Indwelling Urinary Catheter: Indications
The Ann Arbor Criteria are a set of recommendations that define when use of an indwelling urinary catheter is appropriate for hospitalized medical patients.
Please consider using a bladder scanner (PDF) to assess and confirm urinary retention, prior to placing the catheter to release urine. A 2004 research synthesis is available through Ovid.
The following are appropriate indications (PDF) for placing indwelling urinary catheters (based on the CDC HICPAC 2009 guidelines):
Acute urinary retention: e.g., due to medication (anesthesia, opioids, paralytics), or nerve injury
Acute bladder outlet obstruction: e.g., due to severe prostate enlargement, blood clots, or urethral compression
Need for accurate measurements of urinary output in the critically ill
To assist in healing of open sacral or perineal wounds in incontinent patients
To improve comfort for end of life, if needed
Patient requires strict prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fracture)
Selected peri-operative needs:
Urologic surgery or other surgery on contiguous (adjacent) structures of the genitourinary tract
Anticipated prolonged duration of surgery (Note: catheters placed for this reason should be removed in PACU)
Large volume infusions or diuretics anticipated during surgery
Need for intraoperative monitoring of urinary output
Based on work from the full text of the HICPAC 2009 guidelines (CDC archive).
Click the items in the table below with dotted underlines for brief explanations and related literature.
Indwelling Urinary Catheter: Alternatives
Before placing an indwelling urinary catheter, consider these alternatives which may be more appropriate:
| Alternative Device/Action | Reason for Use |
|---|---|
|
Bedside commode,
Urinal, or Continence garments |
Manage incontinence |
|
Assess and confirm urinary retention, prior to placing catheter to release urine† |
|
One-time, intermittent, or chronic voiding needs |
|
For cooperative patients (men and women) without urinary retention or obstruction |
|
Behavioral therapy |
|
Surgically inserted into bladder through an incision above the pubis |
Portable bladder ultrasound is a non-invasive portable tool for diagnosing and managing urinary outflow dysfunction. For example, portable bladder ultrasound could be used to detect that a patient has insufficient quantities of urine to justify catheterization.
More information is available in this research synthesis.
Most facilities underuse external urinary catheters.
A national survey of hospitals found that external catheters were almost always or always used in only 14% of hospitals (however, there was a statistically higher use in VA hospitals).2 This low level of use persists despite evidence that these catheters lower the risk of infectious and other complications associated with urinary catheterization, and are more acceptable to patients.3
When using external catheters, it is important to choose an appropriate size to improve fit and adherence despite patients' movement.
References
- Rose G, Pyle-Eilola AL. The Effect of Urine Collection with a Novel External Catheter Device on Common Urine Chemistry and Urinalysis Results. J Appl Lab Med. 2021 Jun 18:jfab054. doi:10.1093/jalm/jfab054
- Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis. 2008;46:243-50. doi:10.1086/524662
- Saint S, Kaufman SR, Rogers MA, Baker PD, Ossenkop K, Lipsky BA. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc. 2006;54:1055-61. doi:10.1111/j.1532-5415.2006.00785.x
Intermittent catheterization, also known as “in-and-out” or “straight” catheterization (often used in patients with neurogenic bladder or spinal cord injury) lessens the risk of urinary tract infection. Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction.
When the patient returns to the community, intermittent catheterization enhances patient privacy and dignity, and facilitates return to activities of daily living (Gould, et al, 2009). It is important to perform intermittent catheterization at regular intervals to avoid over-distending the bladder. Among hospitalized patients, intermittent catheterization is often used in combination with a portable bladder ultrasound. Portable bladder ultrasound is a non-invasive portable tool for diagnosing and managing urinary outflow dysfunction. For example, portable bladder ultrasound could be used to detect that a patient has insufficient quantities of urine to justify catheterization.
Source: Gould, C., Umscheid, C., Agarwal, R., Kuntz, G., & Pegues, D. (2010). Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Infection Control & Hospital Epidemiology, 31(4), 319-326. doi:10.1086/651091
Suprapubic catheterization is an alternative to the Foley catheter. It can be used for both short- and long-term catheterization. However, in general, intermittent urethral catheterization is preferable to suprapubic catheterization. Insertion of the suprapubic catheter should be performed by a health professional with training and expertise in this procedure.
Guidelines on insertion and care of this device have been published.
A toileting program typically consist of a patient-specific assessment of incontinence followed by a program of prompted voiding, habit retraining, and/or timed voiding as part of an individualized care plan. Evidence from one investigation (PDF) demonstrates toileting programs can significantly lessen risk of falls, skin breakdown—and, if patient lifting technology is available, back injuries experienced by personnel during patient assists. Emphasis on self-voiding also results in less post void residual compared to use of indwelling urinary catheters.
Aseptic Insertion
Aseptic technique is strongly recommended during the insertion of indwelling urinary catheters, based on biologic principles, the pathogenesis of catheter-associated urinary tract infection (CAUTI), and the growing prevalence of multidrug-resistant organisms.
A recent analysis of patient safety practices by the Agency for Healthcare Research Quality emphasized the important role of nurses in preventing CAUTI, the most common healthcare-associated infection. While physicians and medical students occasionally insert indwelling urinary catheters, nurses are generally responsible for the insertion and maintenance of urinary catheters; unlicensed personnel may also insert indwelling catheters under the direction of registered nurses. As part of their nursing education, student nurses are taught catheter insertion practices through simulation and clinical experiences. Once out of school, nurses refine their catheter insertion practices in the practice setting, where they tend to develop practice skills similar to those of other nurses with whom they work.
Anecdotal evidence—coupled with preliminary observations done by the University of Michigan CAUTI research group—reveal that proper aseptic technique is not reliably used when indwelling urinary catheters are inserted.
In this section we provide several resources related to aseptic insertion for anyone inserting an indwelling urinary catheter in male or female patients: nurses, physicians, medical students and unlicensed healthcare personnel. Some resources are in the form of written documents, while others are web-based.
Maintenance
The risk of infection increases by 5% for each day that a catheter remains in place, and the length of time that a catheter remains in place is the most important risk factor for the development of catheter-associated urinary tract infection. Up to half of patients with an indwelling catheter for 5 days or longer will have bacteria or fungus in their urine.
Therefore, once an indwelling urinary catheter is inserted, ongoing vigilance (abstract) is needed to reduce the risks of both infectious and non-infectious complications. Many times physicians are not aware that patients’ urinary catheters are still in place, so we begin this section with assessment strategies to maintain awareness of catheter presence and determine the ongoing need for an indwelling catheter.
In this section we also provide evidence-based guidance for catheter care and securement, drainage, transportation with a catheter, and talking points for patients and families related to indwelling urinary catheters. While it is better for the patient not to have an indwelling urinary catheter at all, when catheters are necessary our recommendations in this section will help minimize risks associated with catheter use.
Prompt Removal
Urinary catheters are often placed unnecessarily, remain in place without physician awareness, and are not removed promptly when no longer needed. Prolonged catheterization is the strongest risk factor for catheter-associated urinary tract infection (CAUTI). Promptly removing unnecessary catheters (abstract) is an important step in reducing a patient’s risk of CAUTI. In most hospitals, 4 steps are required to remove a urinary catheter:
Physician recognizes that a urinary catheter is present
Physician recognizes that the urinary catheter is unnecessary
Physician writes the order for urinary catheter removal
Nurse removes the catheter in response to the physician’s order
Thus, many hours and days can pass before a urinary catheter that is no longer necessary is recognized and removed; by default, urinary catheters usually remain in place until these steps occur. In contrast, using strategies to remind and prompt removal of unnecessary urinary catheters has the potential to bypass several of these steps, and reduce the occurrence of hospital-acquired catheter-associated urinary tract infections.
Reminder System Types
Two types of reminder systems (abstract) have been studied:
“Reminders” function simply to remind the clinicians (physician and/or nurse) that a urinary catheter is still being used, and may provide an educational list of reasons to continue or discontinue the urinary catheter. “Reminders” help bypass steps 1-2.
“Stop orders” prompt the clinician to remove the catheter by default after a certain time period or a set of clinical conditions has occurred (such as 24 or 48 hours post-operative) unless the catheter remains clinically appropriate. Stop orders “expire” in the same fashion as restraint or antibiotic orders, unless action is taken by physicians.
Stop orders directed at physicians require an order to renew or discontinue on the basis of review at specific time intervals (bypassing steps 1-3).
Stop orders directed at nurses will empower nurses to remove the catheter on the basis of a list of indications, without requiring the nurse to obtain a physician-signed order before removing the catheter (bypassing steps 1-4).
Challenges and pearls: Catheter removal strategy implementation
Capitalize on “nurse-to-nurse” communication at times of care transition (between shift and between units) as opportunities to reassess catheter need. Having a nurse champion on every shift may facilitate reassessment, especially if shift schedules make it difficult to share information.
Reminder system chosen should be tailored to the care setting (stickers, electronic, etc.). Both low-tech and high-tech strategies have been effective.
Simple reminders are often ignored. It is challenging to sustain the impact of reminders.
If using electronic reminders/stop orders, make sure the reminder/stop order is directed at the primary team and not the consultants.
Using electronic catheter orders can increase catheter use inadvertently by making indwelling catheters easier to order than alternatives.
Physicians and/or nurses should document the rationale for leaving the catheter in if appropriate indications are not met. Documentation makes the rationale explicit and communicates it to the rest of the healthcare team.
Nurses may not be comfortable initially with the responsibility of removing urinary catheters without a physician order. Supportive nursing and physician leadership can help overcome nurses’ reluctance to act using nurse empowered orders.
Incontinence is a very tempting reason for placing a urinary catheter. Encourage bedside staff to avoid placing catheters for incontinence by providing other readily available strategies to manage incontinent patients, including bedside commodes, incontinence garments, condom catheters for male patients, and “people power” to provide prompted toileting and bed linen changes.
From Saint, et al (2005)
Antimicrobial Catheters
Given the important clinical and economic consequences of catheter-associated urinary tract infection (CAUTI), researchers have tried novel approaches to prevent this common patient safety problem. While the primary preventive focus has been on avoiding the indwelling catheter, using alternatives to the indwelling catheter, and removing the indwelling catheter as soon as possible, investigators have also assessed whether antimicrobial catheters can prevent CAUTI. (See the Prevention Practices section in the Overview.)
Several clinical and economic studies have evaluated antimicrobial urinary catheters, including individual trials, systematic reviews, and meta-analyses. Economic evaluations are important to consider given the additional cost of antimicrobial catheter trays (approximately US$5). Different antimicrobial urinary catheters have been evaluated in patients over the past few decades, including silver (either alloy or oxide) and nitrofurazone-releasing catheters.
A Cochrane Review of antimicrobial catheters conducted in 2008 included 23 trials involving 5,236 hospitalized adults in 22 parallel group trials. Schumm and Lam summarized their findings as follows: "... Silver alloy (antiseptic) coated or nitrofurazone-impregnated (antibiotic) urinary catheters might reduce infections in hospitalized adults ... but the evidence was weak... Larger, more scientifically rigorous, trials are needed on whether catheters impregnated with antibiotics or antiseptics reduce infection."
A large and scientifically rigorous trial – involving 24 hospitals in the United Kingdom and about 7,000 patients (most of whom were undergoing surgery) – was published in The Lancet. This randomized trial compared three different catheters – silver alloy, nitrofurazone-releasing, and a control (polytetrafluoroethylene–coated latex catheter) – and found no significant difference in rates of symptomatic CAUTI between the silver alloy and control catheters. There was a small decrease in rates of symptomatic CAUTI with the use of nitrofurazone-releasing catheters compared with control, however, this decrease was not deemed to be clinically important. The makers of the nitrofurazone-releasing catheter announced (PDF) in 2012 that they will discontinue manufacturing and marketing the device.
An accompanying editorial provides a useful perspective on the limitations of this study as well as the role of antimicrobial catheters in patients at high-risk of CAUTI (e.g., neutropenic and severely immune-compromised patients).
Currently, antimicrobial catheters are not recommended for routine use in hospitalized patients.