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Running Head: INDWELLING URINARY CATHETERS

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Dana Raymer

Bibliographic Essay on the Topic of

Indwelling Urinary Catheters

Ferris State University

INDWELLING URINARY CATHETERS

Abstract

This bibliographic essay was written based upon an assignment for my English 321 writing class.

A topic was chosen and various databases were searched through Ferris State University’s

FLITE Library to come up with a number of articles that pertained to the chosen topic. Relevant

articles were selected and, after review, were grouped into sections based on similarities. This

essay was then written as a review of the various articles and is to be submitted to fulfill the

bibliographic essay requirement of this class.

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Bibliographic Essay on the Topic of Indwelling Urinary Catheters

Indwelling urinary catheters are used to drain the bladder in many patients today, in both

long term and short term care. The purpose of this paper is to review the research available

regarding indwelling urinary catheters and apply this research to my nursing practice. I searched

various databases available through Ferris State University’s FLITE Library and then reviewed

articles that I found related to the topic of indwelling urinary catheters.

The Importance of Indwelling Urinary Catheters

According to Gray (2008), about 25% of patients in acute care facilities receive an

indwelling urinary catheter (IUC) during their hospital stay, with nearly 400 million Americans

undergoing indwelling urinary catheterizations each year. It is estimated that over 50% of these

IUC placements are unnecessary with no specific medical reason for their use (Newman, 2009).

The use of IUC’s is associated with many risks including infection and trauma, which can result

in longer hospital stays and increased health care costs. Gray (2008) states that the cost of

treating a catheter-associated urinary tract infection (CAUTI) ranges from $1000 to almost

$3000, and these infections cumulatively result in an additional 90,000 hospital days each year.

As a floor nurse in an acute care facility, every day while at work I care for patients who

come to our unit with IUC’s in place and I often place them into patients for various reasons. I

am responsible for the care and management of these urinary drainage systems, and each day I

am charged with reviewing the necessity of continuing this intervention and removing the IUC’s

when no longer necessary. With their use so commonplace it is easy to forget that IUC’s are

invasive interventions that carry great risks for the patient. Urinary tract infections (UTI’s)

account for nearly 40% of all hospital-acquired infections with more than 80% of these

infections associated with IUC’s. Due to the fact that UTI’s secondary to IUC’s are so common,

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are expensive to treat, and are deemed largely preventable, in 2008 the Centers for Medicare and

Medicaid Services (CMS) listed CAUTI’s as one of eight hospital-acquired conditions that

health care facilities would no longer receive reimbursement for, making the use and

management of IUC’s an important topic for health care facilities throughout the United States

(Saint, Meddings, Calfee, Kowalski & Krein, 2009). Also, the use of IUC’s is associated with a

four times greater risk of death for inpatients and a two times greater risk of death within 90 days

after discharge, making its use one that should be carefully weighed, instead of considering it a

standard intervention (Holroyd-Leduc et al., 2007).

I began my research by utilizing Ferris State University’s online FLITE Library. I

searched databases by name, and chose CINAHL or EBSCOHOST as the first database because

of my past familiarity with it. I first searched the term “indwelling urinary catheter” with the

search limitation of “find all my search terms”. I did not limit publication dates during this

search. The initial search yielded 380 results. I was able to select some articles that would relate

to my search and then I chose a “major subject” listed under one of the titles. The suggested

“catheter related infections prevention and control” yielded 843 results and through this search I

was able to find the major subject suggestion of “urinary catheterization - adverse effects” which

brought 179 results, many of which were related to my research. The “find it” option through

the FLITE library is invaluable and one of the most useful tools I have found through all my

research. In the past, all searches had to be limited to those with a full text link but with the

“find it” option, I was able to do a more general search and find many more suitable articles than

in the past.

After researching the topic of indwelling urinary catheters and their associated

complications and proper management, I decided to divide my paper into the following sections:

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1) Reasons for catheter placement

2) Proper catheter selection and insertion

3) Risks and complications

4) Best practices for care and management

Reasons for Catheter Placement

With one in four patients in acute care settings receiving IUC’s at some point during their

admission, it is clear that IUC’s are one of the most common interventions being undertaken in

health care today (Gray, 2008). As stated above, Newman (2009) found that up to 50% of IUC’s

are inserted with no specific medical reason identified, and so for this reason, it is important to

review the proper indications for IUC insertion and use, so that I am able to assess for which

patients IUC’s are appropriate and which patients should not have an IUC in place.

The article “Urinary Catheterisation: Assessing the Best Options for Patients” (2009) is a

double-blind and expert peer reviewed article that discusses the history of catheterization and

reasons for usage. The reasons for inserting an IUC are divided into short term and long term

uses. Short term uses, according to the author, include investigations into bladder dysfunctions,

pre and post-op bladder drainage, during labor and delivery, to monitor urine output in the

critically ill and to instill cytotoxic drugs. The author states that appropriate long term uses for

IUC’s include when the patient is unable to function and is awaiting surgery, with urethral

strictures, when the patient has other health conditions that prevent surgery from occurring or

with urinary incontinence that cannot be controlled with other methods.

In the article “How to prevent CAUTIs,” found in the July 2009 issue of Nursing

Management, Diane Newman discusses appropriate indications for use of IUC’s. The reasons

listed include acute urinary retention and obstruction that can’t be relieved by intermittent

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catheterization, for accurate urine output measurement with critically ill patients and

perioperatively with certain surgeries, prolonged surgeries or with incontinent patients during

surgery. The author also states that it is appropriate to insert IUC’s when there are pressure

ulcers present that won’t heal because of urine leakage or incontinence and also during end-of-

life care to keep the patient more comfortable. Ms. Newman states that IUC’s should not be

used in place of nursing care with the incontinent patient or to obtain urine specimens with

patients who are able to void. This article is blind and expert peer reviewed and has also been

reviewed by an editorial board.

Carolyn Freeman (2009) also lists several appropriate reasons to place IUC’s in her

double-blind peer reviewed article entitled “Why More Attention Must be Given to Catheter

Fixation.” The author states that although they should always be used with caution, catheters are

an effective way of managing bladder drainage problems and that it is important for nurses to

assess the need for catheterization when orders are received to place one. The clinical

indications for placement according to the article are during and post surgery, for acute or

chronic urinary retention, for close urine output monitoring in the critically ill patient, to instill

medication into the bladder and to investigate bladder dysfunction.

Proper Catheter Selection and Insertion

Frequently during the course of my job I am required to insert an IUC into a patient for a

variety of reasons. Now that I have researched the proper indications for use of IUC’s, it is

important for me to review articles that discuss how to select the proper catheter and the proper

techniques for insertion, so that I can compare my current practice with the best practices

recommended through research today.

In the article “Reducing Catheter-Associated Urinary Tract Infection in the Critical Care

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Unit”(2010), the author, Mikel Gray, discusses tips for optimal catheter selection and proper

insertion techniques. Latex versus silicone material is discussed and evidence is set forth

regarding which is most appropriate for short and long term uses. Currently there is research

regarding the incorporation of an antimicrobial material into the catheter but the author admits

that more research is needed regarding the benefit versus cost of this for routine use. Smaller

diameter catheters are recommended both for patient comfort and to reduce trauma and irritation

to bladder and urethral mucosa. The author states that it is also very important to select and

maintain a closed drainage system. Other possible strategies are discussed such as antimicrobial

filters, multichamber drainage bags and antimicrobial substances placed in the drainage bags, but

the author states that none of these have been proven to reduce the risk of CAUTI. Proper

insertion technique is also discussed in this article and the author compares results of studies

evaluating infection rates with both sterile and clean insertion techniques applied. The use of

assistive personnel during insertion to assist the licensed personnel was found to be helpful in

reducing rates of CAUTI.

Proper catheter selection and insertion techniques are also described in the double-blind

peer and expert reviewed article entitled “Reducing the Risks Associated with Urinary

Catheters” (2009). According to the authors, a number of factors should be considered when

selecting the appropriate catheter for insertion. The circumference of the catheter should be

considered with the smallest circumference available that will still properly drain the bladder the

best choice, because larger circumference catheters are associated with more complications. The

authors also state that the length of the catheter should be appropriate for the patient, with

women requiring shorter lengths than men. Balloon size should be 10 milliliters unless the

catheter is inserted secondary to bladder surgery, and the article states that anti-infective coatings

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are now available and should be considered when selecting catheters for insertion. The authors

discuss the use of an all-in-one tray which includes all necessary equipment in a sterile package

to improve efficiency of insertion. Proper insertion techniques are also discussed in the article.

Handwashing before handling any part of the drainage system is emphasized, and the authors

state that sterile or aseptic technique is necessary to help prevent complications. Normal saline is

recommended to clean the meatus before insertion because antiseptic agents may irritate the

mucosa adding to the patient’s discomfort. An adequate amount of sterile lubrication should be

applied to the catheter before attempting to insert it, and once the catheter is inserted, it should be

stabilized to prevent movement, migration or possible dislodgement. It should be noted that one

brand of all-in-one Foley trays is discussed in detail which might be an indication that the

authors have some financial or other interest in promoting that product.

Diane Newman (2007) discusses catheter selection in “The Indwelling Urinary Catheter:

Principles for Best Practice,” an article published in the November/December 2007 issue of

Journal of Wound, Ostomy and Continence Nursing. The author discusses many types of

materials such as latex, silicone, and silver alloy, and the known advantages and disadvantages

of each. The smallest circumference catheter is recommended and the balloon size should be 10

milliliters filled with sterile water. A closed drainage system is also recommended with a one-

way valve to prevent urine reflux back into the bladder. The author recommends that the chosen

system should have a bag or cover to keep the system off the floor and help prevent

contamination. Appearance and comfort should also be considered when selecting a catheter

since many patients with long term catheterization find it difficult to conceal the drainage system

under their clothes when they are in public. This was the only article reviewed that discussed the

patients’ perception while selecting the appropriate catheter.

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Risks and Complications

As stated before, although IUC’s are routinely used throughout acute and long term care,

there are many risks and complications associated with their use. One of the most recent

developments that has brought these risks and complications into the spotlight is the Centers for

Medicare and Medicaid Services’ exclusion of catheter-associated urinary tract infections

(CAUTI) from reimbursement (Saint et al., 2009). This means that the hospitals are now

responsible for the additional costs of treatment of complications secondary to IUC’s, and health

care facilities are taking steps to reduce the complications and infection caused by catheter use.

Also, although CAUTI’s are most often the main topic of catheter related complications, there

are many other complications that can be caused by catheter use, and as a floor nurse who deals

with IUC’s daily, it is important for me to be aware of these.

“Best Practices in Urinary Catheter Care” (2009) describes many of the complications

that can occur secondary to IUC use. These complications include trauma to the urethra or

bladder due to improper insertion, removal or accidental dislodgement, blockage of the catheter,

encrustation, renal inflammation, urethral erosion or perforation and introduction of bacteria

resulting in infection and possibly septicemia or death. The authors also describe the impact that

catheterization can have on a patient’s social life, work and psychological well-being,

complications that are often overlooked when physical complications are focused on. CAUTI is

focused on in the article, and methods of infection are discussed. It is interesting to note that the

authors have found that after 30 days of catheter insertion, nearly 100% of patients will have

bacteria in their urine.

In “Internal and External Urinary Catheters: A Primer for Clinical Practice” (2008), a

double-blind peer, expert and editorial board reviewed article, the author lists a number of

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complications related to IUC’s that range from obstruction and blockage to sepsis and death.

CAUTI is listed as the most common and severe complication related to IUC usage, and the

author states that CAUTI is more likely to occur in women and with IUC placement duration

greater than two weeks. Additional complications include obstructions caused by encrustation,

urethral trauma and erosion, epididymitis in men, bladder stones that can lead to obstruction and

possible links to bladder cancer.

Gray (2008) discusses the complications caused by IUC’s in the article entitled “Securing

the Indwelling Catheter.” The author discusses the mechanics behind the trauma caused by

inserting a foreign object into the bladder. Urethral erosion can occur secondary to irritation and

damage and over time, urine may leak around the catheter. Bladder spasms are also common

after IUC’s are introduced into the bladder. Inadvertent dislodgment is another complication that

is discussed in the article, with resulting trauma and damage to the urethra, bladder and urinary

tract. CAUTI’s are also discussed as a complication of IUC’s, and the author discusses how

proper securement of the IUC may prevent many of these complications.

Holroyd-Leduc et al. (2007) report findings of a study conducted at a teaching hospital

that attempted to determine the association between IUC’s without a specific medical indication

and adverse outcomes and complications. Adverse effects were listed as UTI leading to

bacteremia and death, discomfort, functional impairment and frequent restraint requirements in

patients who attempt to remove or dislodge the IUC. The article reports findings of longer

hospital stays and higher mortality rates, with a four times greater risk of death as an inpatient

and a two times greater risk of death within 90 days of discharge. The authors did not go into

detail regarding how acutely ill the subjects of the study were, meaning whether or not their

condition was so compromised that they would not likely live even if they had not received a

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catheter while hospitalized.

Best Practices for Care and Management

Due to the recent CMS reimbursement changes, most of the articles focus on prevention

of CAUTI as opposed to other complications of IUC’s. Most did list a number of evidence based

practice guidelines for the management and care of IUC’s, research that I should be aware of and

incorporate into my daily practice as I care for patients who have an IUC in place.

According to Pellowe (2009), in the article “Reducing the Risk of Infection with

Indwelling Urethral Catheters,” a double blind peer and expert reviewed article, there are 10 key

issues and practice points that should be considered with short term IUC’s. To begin, the author

states that IUC’s should never be used for the convenience of staff to reduce care needed with an

incontinent patient or because a patient requires frequent assistance to the bathroom. Proper

sterile insertion technique should always be used including sterile lubrication, and the meatus

should be cleansed with sterile saline before attempting insertion. Daily assessment for removal

of the catheter should take place and it should be removed as soon as possible. The catheter bag

should always remain below the bladder to prevent reflux and use of a securement device should

be standard for every patient with an IUC. Meatal hygiene should be encouraged and should be

provided if the patient is unable to provide their own perianal and meatal care. When draining

the system, hands should be washed and clean gloves put on before the system is accessed. The

author also stresses the importance of educating staff about infection prevention, a requirement

of the Health and Social Care Act 2008.

Rebmann and Greene (2010) summarize the Association for Professionals in Infection

Control and Epidemiology, Inc., Elimination Guide in a peer reviewed article that appears in the

October 2010 issue of the American Journal of Infection Control. The authors stress the

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importance of risk assessment in the prevention of catheter related complications such as CAUTI

and state that the two most important aspect in infection prevention are avoiding use altogether

and using a closed drainage system. Minimizing use of IUC’s can be accomplished by using

them only when medically necessary, assessing the need for IUC’s daily, utilizing computerized

reminders to assess for continued necessity, trying to use intermittent catheterization whenever

possible, and removing IUC’s as soon as possible. Other interventions include aseptic insertion

techniques, proper training for individuals responsible for insertion and care and changing the

drainage system only when medically necessary. The authors also discuss current research that

is being conducted regarding antimicrobial materials for construction or to be added to the

drainage bag to reduce bacterial growth.

Joyce Wegner (2010) reviews the action plan undertaken by Lancaster General Hospital

in Pennsylvania to reduce the incidence of CAUTI and other complications associated with

IUC’s. The author describes a three-pronged approach that includes education, product research

and early catheter removal. Education included effects of biofilm, proper urine specimen

collection via IUC’s, re-education regarding proper sterile insertion and catheter care. Product

improvement included using a closed drainage system with a tamper evident seal and testing of a

silver-alloy catheter. Finally, the hospital enacted a nurse-driven catheter removal protocol

which gave the floor nurses the authority to remove catheters without an order by following a

pre-approved protocol. The author states that between 2007, when the action plan was first

developed, and 2009 there was a reduction in infection rates by 1.7 per 1000 catheters, which is

considered a clinically significant reduction. The protocol for maintaining catheter insertion was

also discussed in detail and the criteria were listed along with documentation guidelines.

The March/April 2009 edition of the Journal of Wound, Ostomy and Continence Nurses

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contained the final article for this research paper entitled “Nursing Interventions to Reduce the

Risk of Catheter-Associated Urinary Tract Infections: Part 2: Staff Education, Monitoring, and

Care Techniques” (Willson et al., 2009). The guidelines for prevention by three agencies were

listed; the Centers for Disease Control and Prevention, the Joanna Briggs Institute and the

International Consultation on Incontinence. These guidelines were set forth in an easy-to-use

table that compared the guidelines side by side. The authors searched MEDLINE, CINAHL and

Cochrane databases to answer a number of questions posed in this paper, and the evidence is laid

out in a systematic manner and rated between levels one and four. The disappointing conclusion

is that no matter what techniques or care are used, the risk for infection and other complications

continues to be very high.

The information that I have gained by researching this topic and reviewing these articles

will be invaluable to my nursing practice. As stated before, I deal with the insertion and care of

IUC’s every day during my work, and I am now more familiar with the risks and complications

of this intervention. I know that I have left IUC’s in place for my own benefit, so that I did not

have to repeatedly clean up an incontinent patient, but now I understand that this is not

acceptable, that I might actually be putting my patient at risk by doing this. I also have a better

understanding of why certain care techniques are required, so I will be more likely to

consistently follow through on this care with each patient, and I will also be better able to

educate my coworkers on the proper care and the reasoning behind this care. This assignment

was also very helpful practice for searching databases and trying different search techniques to

find what I needed, a skill that will be very helpful as I pursue my bachelor’s degree at Ferris

State University.

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References

Freeman, C. (2009). Why more attention must be given to catheter fixation. Nursing Times, 105(29). Retrieved from http://www.nursingtimes.net

Gray, M. (2008). Securing the indwelling urinary catheter. American Journal of Nursing, 108(12), 44-50. doi: 10.1097/01.NAJ.0000342069.15536.b5

Gray, M. (2010). Reducing catheter-associated urinary tract infection in the critical care unit. AACN Advanced Critical Care, 21(3), 247-257. doi: 10.1097/NC1.0b013e3181db53cb

Herter, R. & Kazer, M.(2010). Best practices in urinary catheter care. Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional, 28(6), 342-349. doi: 10.1097/NHH.0b013e3181df5d79

Holryd-Leduc, J.M., Sen, S., Bertenthal, D., Sands, L.P., Palmer, R.M., Kresevic, D.M., . . . Landefeld, C.S. (2007). The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients. Journal of the American Geriatrics Society, 55(2), 227-233. Retrieved from http://www.americangeriatrics.org/

Madeo, M. & Roodhouse, A. (2009). Reducing the risks associated with urinary catheters. Nursing Standard, 23(29), 47-56. Retrieved from http://www.nursingstandard.rcnpublishing.co.uk

Newman, D. (2007). The indwelling urinary catheter: Principles for best practice. Journal of Wound, Ostomy and Continence Nursing, 34(6), 655-661. doi:10.1097/01.WON.0000299816.82983.4a

Newman, D. (2008). Internal and external catheters: A primer for clinical practice. Ostomy and Wound Management, 54(12), 18-35. Retrieved from http://www.owm.com

Newman, D. (2009). How to prevent CAUTIs. Nursing Management, 40(7), 50-52. doi: 10.1097/01.NUMA.0000357803.91881.ae

Pellowe, C. (2009). Reducing the risk of infection with indwelling urinary catheters. Nursing Times, 105(36), 29-32. Retrieved from http://www.nursingtimes.net

Rebmann, T. & Greene, L. (2010). Preventing catheter-associated urinary tract infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide. American Journal of Infection Control, 38(8), 644-646. doi:10.1016/j.ajic.2010.08.003

Robinson, J. (2009). Urinary catheterisation: Assessing the best options for patients. Nursing Standard, 23(29), 40-45. Retrieved from http://nursingstandard.rcnpublishing.co.uk/

Saint, S., Meddings, J., Calfee, D., Kowalski, C. & Krein, S. (2009). Catheter-associated urinary tract infection and the Medicare rule changes. Annals of Internal Medicine, 150(12), 877-884. Retrieved from http://www.annals.org

Wenger, J. (2010). Cultivating quality: Reducing rates of catheter-associated urinary tract infection. American Journal of Nursing, 110(8), 40-45. doi:10.1097/01.NAJ.0000387691.47746.b5

Willson, M., Wilde, M., Webb, M., Thompson, D., Parker, D., Harwood, J., . . . Gray, M. (2009). Nursing interventions to reduce the risk of catheter-associated urinary tract infection: Part 2: Staff education, monitoring, and care techniques. Journal of Wound, Ostomy and Continence Nursing, 36(2), 137-154. doi: 10.1097/01.WON.0000347655.56851.04

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