The Case

A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular attack with hemiplegia, dysphagia, vascular dementia, speech disorder, benign hypertrophy of prostate with urinary retention, and monocular blindness was admitted to the hospital. He had no known allergies. The patient required total care for his activities of daily living. He received bolus feedings through a gastrostomy tube and required occasional suctioning of his tracheostomy. He was incontinent of bowel and bladder. He was alert and oriented to person and place. He was only able to answer simple yes-or-no questions.

During the day-to-evening shift change, a nursing assistant reported the patient had not voided all shift. The patient's bladder was not distended nor did he complain of discomfort. The hospitalist was called and ordered a urinary catheter insertion. Just prior to insertion of the catheter by a registered nurse (RN), the patient voided but the amount was not recorded. The RN reported this to the charge nurse, who informed the RN to proceed with the catheter insertion. The RN did so, but the procedure did not produce any urine. Since the patient had just voided, the RN assumed the patient's bladder was empty. Two hours later, the patient began to complain of discomfort. The RN attempted to irrigate the catheter but met resistance.

The charge nurse was called to assess the situation and found a blood clot in the tubing. The hospitalist was notified and ordered continuous bladder irrigation (CBI). The same RN removed the catheter and inserted a three-way catheter and the CBI began. An hour later, the patient's pain increased and his bladder was distended. The CBI intake and output were in equal amounts. The patient was transferred to emergency room. A urologist was called, who performed a bladder scan and discovered the urinary catheter was not in the bladder. The second catheter was removed and a new three-way catheter was inserted by the emergency room RN. Blood returned from the new catheter. It was irrigated until clear, and then CBI resumed. The patient was transferred back to the ward for observation and the next day he received two units of blood. CBI was continued for 2 days.

The patient experienced pain from a distended bladder, a misplaced catheter, and three catheter [re-]insertions. He was put at risk for complications that included urinary tract infection, urosepsis, and bladder rupture. The misplaced catheter caused trauma to the urethra and blood loss. The patient's wife filed a complaint with the facility, which prompted an in-house investigation. The investigation revealed that the nursing staff on duty were unaware of the policy regarding bladder scanning prior to catheter insertion or the CBI policy that required documentation of both input/output and urinary volume.

The Commentary

by Diane K. Newman, DNP, MSN; Robyn Strauss, MSN; Liza Abraham, CRNP; and Bridget Major-Joynes, MSN, RN

This case illustrates errors that may occur with urinary catheters. In patients with bladder dysfunction, an indwelling urinary catheter (IUC) allows continuous urine drainage.(1) Catheters are used in both men and women in all care settings. At least 15% to 25% of patients may have an IUC inserted sometime during their hospital stay, with most only used for the short-term (defined as under 30 days).(2) Prevalence is greater in high-acuity patient units, particularly intensive care units. IUCs are invasive devices, which in many instances are placed unnecessarily, remain in without provider awareness, and are not removed when no longer needed.(3) In hospitalized older medical patients with urinary incontinence, an IUC is often placed inappropriately, usually for staff convenience (Table 1). An IUC has been associated with a greater risk of death—four times higher during hospitalization and two times higher within 90 days after discharge.(4) Inappropriate IUC use has been equated to a one-point restraint (5), because like restraints, catheters can cause functional impairment leading to emboli, discomfort, and pressure ulcers.

With regulatory and financial pressures directed toward reducing hospital-acquired infections, attention has been refocused toward IUCs and their misuse. The Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline (6,7) and the Infectious Diseases Society of America clinical practice guidelines (8) provide guidance on specific indications and evidence-based care practices for appropriate use of IUCs (Table 1). Specific measures to reduce catheter-associated urinary tract infections (CAUTIs) include catheter checklists with algorithms to decrease unindicated use, aseptic IUC insertion and maintenance. In addition, the American Nurses Association's CAUTI Prevention Tool provides similar nursing care measures.(9)

Registered nursing staff play a central role in safe IUC practices because they are the primary clinicians who insert and care for patients with them.(1,10) Routine IUC nursing care procedures include care of the entire catheter system: the catheter, drainage tubing, and bag. Although functions related to system care have become standard, few are supported by evidence-based research, and certain care practices have been shown to contribute to complications. In a survey distributed to US hospitals about prevention of hospital–acquired urinary tract infections and other device-associated infections (3), only 9% of hospitals reported using an IUC stop-order or reminder, 14% used external male catheters (a containment product for men with urinary incontinence), and approximately 30% used a portable bladder scanner to determine the volume of urine in the bladder. In a survey of RNs working at 7 nursing homes, 52% did not know that routine irrigation of IUCs is contraindicated, and 43% were unaware that once an IUC is inserted it should not be disconnected from the drainage bag.(11) Another study revealed that only 47% RNs reported competence in IUC insertion.(10) In this study, training in aseptic technique occurred at 64% of the hospitals at the time of initial nursing hire. However, fewer than half the sites annually validated IUC insertion competency (47%).(10) These significant knowledge and practice gaps must be addressed to improve the quality and safety of patient care.

Best practices for IUC maintenance and care are found throughout the nursing literature. The ABCDE Bundle (12) (Table 2) offers practical recommendations for IUC care and these are being used by many hospitals. The best practices include catheter insertion in a sterile fashion with aseptic technique; cleansing of the perineal area and meatus with basic soap and water daily and after each bowel movement; scanning of the bladder to determine urine volume prior to catheterization (13); maintaining the drainage bag below the level of the bladder; and ensuring free and unobstructed urine flow. Periodic validation of IUC insertion, perineal care, and bladder scan competency are effective methods to ensure excellent nursing practice.(14,15) Most guidelines, including the ABCDE Bundle do not address the actual procedure of IUC insertion other than stating the need for sterility.

Formalized nursing competency for the IUC insertion procedure is ill defined in nursing school curricula. Insertion procedures are detailed in medical–surgical nursing textbooks and many videos can be found on the Internet, but inconsistency exists. Most acute care settings develop their own IUC insertion protocols. In undergraduate nursing education, nurses are taught about IUC indications, complications, and management, and practice catheterizations on a simulated model, but the actual insertion in a live patient does not occur unless they are caring for a patient who needs to be catheterized. In reality, a nurse's first experience of catheterizing a patient may occur during their first position as a practicing RN. The same may also be true for medical students.

At our hospital, we recognize this lack of competency and have instituted a policy that newly hired RNs practice catheterization on a female and male simulated model while being observed by an experienced clinical nurse. In addition, we utilize a focused competency-based approach to review the microbiology of CAUTI, urinalysis collection, and urine culture indications. The clinical nurse is educated on management of catheter bypassing (urine leakage around the catheter), bladder scanning, coude tip catheter insertion, pericare, and algorithmic tools for management of the patient post IUC removal. Medical students are also required to demonstrate catheterization using the same method prior to performing on a patient. Furthermore, if a unit has an increase in their CAUTI rates, all nurses must demonstrate IUC insertion competency again. We have also developed benchmarks for nurses to follow and to measure competency.

The ease of catheter placement differs. Because the urethral length is quite short (3–4 cm), female catheter placement is generally simple, straightforward, and uncomplicated. The most challenging aspect of female urethral catheterization is localization of the urinary meatus, especially in woman with obesity or in women with anatomical differences (e.g., urinary meatus located intravaginally). However, men can have difficult urinary catheterizations (DUCs) caused by the length and curves of the male urethra and the skill of the person performing the insertion. The male urethra is far longer (15–25 cm) and is curved (referred to as an S-curve) as it descends in its last 4–5 cm proximally through the urogenital diaphragm and prostate. Prior to catheterization, the patent's history is important as it can guide the insertion process. If the male patient has a history of previous IUC and/or an enlarged prostate, the clinician should probably choose a larger sized (diameter) catheter (e.g., 16 Fr) with a coude (curved) tip.(15)

This case illustrates the damage and complications related to DUC, especially in male patients. Male urethra complications are usually mechanical in nature. They include dislodgement due to trauma, urethral erosion (traumatic hypospadias due to pressure necrosis), and creation of a false passage. One that is rarely reported, but probably common, is incomplete passage of the catheter through the length of the urethra and into the bladder. The catheter may curl or kink in the urethra, butt up against one of the urethral curves, bend at the tip, or the catheter might be unable to pass past the prostate either because of an enlarged prostate or a urethral spasm occurred.

In this case, it is likely that the catheter curled in the urethra and the nurse inflated the balloon, unaware of the incorrect position of the balloon. Most catheters are fairy flexible, and a curled catheter can get stuck at the urogenital diaphragm and prostate. This can be quite painful and it is surprising that the case does not mention any patient complaints at the time of catheterization. A curled or kinked catheter and inflated balloon in the urethra is consistent with the observations reported in this case: the catheter did not produce or drain any urine; the patient's complaint of pain 2 hours after catheterization probably caused by increasing urethral trauma and increasing bladder distension; and the nurse was unable to irrigate the catheter and met resistance when attempting to. The blood clot found in the tubing by the charge nurse may have been related to the trauma of the curled catheter.

Another possible complication may be that the catheter lodged in the wall of the urethra, pushed through the mucosa to create a false passage. This occurs more frequently in men who perform intermittent catheterizations frequently (e.g., spinal cord injury patients), but it can also be produced by unskillful introduction of instruments. When the three-way catheter insertion did not result in urine drainage, this may have been because catheter was lodged in the false passage.

Medical professionals who have experienced difficulty in catheterization of any patient should be required to consult with a specialist (urologist or other suitably trained individual) early in the process, before irreversible damage is done to the urethra. In men where a DUC is suspected, the literature suggests that the next approach should be suprapubic placement (15), cystoscopy use of a guidewire (16) or the use of a filiform, either of which can be inserted in a urethral, facilitating passage through a narrowed area.(17) In this case, prior to irrigation, a urology referral should have been made. When urine was not draining from the catheter, the nurse should have immediately scanned the bladder and, if more than 200 mL of urine was present, deflated the balloon and removed the catheter. Further action should then have awaited the urologist consult.

The standard of care in acute care and rehabilitation facilities is to first determine bladder volume noninvasively, with a portable bladder scanner, prior to catheterizing a patient.(13) The bladder scanner measures ultrasonic reflections on multiple planes within the patient's body to differentiate the bladder from surrounding tissues. A microprocessor within the instrument automatically calculates and displays bladder volume in centimeters. Portable ultrasounds have been found to have a specificity of 96.5% in detecting post-void residual urine under 100 mL in ambulatory women.(18)

This case study illustrates several clinical errors and omissions that involve the IUC and the general care of the patient: (i) A more complete history would have included information on a past history of urinary retention and/or an enlarged prostate and any previous experience with IUC insertion. (ii) More accurate reporting of the patient's voiding history was needed. The nurse reported that the patient had not voided in 2 hours, but history notes the patient is incontinent. Was the incontinence brief dry, indicating that the patient had not been voiding? This is where the main error was made, once the question of "no voiding" occurred, the bladder should have been scanned. (iii) When the initial catheterization did not produce urine, the RN should have scanned the bladder to determine if there was urine in the bladder. (iv) Depending on the volume in the bladder (e.g., 300 to 400 mL), straight catheterization would have been the appropriate intervention. If bladder volume was significant (e.g., 400 to 500 mL), from that point on, no further action should have been performed by the nurse pending expert consultation. If the scan indicated urine in the bladder, the catheter should have been removed, the urology service consulted, and re-catheterization performed using perhaps a coude tip catheter or a catheterization aided with a guidewire.

Take-Home Points

• Insertion of an indwelling catheter should be performed accurately by personnel with demonstrated competency. This competency should be maintained and validated at regular intervals, i.e., every 1–2 years. Staff attrition or clinical misjudgments related to IUC care and maintenance often will dictate frequency of education needs.
• It is imperative to know as much as possible about the patient's genitourinary history prior to inserting an IUC.
• The anatomy of the male and female urethra should be reviewed before inserting a catheter.
• All personnel must follow evidence-based guidelines on urinary catheterizations and receive periodic continuing education and competency demonstration.

Diane K. Newman, DNP, MSN Adjunct Professor of Urology in Surgery, Perelman School of Medicine Research Investigator Senior University of Pennsylvania, Division of Urology, University of Pennsylvania Medical Center Philadelphia, Pennsylvania

Robyn Strauss, MSN Clinical Nurse Specialist VI Heart & Vascular ICU Hospital of the University of Pennsylvania Philadelphia, Pennsylvania

Liza Abraham, CRNP Acute Care Urology Nurse Practitioner Department of Urology Perelman Center for Advanced Medicine Philadelphia, Pennsylvania

Bridget Major-Joynes, MSN, RN Clinical Nurse Specialist V Co-Chair of UTI Evidence Based Nursing Committee Hospital of the University of Pennsylvania Philadelphia, Pennsylvania

References

1. Newman DK. The indwelling urinary catheter: principles for best practice. J Wound Ostomy Continence Nurs. 2007;24:655-661. [go to PubMed]

2. Meddings J, Rogers MA, Macy M, Saint S. Systematic review and meta-analysis: reminder systems to reduce catheter–associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2010;51:550-560. [go to PubMed]

3. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis. 2008;46:243-250. [go to PubMed]

4. Holroyd-Leduc JM, Sen S, Bertenthal D, et al. The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients. J Am Geriatr Soc. 2007;55:227-233. [go to PubMed]

5. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137:125-127. [go to PubMed]

6. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter–associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31:319-326. [go to PubMed]

7. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter–associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35:464-479. [go to PubMed]

8. Hooton TM, Bradley SF, Cardenas DD, et al; Infectious Diseases Society of America. Diagnosis, prevention, and treatment of catheter–associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:625-663. [go to PubMed]

9. Silver Spring, MD: American Nurses Association. ANA CAUTI Prevention Tool. [Available at]

10. Fink R, Gilmartin H, Richard A, Capezuti E, Boltz M, Wald H. Indwelling urinary catheter management and catheter–associated urinary tract infection prevention practices in Nurses Improving Care for Healthsystem Elders hospitals. Am J Infect Control. 2012;40:715-720. [go to PubMed]

11. Mody L, Saint S, Galecki A, Chen S, Krein SL. Knowledge of evidence-based urinary catheter care practice recommendations among healthcare workers in nursing homes. J Am Geriatr Soc. 2010;58:1532-1537. [go to PubMed]

12. Saint S, Olmsted RN, Fakih MG, et al. Translating health care–associated urinary tract infection prevention research into practice via the bladder bundle. Jt Comm J Qual Patient Saf. 2009;35:449-455. [go to PubMed]

13. Newman DK, Gaines T, Snare E. Innovation in bladder assessment: use of technology in extended care. J Gerontol Nurs. 2005;31:33-41. [go to PubMed]

14. Newman DK. How to prevent CAUTIs. Nurs Manage. 2009;40:50-52. [go to PubMed]

15. Averch TD, Stoffe, J, Goldman HB, et al. AUA White Paper on Catheter–Associated Urinary Tract Infections: Definitions and Significance in the Urologic Patient. Lithixcum, MD: American Association of Urology; 2014. [Available at]

16. Bacsu C, Van Zyl S, Rourke KF. A prospective analysis of consultation for difficult urinary catheter insertion at tertiary care centres in Northern Alberta. Can Urol Assoc J. 2013;7:343-347. [go to PubMed]

17. Ghaffary C, Yohannes A, Villanueva C, Leslie SW. A practical approach to difficult urinary catheterizations. Curr Urol Rep. 2013;14:565-579. [go to PubMed]

18. Goode PS, Locher JL, Bryant RL, Roth DL, Burgio KL. Measurement of postvoid residual urine with portable transabdominal bladder ultrasound scanner and urethral catheterization. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11:296-300. [go to PubMed]

Table

Table 1. Indications for Indwelling Urinary Cathether.(6)

Table 2. The ABCDE Bundle for Prevention of CAUTIs.(12)