Lost in place: Docs forget patient urinary catheters

Too many physicians leave them in inappropriately

Though infection risk increases with prolonged catheterization, a surprising number of physicians forget or are unaware that their patients have urethral catheters in place, researchers have found. In a simple but revealing study, the researchers found that physicians are commonly unaware that their own patients are catheterized. They also found that inappropriate catheters — ones that should be removed — are much more often "forgotten" than appropriate ones, says Sanjay Saint, MD, MPH, assistant professor of medicine at the University of Michigan medical school in Ann Arbor.

"Either they were told at one point the catheter was in place and they [have] now forgot, or they were never told in the first place." he tells Hospital Infection Control. "The catheter was maybe put in in the emergency room or by a nurse during cross-cover at night and it was never communicated to the physician." As a result of the findings, Saint and colleagues propose consideration of automatic catheter stop orders, so that after 48 hours of indwelling catheterization, the default "setting" will be that the catheter is removed rather than being left in place.

Previous studies have shown that between one-third and one-half of catheterized patient days are inappropriate, Saint notes. "We hypothesized that one reason that catheters are used inappropriately and left in longer than necessary is that physicians may be unaware that the catheter is place, and therefore do not order its removal," he says. "We wanted to specifically address how often physicians are aware of whether the catheter is in place and whether or not awareness of the catheter predicts its appropriateness."

As part of the study, physicians and students responsible for patients admitted to the medical wards at four U.S. hospitals were asked this question: "As of yesterday afternoon, did this patient have an indwelling urethral catheter?" Chart review assessed catheter appropriateness, with Saint and colleagues finding that of 469 patients, 117 (25%) had indwelling catheters. Catheterization was appropriate in 70% of these patients. Among all catheterized patients, 18% of medical students, 22% of interns, 28% of residents, and 35% of attending physicians were unaware that their patients were catheterized. Among inappropriately catheterized patients, 24% of students, 31% of interns, 41% of residents, and 51% of attending physicians were unaware that their patients were catheterized.

"Among inappropriate catheters, the results [indicate] that a much higher percentage of each care provider was unaware that the catheter was present," Saint says. "We also wanted to see whether or not awareness of the catheter predicts appropriateness, and in fact it does."

Catheter-related urinary tract infection (UTI) is a common nosocomial infection and leads to increased morbidity and costs. The study did not specifically look for infections, but the risk continues for such adverse events as long as an indwelling device remains in place, Saint says. "We know that each day that you have an indwelling catheter, you have about 5% chance of developing [UTI]," he says. Additionally, many patients find indwelling catheters painful and restrictive. "So even if you [put aside] the infection risk, we are doing something to patients that they don’t need and don’t like, and we are unaware that we are doing it."

Saint doubts that other catheters are being forgotten as often as the urinary variety, which are less visible. "The risk for being unaware is higher for catheters such urinary catheters as opposed to vascular catheters that go in the neck, because often when you look at a patient you don’t look under the bed sheet. And if the bag is either covered by the bed sheet or is on the other side of the bed when you enter, you often times are unaware of it."