Ex-Foleyating Your Patients

I feel like I’ve talked to a dozen people about indwelling urinary catheters this week.  Sometimes a topic just keeps coming up.  So let’s review.

Doctors seem to rely on urinary output as a vital sign.*  It’s not.  If the patient is drinking and peeing, things are probably good.  If the urine is yellow, it’s good.  If you suspect retention, scan the bladder, or use a straight cath.  You could even palpate the bladder and actually physically assess the patient like they did in the old days.  Incontinence, while inconvenient, is OK.  Really.  I promise.  Very few patients need all of their urine collected and measured.  

Even dialysis patients.  A chronic dialysis patient will tell you if they make urine or not, and how often. The most accurate I&O comes from the dialysis run--it is the majority of the patient’s volume loss, and is accurately counted.  Use a less invasive method to measure the urine--bladder scan or straight catheter.  Acute renal failure?  Bladder scan to see if urine is being made.  Can I say bladder scan any more?

Indwelling catheters are only for a few select reasons (CDC, APIC)

1.      Critical illness.  When you absolutely need to count every drop in and every drop out.  This patient is in your intensive care unit, on several types of drips, unable to use a urinal or bedpan, experiencing some organ failure, or all of the above.  

There seems to be a lot of misunderstanding amongst physicians about what an “accurate” I &O is and when it is needed.   Your patient is on the telemetry/cardiac unit and is getting IV push Lasix every 8 hours.  Do you need an indwelling/Foley?  Nope.  This is a patient in mild to moderate heart failure. The diuretic will help (minus renal issues).  Your nursing staff will use a bedpan or a hat in the toilet.  If there is incontinence, they will document frequency and a semi-quantitative volume (small, medium, large).  They will monitor heart and lung sounds and edema.  The patient will or will not improve.  It doesn’t matter one bit if the output for a shift is 412mL or 523mL.   If your patient is on an intraaortic balloon pump in cardiogenic shock and can’t get to the toilet for fear of displacing the balloon, then you may have a Foley catheter. :)

2.      Immobility due to fracture.  Unstable pelvic, spinal, or hip fracture where getting on the bedpan is impossible, dangerous, or extremely painful.  Not an ankle fracture, and not a repaired hip fracture (unless ortho says so, but not until after a face-to-face talk).

3.      Non-healing perineal or sacral ulcers.   When you are desperately trying to keep a significant wound dry or a dressing in place, you can have a foley.  This is not a replacement for routine hygiene and incontinence care, or for a chapped bottom.  You do not use it as a preventive measure for skin breakdown.  You use good nursing care for that.  My son was incontinent for the first 3 years of his life. He turned out fine due to good hygiene, skin care, and frequent repositioning. :)

4.      Genitourinary or rectal surgery.  See above, for a site that must be kept dry.

5.      End of life care and comfort.   I’ve been here, personally and professionally.  By all means, the Foley.

6.      Acute urinary retention.  This is a bladder that isn’t working right now (not forever).  Usually due to meds like narcotics, anaesthesia, etc.  The plan is to get the bladder re-trained.  Take the catheter out after a few days, institute your bladder protocol (you have one, right?  No? get one.), and then bladder scan and straight cath until the bladder is working again.  Not working after a few days, then the Foley can go in and you start over.

7.      Outlet obstruction.  Physical issues of the urinary tract that don’t allow urine out: large prostate, strictures, blood clots.

If you qualify for one of these reasons, great….for today.  It’s not a season pass to the catheter club. Tomorrow you reassess all over again to see if the issue has resolved.  You should also have a nurse-driven catheter removal policy.  This is an evidence-based practice.  If the patient doesn’t meet one of those reasons, nurses can remove it.  I’ve heard docs say they didn’t know their patient had a catheter, so don’t wait on them to remove it.  My practice as a nurse was to be sure I saw every inch of my patient on first assessment.  So, sadly, it’s nursing who tells the docs their patient has a catheter.  Or a pessary.  Or that the patient’s contact lenses are still in on day 8.

And give feedback to units, nurses, and doctors.  It’s super simple to make a graph of catheter utilization, using the NHSN 50% median as your benchmark.  Is your unit doing better or worse than other similar units in the US?  And to anyone who says, “Well, our patients are much sicker/older/different”, they’re not.  You’re not special.  There are 5000 hospitals reporting into NHSN. If you are significantly worse than most, you need to improve.

After encouraging more careful assessment of catheter use at my facility last week, a nurse manager called me in a panic on Wednesday.  She said, “We have a young female patient, a new mom who was a multi trauma.  She’s trying not to use narcotics, because she’s pumping breast milk. Unfortunately she’s screaming in pain trying to get on a bedpan.  We took the catheter out yesterday and she wants it back in.  Can we?”

First, holy cow.  Bless you nurses out there on the floors.  

Second, Yes, put that thing back in.

Third, you don’t need to call me to bless your catheter placement.  Be thoughtful about it, be careful and creative to avoid use, but never forget the patient.  I know you are doing your very best.  Do those things, and don’t worry about our utilization rates, or NHSN, or anything else I tell you that you need to worry about.  If you are practicing good care, they will work themselves out.

*I hear other ICPs ask how they can get their docs on board with current guidelines. They use words like 'conservative,' and 'senior' to describe their physicians. These are euphemisms for "Out of Touch With Current Science." Don't be that doctor. As a nurse, I know nothing about Case Management. But if I need to, I'll ask the Case Management nurses. For physicians who don't know current infection control practice, ask your staff...so they don't tell all their colleagues how outdated your practices are.