this action would lessen the risk of nosocomial infection and promote the return of normal elimination patterns in hospitalized adult patients. The project was guided by the Iowa Model of Evidence-Based Practice to Promote Quality of Care (Titler, 2002).

Step 1: Recognize and Define a Problem

The NICHE group from the hospital spoke with nurses from local nursing homes about the use of indwelling urinary catheters. The long-term care staff explained that catheters could be used only for patients who (a) were incontinent and had a stage 3 or 4 pressure ulcer on the coccyx, Co) had neurogenic bladders or an obstruction that prevented normal elimination, (c) needed strict intake and output measurement, or (d) required comfort care if terminally ill (Newman, 2006). Based on these criteria, the hospital nurses could identify at least one recent patient who did not have an appropriate reason for his or her indwelling urinary catheter.

Step 2: Determine if the Topic Is a Priority for the Organization

At about the same time, the director of nursing of the hospital attended a conference where she viewed a poster about another hospital's attempted reduction of indwelling urinary catheter use. She shared the information and encouraged study of the problem. Members of the NICHE group then reviewed records of 30 patients who had indwelling urinary catheters. They found that five (17%) had developed documented urinary tract infections. Eight (27%) additional patients had one or more symptoms of urinary tract infection at discharge (temperature elevation of 1 degree, dysuria, cloudy urine) which may have developed subsequently into a urinary tract infection. The topic became a priority for the hospital.

Step 3: Form a Team

The hospital's NICHE group was a ready-made team that had worked together for several years. The group consisted of 11 nurses from different areas of the hospital, including medical-surgical, renal, emergency, and critical care units.

Step 4: Assemble and Critique Research

The group reviewed 32 articles on indwelling urinary catheter use. The hospital librarian assisted with the search for studies published over the last 10 years using Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). A grading schema was used to rate the quality of evidence as follows (Titler, 2002):

A = Evidence from well-designed meta-analysis or integrated literature review

B = Evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action (for example, assessment, intervention, or treatment)

C = Evidence from observational studies (for example, correlational descriptive studies) or controlled trials with inconsistent results

D = Evidence from expert opinion or multiple case reports

Seventeen of the articles were rated B or A, providing strong evidence for the problem of overuse of indwelling catheters. A summary of their conclusions follows.

Up to 25% of hospitalized patients, or approximately 5 million people, undergo urinary catheterization yearly (Saint & Lipsky, 1999). Estimates indicate that 8.5%-10% of all patients who have indwelling catheters develop urinary tract infections (UTIs) (Purl et al., 2002; Saint & Lipsky, 1999). UTIs account for at least 40% of nosocomial infections, the majority of which are precipitated by catheter use. Urinary catheter-related infection leads to an almost three-fold increase in risk for death, independent of other co-morbid conditions (Goolsarran & Katz, 2002).

The most important risk factor for bacteriuria and development of UTI is the duration of urinary catheterization (Purl et al., 2002). A low percentage of patients become infected during the first 3-5 days. In patients with catheters in place for more than 7 days, the rate of infection is 10%-40%. A patient who has a catheter for 14 days is almost certain to have bacteria in the bladder that are resistant to antibiotics (Goolsarran & Katz, 2002; Kalsi, Arya, Wilson, & Mundy, 2003; Saint & Lipsky, 1999). Continuation of catheter use frequently is not reviewed by members of the health care team (Cornia, Amory, Fraser, Saint, & Lipsky, 2003).