Each year, urinary catheters are inserted in more than 5 million patients in acute care hospitals and long-term care (LTC) facilities. Historically, indwelling catheters have been used in the chronically, medically compromised elderly person.
The settings in which the prevalence of long-term indwelling catheter usage is the greatest are: 1) skilled nursing facilities, where they are used in residents with UI, and 2) homes where the person requires skilled nursing visits.
In the home-care setting, the prevalence of indwelling catheters is growing with the increasing number of older adults. However, the number of “home-bound” patients who use a catheter indefinitely to manage UI or because of urinary retention has not been well documented in medical or nursing research.
- Short term for acute urinary retention:
- Sudden and complete inability to void
- Need for immediate and rapid bladder decompression
- Monitoring of intake and output
- Temporary relief of bladder outlet obstruction secondary to:
- Enlarged prostate gland
- Urethral stricture
- Obstructing pelvic organ prolapse
- Chronic urethral obstruction or urinary retention and surgical interventions, or the use of intermittent catheterization, has failed or is not feasible, or both
- Short term following a urological or gynecological surgical procedure
- Irreversible medical conditions are present (e.g., metastatic terminal disease, coma, end stages, of other conditions)
- Presence of stage III or IV pressure ulcers that are not healing because of continual urine leakage
- Instances in which a caregiver is not present to provide incontinence care
Although indwelling urinary catheters are commonly used in most clinical settings, data suggest that more than 20% of these catheters are placed without a specific medical indication and that they often remain in place without the knowledge of the patient’s physician. Studies of the appropriateness of use of urinary catheters indicate that 21 to 38% of initial urinary catheterizations are unjustified, and one-third to one-half of days of continued catheterization are unjustified. The current challenges are to develop effective methods to sensitize the minds of clinicians to avoid the routine use of indwelling catheters, remove catheters when they are no longer needed, develop alternative methods for care of incontinence, employ noninvasive methods to measure bladder function and urine output, and improve urine drainage systems.
In acute care hospital settings, 15 to 25% of patients may have a catheter inserted some time during their stay, usually for surgery, urine output measurement, urinary retention, or UI.
Hospitals use indwelling catheters more than any other medical device. Because the most important risk factor for catheter-associated bacteriuria is duration of catheterization, most catheters in hospitalized patients are placed for only 2 to 4 days.
Extended indwelling catheter use in older patients sustaining hip fracture who are discharged to skilled nursing facilities with a catheter in place have been associated with poorer outcomes because these individuals are at higher risk of rehospitalization for CAUTIs and sepsis. Increased mortality at 30 days is seen in these individuals when compared to patients whose catheter was removed prior to discharge.
The risk of infection is associated with the method and duration of catheterization, the quality of catheter care, and host susceptibility. Around 50% of hospitalized patients catheterized longer than 7 to 10 days contract bacteriuria.
Although frequently asymptomatic, 20 to 30% of individuals with catheter-associated bacteriuria will develop symptoms of CAUTI. Many of these infections are serious and lead to significant morbidity and mortality.
- Bedside commode, urinal, or continence garments: to manage incontinence.
- Bladder scanner: to assess and confirm urinary retention, prior to placing catheter to release urine.
- Straight catheter: for one-time, intermittent, or chronic voiding needs.
- External “condom” catheter: appropriate for cooperative men without urinary retention or obstruction.
2. Before placing an indwelling catheter, does the patient have one of the following appropriate indications* for placing indwelling urinary catheters?
- Acute urinary retention: e.g., due to medication (anesthesia, opioids, paralytics), or nerve injury
- Acute bladder outlet obstruction: e.g., due to severe prostate enlargement, blood clots, or urethral compression
- Need for accurate measurements of urinary output in the critically ill
- To assist in healing of open sacral or perineal wounds in incontinent patients
- To improve comfort for end of life, if needed
- Patient requires strict prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fracture)
Selected peri-operative needs:
- Urologic surgery or other surgery on contiguous (adjacent) structures of the genitourinary tract
- Anticipated prolonged duration of surgery (Note: catheters placed for this reason should be removed in PACU)
- Large volume infusions or diuretics anticipated during surgery
- Need for intraoperative monitoring of urinary output
The prevalence of indwelling urinary catheter use in nursing homes has been established as 7%.
It may be greater in facilities that have poor success with toileting programs because the catheter is used as a means to maintain resident dryness.
At least 40% of all infections seen in nursing homes are in the urinary tract. Of these infections, 80% are due to urinary tract catheterization and instrumentation.
CAUTI is of major importance because of its effect on outcomes and treatment costs. The major reason for use of an indwelling catheter in LTC is incontinence or pressure ulcers.
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