A Novel Clinical Protocol for Placement and Management of Indwelling Urinary Catheters in Older Adults in the Emergency Department

Abstract

Objectives: Indwelling urinary catheters (IUCs) are placed frequently in older adults (age ≥ 65 years) in the emergency department (ED) and carry significant risks. The authors developed, implemented, and assessed a novel clinical protocol to assist ED providers with appropriate indications for placement, reassessment, and removal of IUCs in elders in the ED.Methods: A comprehensive, evidence-based clinical protocol was built from an extensive literature review and ED provider focus groups. It was implemented at a university-based medical center with a 20-minute scripted slide presentation. Written surveys were administered before, after, and at 6 months to assess providers' baseline practice and the protocol's effects. Surveys included asking providers for IUC management decisions in 25 unique clinical scenarios. Rates of IUC placement and catheterassociated urinary tract infections (CAUTIs) were compared in ED older adult patients admitted to the hospital in the 6 months before and after protocol implementation.Results: A total of 111 ED providers participated in the all three surveys. Immediately after protocol introduction, providers anticipated that this intervention would reduce rates of IUC use and increase patient safety. At 6-month follow-up, 81% felt the protocol had changed their practice, and 39% reported frequently referencing the protocol. In the clinical vignettes, ED providers correctly identified the appropriate approach for IUC placement in 63% of cases at baseline with an increase of 22% (95% confidence interval [CI] = 19% to 25%) postintervention and an increase of 8% (95% CI = 6% to 12%) between baseline and 6 months. An absolute reduction in the use of IUCs of 3.5% (p < 0.001) for older adults admitted to the hospital was observed after implementation of the protocol. There were three CAUTIs attributable to the ED in the 6 months prior to implementation and none in the 6 months after.Conclusions: This comprehensive, evidence-based clinical protocol was well received by participants and was associated with a sustained change in self-reported practice, as supported by a reduction in IUC placement in admitted older adults and a reduction in CAUTIs attributable to the ED for this vulnerable population over the 6-month study period.ACADEMIC EMERGENCY MEDICINE 2015;22:1056-1066 by the Society for Academic Emergency Medicine C atheter-associated urinary tract infections (CAUTIs) have been one of the most prevalent hospital-acquired infections, with significant associated morbidity, mortality, and cost.1,2 Recent research found it to be the fourth most active, accounting for 12.9% of all health care-associated infections. Older adult patients (aged ≥ 65 years) are disproportionately affected, as they more commonly receive indwelling urinary catheters (IUCs) 2,4 and are more susceptible to associated complications. 5 In addition to urinary tract infections, this population is more susceptible to the noninfectious side effects of IUCs, including falls from tethering, delirium, urethral trauma...

Implementation of a multifaceted nurse‐led intervention to reduce indwelling urinary catheter use in four Australian hospitals: A pre‐ and postintervention study

“…One possible reason for lack of improvement is that around one third of IDCs were inserted in EDs, and the intervention did not directly target ED. This study, along with other study findings, highlights the need for future interventions purposively targeted at EDs, taking into account specific contextual practices and reasons for insertion, which differ from other contexts Gokula, Smith, & Hickner, 2007;Mulcare et al, 2015). Whilst the point prevalence data did not reveal an improvement in documentation of indication for IDC insertion, the practice adherence audits did show a significant increase in documentation of indication from the first period of the intervention as compared with the remainder of the intervention period (81%-88%).…”

Prevalence and predictors of continence containment products and catheter use in an acute hospital: A cross-sectional study

“…In recent years, there have been significant efforts to successfully reduce the inappropriate usage of UC and increase documentation for the reasons for insertion. 67 Previous research has shown that well-organised interventions can reduce the prevalence of inappropriate UC usage. 68,69 Much less attention has been paid to the inappropriate use of absorbent pads and we can hypothesize this is the reason for the higher prevalence of inappropriate pad use compared with inappropriate UC use.…”

Infection Prevention for the Emergency Department

“… 83 Multifaceted approaches combining ED HCP education, guidelines, and decision-making tools emphasizing clearly defined criteria for appropriate UC use supported by physician and nurse champions have been shown to be effective in curbing unnecessary ED UC use. 84 , 85 , 86 In a quality improvement initiative spanning 18 US EDs, implementation of a multifaceted intervention led to an overall reduction in UC insertions of more than 30%, with the greatest reductions seen at hospitals with a baseline UC use of ≥5%. 84 …”