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ORIGINAL ARTICLE
Ahead of print publication  

Appropriateness of indwelling urinary catheter use in medical inpatients: A prospective observational study


 Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission22-Dec-2021
Date of Decision16-Mar-2022
Date of Acceptance09-Apr-2022
Date of Web Publication07-Jun-2022

Correspondence Address:
Surendran Deepanjali,
Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijamr.ijamr_247_21

  Abstract 

Background: Indwelling urinary catheters (IUCs) are commonly used in hospitalized patients, but often for inappropriate indications. Aims: We aimed to study the appropriateness of IUC insertion among patients admitted under the department of medicine in a tertiary care hospital in southern India. We also studied the proportion of patients in whom the continued use of IUC was unjustified. Methods: During June–August 2019, we prospectively studied adult patients admitted to the emergency and medicine wards in whom an IUC was inserted in the past 48 hours. Appropriateness of catheter use was determined based on predefined criteria. Results: We studied 132 patients; 96 (72%) were male. IUC insertion was found to be inappropriate in 16 (12%) patients. The most common reason for inappropriate use was placing an IUC to monitor urine output in noncritically-ill patients (50%, 8/16). Of the 74 patients with appropriate indications for IUC insertion who were followed up, continued use of IUC was found inappropriate in 23 (31%) patients. In patients without appropriate indications for continued IUC use, the catheter remained in situ longer for a mean duration of 2.9 (95% confidence interval 1.0–4.7) days. Conclusion: More than one in ten IUC insertions were found to be inappropriate. Even when the insertion was appropriate, IUCs were not removed in time in about a third of patients. Institutional policies and physician engagement are urgently needed to promote the appropriate use of IUCs.

Keywords: Catheter days, catheter-associated urinary tract infection, inappropriate use, indwelling urinary catheters, medical inpatients



How to cite this URL:
Susan SS, Deepanjali S. Appropriateness of indwelling urinary catheter use in medical inpatients: A prospective observational study. Int J Adv Med Health Res [Epub ahead of print] [cited 2022 Jun 25]. Available from: https://www.ijamhrjournal.org/preprintarticle.asp?id=346832


  Introduction Top


Indwelling urinary catheters (IUCs) are being extensively used in inpatient care for many decades. About 25% of hospitalized patients will have an IUC inserted during their hospital stay.[1] However, research from India and abroad suggests that knowledge regarding appropriate indications for IUC use is suboptimal among physicians and nurses.[2],[3] Almost 20%–50% of IUC insertions are unjustified, and a significant proportion of IUCs remain in place even when the initial indication for its use is no longer present.[4],[5],[6] Inappropriate use of IUCs may result in unnecessary pain, discomfort, and catheter-associated urinary tract infection (CAUTI), which is one of the common health-care-associated infections in India and elsewhere.[7] Published data from India on this important aspect of patient care are limited.[8] We, therefore, aimed to study the appropriateness of IUC insertion and its continued use among medical inpatients.


  Methods Top


This prospective observational study was conducted at the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India, from June 2019 to August 2019. The study protocol was approved by the Institute Ethics Committee (IEC No. JIP/IEC/2019/0109), and a waiver of informed consent was granted. Patients aged ≥18 years admitted under the department of medicine in whom an IUC was inserted after hospital admission in the past 48 h were eligible for inclusion. We excluded patients admitted in the medical intensive care units (ICU) and those with condom or suprapubic catheters or a percutaneous nephrostomy drain.

We identified patients admitted to the medical emergency or general medical wards in whom an IUC was inserted in the previous 48 hours. Data were collected using a predesigned pro forma. A careful review of the patients' bedside charts was done to obtain information regarding the age, gender, working diagnosis, place of IUC insertion, vital signs, mental status, and daily fluid intake/urine output status at admission as well as for the next 5 days. We noted the serum creatinine value on admission to diagnose acute kidney injury (AKI), defined as serum creatinine ≥1.2 mg/dL for the purpose of the study. We also reviewed inpatient records for documentation of orders for IUC insertion, removal, or reinsertion. Postgraduate residents in charge of the patient were interviewed to elicit the reason for initial catheterization and the need for its continued use. Appropriateness of IUC insertion and continued use were determined based on both Health-care Infection Control Practices Advisory Committee guidance and Ann Arbor criteria adapted to our practice setting [Table 1].[9],[10]
Table 1: Appropriate and inappropriate indications for indwelling urinary catheters insertion and continuation

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Sample size calculation

To estimate an assumed frequency of inappropriate use of 20% with 7% absolute precision, we needed to study 130 patients. To study unjustified continuation after initial appropriate insertion, a convenient sample of 74 patients was chosen.

Statistical analysis

We summarized categorical variables such as appropriateness of IUC insertion as frequency and proportion (n [%]). Independent sample t-test and Chi-square test were employed to identify factors associated with inappropriate catheterization and its continued use. P < 0.05 was considered statistically significant. All analyses were performed using Stata/IC 12.1 (Stata Statistical Software: Release 12. College Station, TX: StataCorp LP).


  Results Top


We studied a total of 132 patients; 96 (72%) were males. The mean (± standard deviation [SD]) age of patients was 53.8 ± 16.9 years. Of the 132 patients, 125 (94%) were catheterized in the emergency department. Overall, 77 (58%) had altered sensorium, 76 (57%) had AKI, and 13 (9%) had hypotension at admission.

On interviewing the treating doctors, the most cited indications for IUC insertion were the presence of altered sensorium (62 [46%]) of patients, followed by urine output monitoring [46 (35%); [Table 2]]. A written physician order for IUC insertion was present for only two (1.5%) patients. IUC insertion was inappropriate in 16 (12%) patients. Of them, the most common reason for inappropriate insertion was urine output monitoring in eight patients who were neither critically ill nor had AKI. We found no statistically significant association of inappropriate IUC insertion with age, gender, and place of catheter insertion [Table 2].
Table 2: Characteristics of patients with appropriate and inappropriate indwelling urinary catheter insertion

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We followed up 74 patients who had an initial appropriate indication for IUC insertion until hospital discharge. The mean duration of catheter use was 6.6 ± 3.8 days (minimum 1 day and maximum 23 days). We found that continued use of IUC was inappropriate in 23 (31%) patients. The mean duration, for which IUC was in place in these patients, was 8.5 ± 4.6 days. Age and gender were not associated with inappropriately prolonged IUC use.


  Discussion Top


In this prospective observational study, we found that 12% of IUCs inserted in patients admitted under the medical department were inappropriate. The continued use of IUC was unjustified in about one-third of those who had an initial appropriate indication for IUC insertion. Importantly, we also observed that written orders for placement of an IUC were missing in most cases. Further, despite IUC insertion being an invasive procedure, it was not documented in the patients' medical records.

Jain et al., in a prospective analysis of the appropriateness of IUC use among patients admitted to the medical floors and ICU, in a New York hospital, found that the initial indication was unjustified in 21% of the patients.[4] Another study, including patients in medical wards of a teaching hospital in New Delhi, India, found that the use of IUC was inappropriate in 29% of patients.[8]

Compared to these studies, we found a lesser proportion (12%) of unjustified insertion of IUC. In the study by Jain et al., a major proportion of patients were recruited from the ICU setting, where the use of IUCs would be more common.[4] Similarly, the New Delhi study had many patients with a neurological diagnosis in whom the use of IUCs could have been higher. As the proportion of patients with IUCs increases, the number of inappropriate insertions may also show a corresponding rise.

In our study, 30% of patients had unjustified continued IUC use. In the study by Jain et al., this proportion was 47%.[4] Indeed, evidence suggests that treating physicians are often unaware of their patients' IUC and those “forgotten catheters” remain in situ for many days.[11] Similar to our findings, other studies also found that physicians seldom document IUC insertion.[12]

Our study findings indicate the need for educational interventions to raise health-care personnel's awareness regarding the appropriate indications for IUC use. In addition, firm institutional norms are essential to curb the unjustified use of IUCs; such measures have been shown to be effective in some settings.[13] We also need to put in place institutional mechanisms to prevent unwarranted prolonged use of IUCs once they are inserted.

Our study could have been more informative, had we collected data on the incidence of urethral trauma, discomfort, and pain as well as the incidence of CAUTI. Nonetheless, our findings make a strong case for physician engagement and institutional norms to promote appropriate use of IUC as well as proper documentation of its use.


  Conclusion Top


Inappropriate insertion of IUC was seen in one-tenth of patients admitted to medical wards while among those with an appropriate initial indication for IUC insertion, its continued use was unjustifiable in a significant proportion. Urgent institutional policies and physician engagement are needed to reduce preventable harm related to IUC use.

Acknowledgment

The authors thank the junior residents of the Department of Medicine JIPMER, for their cooperation.

Financial support and sponsorship

The study was supported by a student's research grant given to the first author by JIPMER, Puducherry as a Golden Jubilee Short-Term Research Award project (JIP/UGRMC/GJSTRAUS- 2019/24). The authors declare no competing interests.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Clarke K, Hall CL, Wiley Z, Tejedor SC, Kim JS, Reif L, et al. Catheter-associated urinary tract infections in adults: Diagnosis, treatment, and prevention. J Hosp Med 2020;15:552-6.  Back to cited text no. 1
    
2.
Jain M, Dogra V, Mishra B, Thakur A, Loomba PS. Knowledge and attitude of doctors and nurses regarding indication for catheterization and prevention of catheter-associated urinary tract infection in a tertiary care hospital. Indian J Crit Care Med 2015;19:76-81.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Murphy C, Prieto J, Fader M. “It's easier to stick a tube in”: A qualitative study to understand clinicians' individual decisions to place urinary catheters in acute medical care. BMJ Qual Saf 2015;24:444-50.  Back to cited text no. 3
    
4.
Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 1995;155:1425-9.  Back to cited text no. 4
    
5.
Munasinghe RL, Yazdani H, Siddique M, Hafeez W. Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service. Infect Control Hosp Epidemiol 2001;22:647-9.  Back to cited text no. 5
    
6.
Gokula RM, Smith MA, Hickner J. Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters. Am J Infect Control 2007;35:589-93.  Back to cited text no. 6
    
7.
Nair V, Sahni AK, Sharma D, Grover N, Shankar S, Chakravarty A, et al. Point prevalence & risk factor assessment for hospital-acquired infections in a tertiary care hospital in Pune, India. Indian J Med Res 2017;145:824-32.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Bhatia N, Daga MK, Garg S, Prakash SK. Urinary catheterization in medical wards. J Glob Infect Dis 2010;2:83-90.  Back to cited text no. 8
    
9.
Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of Catheter-Associated Urinary Tract Infections; 2009. Available from: https://www.cdc.gov/infectioncontrol/guidelines/cauti/. [Last accessed on 2019 Oct 25].  Back to cited text no. 9
    
10.
Meddings J, Saint S, Fowler KE, Gaies E, Hickner A, Krein SL, et al. The Ann Arbor criteria for appropriate urinary catheter use in hospitalized medical patients: Results obtained by using the RAND/UCLA appropriateness method. Ann Intern Med 2015;162:S1-34.  Back to cited text no. 10
    
11.
Saint S, Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med 2000;109:476-80.  Back to cited text no. 11
    
12.
Fakih MG, Pena ME, Shemes S, Rey J, Berriel-Cass D, Szpunar SM, et al. Effect of establishing guidelines on appropriate urinary catheter placement. Acad Emerg Med 2010;17:337-40.  Back to cited text no. 12
    
13.
Knoll BM, Wright D, Ellingson L, Kraemer L, Patire R, Kuskowski MA, et al. Reduction of inappropriate urinary catheter use at a Veterans Affairs hospital through a multifaceted quality improvement project. Clin Infect Dis 2011;52:1283-90.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2]



 

 
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