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CHAMPFoley Catheter Use
Catherine E. DuBeau, M.D.
University of Chicago
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Learning Objectives
• Name short and long term risks of catheterization
• Differentiate the medical reasons for incomplete voiding
• Analyze catheter management problems
• Perform bedside evaluation of need for catheter and construct plan for catheter removal
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Outline
1. Scope of the problem2. Rationale for targeting catheter
use3. Appropriate indications for
catheter use4. Catheter management5. Trouble-shooting failure to void6. Teaching triggers
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Emphases and Links
Text will be repeated in YELLOW to indicate links to other CHAMP modules
Further content in CHALK will be listed at the end
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Scope of the Problem
• Prevalent and morbid– 25% of hospitalized pts have a catheter– Cause of 40% of nosocomial infections– Uncomfortable and restrictive (“one-point
restraint”)– Urethral and meatal trauma (traumatic
hypospadius in men, patulous meatus in women, scarring, bleeding)
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Scope of the Problem
• Prevalent and morbid– 25% of hospitalized pts have a
catheter– Cause 40% of nosocomial infections– Uncomfortable and restrictive (“one-
point restraint”)– Urethral and meatal trauma
PAINDELIRIUMFALLS
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Scope of the Problem
• Often an “invisible” problem– Hospital MDs unaware of catheter use in
about 1/3 of their catheterized patients– Being unaware associated with
inappropriate use and longer catheterization periods
• Internists have little training in the medical reasons for failure to void
• Resulting Urology consults don’t always lead to mutual satisfaction/learning
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Rationale for targeting catheters
1. Morbidity2. Quality3. Expense
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Morbidity
• Indwelling– Polymicrobial
bacteriuria (universal at 30 days)
– Fever (1/100 pt-days)– Chronic pyelo– Bladder and renal
stones– Urethral and meatal
injury– Agitation
• External– Bacteriuria and
infection– Penile cellulitis and
necrosis– Urinary retention
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Morbidity
• Indwelling– Polymicrobial
bacteriuria (universal at 30 days)
– Fever (1/100 pt-days)– Chronic pyelo– Bladder and renal
stones– Urethral and meatal
injury– Agitation
• External– Bacteriuria and
infection– Penile cellulitis and
necrosis– Urinary retention
DELIRIUM
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Morbidity
More people die from hospital-acquired infections than from auto accidents and homicides combined
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Quality
• Joint Commission Patient Safety requirement: reduce the risk of health care-acquired infections
• Illinois: Public Act 93-0563, SB 59, 2003: mandates quarterly reporting of hospital infection rates, with yearly publishing by hospital
• Consumers: StopHospitalInfections.org
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Expense
• Unnecessary equipment and labor costs
• Hospital infections cost $5 billion annually
• Longer length of stay
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Expense
• Unnecessary equipment and labor costs
• Hospital infections cost $5 billion annually
• Longer length of stayIATROGENIC ILLNESS FUNCTIONAL DECLINE
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Indications for using catheters
There are only FOUR indications:1. Inability to void2. Incontinence AND
• Open wounds needing protection• Terminal illness/palliative care
3. Monitor urine output AND patient unable to assist/comply
4. After anesthesia (short term only)
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Catheter management
• Closed drainage systems• Changing
– Any acute infection– Monthly for chronic catheter
• Leakage around catheter– Balloon too big (size or inflation)– Infection– Bladder spasm: consider pyridium or bladder
relaxant, eg. Detrol or Ditropan (but only if catheter indication is not retention)
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Trouble-shooting insertion
1. “Can’t pass”• Discomfort/spasm at sphincter:
• Use lidocaine gel• Insert with slight ‘torque’ while patient
exhales• Try larger catheter• Coudécatheter
2. Inflate the balloon only aftercatheter is inserted all the way in, up to the meatus
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Trouble-shooting failure to void
• Two basic reasons– Poor pump– Blocked outlet
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Trouble-shooting failure to void
• Two basic reasons– Poor pump– Blocked outlet
Pump action: Ach, Ca++
Sphincter closure: Alpha adrenergic
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Trouble-shooting failure to void
• Two basic reasons– Poor pump
– Blocked outlet
Meds: anticholinergic, Ca+ blkrs
Sacral cord disease
Neuropathy: DM, vit B12 defic
Constipation
Prostate disease
Meds: alpha-agonists
Neurological disease: dyssynergia
Women: scarring, cystocele
Constipation
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Teaching Triggers
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Action step 1: Look for catheter on every patient when at bedside
Trigger: Catheter found
“Why does this pt have a catheter?
Unsure/inappropriate indication:
Review indications
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Action step 1: Look for catheter on every patient when at bedside
Trigger: Catheter found
“Why does this pt have a catheter?
Review indications:1. Inability to void
2. Incontinent with wounds/palliative care
3. Monitor output
4. Post anesthesia
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Action step 1: Look for catheter on every patient when at bedside
Trigger: Catheter found
“Why does this pt have a catheter?
Appropriate indication Action Step 2
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Action step 2: “Does this patient Action step 2: “Does this patient still need the catheter?still need the catheter?
Yes Action step 3
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Action step 3: “Does this patient have a medical reason for inability to void?
A. Review MAR
B. Review medical history
C. *Additional exam, Post voiding residual
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Anus
Clitoris
Anal wink
Bulbocavernosus Reflex
Sacral Reflexes
Adapted from Geriatric Review Syllabus Urinary Incontinence slide set, American Geriatric Society, 2006
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Cystocele
RectocelePhotographs from: Abrams P, Cardozo L, Khoury S, Wein A, ed. Incontinence. 2nd International Consultation on Incontinence.
Plymouth UK: Health Publications Ltd, 2002; pp 381-2.
Pelvic Exam
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Action step 2: “Does this patient still need the catheter?
No Action step 4
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Action step 4: Discontinue all catheters before discharge unless there is chronic retention
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Action step 4: Discontinue all catheters before discharge unless there is chronic retention
TRANSITIONS OF CARE
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Action step 4: Discontinue all catheters
A. Deflate balloon and remove catheter (never clamp!)
B. Insure adequate fluid intake (PO or IV)
C. Monitor for 8 hours
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D. If no void, reinsert catheter and note volume. If < 200, increase fluids and repeat trial. Review causes of failure to void.
E. If voids, check PVR
PVR < 100 (men) or <200 (women): done
Higher PVR: re-insert, review causes of failure to void
Action step 4: Discontinue all catheters
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Does the pt have a Foley?
Why does pt have Foley?
Does the pt still need Foley?
Medical reason for inability to void?
YES
Review the 4 indications
InappropriateAppropriate
YES
Review PMHx, MAR, exam
Plan to D/C Foley
NO
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Who to discharge with a catheter
• Patients with retention who fail voiding trials
• Patients who have not completed at least 7 days of decompression for new retention (they will need PCP, GU, and/or VNA follow-up to do and monitor voiding trial)
• Transitions of care:– Leg bag for day & large bag for night, or large bag alone– Family instruction re: emptying bag; changing bags (if
necessary); using straps to secure catheter (and leg bag) to leg; monitoring for output, hematuria, fever, SP pain; importance of adequate fluids
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When to refer to Urology
• Failure to insert catheter even after trying earlier suggestions
• Large volume hematuria that does not clear with 3-way irrigation
• If you have treated medical reasons for failure to void and pt still has retention, then outpatient referral to Urology
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Using Foleys to Teach Practice-Based Learning: Going Beyond Content
• What is the team’s practice and how can we learn from it?– PLAN to focus on Foleys for a teaching
session/rounds– DO a “census audit”, based on triggers:
• How many patients have a Foley?• Of these, how many did the team know about?• How many have a correct indication?
– STUDY the results• Share tally results with team and discuss implications
and the practice-based learning process
– ACT: how can we improve Foley care? Repeat audit?