” A finger or tube in every orifice” – Old School emergency medicine motto
In my humble opinion foley catheters are the work of the devil. Yes I know that in the right circumstances they are important in the care of patients and are a god send to those in acute urinary retention.
Trust me I know (See The Day I Almost Died…). But everyone also knows many are placed for reasons that do not obviously benefit the patient. (perhaps up to half of those placed).
And to boot they cause infections. Nasty multi-drug resistant infections. Close to 2,000 to 9,000 deaths per year are attributed to CAUTI (catheter associated urinary tract infections).
And, of course, there is a financial cost. Estimates are $400M in 2007 dollars (http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf)
The good news is that there is help out there to help us break our habit!
This is a great initiative that is working on the state level to help emergency departments bring change to their systems and culture. ( OnTheCusp). They give you all the tools you need to implement change and produce real results. We will be focusing on the inappropriate reasons that catheters get placed (particularly in the ER):
- Incontinence (without additional indication)
- Diuresis (think non-ICU CHF exacerbations)
- Frequent, nonessential measurement of UOP
- Nurse’s concern about patient comfort
- Diarrhea (without additional indication)
- Patient’s preference (without additional indication)
PatersonER will be participating in this initiative and looking forward to increasing the safety of our patients. We will rely on the systems we have already developed (See previous posts on Collaborative Leadership in the ED and EDQA).
Below is a link to a slide set related to how physician leadership plays a vital role.
David
PS: Let me know if you will be at MEMC VII this September in Marseille. This is going to be my first trip out there!
Quality Initiatives: Physician Leadership in the Emergency Department
Valid points, but it’s also axiomatic that all elderly women have a UTI til proven otherwise, and seldom can provide a truly clean specimen. An article in JACEP years ago showed that presence or absence of squames did not truly correlate with whether a specimen was clean. What is the cost of treating all those phantom UTI’s, and to what extent does that contribute to drug resistance? I have seen many cases where pts were treated for a UTI that was disproven by culture, and a more serious Dx missed.
I have been looking into this problem , more generally catheter related A&E presentations in our department for the last 2 years and its a complex subject. Very little recent research data available because its not a glamorous subject like cardiology , but the costs are spiralling.
In the UK we have a long term catheter problem population( community) who attend A&E via ambulance when problems arise i.e bypassing or blocking. Very few new catheters are inserted in A&E other than for acute retention or acute elderly confusional states. The cost of each A&E trip for treatment via emergency ambulance is approx £1000 ( if they return home).
From an infection point of view – the septicaemia risk is 90% have bacteriuria at 10 days – asymptomatic , but ? time bomb. Short term catheter urethral trauma and as many problems as sepsis alone.
Possible solutions:
1. Don’t insert them unless necessary – best plan
2. If you have to insert them – remove within 4 days
3.Change regularly – may cause excess trauma
4.Anti-biofilm material preventing biofilm growth for 3 months – unlikely to be discovered
5.Clean them while in place – something we are looking into, although not easy because they will have to be cleaned every 3 -4 days, the biofilm removed and any chemical agent used will need to be tissue friendly e.g citric acid.
With the UK elderly population rising , the long term catheter population will rise with it and unless urinary catheters can remain clean and biofilm free while in situ – drug resistant organisms , when released from the biofilms will , in many cases, prove fatal.
I have been looking into this problem , more generally catheter related A&E presentations in our department for the last 2 years and its a complex subject. Very little recent research data available because its not a glamorous subject like cardiology , but the costs are spiralling.
In the UK we have a long term catheter problem population( community) who attend A&E via ambulance when problems arise i.e bypassing or blocking. Very few new catheters are inserted in A&E other than for acute retention or acute elderly confusional states. The cost of each A&E trip for treatment via emergency ambulance is approx £1000 ( if they return home).
From an infection point of view – the septicaemia risk is 90% have bacteriuria at 10 days – asymptomatic , but ? time bomb. Short term catheter urethral trauma and as many problems as sepsis alone.
Possible solutions:
1. Don’t insert them unless necessary – best plan
2. If you have to insert them – remove within 4 days
3.Change regularly – may cause excess trauma
4.Anti-biofilm material preventing biofilm growth for 3 months – unlikely to be discovered
5.Clean them while in place – something we are looking into, although not easy because they will have to be cleaned every 3 -4 days, the biofilm removed and any chemical agent used will need to be tissue friendly e.g citric acid.
With the UK elderly population rising , the long term catheter population will rise with it and unless urinary catheters can remain clean and biofilm free while in situ – drug resistant organisms , when released from the biofilms will , in many cases, prove fatal.
Some of the above has been chopped in transit:
The short term infection risk of catheter insertion (septicaemia) with a bacteraemia is only 5% – so not large
90% of long term catheter users have a bacteraemia within 10 days of catheter insertion – this may be the time bomb?
Remember the organisms in the biofilm are NOT the same as those in the bladder – those from the biofilm are likely to be more lethal than the free planktonic bladder bacteria.