Incidence, Contributing Factors, and Morbidity Associated with Catheter Related Urethral Injuries (CRUI)

Transcription

1 Incidence, Contributing Factors, and Morbidity Associated with Catheter Related Urethral Injuries (CRUI) Susan Tocco MSN, RN, CNS, CNRN, CCNS Sarah Frewin MSN, RN, CNS, PCCN, CCNS Mary Lou Sole PhD, RN, CCNS, FAAN, FCCM

2 What prompted our study? Physician generated concerns about nurses competence in Foley catheter insertion in males As CNS s this led us to question: What is known about catheter related urethral injuries in the literature? Is this a widespread problem in our organization? Are there issues beyond Foley insertion that contribute to catheter related urethral injuries? What is the impact on female patients?

3 Historical perspectives Celsus (1 st century AD) First described the use of urinary catheters Avicenna ( ) Catheterization should be performed gently and without force Made catheters from animal or fish skins Foley (20 th century) Created an inflatable balloon catheter 1950 Sterile Foley kits that we use today

4 What is known about catheter related urethral injuries? Mostly isolated case reports Only one study systematically examined the incidence of iatrogenic urethral injuries Kashefi et al. (2008). Incidence and prevention of iatrogenic urethral injuries. The Journal of Urology, 179, Cited by the authors as the first study to document the incidence of iatrogenic urethral injuries in hospitalized adult male patients.

5 Kashefi et al. findings: Six month prospective trial Only studied catheter insertion related injuries in men that prompted a urology consultation for catheter placement Insertion related catheter injuries occurred in 14 men during their 6 month study period for an incidence of 3.2 injuries per 1,000 male admissions

6 Kashefi (et al) conclusion: Proper insertion technique is the single most important factor in preventing (catheter related urethral) injury

7 Gaps in the literature The first use of catheters was described over 2009 years ago and Foley catheter has been in widespread use for more than 70 years yet: There are only 17 systematically studied cases of CRUI reported in the literature There is no evidence regarding: Non-insertion CRUI The incidence of CRUI in women

8 Our research questions 1. What is the incidence of CRUI at our organization? 2. How does the incidence, injury manifestation, and associated treatment of CRUI amongst male and female patients compare? 3. How does the etiology of CRUI (insertion vs. noninsertion) amongst male and female patients compare? 4. How does the incidence, injury manifestation, and required treatment of insertion vs. non-insertion related CRUI compare? 5. Which hospital departments have the highest incidence of insertion-related CRUI?

9 Methods Retrospective Chart Review 3 years (October 1 st, 2005-September 30 th, 2008) Diagnosis Code: Urethral injury Included the four adult hospitals in our system Inclusion Criteria Adults (>18 years) Documented CRUI Exclusion Criteria Urethral injury related to non-catheter causes, such as trauma or surgery CRUI present on arrival e.g. from home, SNF

10 Methods Specific factors examined Demographics (gender, age) Urological history Etiology of injury (insertion vs. non-insertion) Clinical manifestations Associated treatments Department in which injury occurred Provider who inserted the catheter (RN, ACT, MD)

11 Etiology of injury Insertion related documentation that the injury clearly occurred during insertion of the catheter e.g. inflation of the balloon in the urethra Non-insertion related patient self-removal of the catheter, tension/pulling on the catheter

12 Results: Total of 215 cases reviewed: 90 excluded as non-catheter related 125 included as catheter related 58% 42% Excluded Included

13 Results: Incidence 125 cases per 177,583 consecutive adult admissions Overall incidence of 0.7 cases per 1,000 admissions Our sample includes: Both male and female cases All causes of CRUI (insertion and non-insertion) Sample population of males with insertion related urethral injuries Kashefi et al. (2008) 3.2 Incidence per 1,000 male admissions Orlando Health 0.46

14 Results: Gender Women N=14 (11%) CRUI Sample: Men vs. Women Men N=111 (89%) Men Women p=.006

15 Results: Etiology of CRUI in men 3% 16% 32% Insertion Self-removal 49% Tension UTD Patient self-removal of the catheter was the most common cause of CRUI in men Insertion related causes accounted for less than one-third of all CRUI in men

16 Results: Etiology of CRUI in women n = 14 3 cases (21%) patient removed catheter 11 cases (79%) hematuria of unknown cause No definitive cases of insertion related injury Lack of documentation regarding catheter anchoring limited evaluation of this variable s impact on CRUI

17 Percentage Results: Clinical Manifestations 100 Injury Manifestation in CRUI p= Men Women All 0 Pain Hematuria Blood Meatus Urinary Retention Clinical Manifestation Presence of blood at the urethral meatus was more prevalent in men p =.017

18 Percentage Results: Clinical Manifestations Clinical Manifestations Comparison between Insertion and Non-Insertion CRUI 100 P=.006 P=.008 P= Insertion-Related Non-Insertion Related UTD All 0 Pain Hematuria Blood Meatus Clinical Manifestations Urinary Retention Pain was difficult to evaluate in patients who removed their own catheters as the majority of these patients had obvious impairment in cognition Patient reports of catheter related pain warrant immediate assessment and intervention

19 Antibiotic Urology Consult Catheter Replaced- Catheter Replaced- Irrigation Suprapubic Catheter Blood Products OR Diagnostic Procedures Percentage Results: CRUI Treatments Treatments for CRUI Men Women Total Treatments The treatments of antibiotic administration (p =.045) and urology consultation (p =.001) were more prevalent in men

20 Results: CRUI treatments/morbidity Blood transfusions 17 (13.6%) of total cases had injuries severe enough to warrant blood transfusion 16 men, 1 woman (p =.454) This is a conservative number based on the documentation standards for this retrospective study

21 Results: CRUI treatments/morbidity 11% of the males required aggressive interventions including OR procedures or placement of a suprapubic catheter for their injuries 8 men taken to the operating room for replacement of catheter 4 men required placement of suprapubic catheters

22 Results: CRUI Treatments Non-Insertion Related 32% Insertion vs. Non-insertion CRUI Treatment: Urologist replaced catheter Insertion Related 68% Insertion Related Non-Insertion Related CRUI requiring an urologist to replace the catheter was more prevalent in insertion-related cases (p<.001). This explains the physician focus on this etiology of injury.

23 Results: Departments Incidence of Insertion-Related CRUI per Department UTD 3% ED 38% Nursing unit 50% N=36 Surgery 9% From a PI perspective, the ED is a key area to focus on in both improving insertion and minimizing catheter utilization

24 Conclusions CRUI is significantly more prevalent in men and is associated with considerable morbidity Patient self-removal of the catheter was found to be the most common cause of CRUI Contrary to Kashefi, our study found that efforts to minimize the use of urinary catheters would be the single most effective strategy to prevent injury. Perspective of nursing vs. physician generated research questions

25 Conclusions Avoid catheter placement in cognitively impaired patients whenever possible Education regarding proper catheter insertion technique in male patients is essential Hub Urine---Balloon PI efforts directed towards the ED are likely to reap the greatest benefit Further investigation is needed to determine the role of catheter stabilization in CRUI of unknown cause

26 Next steps Plan a repeat study using similar methods to evaluate the impact of our three phase PI interventions: 1. Anchoring (Stat-lock device added to Foley kits) 2. Insertion (Urology Dept. Chair made instructional video, difficult male catheterization orders) 3. Utilization (catheter alternatives including bladder scanner and prompt removal)

27 Questions?