Does a Foley Ever Have an Indication? Cole Beeler, MD Infection Prevention Indiana University Hospital
Objectives • Discuss CAUTI Epidemiology and the risks of colonization over time. • Understand the approved indications for catheter placement. • Challenge the indications to drive harm reduction despite appropriate usage. • Use data to implement algorithmic changes with key stakeholders to reduce Foley utilization despite approved indications.
CAUTI Epidemiology • 1.4-1.7 infections per 1,000 catheter days • 100,000 cases estimated per year • 12-16% of admitted patients have Foleys • 20% of healthcare associated bacteremias associated with CAUTI • 10% Mortality in this group NHSN. CAUTI. 2019. Dudeck et al. Am J Infect Control. 2013. Gould CV et al. ICHE. 2010.
Colonization Is the Rule 100% by 2 weeks 50% by 1 week Nicolle, LE. Infect Dis Clin N Am 17. 2003. Warren, JW et al. JID. 1982
Biofilms Ohkawa M et al. J Urol. 1990. Ganderton L et al. Eur J ClinMicrobiol Infect Dis. 1992. 88% of Catheters removed between 3d and 3mo. • 75% of Catheters removed between 1-2 weeks
Prevention Strategy #1 Highway Urethra
But my patient NEEDS their Foley! Gould. CDC. 2017.
When do guidelines become rules? • Problems: • Indication becomes a free pass • Path of lowest resistance • Simplifies care for physicians and nurses • Cultural reliance • Missed contributing diagnosis
I Doubt Your Indication Doctors IP
Clinical Case I Doubt Your Indication I’ve got this patient with BPH who came in with acute kidney injury and can’t urinate. I need a Foley to help relieve his obstruction and improve his kidney function! I really need this Foley!!!
Causes of Acute Urinary Retention = Easy reversibility Park et al. Korean Journal of Urology. 2012.
Immediate Removal • 60 patients with Acute Retention with immediate removal of catheter placed on admission • 17/60 (28%) started urinating on their own • Majority had to be reanchored • BUT Taube M, Gajraj H, British Journal of Urology. 1989.
Even if they need it… • Can likely get it out faster than we do. Yoon et al. Prostate Cancer and Prostatic Diseases. 2015.
Immediate Removal • 2618 men with acute retention • Had foley placed initially • 73% with successful urination after 3 days • Better success with Alpha blockers 72 Hours Desgrandchamps F, et al. BJU International. 2006.
Serial I/Os • 50 patients with Acute Retention randomized to: • Clean Intermittant Cath (CIC) • Foley Catheter and leg bag • CIC associated with: • Higher rate of spontaneous voiding (56% vs. 25%) • Lower rate of UTI (32% vs. 75%) • High patient preference • Less pain Patel, MI et al. BJU International. 2001.
Serial I/Os • 515 pts with Acute Retention randomized to: • I/O cath x 1 • Foley to be removed at the decision of the outpatient urologist • TWOC success • 25% vs. 30% • P = 0.71 • Age, retention volume, prostate size The ER Ko, YH et al. Neurourology and Urodynamics. 2012.
Key Issues with Acute Retention • Usually transient and has reversible causes • Anchoring a Foley as the initial management is likely overkill and has greater risks • Attempt IntermittantCaths to start • Revisit for Foley removal after 72 hours
Clinical Case Let’s try cathing once and seeing what happens when we reverse potential causes. We could even start out with clean intermittent caths. If a Foley needs to be placed, let’s revisit in 72 hours and attempt a voiding trial. I’ve got this patient with BPH who came in with acute kidney injury and can’t urinate. I need a Foley to help relieve his obstruction and improve his kidney function! I really need this Foley!!!
Clinical Case I Doubt Your Indication I’ve got this patient in the unit. They got tons of sepsis and I need a foley so I can determine how much fluid I should give them. They are really sick and I’m going to be watching the urine every second! I really need this Foley!!!
Septic Shock and Volume Resuscitation The only thing that works • Early Goal Directed Therapy (EGTD)- Surviving Sepsis 2012 • ScvO2 > 70% • CVP 8-12 mmHg • MAP > 65 • UOP > 0.5 mL/kg/hr • 19,998 pts from 6 randomized trials and 31 observational trials • 23% morality reduction with EGDT • BUT this is solely due to early antibiotic administration NOT the above parameters • May be associated with HIGHER mortality Hamer. Annals of Emergency Medicine. 2018. Kalil AC et al. Crit Care Med. 2017.
Volume Resuscitation in Shock • Surviving Sepsis 2016 • 30 mL/kg within the first 3 hours • Acknowledge little evidence to support it’s use • May need more based on hemodynamics • Urine output monitoring NOT mentioned as a monitoring parameter in the most recent guidelines (but suggested for clinical gestaldt) • Dropped rec for UOP > 0.5 mL/kg/hr • *** Not using this for titration anymore • Volume resuscitation should be completed in (max) 48h Rhodes A et al. Intensive Care Med. 2017.
Devices in Surviving Sepsis 2016 Commented on Not Commented on
“High Dose” Diuretics • Unable to define dose • Makes sense • Could be renamed “Absolute volume crucial” • 24h urine collections • Adequacy of diuresis should be based on volume status • No data to say absolute volume is crucial Kalantari, K et al. Kidney International. 2013.
Exdwelling Devices Gray, M et al. J Wound Ostomy Continence Nurs. 2016.
MAGIC Appropriateness Criteria *** Almost everything (except retention and uncooperative patients) Meddings, J et al. Ann Intern Med. 2015.
Does it work? • VA RCT • 75 men who require urinary collection device to condom vs. foley • 70 infections/1,000 pt days • 131 infections/1,000 pt days • P = 0.04 • Foley HR for death = 4.85 (1.46-16.02, p = 0.01) Saint, S. et al. JAGS. 2006.
What else could I do? • Quasiexperimental 7 mo before/after • Foleys only for obstruction, hourly output, skin breakdown unresponsive to barrier methods • Diapers • Reduced Utilization, CAUTI Rothfeld, AF, Stickley, A. AJIC. 2010.
Diaper party!! • Used with Neonates • Weighed before placed then after • 1kg = 1L • Could also use underpads Galen, BT. Journal of Geriatric Cardiology. 2015.
Diapers for adults • Attrition Hermansen MC, Buches, M. Pediatrics 1988.
Key Issues with Accurate I/Os • Hourly accuracy down to the milliliter is almost never necessary • Volume resuscitation is better assessed by exam and non-invasive measurements • Even if you need urine, using exdwellings and diapers should be adequate • Even if a Foley is placed, a 48 hour timeout is appropriate
Clinical Case I’ve got this patient in the unit. They tons of sepsis and I need a foley so I can determine how much fluid I should give them. They are really sick and I’m going to be watching the urine every second! I really need this Foley!!! Perhaps we could start with a condom cath. If you feel like you aren’t getting helpful numbers and a Foley gets placed, let’s reevaluate at 48 hours.
Clinical Case I Doubt Your Indication I’ve got this patient that was in the OR yesterday and has an epidural catheter. If I take the catheter out too early, he may obstruct and DIE! I really need this Foley!!!
Specific Situations • Urologic surgery • Potential for wound contamination • Epidural Catheters • Prolonged procedures • Immobilization needed
Post-op Foleys • Default for some procedures and some physicians for 48-72h to assure urine being made and no retention • Post-op Urinary retention = 5-70% Baldini, G et al. Anesthesiology. 2009.
I/O vs. Foley • 1448 pts post-op • If retention (60 pts), randomized to Foley x24h vs. I/O caths • No difference in need for recatheterizationand UTI • Foley had increased hospital stay by 1 day Lau H, Lam B. ANZ J Surg. 2004.
Protocolizing • Removal in OR and Nurse Driven Removal Protocol • Significant increase in Foleys removed in OR • Significant decrease in catheter days (8.3% reduction), Catheter placements, and UTI GNS, Vascular, NUS, Ortho, Plastics Sadeghi, M et al. BMJ QS. 2019
Epidural Catheters for Pain Block- Debateable • Thoracic Surgery • POD2 vs. • MD decision • 275 Thoracic patients • No difference in UTI in those requiring reinsertion and those not • Of those with reinsertion 1/60 (1.7%) had urethral trauma • 4/60 (6.7%) required DC with Foley Hu et al. J CardiothoracVascAnesth. 2014 Young J, et al. J ThoracCardiovasc Surg. 2018.
Anorectal Surgery • Average Opinion- 5 days post-op • Higher incidence of obstruction • 42-60% chance of UTI • 126 pts randomized to 24h Foley vs. 5 day Foley • Patient’s with lower rectal carcinoma at higher risk. When excluded: • 14% vs. 7% obstruction (“non-sig”) • 14% vs. 40% UTI (p<0.01) Benoist, SB et al. Surgery. 1998.
Clinical Case There have been trials that support early removal of urinary catheters in patients with epidurals. Though they do have a high risk of obstruction, recatheterization can often be avoided and is worth a try. I’ve got this patient that was in the OR yesterday and has an epidural catheter. If I take the catheter our too early, he may obstruct and DIE! I really need this Foley!!!
Clinical Case I Doubt Your Indication I’ve got this patient with a huge bed sore and chronic sacral OM! The only way I can get it to heal is with urinary diversion! I really need this Foley!!!
Pressure Injury and Urinary Incontinence Gray, M, Giuliano KK. J Wound Ostomy Continence Nurs. 2018.
IAD with Pressure Injury • “Incontinence or moisture may not be a primary factor, but rather an indicator of poor physical condition …[and] has not been identified by prospective cohort studies.” • Questions on Validity of Braden’ Moisture criteria Ersser SJ et al. International Journal of Nursing Studies. 2005.
MAGIC Appropriateness Criteria ***Try other methods: Barrier Creams, Absorbent pads, Prompted toileting, etc. Meddings, J et al. Ann Intern Med. 2015.