INDWELLING URINARY CATHETERS

Evidence Based Use of Indwelling Urinary Catheters

Jack Arnold
Ferris State University

INDWELLING URINARY CATHETERS

Abstract
The following paper covers the practices of use of indwelling urinary catheters and the
associated infections. First, the old standard is discussed which remained in effect for 30 years,
not because it was wrong, but because the process worked and indwelling urinary catheter
acquired infections were not considered to be a big problem, second, the current rates and costs
associated with catheter acquired infection and third, new standards of practice are presented to
reduce hospital acquired infections from urinary catheters since insurance companies are no
longer covering the costs from these type infections, and fourth, alternatives to indwelling
urinary catheters is discussed in addition to new alternatives still requiring more research.

INDWELLING URINARY CATHETERS

Evidence Base Use of Indwelling Urinary Catheters

Evidence based practice takes the research of these practices or techniques and applies
them to the clinical setting. The guidelines for use and maintenance of an indwelling urinary
catheter were published in 1981 by the Center for Disease Control, before then it was the
discretion of the physician. Since then there has not been much thought given to the standards of
use of catheters. The standards sat idle so long not because they worked and no one gave them
much consideration until insurance companies stopped paying for hospital acquired infections.
Urinary catheters have been used for years and as long as sterile procedure was followed, the
patient was thought to be safe. Catheter acquired urinary tract infections (CAUTI) have become
one of the most common hospital acquired infections today. Within this paper old methods and
the new evidence based methods for the use of urinary catheters will be discussed.
Old Methods
The old methods for catheter use did not disappear; they simply were used without
question and have been the standard of practice up until 2010 when new revisions and practices
were put into use. The old method guidelines only had several guidelines actually dealing with
CAUTI prevention.

In Grays article on Nursing Interventions (January/February 2004, p.5),

the first guideline recommended daily cleansing of the meatal area, but there is insufficient
evidence to support this. The second recommended avoiding arbitrary and routine changing
intervals of catheters to avoid infection, and third was to separate patients with infected
indwelling catheters from those patients with uninfected urinary tracts. The others dealt with
securing, drainage, and irrigation.

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Current Rates and Costs

The rate of new infection from catheter use is 3-7% per day based on the catheter
remaining in place and more than 80% of hospital acquired infections are from the use of
indwelling urinary catheters (Lindsay, 2010, p. 327). The problem with these hospital acquired
infections are insurance companies are no longer covering the costs. CAUTI costs run on
average of $589 and increase the length of stay 2 days for symptomatic patients and 0.4 days for
asymptomatic patients (Lindsay, 2010, p. 327). These numbers may seem trivial, but they do not
take into consideration the long-term care patient or the nursing home/adult foster care patient
with a chronic indwelling urinary catheter. What these numbers also do not take into
consideration is the effects beyond the infection itself. The trauma and inflammation from the
catheter alone are uncomfortable enough, not to mention the adverse effects from anti-biotics
that can develop (Lindsay, 2010, p. 328). So, why the change in standards after 30 years you
wonder? With the increase in hospital acquired infections, CAUTIs seemed to be the easiest area
to tackle. Back in the 1980s a study was published that reported nosocomial urinary tract
infections could be decreased by 31%-41% with an infection control program versus programs to
prevent other type hospital infections like surgical wounds, lower respiratory or bloodstream
infections (Lindsay, 2010, p. 328).
New Methods
The two biggest advances that have been developed to deal with CAUTIs is first, not
focusing so much on technique and procedure of insertion, but limiting the use of urinary
catheters themselves. Second, minimizing the length of time a patient has a catheter, every
patient with a catheter remaining in situ long enough becomes infected (Lindsay, 2010, p. 327).

INDWELLING URINARY CATHETERS

The only way to truly prevent infection is to not use a catheter at all, or remove the catheter
before bacteria is formed. According to the Centers for Disease Control and Prevention (2009)
the appropriate indications for use of an indwelling urinary catheter are:
if the patient has acute urinary retention or bladder outlet obstruction, accurate urinary
output measurement in critically ill patients, perioperative use for selected surgical
procedures such as urologic surgery or organs of the urologic system, long surgeries,
patients who are to receive large amounts of fluids or diuretics during surgery, and a need
for intraoperative monitoring of urinary output, also to help with healing open wounds
such as sacral or perineal in incontinent patients, to help with comfort for the terminally
ill, and for patients requiring a long period of immobilization such as spine or pelvic
injury. (table 2)
These decisions are solely left in the hands of the physician and now they have a more
comprehensive current guideline to follow. Hip fracture patients, who once received a catheter,
now, do not; the reasoning is the patient can still use a fracture bed pan. Nurses are questioning
the need for catheters also. Verifying the protocols for catheter use and working with physicians
to determine which patients are best candidates for a catheter. The days of using catheters for
incontinent patients or for urine specimens from patients who are capable of voiding voluntary
are over.
Alternatives
Some other choices to consider for patients that are incontinent or do not meet the criteria
for an indwelling catheter are: the use of condom catheters for male patients or intermittent
catherization for immobile patients. Further research needs to be done on other alternative

INDWELLING URINARY CATHETERS

methods such as urethral stents or the use of suprapubic catheters and microbial coated catheters.
New technology in the development of catheters such as biofilm-resistant materials like
antimicrobial and antiseptic coatings and new drainage systems with modifications to seals, drip
chambers, valves, and antimicrobial cartridges (Lindsay, 2010, p. 327) have been tested. The
problem with these new technologies is there has not been enough testing to prove their
effectiveness, plus the possible effects of these special coatings and materials on patients has not
been tested or proven either.
Conclusion
Indwelling urinary catheters have a use and need in patient care, but attention needs to be
paid to the circumstances involved for the physician order. What used to be a quick fix for a
patient that would not give a urine specimen now has a greater overall consequence. Physicians
and nurses now have a current standard of practice guideline to follow for proper usage of
indwelling urinary catheters to assist in patient placement and help reduce the number of
CAUTIs seen in the practice setting today. Health care professionals are now being held
accountable for and needing to show just cause for ordering the placement of a catheter. With
these new standards, patients are exposed to less risk for infection, have a decrease in length of
hospital stays, require less anti-biotics, which reduces their risk of other possible symptoms and
infections, and gives the physician a clear set of standards to follow for ordering the placement
of a urinary catheter.

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7
References

Lindsay, N. E. (2010, April). Catheter-acquired urinary tract infection: the once and future
guidelines [Electronic version]. Infection Control and Hospital Epidemiology, 31(4),
327-329. doi:10.1086/651092
Gray, M. (2004, January/February). What nursing interventions reduce the risk of
symptomatic urinary tract Infection in the patient with an indwelling catheter?
[Electronic version]. Journal of Wound, Ostomy and Continence Nursing, 31(1), 3-13.

Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009 (n.d.). In Centers
for Disease Control and Prevention. Retrieved November 14, 2013, from
http://www.cdc.gov/hicpac/cauti/02_cauti2009_abbrev.html