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Running head: INVESTIGATING ALT TO INDWELLING URINARY CATHETERS IN THE

ICU

Investigating Alternatives to Indwelling Urinary Catheters in the Intensive Care Setting

Grace Dimond, Brooke Bollinger, Rachael Whitney, Natalie Bonzano, Quinlan Firment, Dana

Panganiban

James Madison University

Nursing Inquiry and Research Methods

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INVESTIGATING ALT TO INDWELLING URINARY CATHETERS IN THE ICU

Abstract

Indwelling urinary catheters are used in critical care settings across the globe to provide

accurate measurements of urinary output. These measurements are crucial to determine kidney

function as well as the overall health status of the critically ill patient. Despite their immense

usefulness during acute illnesses, indwelling catheters carry the risk of catheter associated

urinary tract infections (CAUTI), which are costly to both the patient affected and their

healthcare providers alike. The following literature synthesis investigates alternatives to the

commonplace indwelling catheter in an effort to determine what healthcare providers are already

doing right, as well as what they can improve on. Existing studies were examined for effective

alternatives to indwelling catheters, as well as past protocols and methods that were not effective

in order to determine the best current practice. It was determined that external catheters, nurse

driven protocols, preventative education, and peer-to-peer education are most effective at

reducing the incidence of CAUTI among patients in a critical care setting. A 2018 study by

Siegel, Fijueora, and Stockwell, discovered that catheter checklists were also found to be

extremely effective and resulted in a 40% decrease in indwelling urinary catheters used, as well

as an 89% decline in the overall CAUTI rate on the unit where the study was performed. In

addition, different methods of urethral cleaning were found to be ineffective when compared to

one another. More in depth research should be performed on other external collection devices, as

well as the reasoning behind low policy adherence rates. Implementing the effective methods

found in this study into daily nursing care has the potential to decrease the rates of CAUTI

nationwide.

Introduction
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INVESTIGATING ALT TO INDWELLING URINARY CATHETERS IN THE ICU

Urine output is often used as a marker of fluid status and kidney function. It can be used

as a guide to determine acute patient deterioration or improvement, as well as need for fluid

resuscitation or diuresis in the critically ill patient. The indwelling urinary catheter is an

important tool used in managing urinary output for hospitalized patients, and it is crucial in

instances of high urinary output, urinary obstruction, and immobility, as well as in critical care

settings. Most hospitals and medical facilities have protocols and guidelines regarding indwelling

catheter removal, but the complex care of the critically ill patient often makes continuous

removal readiness evaluation tedious. According to Parker et al. (2017), “Urinary tract infection

(UTI) is considered the most common healthcare-associated infection (HAI), accounting for up

to 36% of all healthcare-associated infections (HAIs). Catheter-associated urinary tract infections

(CAUTIs) represent the majority of UTIs (up to 67% of UTIs in all hospital inpatients, and up to

97% in ICUs).” Compared to fungi and gram-positive bacteria, gram-negative bacteria displays

the highest resistance to antibiotics and is a major cause to CAUTIs in the ICU (Peng & Li,

2018). Due to the commonality of CAUTIs, there is an increasing need to determine alternatives

to indwelling (Foley) catheterization. In this literature review, indwelling catheters and external

urine collection devices (ECDs) will be compared in critical care patients who require strict

monitoring of urine output to determine which is the most effective and least likely to lead to

hospital acquired infections.

Synthesis of the Literature

Upon initiation of research, evidence-based literary sources including randomized clinical

trials, quality improvement studies, and case study reviews were gathered. From these databases,

information pertaining to alternatives to indwelling catheters were extracted, as well as any

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INVESTIGATING ALT TO INDWELLING URINARY CATHETERS IN THE ICU

methods to decrease the occurrence of CAUTI. Literary sources provided multiple viable

alternatives that may be used in critically ill patients. These alternatives would still allow for

accurate urinary output to be documented while avoiding the use of an indwelling device.

A predominant amount of the literature provides suggestions on alternative methods to

using indwelling urinary catheters in critical care settings to prevent CAUTIs and HAIs.

According to Beeson and Davis (2018), the use of external female urinary catheters over

indwelling urinary catheters decreases the chances of impaired skin integrity and infection in

women with urinary incontinence. In addition, the article written by Tyson et al. (2018) states

that the implementation of protocols regarding early urinary catheter removal can result in a

significant decline in both catheter utilization and CAUTI rates. Although many of the articles

supported ECD usage, research from Gray, Skinner and Kaler (2016) stated “a 2014 analysis by

the National Hospital Safety Network revealed that only 6% to 27% of hospitals reported

adherence to CAUTI prevention policies” and the lack of adherence was due to patient

“discomfort, application challenges associated with appropriate application for small and

retracted male anatomy, and difficulties with leak prevention.” Furthermore, policies and

protocols related to the care of the indwelling catheter were also studied. One study found in the

International Journal of Infectious Disease performed a meta-analysis of several methods of

catheter care and disinfection policies and determined there is no significant difference between

them (Cao, 2018).

Throughout this research, limitations within the literature review have been identified.

Some studies are international, smaller in size, or located on very specific types of ICUs. An

important limitation from various articles pertains to the varying sample sizes. The literature
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INVESTIGATING ALT TO INDWELLING URINARY CATHETERS IN THE ICU

written by Alexander, Fergus, Sinha, and Omar (2016) has a sample of 107 participants in 3

different healthcare settings. This provides a varying sample size compared to the article written

by Siegel, Fijueora, and Stockwell (2018) whose 10 year retrospective review study consisted of

about 95,000 patients. Limitations were also identified in the study by Ding, Li, Zhang, & Ma

(2018), which contained research pertaining to a country outside of the United States where the

protocols for indwelling catheter usage are unknown. In addition, there is a significant limit of

evidence-based literature associated with ECDs indications and usage. Therefore, further studies

should be implemented to compare ECDs with indwelling urinary catheters regarding cost,

patient gratification, and quality of life.

Conclusions

The evidence shows that alternative methods to indwelling urinary catheter use such as

the external female catheter reduce the rate of infection during hospital stays. It is also known

that policies regarding the removal of indwelling catheters are put into place to prevent CAUTIs,

but they often have low adherence rates. Strict indwelling urinary catheter use policies and

training related to catheter use are factors that can greatly influence CAUTI rates (Gupta, 2017).

In summary, further research should be executed regarding policies and their associated low

adherence rates. Advanced research can result in improved policies in order to optimize their

effect. Alternative external methods should also be studied to determine optimal practice. By

implementing these findings into daily practice, the rate of hospital acquired infections, as well

as cost and length of stay, would be greatly reduced, and should be made a priority across

hospitals nationwide.

Recommendations
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INVESTIGATING ALT TO INDWELLING URINARY CATHETERS IN THE ICU

One revolutionary alternative to indwelling catheters are external collection devices,

which can be used for male or female patients. Recent studies have found that the use of external

catheters when compared to indwelling catheters improve patient outcomes immensely. As

mentioned above, Beeson and Davis (2018) performed a study which determined that the use of

external female collection devices lowered the incidence of impaired skin integrity and infection

in women with urinary incontinence. Hospitals with a policy requiring nurse driven protocol on

catheter use and early removal has been shown to also prove better outcomes for patients..

Tyson et al. (2018) conducted a study within a fifteen-month period where nurses implemented

indwelling catheter protocols to identify patients that are candidates for early removal. It was

found through this study that there was a significant decrease in catheter utilization and CAUTI

rates in the hospital. A similar study was conducted by Pashnik, Creta, and Alberti (2017), which

focused on preventing the use of indwelling catheters and peer-to-peer education. This study

found that nurses who are properly educated on CAUTIs are able to support each other in

practice by checking quality of care, implementing a sterile field, and diligently caring for the

catheter. As a result, there was a significant decrease in CAUTI rates. An additional

recommendation that significantly decreases CAUTI rates in hospitals would be the utilization of

a catheter checklist for each patient. Siegel, Fijueora, and Stockwell (2018), completed a ten-year

retrospective study that showed that the use of a checklist for catheter implementation, care, and

removal significantly improved patient outcomes. It was proven in the study that there was a

40% decrease in urinary catheters used and an 89% decline in CAUTI rate for that unit. With the

rising use of technology in the healthcare field, electronically driven protocols are becoming

increasingly popular. A study that evaluated the effectiveness of these protocols was conducted

by Youngerman and Salmasian, (2018). This study’s goal was to reduce indwelling catheter use
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INVESTIGATING ALT TO INDWELLING URINARY CATHETERS IN THE ICU

through staged electronic clinical decision making support. It was designed to electronically

remind physicians of the total days of indwelling catheters for each patient as well as advise the

physicians on external catheter alternatives. The interventions resulted in progressive declines in

new catheters, total catheter days, and CAUTIs. External catheters, nurse driven protocols,

preventative education, peer-to-peer education, and catheter checklists are all basic practices that

could be introduced to hospitals across the United States in order to decrease infection rates and

improve patient outcomes.

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INVESTIGATING ALT TO INDWELLING URINARY CATHETERS IN THE ICU

Reference Page

Alexander, C.E., Fergus, P.C., Sinha, S., & Omar, M. (2016). Policies for replacing

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Beeson, T., & Davis, C. (2018). Urinary management with an external female collection

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