ArticlePDF Available

Indwelling Urinary Catheter Insertion Practices in the Emergency Department: An Observational Study

Authors:

Abstract and Figures

Indwelling Urinary Catheter Insertion Practices in the Emergency Department: An Observational Study - Volume 37 Issue 1 - Milisa Manojlovich, Sanjay Saint, Jennifer Meddings, David Ratz, Renee Havey, Jonathan Bickmann, Caitlin Couture, Karen E. Fowler, Sarah L. Krein
Content may be subject to copyright.
Infection Control & Hospital Epidemiology
http://journals.cambridge.org/ICE
Additional services for Infection Control & Hospital Epidemiology:
Email alerts: Click here
Subscriptions: Click here
Commercial reprints: Click here
Terms of use : Click here
Indwelling Urinary Catheter Insertion Practices in the Emergency
Department: An Observational Study
Milisa Manojlovich, Sanjay Saint, Jennifer Meddings, David Ratz, Renee Havey, Jonathan Bickmann, Caitlin Couture, Karen
E. Fowler and Sarah L. Krein
Infection Control & Hospital Epidemiology / FirstView Article / October 2015, pp 1 - 2
DOI: 10.1017/ice.2015.238, Published online: 05 October 2015
Link to this article: http://journals.cambridge.org/abstract_S0899823X1500238X
How to cite this article:
Milisa Manojlovich, Sanjay Saint, Jennifer Meddings, David Ratz, Renee Havey, Jonathan Bickmann, Caitlin Couture, Karen
E. Fowler and Sarah L. Krein Indwelling Urinary Catheter Insertion Practices in the Emergency Department: An
Observational Study. Infection Control & Hospital Epidemiology, Available on CJO 2015 doi:10.1017/ice.2015.238
Request Permissions : Click here
Downloaded from http://journals.cambridge.org/ICE, by Username: mmanojlo, IP address: 141.211.191.146 on 07 Oct 2015
research brief
Indwelling Urinary Catheter Insertion Practices
in the Emergency Department: An
Observational Study
We know little about the use of aseptic insertion technique for
indwelling urinary catheters and catheter insertion practices in
real-world clinical settings. Aseptic insertion technique is
strongly recommended
1
because bacteria ascending after
catheter insertion come from the patients own ora or the
hands of healthcare providers
2
and can lead to signicant
bacteriuria.
3
The emergency department (ED), as a primary
source of hospital admissions
4
and common location for
urinary catheter placement,
5
is the ideal site to explore
adherence to aseptic insertion practices. We sought (1) to
determine how frequently major breaks in aseptic insertion
technique occur, (2) to identify barriers or facilitators to
aseptic insertion, and (3) to identify the number of patients
who developed bacteriuria after catheter placement in the ED.
We prospectively observed patients who had indwelling
urinary catheters inserted from January 29 through June 30,
2014, in the ED of a level 1 trauma center within an academic
medical center. Our protocol was deemed not regulatedby
our institutional review board.
The primary outcome was an observed major break in
aseptic technique. We synthesized published guidelines
1
to
place major breaks into categories: contamination of sterile
eld, contamination of catheter, and breach of sterile barrier.
During observed catheter insertions research assistants com-
pleted an assessment tool. The preinsertion section asked
questions about the inserter (nurse vs other); the insertion
section contained quantitative, validated checklists
1,6,7
and
space for descriptive eld notes; and the postinsertion section
asked questions about patient characteristics. During catheter
insertion one research assistant lled out the checklist while
the other focused on barriers and facilitators to aseptic
insertion. Research assistants also reviewed medical records of
observed patients.
Two authors (M.M. and S.L.K.) conducted independent
content analysis of eld notes to determine the number of
insertion attempts with a major break in aseptic insertion
technique, the frequency of breaks, and what type of break
occurred. We assessed the association between inserter or
patient characteristics and a major break in aseptic insertion
technique using ttest and χ
2
statistics.
A total of 81 insertion attempts among 65 patients were
observed. Registered nurses attempted to insert 77 catheters
(95%); a helper assisted with 64 (79%) of these 81 attempts.
Major breaks in aseptic insertion technique occurred in 48
(59%) of 81 insertion attempts. Some insertions included
more than one category of break (Table 1). There was no
association between inserter or patient characteristics and
major breaks in technique. Barriers to aseptic insertion
included inconsistent or inconvenient locations for hand
sanitizers and limited room to set up sterile elds. Nurses
commonly donned sterile gloves over clean gloves without
cleaning their hands before or after catheter insertion. We
identied 7 patients with bacteriuria after insertion; 5 of these
had experienced a major break in technique.
Aspects of the ED environment coupled with certain
common ED practices may have contributed to breaks in
aseptic insertion technique in more than half of the cases.
Possible improvement strategies should target equipment and
social domains; although very common, insertion of urinary
catheters is a complex multistep task. In the equipment
domain, the following human factors principles could be
applied: standardization (eg, consistent and convenient
placement of hand sanitizers), education and surveillance (eg,
annually assessing competence during insertion), and product
redesign (eg, trays that incorporate human factors principles to
table 1. Categories and Frequencies of Major Breaks of Sterility
Category
Frequency as a proportion of
all insertions (%) Examples
At least one major breach 48/81 (59%)
a
Contamination of sterile eld 22/81 (27%) Nurse touched items on sterile eld with bare nonsterile hands.
Stethoscope/garment/torso touched sterile eld.
Contamination of the catheter 25/81 (31%) Patients labia closed over the catheter during insertion and contaminated the
catheter; nurse did not get a new one.
Catheter tip touched genitalia before being introduced into urethra.
Breach of sterile barrier 31/81 (38%) Sterile gloved hand used to swab genitalia (without tongs); same hand used to
insert catheter.
Nurse inserting catheter ripped her sterile gloves and did not get new ones.
a
Many of the observed insertions involved multiple breaks of sterility.
infection control & hospital epidemiology
ensure proper technique).
8
In the social domain, the unique
ED culture may have contributed to our ndings. Infection
prevention can be overlooked in the fast-paced environment
of an ED where life-threatening conditions take priority.
4
Applying principles of mindfulness at the bedside, recently
described for preventing catheter-associated urinary tract
infection,
9
is a potentially promising solution.
Although our investigation was conducted in 1 site, an overall
lack of adherence to aseptic insertion technique was found in an
observational study conducted in 5 nursing homes.
10
Our small
sample limits the capacity to evaluate outcomes; the nature of
the single center limits our ability to generalize results.
However, possible reasons for observed breaks provide insight
into how to overcome identied barriers. Without attending to
complexities found in actual clinical practice, meaningful
improvements are less likely to be realized.
acknowledgments
We acknowledge the assistance of Ashley Tupper MS, RN, Hayley Hekker, RN,
and Audrey Cialek RN, in data collection.
Financial support. Agency for Healthcare Research and Quality
(HHSA290201000025I and HHSA29032001T to S.S.; 1K08HS019767 to J.M.);
2009-2015 National Institutes of Health Clinical Loan Repayment Program
(to J.M.).
Potential conicts of interest. S.S. reports that he has received personal fees
from his work on advisory boards of Doximity and Jvion; J.M. reports that she
has receiving honoraria from hospitals and professional societies devoted to
complication prevention for lectures and teaching related to prevention and
value-based purchasing policies involving catheter-associated urinary tract
infection and hospital-acquired pressure ulcers. All other authors report no
conicts of interest relevant to this article.
Milisa Manojlovich, PhD, RN, CCRN;
1
Sanjay Saint, MD;
2,3
Jennifer Meddings, MD, MSc;
2,3
David Ratz, MS;
3,4
Renee Havey, MS, RN, CCRN, ACNS-BC;
5,1
Jonathan Bickmann, BSN, RN;
6
Caitlin Couture, MS, RN, CNM;
7
Karen E. Fowler, MPH;
2,4
Sarah L. Krein, PhD, RN
2,3,4
Afliations: 1. University of Michigan School of Nursing, Ann Arbor,
Michigan; 2. Veterans Affairs/University of Michigan Patient Safety Enhance-
ment Program, University of Michigan Medical School, Ann Arbor,
Michigan; 3. Department of Internal Medicine, University of Michigan
Medical School, Ann Arbor, Michigan; 4. Veterans Affairs Ann Arbor
Healthcare System, Ann Arbor, Michigan; 5. University of Michigan Health
System, Ann Arbor, Michigan; 6. Coronary Care Unit, Northwestern
Medicine, Chicago, Illinois; 7. The Birth Place, Mercy Hospital, Chicago,
Illinois.
Address correspondence to Milisa Manojlovich, PhD, RN, CCRN,
University of Michigan School of Nursing, 400 N. Ingalls St, Rm 4306, Ann
Arbor, MI 48109 (mmanojlo@umich.edu).
Received June 9, 2015; accepted: September 6, 2015.
Infect. Control Hosp. Epidemiol. 2015;00(0):12
© 2015 by The Society for Healthcare Epidemiology of America. All rights
reserved. DOI: 10.1017/ice.2015.238
references
1. 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:
319326.
2. Tambyah P, Halvorson K, Maki D. A prospective study of
pathogenesis of catheter-associated urinary tract infections. Mayo
Clin Proc 1999;74:131136.
3. Felix K, Bellush MJ, Bor B. Guide to preventing catheter-
associated urinary tract infections. www.apic.org/Professional-
Practice/Implementation-guides#Catheter. Accessed September
24, 2015.
4. Liang SY, Theodoro DL, Schuur JD, Marschall J. Infection
prevention in the emergency department. Ann Emerg Med
2014;64:299313.
5. Fakih MG, Pena ME, Shemes S, et al. Effect of establishing
guidelines on appropriate urinary catheter placement. Acad
Emerg Med 2010;17:337340.
6. Ortega R, Ng L, Sekhar P, Song M. Female urethral catheteriza-
tion. N Engl J Med 2008;358:e15.
7. Thomsen T, Setnik G. Male urethral catheterization. N Engl J Med
2006;354:e22.
8. Anderson J, Gosbee LL, Bessesen M, Williams L. Using human
factors engineering to improve the effectiveness of infection
prevention and control. Crit Care Med 2010;38:S269S281.
9. Kiyoshi-Teo H, Krein SL, Saint S. Applying mindful
evidence-based practice at the bedside: using catheter-associated
urinary tract infection as a model. Infect Control Hosp Epidemiol
2013;34:10991101.
10. DuBeau C, Lemay C, Field T, Mazor K, Gurwitz J. Simulation
assessment of catheter insertion by nursing home staff:
a disappointing picture. J Am Geriatr Soc 2014;62:S66.
2 infection control & hospital epidemiology
... An association was found between the use of the term "sterile technique" for indwelling urethral catheterization and performing in agreement with the sterility precautions advocated in the EAUNguidelines (OR 1.67, CI 1.13-2.47). The inconsistent use of different terms for insertion technique during urethral catheterization and uncertainties in understanding how proper aseptic insertion of the sterile catheter is accomplished has also been reported by others [10][11][12][13]. ...
... Further, local implementation of the updated guidelines in health-care settings is important [16]. This can be accomplished by training the nurses in aseptic urethral catheterization and validating the compliance to aseptic technique by evaluating the practiced skills on a yearly basis [13,[17][18][19]. Validated checklists for indwelling urethral catheterization can be used as a facilitator [20]. ...
... As the aim of the study was to investigate the nurses´ self-reported sterility precautions in indwelling urethral catheterization in the light of different sterility requirements in present local hospital guidelines and the EAUN-guidelines, a questionnaire made it possible to cost-e ciently reach many more nurses from different departments at two hospitals than observation. A validation of the procedure described by the participants requires an observational study of the practiced skills such as conducted by Manojlovich et al [13]. Another limitation is that the study did not include physicians. ...
Preprint
Full-text available
Background: To support a uniform and evidence-based practice for indwelling urinary catheterization in adults The European association of Urology Nurses (EAUN) published guidelines for this procedure in 2012. The Swedish national guidelines are based on the sterility precautions advocated by EAUN. Nevertheless, some hospitals have local guidelines with other requirements concerning sterility and leave to staff to decide what equipment to use and how to perform the catheterization. The aim of this study was to investigate the nurses´ self-reported sterility precautions during indwelling urethral catheterization at two acute-care hospitals, where the local guidelines differ in their sterility requirements. The study also aimed to analyse factors affecting the participants´ conformity with sterility precautions recommended in the EAUN-guidelines. Methods: A structured questionnaire with questions concerning the participant, working conditions and performance of indwelling urethral catheterization was left to 931 nurses in two acute care hospitals. Chi-square test, Fisher´s exact test and Mann-Whitney U-test were used for descriptive statistics. Logistic regression was used to analyse variables associated with practicing the sterility precautions as recommended in the EAUN-guidelines. Results: Answers were obtained from 852 persons (91.5 %). A majority of the participants called their insertion technique “non-sterile”. Regardless of what the insertion technique was called, the participants said that the IUC should be kept sterile during procedure. In spite of that not everyone used necessary sterile equipment to maintain the sterility of the catheter. The nurses´ conformity with all the sterility precautions as advocated in the EAUN-guidelines were associated with working at departments for surgery and cardiology (OR 2.50, CI 1.78-3.49) and years in profession (OR 1.54, CI 1.03-2.30). It was also associated with use of sterile set for catheterization (OR 2.03, CI 1.40-2.94), use of sterile drapes for dressing of the insertion area (OR 1.94, CI 1.25-3.00) and using the term “sterile technique” for indwelling urethral catheterization (OR 1.67, CI 1.13-2.47). Conclusions: To achieve a uniform practice in aseptic urethral catheterization national and local hospital guidelines should advocate same sterility precautions. Evidence-based guidelines should describe how sterility precautions are accomplished and should be implemented in healthcare-settings.
... For example, EAUN stresses that "non-sterile technique" is applicable only for a patient performing intermittent self-catheterization at home [17]. The inconsistent use of different terms for insertion technique during urethral catheterization and uncertainties in understanding how proper aseptic insertion of the sterile catheter is accomplished by nurses has also been reported by others [18][19][20][21]. ...
... Using a questionnaire, however, made it possible to cost-efficiently reach many more nurses from different departments at two hospitals, with different sterility requirements in local hospital guidelines, than observation would have done. A validation of the procedure described by the participants requires an observational study of the practiced skills such as conducted by Manojlovich et al. [21]. Another limitation may be that the study did not include physicians. ...
Article
Full-text available
Background To support a uniform and evidence-based practice for indwelling urinary catheterization in adults The European association of Urology Nurses (EAUN) published guidelines for this procedure in 2012. The Swedish national guidelines are based on the sterility precautions advocated by EAUN. Some hospitals have local guidelines with other requirements concerning sterility and leave to staff to decide how to perform the catheterization. The aim of this descriptive survey was to investigate the nurses´ self-reported sterility precautions during indwelling urethral catheterization at two acute-care hospitals, where the local guidelines differ in their sterility requirements. The study also aimed to analyze factors affecting conformity with sterility precautions in the EAUN-guidelines. Methods A structured questionnaire with questions concerning the participant, working conditions and performance of indwelling urethral catheterization was left to 931 nurses in two acute care hospitals. Chi-square test, Fisher’s exact test and Mann-Whitney U-test were used for descriptive statistics. Logistic regression was used to analyze variables associated with practicing the sterility precautions in the EAUN-guidelines. Results Answers were obtained from 852 persons (91.5%). Most of the participants called their insertion technique “non-sterile”. Regardless of designation of the technique the participants said that the indwelling urinary catheter (IUC) should be kept sterile during procedure. Despite that not everyone used sterile equipment to maintain sterility of the catheter. The nurses´ conformity with all the sterility precautions in the EAUN-guidelines were associated with working at departments for surgery and cardiology (OR 2.35, 95% CI 1.69–3.27), use of sterile set for catheterization (OR 2.06, 95% CI 1.42–2.97), use of sterile drapes for dressing on insertion area (OR 1.91, 95% CI 1.24–2.96) and using the term “sterile technique” for indwelling urethral catheterization (OR 1.64, 95% CI 1.11–2.43). Conclusions Only 55–74% of the nurses practiced one or more precautions that secured sterility of the IUC thus demonstrating a gap between the EAUN-guidelines and the actual performance. Adherence to the guidelines was associated with factors that facilitated an aseptic performance such as using a sterile set and sterile drapes. Healthcare-settings should ensure education and skill training including measures to ensure that the IUC is kept sterile during insertion.
... An evidence-based CAUTI prevention practice checklist for use in hospitals has been endorsed by the American Nurses Association [9]. Yet, breaks of evidence-based catheter care protocols can occur, putting patients at an increased risk of CAABU and CAUTI [11,14,15]. ...
... Although not all surveyed hospitals monitored individual clinicians, those that did reported low and variable practice use rates in ICUs, ranging from 6-27%, [11] echoing findings of an earlier nation-wide survey of hospital infection preventionists [38]. In one recent observational study [15], of 81 catheter insertions (65 patients) performed by emergency department (ED) nurses, researchers observed one (or more) major breaches of aseptic insertion technique in nearly 6 out of every 10 insertions, with many insertions involving multiple breaches. ...
Article
Full-text available
Catheter-associated asymptomatic bacteriuria (CAABU) is frequent in intensive care units (ICUs) and contributes to the routine use of antibiotics and to antibiotic-resistant infections. While nurses are responsible for the implementation of CAABU-prevention guidelines, variability in how individual nurses contribute to CAABU-free rates in ICUs has not been previously explored. This study's objective was to examine the variability in CAABU-free outcomes of individual ICU nurses. This observational cross-sectional study used shift-level nurse-patient data from the electronic health records from two ICUs in a tertiary medical center in the US between July 2015 and June 2016. We included all adult (18+) catheterized patients with no prior CAABU during the hospital encounter and nurses who provided their care. The CAABU-free outcome was defined as a 0/1 indicator identifying shifts where a previously CAABU-free patient remained CAABU-free (absence of a confirmed urine sample) 24-48 hours following end of shift. The analytical approach used Value-Added Modeling and a split-sample design to estimate and validate nurse-level CAABU-free rates while adjusting for patient characteristics, shift, and ICU type. The sample included 94 nurses, 2,150 patients with 256 confirmed CAABU cases, and 21,729 patient shifts. Patients were 55% male, average age was 60 years. CAABU-free rates of individual nurses varied between 94 and 100 per 100 shifts (Wald test: 227.88, P<0.001) and were robust in cross-validation analyses (correlation coefficient: 0.66, P<0.001). Learning and disseminating effective CAABU-avoidance strategies from top-performers throughout the nursing teams could improve quality of care in ICUs.
... Furthermore, practice differences regarding catheterisation techniques exist, as well as misperceptions regarding the concept of sterile, aseptic and clean insertion techniques and the practical implications of using these approaches (Manojlovich et al., 2016;Kulbay and Tammelin, 2019;Vahr et al., 2013). Previous studies have indicated that healthcare workers have contradictory views on devicerelated best practice, that is, adhering to hand hygiene guidelines and aseptic techniques were not viewed by some as vital measures to prevent infection (Erichsen Andersson et al., 2018;Wikström et al., 2019). ...
Article
Full-text available
Background: Urinary catheter (UC)-associated infections are one of the most common preventable healthcare-associated infections (HAIs) and they frequently occur in older, frail populations. Aim: The study aim was to describe the incidence of UC-associated infection in elderly patients undergoing hip fracture surgery after implementing a preventive care bundle. Methods: A longitudinal prospective study using a before-and-after design. The bundle was theory driven and involved the co-creation of a standard operational procedure, education and practical training sessions. Prospectively collected registry data were analysed. Univariable statistics and multivariable logistic regressions were used for analyses. Results: 2,408 patients with an acute hip fracture were included into the study. There was an overall reduction in UC catheter associated-associated urinary tract infections, from 18.5% (n = 75/406) over time to 4.2% (n = 27/647). When adjusting for all identified confounders, patients in phase 4 were 74% less likely to contract an UC-associated infection (OR, 0.26; 95% CI, 0.15-0.45, p < 0.0001). Discussion: Bundled interventions can reduce UC-associated infections substantially, even in elderly frail patients. Partnership and co-creation as implementation strategies appear to be promising in the fight against HAI.
... The use of reminders or stop orders facilitates the daily reevaluation of a catheter's indication and potential for removal, thus reducing complications [14,19,37,38]. The third element, ensuring that healthcare workers are properly trained in the aseptic insertion of urinary catheters and subsequent maintenance, lacks the level of supporting evidence that the other bundle components enjoy -yet it is a prominent feature in recent CAUTI prevention guidelines [39] and was therefore included in the bundle [35,40]. ...
Article
Full-text available
Background Multicentre intervention studies tackling urinary catheterization and its infections and non-infectious complications are lacking. Aim To decrease urinary catheterization and consequently catheter-associated urinary tract infections (CAUTI) and non-infectious complications. Methods Before/after non-randomized multicenter intervention study in seven hospitals in Switzerland. Intervention bundle consisting of 1) a concise list of indications for urinary catheterization, 2) daily evaluation of the need for ongoing catheterization, and 3) education on proper insertion and maintenance of urinary catheters. The primary outcome was urinary catheter utilization. Secondary outcomes were CAUTI, non-infectious complications, and process indicators such as proportion of indicated catheters and frequency of catheter evaluation. Findings We included 25,880 patients [13,171 before the intervention (August-October 2016) and 12,709 after the intervention (August-October 2017)]. Catheter utilization dropped from 23.7% to 21.0% (p=0.001), and catheter-days per 100 patient-days from 17.4 to 13.5 (p=0.167). CAUTI remained stable on a low level with 0.02 infections per 100 patient-days (before) and 0.02 infections (after), (p=0.98). Measuring infections per 1,000 catheter-days, the rate was 1.02 (before) and 1.33 (after), (p=0.60). Non-infectious complications dropped significantly, from 0.79 to 0.56 events per 100 patient-days (p<0.001), and from 39.4 to 35.4 events per 1,000 catheter-days (p=0.23). Indicated catheters increased from 74.5% to 90.0% (p<0.001). Reevaluations increased from 168 to 624 per 1,000 catheter-days (p<0.001). Conclusion A straightforward bundle of three evidence-based measures reduced catheter utilization and non-infectious complications, whereas the proportion of indicated urinary catheters and daily evaluations increased. The CAUTI rate remained unchanged, albeit on a very low level.
... Despite the wealth of available evidence on ensuring proper aseptic insertion, a recent study (48) in which researchers observed 81 catheter insertion attempts in a level 1 trauma center emergency department showed that 59% of attempts had at least 1 major break in aseptic insertion technique, demonstrating room for improvement in this domain. Participants in the STRIVE initiative were encouraged to utilize a simple checklist developed by the American Nurses Association to guide the insertion process (20). ...
Article
Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, but preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Duration of urinary catheterization is the most important modifiable risk factor for development of CAUTI. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and use of a closed catheter collection system are essential for preventing CAUTI. The use of intervention bundles and collaboratives helps in the effective implementation of CAUTI prevention measures.
Article
Résumé Introduction La plateforme informatique des méthodes de soins infirmiers (MSI) fournit la documentation dénotant la meilleure pratique infirmière actuelle. L’évaluation de l’usage des MSI, de l’impact sur les soins et les coûts associés constitue une priorité pour le centre hospitalier universitaire de Québec. Objectifs de l’étude L’objectif principal est de documenter l’utilisation des MSI. Les objectifs secondaires sont d’évaluer l’impact de l’utilisation des MSI sur la sécurité des soins ainsi que les coûts directs et indirects associés aux MSI et à leurs impacts. Méthodes Un devis de recherche mixte, intégrant les constats issus d’une étude qualitative de l’expérience d’usage des MSI sera adopté. Du côté quantitatif, une étude observationnelle prospective, une étude temps-mouvement, une analyse de conformité des pratiques, une révision de dossiers et une analyse économique permettront l’atteinte des objectifs. Discussion Plusieurs bénéfices résultent de l’usage des MSI dont l’accès rapide à l’information, la réduction des erreurs dans les procédures de soins, etc. Or, en l’absence d’évaluation de l’utilisation des MSI et des retombées, ces bénéfices sont peu documentés. © 2021
Article
To assess complications of condom catheters compared with indwelling urethral catheters, we conducted a prospective cohort study in two Veterans Affairs hospitals. Male patients who used a condom catheter or indwelling urethral catheter during their hospital stay were followed for one month by interview and medical record review. Participants included 36 men who used condom catheters and 44 who used indwelling urethral catheters. At least one catheter-related complication was reported by 80.6% of condom catheter users and 88.6% of indwelling catheter users (P = .32), and noninfectious complications (eg, leaking urine, pain, or discomfort) were more common than infectious complications in both groups. Condom catheter patients were significantly less likely than indwelling catheter patients to report complications during catheter placement (13.9% vs 43.2%; P < .001). Patients reported approximately three times more noninfectious complications than the number recorded in the medical record.
Article
Full-text available
Infection prevention remains a major challenge in emergency care. Acutely ill and injured patients seeking evaluation and treatment in the emergency department (ED) not only have the potential to spread communicable infectious diseases to health care personnel and other patients, but are vulnerable to acquiring new infections associated with the care they receive. This article will evaluate these risks and review the existing literature for infection prevention practices in the ED, ranging from hand hygiene, standard and transmission-based precautions, health care personnel vaccination, and environmental controls to strategies for preventing health care-associated infections. We will conclude by examining what can be done to optimize infection prevention in the ED and identify gaps in knowledge where further research is needed. Successful implementation of evidence-based practices coupled with innovation of novel approaches and technologies tailored specifically to the complex and dynamic environment of the ED are the keys to raising the standard for infection prevention and patient safety in emergency care.
Article
Full-text available
We introduce a mindful evidence-based practice model to operationalize mindfulness to improve bedside infection prevention practices. Using catheter-associated urinary tract infection prevention as an example, we illustrate how clinicians can be more mindful about appropriate catheter indications and timely catheter removal.
Article
Full-text available
Female urethral catheterization is indicated for both therapeutic and diagnostic purposes. It permits effective bladder drainage in patients with acute or chronic urinary retention. A urinary catheter may be used to instill medication for local intravesical therapy or for irrigation to remove blood and clots from the urinary bladder. Urethral catheterization facilitates diagnosis in several circumstances, such as obtaining sterile urine specimens for urinalysis, measuring residual volumes after voiding, instilling contrast media for imaging procedures, and monitoring the urinary output of critically ill patients. 1 C on t r a i ndic a t ions Urethral injury can be a contraindication to catheterization. Urethral injuries are rare and most commonly result from pelvic fractures. If blood is found at the urethral meatus, urethral or bladder neck injury should be considered. If there is any question of injury, genital and rectal exams should be performed and retrograde urethrography should be considered before catheterization is attempted; consultation with a specialist before catheterization is prudent. Since urinary catheterization can cause infection or trauma, it should not be used for routine management of urinary incontinence but should be reserved for circumstances in which noninvasive methods fail.
Article
Urethral catheterization may be indicated for diagnostic or therapeutic purposes: to decompress the bladder in patients with urinary retention, to permit irrigation to remove blood and clots from the urinary bladder, to obtain sterile urine for diagnostic purposes, to measure urinary output in critically ill patients or during surgical procedures, or to measure the residual urinary volume after voiding. This procedural video demonstrates how to perform male urethral catheterization.
Article
Human factors engineering is a discipline that studies the capabilities and limitations of humans and the design of devices and systems for improved performance. The principles of human factors engineering can be applied to infection prevention and control to study the interaction between the healthcare worker and the system that he or she is working with, including the use of devices, the built environment, and the demands and complexities of patient care. Some key challenges in infection prevention, such as delayed feedback to healthcare workers, high cognitive workload, and poor ergonomic design, are explained, as is how human factors engineering can be used for improvement and increased compliance with practices to prevent hospital-acquired infections.
Article
Avoiding placement of unnecessary urinary catheters (UCs) in the emergency department (ED) affects UC utilization during hospitalization. The authors sought to evaluate the effect of establishing institutional guidelines for appropriate UC placement coupled with emergency physician (EP) education on UC utilization. Urinary catheter utilization was measured before and after the establishment of guidelines and EP education. Data collected included the presence of a UC on ED arrival, placement of a UC in the ED, documentation of a physician order for UC placement, reasons for placement, and compliance with the guidelines. Chi-square analyses were used to study the association between pre- and postintervention time periods and catheter use. A total of 377 (15%) patients had UCs; only 151 (47%) UCs initially placed in the ED had a physician order documented. UC placement was appropriately indicated in 75.5% of patients with a documented physician order, but in only 52% of cases without a documented physician order (p<0.001). The physician intervention was associated with an overall reduction in UC utilization from 16.4% to 13% (p=0.018). Physicians ordered 40% fewer UCs postintervention compared to preintervention. Preintervention, a physician order for UC placement was found indicated in 72.6% patients, compared to 82.2% patients with UC placed postintervention (p=0.21). Establishing guidelines for UC placement and physician education in the ED were associated with a marked reduction in utilization. However, addressing appropriate UC utilization may require evaluating other factors such as nursing influence on utilization.
Article
To determine the pathogenesis of catheter-associated urinary tract infection (CAUTI) and the relative importance of each of the possible mechanisms of entry of infecting microorganisms to the catheterized urinary tract. We conducted a prospective study of 1,497 newly catheterized patients. Paired quantitative urine cultures were obtained daily, from the catheter specimen port and from the collection bag, using a technique that could detect 1 colony-forming unit/mL. We assumed that with extraluminal infections, caused by microorganisms ascending from the perineum in the mucous film contiguous to the external surface of the catheter, the organisms would be detected first in bladder urine or in far higher concentrations in urine from the specimen port than from the collection bag. With intraluminal CAUTIs, caused by microorganisms gaining access to the catheter lumen because of failure of closed drainage or contamination of collection bag urine, the organisms would be detected first or in far larger numbers in a collection bag specimen. The probable mechanism of infection could be determined for 173 of 250 organisms (69.2 %) identified in 235 new-onset CAUTIs. Among these 173 cases, 115 (66%) were extraluminally acquired, and 58 (34%) were derived from intraluminal contaminants. For these determinable cases, CAUTIs caused by gram-positive cocci (enterococci and staphylococci) and yeasts were far more likely to be extraluminally acquired (extraluminal:intraluminal, 2.9) than were gram-negative bacilli, which caused CAUTIs by both routes equally (extraluminal: intraluminal, 1.2; P = 0.007). Surprisingly, no significant differences were noted in pathogenetic mechanisms between men and women. We conclude that, in both men and women, CAUTIs occur by both extraluminal and intraluminal portals of entry but derive preponderantly from organisms that gain access extraluminally. Strategies for prevention of CAUTIs must focus on new technologies to prevent access of organisms by all possible routes.
Article
INDICATIONS Urethral catheterization may be performed for diagnostic or therapeutic purposes. Therapeutically, catheters may be placed to decompress the bladder in patients with acute or chronic urinary retention as a result of conditions such as infravesicular obstruction of the urinary tract or neurogenic bladder. Catheterization and subsequent irrigation may be required in patients with gross hematuria to remove blood and clots from the urinary bladder. Diagnostically, urethral catheterization may be performed to obtain an uncontaminated sample of urine for microbiologic testing, to measure urinary output in critically ill patients or during surgical procedures, or to measure the residual urine volume after voiding if noninvasive methods (such as ultrasonography) are not available. 1 Catheters should not be used for the routine management of urinary incontinence. If feasible, less invasive measures (such as incontinence pads, intermittent catheterization, or penile-sheath catheters) should be used in order to avoid the complications of indwelling catheterization. In addition, surgery to correct incontinence or the use of antimuscarinic agents may be beneficial in selected patients. CONTRAINDICATIONS The only absolute contraindication to urethral catheterization is urethral injury, either confirmed or suspected. Urethral injury is usually encountered in patients who have had substantial trauma to the pelvis or patients who have a pelvic fracture. Physical findings associated with urethral injury include blood at the urethral meatus and gross hematuria (found in more than 90 percent of cases of urethral disruption), perineal hematoma, and a “high-riding” prostate gland. A high-riding prostate gland may be obscured by the presence of a large pelvic hematoma or may be missed if the patient is reluctant to have a thorough examination owing to tenderness in the area. The use of retrograde urethrography is mandatory before catheterization if a urethral injury is suspected. 2 Relative contraindications to urethral catheterization include urethral stricture, recent urethral or bladder surgery, and a combative or uncooperative patient. preparation The equipment required for urethral catheterization is often available in a prepackaged catheterization tray. A typical tray includes sterile gloves, antiseptic solution, sterile drapes, a Foley catheter, sterile lubricant, forceps and cotton balls, sterile water for balloon inflation, and tubing and a collection bag. Additional required equipment that is often not in the prepackaged tray includes viscous lidocaine, tape or another device to secure the catheter to the patient, and occasionally, antiseptic solution. Numerous sizes and types of urethral catheters are available. The Foley catheter — a double-lumen, straight-tip catheter — is used most frequently. The coude cathvideos in clinical medicine