Intervention to Reduce Catheter Complications in Older Patients

Study Overview and Research Background

• General Context: Indwelling urethral catheters are extensively utilized in clinical practice. Statistics indicate that approximately $19.8\text{--}61.1\%$ of patients are catheterized during their period of hospitalization.

• Infectious Complications (CAUTIs): Catheter-associated urinary tract infections (CAUTIs) are recognized as a common adverse event. These can lead to severe outcomes such as bacteraemia and death, particularly in acutely ill elderly patients.

• Noninfectious Complications: Research highlights that noninfectious complications are often overlooked despite their high frequency:

  • Hollingsworth et al. (2013) found in a meta-analysis of 37 studies that noninfectious complications were as common as CAUTIs.

  • Saint et al. (2018) conducted a multicentre cohort study of $2,076$ patients, finding that noninfectious complications ($55\%$) were five times as common as infectious complications ($11\%$).

  • Examples of noninfectious complications include pain, discomfort, bladder or kidney stones, paraphimosis, meatal erosion, and gross haematuria.

• Functional Implications: Indwelling catheters are often equated to a "one-point restraint." This status can lead to pressure injuries, a decline in activities of daily living (ADLs), and an increased incidence of new nursing home admissions.

• The Research Gap: While reminders and "stop orders" are known to minimize inappropriate use, up to $20.6\%$ of hospitalized older patients undergo catheter reinsertion on the same day, and $49.5\%$ of these reinsertions are deemed preventable. No previous strategy specifically addressed timely removal while simultaneously promoting the recovery of self-voiding function.

Research Objectives and Study Design

• Primary Purpose: To develop a novel intervention consisting of strategies to reduce inappropriate catheter use and promote the recovery of self-voiding function.

• Evaluation Metrics: The study aimed to explore the effects of this intervention on reducing:

  • Catheter-associated urinary tract infections (CAUTIs).

  • Catheter-associated noninfectious complications.

  • Decline in activities of daily living (ADLs).

  • New nursing home admissions.

• Design: A quasi-experimental study design was adopted at a tertiary-care medical centre in southern Taiwan.

• Timeline:

  • Control Group: Patients admitted from October 2017 through February 2018 (received usual care).

  • Intervention Group: Patients admitted from March 2018 through July 2018 (received the novel intervention followed by a research nurse).

• Inclusion Criteria: Patients aged $65$ and older who had a urinary catheter placed within $24\,h$ of hospital admission.

• Exclusion Criteria:

  1. Patients immediately requiring intensive care.

  2. Patients needing hospice care.

  3. Patients needing surgery (perioperative management varies significantly by procedure).

The Novel Intervention Protocol

The intervention was developed following an extensive literature review and refined through consultation with a multidisciplinary panel of five experts (two geriatricians, one gerontological clinical nurse specialist, one urologist, and one physical medicine and rehabilitation physician). The expert consensus on the flow diagram reached $98\%$ in the second round of questioning.

Part 1: Appropriate Use and Timely Removal

Nurses followed up daily to evaluate the appropriateness of the catheter based on the following indications:

• Medication instillation or bladder irrigation.

• Dysuria due to bladder outlet obstruction without better solutions.

• Urinary retention $\ge 400\,cc$ without better solutions.

• Close monitoring of urine output in critically ill patients.

• Perioperative management.

• Open sacral or perineal wounds in incontinent patients needing urinary diversion.

• Special needs considering medical, physiological, psychological, or social domains.

Part 2: Promoting Self-Voiding Recovery

If the catheter was no longer necessary, clinicians assessed risk factors for urine retention (e.g., bladder obstruction, UTI, trauma, drug induction, neuropathy) before removal. After removal, strategies included:

• Establishing a urination schedule (regularly every $2$ to $4\,h$).

• Monitoring water intake.

• Selection of the Valsalva manoeuvre or Crede’s method.

• Maintaining a voiding diary.

• Post-Removal Monitoring (The 8-Hour Rule): If the patient self-voids within $8\,h$, volume is recorded and residual urine is measured via bladder scanning or intermittent catheterization (IC).

• Successful Removal Definition: Defined as a postvoid residual volume (PVR) $\le 100\,ml$ or a ratio of actual void volume to PVR of > 2:1.

• Intermittent Catheterization (IC) Schedule based on PVR:

  • If PVR is $100\text{--}200\,ml$: Apply IC every $12\,h$ ($Q12H$).

  • If PVR is $200\text{--}300\,ml$: Apply IC every $8\,h$ ($Q8H$).

  • If PVR is > 300\,ml: Apply IC every $6\,h$ ($Q6H$).

Baseline Measurements and Data Collection

• Demographics and Health Conditions: Collected within $48\,h$ of admission via medical records and interviews.

  • Charlson Comorbidity Index (CCI): Scores range from $0$ to $37$, with higher scores indicating more severe comorbidities.

  • Body Mass Index (BMI): Recorded for all participants.

  • Urinary Incontinence: Defined as wetting oneself within the previous $2$ weeks.

• Cognitive and Psychological Assessment:

  • Short Portable Mental Status Questionnaire (SPMSQ): Cognitive impairment was defined as $2$ or more errors (adjusted for education). Patients incompetent in communication were automatically coded as having cognitive impairment.

  • Geriatric Depression Scale Short-Form (GDS-SF): Depressive symptoms identified by a total score > 8.

• Functional Status:

  • Katz ADL Score: Measured using $6$ items (bathing, dressing, toilet use, transfers, eating, use of incontinence materials). Scores range from $0\text{--}12$; higher scores indicate greater independence.

Statistical Results and Adverse Outcomes

Participant Characteristics

• Total Screened: $487$ older patients.

• Total Enrolled: $106$ patients ($53$ in intervention, $53$ in control).

• Completed Follow-up: $92$ patients ($43$ intervention, $49$ control).

• Mean Age: $81.99 \pm 8.59$.

  • The intervention group was significantly older than the control group ($83.72 \pm 9.18$ vs. $80.26 \pm 7.66$, $p = 0.038$).

• Gender: $53.8\%$ ($n = 57$) were female.

Effect on Adverse Outcomes (Multivariable Logistic Regression)

Adjustments were made for the age difference between groups.

• Noninfectious Complications: The control group was significantly more likely to develop these complications.

  • Adjusted Odds Ratio ($OR$): $3.01$.

  • $95\%$ Confidence Interval ($CI$): $1.32\text{--}6.81$.

  • $p = 0.008$.

• ADL Decline: The control group showed a much higher risk of functional decline.

  • Adjusted Odds Ratio ($OR$): $11.20$.

  • $95\%$ Confidence Interval ($CI$): $3.68\text{--}34.00$.

  • p < 0.001.

• Infectious Complications (CAUTI): No significant difference was found ($p = 0.422$).

• New Nursing Home Admission: No significant difference was found ($p = 0.616$).

Categorization of Noninfectious Complications

In total, $41$ of $106$ patients ($38.6\%$) experienced noninfectious complications.

• Intervention Group: $14$ patients ($34.1\%$) developed complications.

• Control Group: $27$ patients ($65.8\%$) developed complications.

Specific Complication Breakdown (Overall Percentage):

• Blood in urine: $29.2\%$

• Protective constraint from accidental removal: $29.2\%$ (Significantly higher in control at $44.4\%$ vs. intervention at $0.0\%$, $p = 0.003$).

• Trauma to skin (catheter securement/insertion): $17.0\%$

• Pain or discomfort: $15.0\%$

• Leakage or incontinence: $4.8\%$

• Accidental removal: $4.8\%$

Discussion and Practical Implications

• Effectiveness: The novel intervention reduced noninfectious complications by $69\%$ and ADL decline by $93.6\%$ compared to usual care.

• CAUTI Observations: The study failed to show a reduction in CAUTI rates in adult wards, contrasting with some ICU-based studies. This might be due to the underestimation of CAUTI rates as urinary cultures were not performed for every patient.

• The "One-Point Restraint" Factor: The intervention reduced the need for physical restraints (like restraint gloves) intended to prevent accidental catheter removal. In the control group, $44.4\%$ of patients had restrictions in ADLs, while the intervention potentially increased physical activity by facilitating catheter removal.

• Clinical Value: The intervention provides a standardized consensus for catheter care and clinical decision-making. It highlights the role of healthcare professionals in preventing harm beyond simple infection control.

Study Limitations and Conclusion

• Attrition: An attrition rate of $11.3\%$ in the intervention group (due to ICU transfer or deterioration) may introduce bias.

• Methodological Limitations: CAUTI diagnosis was based on medical records rather than universal culture, and the recruitment periods for groups were different (though demographics were mostly similar).

• Nurse Workload: The intervention requires additional time from nurses to integrate into daily practice, suggesting a need for future cost-effectiveness analysis.

• Generalizability: Patients undergoing surgery were excluded, limiting the application of results to the broader perioperative population.

• Final Conclusion: A novel intervention focusing on appropriate use and self-voiding recovery effectively reduces noninfectious complications and functional decline in hospitalized older patients. Further modifications are needed to generalize the intervention for all clinical practice settings.