Elderly women get unnecessary UCs
Elderly women get unnecessary UCs
They have higher morbidity with infections
A study conducted in the ED at St. John Hospital and Medical Center in Grosse Pointe, MI, has found that ED staff placed unnecessary urinary catheters (UCs) in nearly half of women 80 or older. The study was published in the November 2010 issue of the American Journal of Infection Control.1
Such a practice could unnecessarily expose these women to the risk of infection, a hazard of urinary catheterization, notes Mohamad G. Fakih, MD, MPH, medical director of infection prevention and control and lead author of the study. (For his tips on minimizing the risk of infection, see the story, below.)
Ironically, these findings occurred subsequent to the institution of new catheterization guidelines which, a previous study by Fakih showed, actually reduced overall utilization of urinary catheters.2 "The first study showed a drop from 14.9% to 10.6% in initially placed catheters," says Fakih. "But there is still a large minority of patients that have urinary catheter placed unnecessarily; 30.3% of all initially placed catheters did not comply with institutional guidelines."
Nonetheless, the guidelines were essential, says Margarita Pena, MD, FACEP, the ED director and "physician champion" for the guidelines. "The best thing about them is that you have clear-cut indications and non-indications," Pena says. [A copy of the guidelines are available.]
There still is a judgment factor involved, she adds. "It's not specifically mentioned in the guidelines, but if someone comes in drunk and out of it, we're going to put a Foley in them." says Pena.
Given the guidelines, why did so many of these women still receive unnecessary catheters? One problem is that people don't always follow guidelines, says Fakih.
"The more we push to improve quality, the more you dig into each department finding more and more that a lot of people do not follow guidelines," he says. "In this case, 41% of those patients who were catheterized did not have a documented doctor's order," which is a requirement of the guidelines.
Nurses often think the catheter makes the patients more comfortable and insert it as a convenience, Fakih says.
Pena says, "My personal feeling is that number one, people are still not completely aware of or know about the guidelines. We have rotating physicians who come through the department every so often, and the nurse just asks if it's OK to put the catheter in, and they say 'Sure.' Newer nurses may also not be aware of the guidelines." However, she says that the regular nurses are now cognizant that they have to have a physician's order before inserting the catheter. (How can the compliance rate be improved? See the story below.)
References
- Fakih MG, Shemes SP, Pena ME, et al. Urinary catheters in the emergency department: Very elderly women are at high risk for unnecessary utilization. Am J Infect Control 2010; 38:683-688.
- Fakih MG, Pena ME, Shemes S, et al. Effect of establishing guidelines on appropriate urinary catheter placement. Acad Emerg Med 2010; 17:337-340.
Feedback is key to compliance Despite new guidelines for urinary catheter insertion, nearly half of women 80 or older received unnecessary urinary catheters, according to a study conducted in the ED at St. John Hospital and Medical Center in Grosse Pointe, MI. What can be done to improve the compliance rates? "Giving regular feedback and reminders is very important," says Margarita Pena, MD, FACEP, the ED director and "physician champion" for the guidelines. "There has also got to be a cultural change." Mohamad G. Fakih, MD, MPH, medical director, infection prevention and control, agrees. "What would help is intervening with nurses," Fakih says. "A big component is nurses placing a catheter without orders." Another strategy would be to target these people who are at high risk, he says. "If you have good electronic records, you can say 'Identify all females 80 or above,' and go look at them and see if they have catheters in and see if they meet the guidelines," Fakih suggests. |
Keep catheter a closed system "One way to minimize the risk of infection in catheterized patients is to keep the catheter system as a closed system," says Mohamad G. Fakih, MD, MPH, medical director of infection prevention and control at St. John Hospital and Medical Center in Grosse Pointe, MI. "Don't break the system," Fakih cautions. "The catheter is connected to a tube, the tube is connected to a bag. Do not disconnect these from each other." In addition, when placing a catheter, place it under aseptic conditions, he says. "Secure the catheter on the patient's thigh so as to reduce the trauma related to catheterization," Fakih advises. "Then, only keep it in as long as necessary and no longer." |
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