Running head: CATHETERS, OR NOT?

Catheters, or Not?
Mary Cooper
Jeonghee Lee
Emily Lewis
Amy Owens-Ratcliffe
Emmy Woolard
Old Dominion University

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Catheters, or not?

We began work on this paper by asking ourselves the following question: Does having an
indwelling urinary catheter increase the incidence of urinary tract infections (UTI) as compared
to patients without catheters? This topic would be of interest to any nurse who cares for patients
with indwelling catheters. We chose to focus on patients hospitalized in a respiratory intensive
care unit, labor and delivery unit, and a tertiary care center. Nonetheless, this topic would apply
to any patients with an indwelling catheter.
Usual Patient Outcomes and Research Available
According to the CDC, 15 - 25% of hospitalized patients will receive a urinary catheter
during their stay (2015). The outcome of the use of a catheter has been widely studied and the
determination is that prolonged use of a urinary catheter increases the risk for a urinary tract
infection (UTI). A year-long, observational study that looked at patients in two medical/surgical
ICUs in Athens, Greece states that the incidence of UTIs in patients with catheters was 7.7%
(Apostolopoulou, 2015). Similarly, a study in a central Italy surgical ward found that 6.2% of
the 641 catheterized patients developed a catheter-associated UTI (Barbadoro, 2015).
There are many types of research that address the incidence of UTIs caused by the use of
indwelling catheters in hospitalized patients. Many of the articles utilize a prospective
quantitative approach with meta-analysis, systematic review, or randomized controlled trial
method as the primary designs. These designs are essential to guide nursing interventions using
evidence-based practice because they are more rigorous and allow for less bias or systematic
error that may distract from the truth (Duke University Medical Center Library, 2015).

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Synthesize Three Articles

Using a Criteria-Based Reminder to Reduce Use of Indwelling Catheters and Decrease

Urinary Tract Infections (Chen,et al., 2013) the results of a study designed as a randomized
controlled trial (RCT) performed in two respiratory care units with a sample size of 278. The
purpose of this research was to determine if a reminder system reduces the use of urinary
catheters and the incidence of. The research question could be stated as follows: Does a reminder
system in hospitalized patients with urinary catheters reduce the duration of catheterization,
thereby, reducing the risk of catheter-associated-urinary-tract-infections (CAUTI)? The authors
hypothesize that the use of a reminder system can reduce the duration of urinary catheterization
and the incidence of CAUTIs. The dependent variables used in this research were the duration
of catheterization and the incidence of CAUTIs. The dependent variables were measured by
routine urine analysis and counting catheter days. The independent variable was the use of the
remainder system. Findings showed that the use of a criteria-based reminder approach in
determining when to remove an indwelling urinary catheter could reduce the duration of
catheterization. This would subsequently decrease the incidence of CAUTIs. An implication for
clinical practice from this research includes the critical role nurses play in the process of
assessing need for continuing catheterization The authors suggest that future research could
focus on a bundle with an increased number of interventions to minimize the risk of CAUTIs.
The article Evaluation of the Use Versus Nonuse of Urinary Catheterization During
Cesarean Delivery: A Prospective, Multicenter, Randomize Controlled Trial (Nasr, et al., 2009)
evaluated the effects on UTIs based on indwelling urinary catheter placement during cesarean
section delivery using a sample size of 420. The research design, as stated in the title, was a
prospective, multicenter, randomized controlled trial. The purpose of this study was to evaluate

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the safety, feasibility, and benefits of cesarean delivery without a routine indwelling urinary
catheter. The research question could be stated thus: What are the effects on the rate of urinary
tract infections and or surgical complications in hemodynamically stable women of indwelling
urinary catheter placement during cesarean deliver? No hypothesis is explicitly stated. The
variables were catheter or no catheter as the independent variable and the rate of urinary tract
infections and/ or surgical or post-surgical problems, as well as, patient satisfaction as the
dependent variables. The variables were measured with a structured questionnaire administered
to the women post-cesarean regarding symptoms of urinary tract infections, as well as, their level
of satisfaction and comfort. Clinical measures were conducted with laboratory analysis. There
was also a questionnaire filled out by the surgeon regarding intraoperative complications. The
findings from this study demonstrate that the routine use of indwelling urinary catheters in
hemodynamically stable women undergoing cesarean sections is not necessary and may
contribute to UTIs. The implications for the future, in order to generalize these study findings,
would be to conduct a larger, randomized, controlled trial.
The focus of the article Role of Duration of Catheterization and Length of Hospital Stay
on the Rate of Catheter-Related Hospital-Acquired Urinary Tract Infections (Al-Hazmi, 2015)
is on determining if duration of urinary catheters and length of hospital stay (LOS) contribute to
increased rates of UTI. The purpose of this research was to prove a positive correlation between
the duration of urinary catheterization and LOS, and the rate of nosocomial UTIs. This study
was designed as a retrospective descriptive study using a sample size of 250. The hypothesis is
that reducing the rates of unnecessary urinary catheterization and length of hospital stay may
impact rates of CAUTI. The research question could be stated as follows: Does the reduction of
the duration of indwelling urinary catheters as well as LOS effect rates of nosocomial CAUTIs in

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hospitalized patients? No new variables were introduced during this retrospective study. Rather,
data was extracted from archived patient files and examined for duration of urinary catheters and
LOS as they related to the rate of urinary tract infections. The variables under consideration
were duration of catheter and LOS as the independent variables and rate of UTI as the dependent
variable. A Chi-square test and a T-test were used to compare the data. The findings from this
study support the hypothesis that reducing duration of urinary catheterization and length of
hospital stay has a positive impact on reducing hospital acquired urinary tract infections. The
implications for clinical practice are to review the need daily for indwelling urinary catheters and
to discontinue them as soon as their use is no longer indicated.
In summary, these research findings clearly demonstrate the positive correlation between
indwelling urinary catheters use and the rate of urinary tract infections. The longer an indwelling
urinary catheter is in place, the greater risk for infection. Clinical criteria development, such as a
criteria-based reminder checklist, for monitoring long term placement is important in reducing
the risk of UTIs.
Systematic Review
Studies have shown a significant connection between catheter use and UTIs. According
to a recent literature review, the majority of UTIs in the United States can be attributed to urinary
catheters (Krein & Saint, 2014). Furthermore, even when controlling the sterility of the catheter,
catheter use was still linked to urinary tract infections, with the use of antimicrobial catheters
found to be ineffective in preventing symptomatic catheter-associated UTIs (Pickard et al.,
2012).
Studies have also indicated the management of catheters as a determinant in the incidence
of UTIs. Krein & Saint (2014) identified multiple studies stating that prompt removal of urinary

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catheters (UC) is one of the most effective methods for preventing catheter associated urinary
tract infections. Meddings et al. (2014) found a reduction of over 50% in CAUTIs in a metaanalysis of articles utilizing a stop order or reminder, with a few studies including interventions
targeted at reducing the number of initial UC placements. CAUTIs can be largely controlled
with measures that reduce the use of catheters or removal of the catheters during the appropriate
time.
Practice guidelines concerning catheter use primarily include educational interventions
"to decrease inappropriate catheter use; however, restrictions on catheter placement have been
recommended to remind healthcare providers about appropriate use, generate accountability for
catheter placements, and suggest alternatives such as condom catheters or intermittent straight
catheterization (Meddings et al., 2014, p. 279). There are already some catheter restriction
protocols that work to reduce the number of catheter placements. Urinary retention protocols in
particular help to reduce catheter placements by utilizing a portable bladder ultrasound to verify
retention and stressing the use of intermittent catheterization whenever possible (Meddings et al.,
2014).
Specific Recommendations
In every scenario the studies have shown that there is an increased incidence of UTI
related to the use of an indwelling urinary catheter. The second article Evaluation of the Use vs
Nonuse of Urinary Catheterization During Cesarean Delivery: A Prospective, Multicenter,
Randomized Controlled Trial has an evidence level of two because it is a relatively small study
and a randomized control trial. It speaks to implications for nursing care, as well as, the two
other articles. In trying to prevent the use of catheterization as much as possible there are a few
interventions that can be kept in mind.

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The single most important intervention that has been taught throughout our nursing
experience, and in these articles, is to assess the need for the indwelling catheter daily.
Assessing the need is accomplished in a variety of ways. The second article Using A CriteriaBased Reminder to Reduce Use of Indwelling Urinary Catheters and Decrease Urinary Tract
Infections is also an evidence level of two and discusses the use of a reminder sheet used daily
to assess the need to continue the use of the indwelling catheter (Hopp & Rittenmeyer, 2012, p.
147). Once the nurse makes her assessments she can use the information in the assessment tool
to determine if he/she should let the doctor know if the catheter is ready to be removed
("Nursing Resources: Home," 2015).
The final article Role of Duration of Catheterization and Length of Hospital Stay on the
Rate of Catheter-Related Hospital-Acquired Urinary Tract Infections is an evidence level of six
because it focuses on one retrospective descriptive study (Hopp & Rittenmeyer, 2012, p. 147).
Interventions that can be done to decrease the duration of catheterization and the length of
hospital stay will help reduce the occurrence of urinary tract infections.
The first option is to use a condom catheter if possible to prevent the invasiveness of
catheterization. Following surgery, it is important that the nurse keep urinals/bedpans at the
bedside once the patient is able to use them. Early ambulation after surgery will help prevent
any complications from immobility and decrease the length of stay. Finally, using catheters for
less than eight days will decrease the risk of UTIs. If a catheter is necessary, it is imperative that
the nurse keep the area clean and follow strict aseptic technique when inserting and removing the
catheter.

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Recommendations for Policy and Procedure Changes

The major recommendation in the research articles was to assess the need of the
indwelling catheter on a daily basis. After reviewing our hospitals policy and procedure manual,
we were unable to locate criteria for appropriate versus non-appropriate indications for
indwelling catheter use or specific time frames for use. The Center for Disease Control (CDC)
(2009) has specific guidelines for prevention of CAUTIs that could easily be added to our
current policy and procedure. The CDC list the following indications as examples of appropriate
indications for indwelling catheters: acute urinary retention or bladder outlet obstruction, acute
measurement of urinary output in critically ill patients, to promote healing of open perineal or
sacral wounds in incontinent patients, patients requiring long immobilization, for example those
with unstable spinal fractures, perioperative use designated surgical procedures, and to improve
comfort for end of life care (Guidelines for Prevention of Catheter-associated Urinary Tract
Infections, 2009).
Conclusion
The routine use of indwelling urinary catheters is unnecessary and places patients at an
unacceptable level of risk for complications. Indwelling urinary catheters are sometimes
necessary short term, but complications can and do arise when they are utilized long term. The
need for original placement of catheters as well as continuation must be carefully assessed daily.
These findings also demonstrate the vital role of the nurse in monitoring the ongoing need for or
discontinuation of indwelling urinary catheters.

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References

Al-Hazmi, H. (2015). Role of duration of catheterization and length of hospital stay on the rate
of catheter-related hospital-acquired urinary tract infections. Research & Reports in
Urology, 741-47. doi:10.2147/RRU.S75419
Apostolopoulou, E., Zikos, D., Drosatou, X., Stefanidis, E., Avgi, X., & Kalliakmanis, A.
(2015). Clinical and Economic Consequences of Catheter Urinary Tract Infections in
Intensive Care Unit. Health Science Journal, 9(1), 1-6.
Barbadoro, P., Labricciosa, F. M., Recanatini, C., Gori, G., Tirabassi, F., Martini, E., &...
Prospero, E. (2015). Catheter-associated urinary tract infection: Role of the setting of
catheter insertion. American Journal of Infection Control, 43(7), 707-710.
doi:10.1016/j.ajic.2015.02.011
CDC. (2015). Healthcare associated infections: Catheter associated urinary tract infections
(CAUTI). Retrieved from http://www.cdc.gov/HAI/ca_uti/uti.html
Center for Disease Control. Guidelines for Prevention of Catheter-associated Urinary Tract
Infections. (2009). Retrieved from:
http://www.cdc.gov/hicpac/cauti/02_cauti2009_abbrev.htm
Chen, Y., Chi, M., Chen, Y., Chan, Y., Chou, S., & Wang, F. (2013). Using a criteria-based
reminder to reduce use of indwelling urinary catheters and decrease urinary tract
infections. American Journal of Critical Care, 22(2), 105-114. doi:
10.4037/ajcc2013464
Duke University Medical Center Library. (2015). Introduction to evidence-based practice.
Retrieved from http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036068
Hopp, L., & Rittenmeyer, L. (2012). Introduction to evidence-based practice: A Practical Guide

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for Nursing. Philadelphia, PA: F.A. Davis.

Krein, S. L., & Saint, S. (2014). Preventing catheter-associated urinary tract infection: A happy
marriage between implementation and healthier patients. Healthcare Infection, 19(1), 13. doi: 10.1071/HI13047
Meddings, J., Rogers, M. M., Krein, S. L., Fakih, M. G., Olmsted, R. N., & Saint, S. (2014).
Reducing unnecessary urinary catheter use and other strategies to prevent catheterassociated urinary tract infection: An integrative review. BMJ Quality & Safety, 23(4),
277-289. doi:10.1136/bmjqs-2012-001774
Nasr, A., El Bigawy, A., Abdelamid, A., Al-Khulaidi, S., Al-Inany, H., & Sayed, E. (2009).
Evaluation of the use vs nonuse of urinary catheterization during cesarean delivery: A
prospective, multicenter, randomized controlled trial. Journal of Perinatology, 29(6),
416-421. doi:10.1038/jp.2009.4
Nursing Resources: Home. (n.d.). Retrieved June 4, 2015, from
http://researchguides.ebling.library.wisc.edu/c.php?g=293229&p=1953406
Pickard, R., Lam, T., MacLennan, G., Starr, K., Kilonzo, M., McPherson, G., . . . N'Dow, J.
(2012). Antimicrobial catheters for reduction of symptomatic urinary tract infection in
adults requiring short-term catheterization in hospital: A multicentre randomized
controlled trial. Lancet (London, England), 380(9857), 1927-1935.
doi:http://dx.doi.org/10.1016/S0140-6736(12)61380-4

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Honor Pledge
"I pledge to support the honor system of Old Dominion University. I will refrain from any form
of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a
member if the academic community, it is my responsibility to turn in all suspected violators of
the honor system. I will report to Honor Council hearings if summoned."
Mary Cooper
Jeonghee Lee
Emily Lewis
Amy Owens-Ratcliffe
Emmy Woolard
Date: August 2, 2015

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Grading Criteria

Requirement

Possible
Points

Introduction

Clearly introduce/identify the topic

Identify the types of organizations or
nursing units that would be interested
in topic and able to apply EBP
recommendations related to this topic
Identify the relevant patient population
for this topic
Identify the usual patient outcomes related
to this topic.
Identify the type and quantity of research
available to guide nursing interventions
intended to accomplish the outcomes
identified.

Synthesize at least 3 research articles

related to the topic. Discuss individual
articles separately, identifying the
following:

Purpose/Research
Question/Hypothesis
Identify variables in the study. If
appropriate, label them as
independent or dependent. State
how each variable is measured.
Sample size
Design: Identify the type of design
the researchers used.
Findings: Briefly state in your own
words the findings of the study. If
multiple research questions are
present in the study, state the
findings for each.
Implications: Briefly state in your
own words what the researchers
indicated future studies should
focus on, what new areas should

15

Faculty Comments

Points
Awarded

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be researched, or how the findings

impact clinical practice.
Synthesize the findings of all three (or
more) articles into a summary of research
on your topic.
Identify and summarize systematic review
articles related to the topic.

Include a summary of any metaanalysis articles that are related to the

topic.
Identify and summarize any practice
guidelines related to the topic area.
Identify specific recommended nursing
interventions discussed in the evidenced
based literature, systematic review or
practice guidelines.

15

10

Identify the level of evidence for

each recommendation.
For each of the major recommendations
identified, discuss whether there is
sufficient evidence to warrant a change to
policies and procedures according to what
is current in Policy and Procedure manuals
of where you are employed. Identify which
policies or procedures are inconsistent with
the recommended nursing interventions.

15

Conclusion: should be brief but thoughtful.

As part of the conclusion,

summarize the overall evidence
base for this topic.
Identify the areas most in need of
additional systematic research.
Correct grammar, spelling and punctuation.

10

10

Correct use of APA format

10

Total Points

100