Practi?e of Urinary Catheterization

Catheter associated urinary tract infections (CAUTI) are the most prevalent of all nosocomial infections inflicted upon patients while hospitalized. Approximately 30% of all hospital reported infections are of the urinary tract (Joint commission: New year will usher in new CAUTI prevention requiremants, 2011). The Joint Commission estimates the annual cost of CAUTI care is in excess of $400 million; furthermore, CAUTI care is targeted by Medicaid and Medicare services as a non-reimbursable infection.

For years, postoperative urinary catheter utilization has been contested regarding the appropriate criteria required for its application, maintenance, and discontinuation.

Patients hospitalized for short term postoperative care, specifically, orthopedic patients, are often catheterized due to their limited immobility. The goal of therapy with surgical orthopedic procedures is to improve mobility, not render the patient immobile. Urinary catheters are often viewed as cumbersome, inconvenient instruments of immobility by the patient. Conversely, nurses have often viewed urinary catheters as an instrument of convenience and standard of care for hospitalized patients. The use of short term urinary catheter use, whether indwelling or intermittent, in orthopedic patients has been surveyed through multiple studies, resulting in evolutionary changes in the standard of care of postoperative orthopedic patients.

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The contrasts in patient outcomes utilizing indwelling catheterization, intermittent straight catheterization, and non-use of catheterization will be reviewed.
PICO
In postoperative orthopedic patients, how does the discontinuation of an indwelling urinary catheter compare to non-catheterization in relation to the prevention of urinary tract infection?

Population: Postoperative orthopedic patients
Intervention: Discontinuation of an indwelling catheter
Comparison: Non-catheterization of postoperative orthopedic patients Outcome: The patient will not exhibit any symptomology of a urinary tract infection Evidenced Based Practice Models The Johns Hopkins Nursing Evidence Based Practice Conceptual Model (JHNEBPCM) can be utilized in this area of focus as it comprises the foundations of nursing: practice, education, and research.

There are three phases to this model known as the PET process: Practice question, Evidence, and Translation. The practice question identifies a problem with a current practice. Evidentiary support to answer the practice question is produced through the utilization and evaluation of research and non-research evidence. The outcome of the implemented research is then translated into practice change, the measurement of those outcomes, and the dissemination the new research (Buchko & Robinson, 2012).

The Iowa Model of Evidenced Based Practice (IMEBP) is appropriate for use in this area of focus. It allows for the entire healthcare system to be utilized in determining the need for change in the delivery of care. Employing this model allows the researcher to elect to choose between a current problem and new research as the basis for change in patient care. Once the trigger has been substantiated as a priority, a team is put in place to assemble, critique, and determine if enough research has been presented to pilot a change in current practices. If there is sufficient evidence for change and the pilot program is successful, a change in practice will occur. Once a change has been made, the data obtained from the practice change can be further developed utilizing this model and continuing the evolutionary cycle of improving standard of care practices.

Otherwise, if there is not enough evidence, further research may be conducted to provide enough of a base to continue toward obtaining a practice change (Dontje, 2007). The differences between the JHNEBPCM and the IMEBP are minor. They both provide a common goal: to change current practices by employing evidenced based research to foster the evolution of healthcare practices. Both models use a question or a trigger to initiate a change in practice. The minor difference between the JHNEBPCM and the IMEBP is the JHNEBPCM validates its change of practice question with the application of non-research data in addition to its research data. In this way, the JHNEBPCM can consider patient preference as an indicator to best practices.

Determining the Question The National Patient Safety Guidelines, as determined by the Joint Commission, include the prevention of indwelling CAUTI, emphasizing the prompt removal of these instruments and the observation for subsequent infection (Joint commission: New year will usher in new CAUTI prevention requiremants, 2011). The initial question was, “In admitted orthopedic surgical patients, does prompt removal of an indwelling Foley catheter within 48 hours of surgery reduce the incidence of catheter associated urinary tract infection?” In order to have a broader result list in searching for articles, the PICO parameters were refined. The population parameter was reduced to “postoperative orthopedic patients.” The intervention parameter was refined to “discontinuation of an indwelling catheter.” This removed the time constraint from the initial PICO question. Using “non-catheterization,” employed the comparison tool to serve as the basis for improved practice. The outcome parameter, “prevention of urinary tract infection” aligns with the Joint Commission’s National Patient Safety Guidelines to preventing CAUTI, ensuring better patient care by eliminating infections. Search of Evidence
PubMed was the first database searched for postoperative urinary catheter indications and subsequent infections. The key terms, “indwelling urinary catheter AND urinary tract infection AND surgery,” were entered into the search bar, yielding 320 results. Accordingly, a second search using the key terms, “orthopedic surgery AND catheter associated urinary tract infection,” resulted in eight articles. Of those eight, two articles were chosen for review due to their specificity to joint surgery and urinary catheterization.

The Cumulated Index of Nursing and Allied Health (CINAH) database was the second database searched. The key terms, “surgical patients and urinary tract infection,” produced 14 articles, of which two retrospective cohort studies were chosen for review based on the PICO criteria of urinary catheter use in the postoperative period. Additionally, a search for the key terms, “orthopedic surgery and catheter associated urinary tract infection” resulted in zero hits. The third database searched was Science Direct. The key terms searched for in this database were, “surgical patients, indwelling catheter, sterile field, and urinary tract infection.” This search resulted in 845 articles in which they were further limited to, “infection control,” which yielded 27 articles. Of those 27 articles, two were chosen for further review; a prospective observational study with descriptive and comparative design and a randomized control trial with cost-effectiveness analysis.

Evidence Review
The first, and oldest, article reviewed was discouraging. Knight and Pellegrini’s (1996) randomized control trial determined utilization of indwelling catheters for urinary retention in postoperative total hip arthroplasty (THA) or total knee arthroplasty (TKA) procedures was beneficial for the patient. It was also determined urinary tract infections were not a consequence of indwelling catheter usage. The level of evidence met level one criteria, yet the grade of recommendation was D due to the weak recommendations with alternative approaches likely to better suit a different group of patients, those requiring urinary catheterization for urinary retention.

The next study, a retrospective cohort study, sampled 35,904 patients who underwent major cardiac, vascular, orthopedic, or gastrointestinal surgery. A urinary catheter was placed intraoperatively, resulting in the development of a urinary tract infection if left in for more than two days; these patients were twice as likely to develop a urinary tract infection compared to patients whose catheters were removed within 48 hours of surgery (Wald, Allen, Bratzler, & Kramer, 2008). That same year, another retrospective cohort study by two of the previous authors along with two additional researchers, concluded postoperative patients admitted to skilled nursing facilities where their indwelling urinary catheters were maintained over the course of their care were associated with poorer outcomes. This study was restricted to the patients in skilled nursing facilities where direct patient care was limited and ongoing surveillance was minimal (Wald, Epstein, Radcliff, & Kramer, 2008). Both of these studies level of evidence met two-b criteria, grade of recommendation A and B respectively; the first study could apply to most patients in most circumstances, while the second study could apply to most circumstances.

The final review of Nyman, et.al, (2013), resulted in a one-a level of evidence with an A for grade of recommendation. This randomized control trial concluded the employment of indwelling catheters and intermittent straight catheterization during the postoperative period for hip surgery patients had both benefits and disadvantages, yet non-catheterization was best for postoperative patient outcomes. This study was the most recent on record and aligned with the Joint Commission’s National Patient Safety Guidelines.

Summary
Evidence based practices have become the cornerstone for the standard of care in healthcare facilities. Over the course of the past 20 years, healthcare providers have provided the research necessary to remove indwelling urinary catheters as the standard of care in postoperative orthopedic patients; from advocating of their use for urinary retention in the late 1990’s to limiting their utilization today.

The higher incidence of CAUTI has provided Medicaid and Medicare programs support in rejecting reimbursement measures to facilities for these types of nosocomial infections. New nurse directed protocols supported by evidenced based research have decreased the incidence of CAUTI, although, if these practices are to continue to be successful, a physician culture change must be embraced. The entire healthcare team must continue to participate in an active role to eliminate unnecessary and preventable infections, specifically CAUTI’s. To appropriately act on the behalf of the patient, clinicians must ensure best practices not only for the well-being of the patient, but for the fiscal survival of a healthcare facility.

References
Buchko, B., & Robinson, L. (2012). An evidenced-based approach to decrease early postoperative urinary retention following urogynecologic surgery. Urology Nursing, 32(5), 260-264.
Dontje, K. (2007). Evidence-based practice:Understanding the process. Topics in Advanced Practice Nursing eJournal, 7(4).
Joint commission: New year will usher in new CAUTI prevention requiremants.
(2011). AIDS ALERT, 26(11), 1-2.
Knight, R., & Pellegrini, V. (1996). Bladder management after total joint arthoplasty. The Journal of Arthroplasty, 11(8), 882-888.
Nyman, M., Gustafsson, M., Langius-Eklof, A., Johansson, J.-E., Norlin, R., & Hagberg, L. (2013). Intermittent versus indwelling urinary catheterisation in hip surgery patients: A randomised controlled trial with cost-effectiveness analysis. International Journal of Nursing Studies, 50, 1589-1598. doi:10.1016/j.ijnurstu.2013.05.007 Wald, H., Allen, M., Bratzler, D., & Kramer, A. (2008). Indwelling urinary catheter use in the postoperative period: Analysis of teh national surgical infection prevention project data FREE. Arch Surg, 143(6), 551-557. doi:10.1001/archsurg.143.6.551 Wald, H., Epstein, A., Radcliff, T., & Kramer, A. (2008). Extended use of urianry catheters in older surgical patients: A patient safety issue? Infevtion Control and Hospital Epidemiology, 29(2), 116-124. doi:10.1086/526433