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Strategy of Limiting the Use of FoleyResearch Paper

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¶ … Strategy of Limiting the Use of Foley Catheter to Reduce the Rate of Health Care Associated Infections

The study proposed herein will examine a simple strategy to limit the use of Foley catheters in order to reduce the rate health care-associated infections (HAIs). The overarching objective of this study will be to develop a simple strategy for this purpose that is based on a targeted systematic review of the best available evidence, with specific links between the evidence and the recommended strategy.

Rationale in Support of this Method:

Indwelling Foley catheters can cause urethral trauma and urinary tract infections (Orris & Jahoda, 2008). In fact, catheter-associated urinary tract infections are the most commonly reported HAIs in the United States today (Trevellini, 2014). The adverse clinical outcomes that are associated with catheter-associated urinary tract infections include higher health care costs, increased patient mortality and longer hospital stays (Trevellini, 2014). Moreover, the prolonged and overuse of Foley catheters is the most important risk factor that is associated with developing catheter-associated urinary tract infections (Trevellini, 2014).

As the term indicates, HAIs can be acquired in any setting where health care services are provided (Davis, 2015). These health care settings include both in- and outpatient facilities such as tertiary health care centers, renal disease facilities, outpatient acute care clinics, and ambulatory care centers (Davis, 2015). In addition, patients can also contract HAIs in long-term health care facilities including nursing homes, assisted care facilities and rehabilitation centers (Davis, 2015). A number of infectious agents that have been implicated with HAIs include bacteria, fungi, viruses and other types of pathogens (Davis, 2015). Irrespective of their source of acquisition, studies have consistently found that patients with Foley catheters experience discomfort that adversely affects their ability to rest and sleep, factors that may extend their length of stay in inpatient settings (Humphries, 2009).

Moreover, the discomfort that is associated with Foley catheters has even been sufficiently severe to cause some disoriented patients to remove the fully inflated catheter on their own, resulting in severe physical harm (Neher, 2004). In this regard, Getz (2015) reports that, "There are important noninfectious complications that also need to be considered. These would include pain due to the catheter, discomfort, and lack of mobility because it functions as a one-point restraint" (p. 15). Beyond the foregoing considerations, there is also the dehumanizing element involved in being catheterized that must be taken into account in the catheter-placement decision-making process (Getz, 2015). As Getz points out, "Anytime you have to be moved to a different location in the hospital for a procedure, the entire hospital community can see your urine. I don't think the impact of that dehumanization should be underestimated" (p. 15). Furthermore, nosocomial urinary tract infections caused by Foley catheters are far more difficult to treat compared to simple infections because they are more likely to be resistant to antibiotics (Getz, 2015). The most powerful antibiotics that are required to treat nosocomial urinary tract infections can introduce additional risks, especially for elderly patients, and the potential for the spread of the bladder infection to the kidneys or the bloodstream is more pronounced (Getz, 2015).

In response to the alarmingly high rates of HAIs that are associated with indwelling catheters such as Foleys and their associated non-infections constraints, a growing number of health care authorities have sought to have their use reduced or eliminated entirely (Meddings, Krein, Fakih, et al., 2013). In this regard, Getz (2015) emphasizes that, "The high risk of infection and other complications due to urinary catheterization suggests a need for physicians and hospitals to reevaluate their catheterization procedures" (p. 14). Nevertheless, there are some constraints to reducing the use of Foley catheters, including most especially the fact documentation of evidence-based criteria for the insertion decision is lacking in as many as half of all of the patients who develop catheter-associated urinary tract infections (Weldon, 2013). Similarly, a study by Patrizzi, Fasnacht, & Manno (2009) also found that patients are catheterized in many cases who do not actually require a catheter. Based on these findings, Patrizzi et al. (2009) concluded that reducing the unnecessary use of Foley catheter placement could reduce the HAI rate among patients.

These findings indicate that in far too many cases, the decision to catheterize patients is arbitrary and perhaps even automatic rather than evaluating potential alternative approaches. While there are still several valid medical reasons for prescribing a urinary catheter, there are also a number of invalid reasons included those set forth below.

Examples of Appropriate Indications for Indwelling Urethral Catheter Use

Patient has acute urinary retention or bladder outlet obstruction

Need for accurate measurements of urinary output in critically ill patients

Perioperative use for selected surgical procedures:

Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract

Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU)

Patients anticipated to receive large-volume infusions or diuretics during surgery

Need for intraoperative monitoring of urinary output

To assist in healing of open sacral or perineal wounds in incontinent patients

Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)

To improve comfort for end of life care if needed

Examples of Inappropriate Indications for Indwelling Urethral Catheter Use

As a substitute for nursing care of the patient or resident with incontinence

As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void

For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc.) (Gould & Umscheid, 2009, p. 11).

Moreover, there are substantial economic costs involved in the decision to use a Foley catheter, and research has shown that the Foley catheter results in as much as $676 in additional health care costs per inpatient admission (Meddings, Krein, & Fakih et al., 2013). Not surprisingly, catheter-associated urinary tract infections were targeted by Medicare in 2008 for non-payment in an attempt to reduce urinary catheter use by half by 2014 (Davis, 2014). Likewise, the Centers for Disease Controls and Prevention released the results of an extensive study of more than 14,500 health care facilities nationwide that indicated while some progress had been made in reducing the incidence of HAIs due to urinary catheters, more work was still needed to further reduce their use at the state and national levels (Davis, 2014).

The Centers for Disease Control and Prevention provides several alternatives to indwelling urinary catheter use, including the following:

Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction.

Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients.

Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction.

Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration.

Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction.

Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short or long-term catheterization, particularly with respect to complications related to catheter insertion or the catheter site (Gould & Umscheid, 2009, p. 11).

Beyond the foregoing alternatives, there is also a simple and cost-effective alternative to urinary catheters that is available that can further reduce or even eliminate Foley catheter use, at least in those cases where the medical decision was arbitrary rather than being based on medical need or the other reasons cited above. According to Davis (2014), super-absorbent diapers offer a viable alternative to Foley catheter use. With the cost of a single Foley catheter kit averaging about $14 and the cost of two super-absorbent under-pads running around $1.78, making the cost of one pad about $0.89 (Davis, 2015). The rated urine-holding capacity of two pads is 1500 cc of while still maintaining dry contact surfaces (Davis, 2015).

Based on a clinical intervention study of telemetry units containing 60 beds with an 83% occupancy rate over a 3-month period, Davis evaluated the efficacy of super-absorbent diaper use vs. Foley catheters and identified a number of positive clinical outcomes. Most importantly, the rate of HAIs was significantly reduced, but perhaps just as importantly, patient acceptance rates were high and the alternative approach received widespread support from nursing staff and few objections from physicians (Davis, 2015). Based on these findings, Davis concluded that super-absorbent adult diapers represent a useful alternative to conventional urinary catheterizations.


The proposed study will generally follow the clinical intervention study design used by Davis (2014). A randomly selected control group where conventional Foley catheter use is continued and a randomly selected experimental group where super-absorbent adult diapers are used on medical care wards will be evaluated for respective urinary tract infection rates. According to Thomas and Hersen (2003),… [END OF PREVIEW]

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