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Methods

During a 6‐month period, we evaluated patients at a nonteaching hospital (21,394 admissions yearly) in Catanzaro, Italy, who received IUTCs during their hospital stay in the following wards: geriatrics, general surgery, urology, internal medicine, orthopedics, and gynecology (4,629 admissions in the study period).

Patients’ medical records were retrospectively reviewed by 2 physicians after discharge, to collect information to determine whether IUTCs were used appropriately and to assess indications for their use. Data recorded were date and ward of admission and discharge, sociodemographic characteristics, source of referral (eg, primary care physician or emergency department), underlying chronic diseases, diagnosis, length of stay, surgical interventions during stay, state of consciousness, type of IUTC used, duration of and reasons for catheterization, and presence of infection. Urine cultures were not performed routinely after catheterization, and therefore the incidence of asymptomatic bacteriuria could not be ascertained.

If no explicit documentation of the indication for IUTC use was available, the clinical situation was determined from the clinical record by the 2 examiners independently, and discordant results about the reason for IUTC use were resolved through consensus.

Because we assessed appropriateness of IUTC use using information retrieved from the medical records, patients who had an IUTC in situ at the time of admission to the hospital were excluded, whereas those who were referred from other wards of the hospital (eg, from the emergency room) were not excluded. Criteria used to define appropriate IUTC use were derived from previously accepted indications^1,4‐8 and were as follows: (1) obstruction of the urinary tract distal to the bladder; (2) need for accurate measurement of urine output for an uncooperative patient (eg, an intoxicated, unconscious, or comatose patient); (3) need for preoperative IUTC insertion for patients going directly to the operating room; (4) urinary tract hemorrhage requiring continuous bladder irrigation; (5) alteration in the blood pressure or volume status requiring continuous, accurate urine volume measurement; (6) neurogenic bladder dysfunction and urinary retention requiring urinary drainage; and (7) urinary incontinence posing a risk to the patients.^6,7 Urinary catheterization was considered inappropriate if used as a means of obtaining urine for culture or for certain diagnostic tests for a patient who could voluntarily urinate or as a substitute for nursing care of an incontinent patient.¹

Stepwise multiple logistic regression analysis was performed to identify the variables associated with inappropriate IUTC use. The explanatory variables included were the following: patient’s age (continuous); patient’s sex (male = 0, female = 1); ward of admission (categorical: internal medicine = 1, general surgery = 2, urology = 3, geriatrics = 4, orthopedics = 5, gynecology = 6); presence of chronic comorbidities (ordinal: none = 0; 1 disease = 1; 2 diseases = 2; 3 diseases = 3; at least 4 diseases = 4); surgical intervention (no = 0, yes = 1); mental status (ordinal: alert = 0, confused = 1, comatose = 2); duration of urinary catheterization (continuous); and length of hospital stay (continuous). The data were analyzed using Stata software (Stata).

Results

A total of 461 patients received an IUTC in the surveyed wards. The mean length of stay was 10.8 days, for a total 4,992.6 patient days of hospitalization. The mean duration of urinary catheterization was 5 days, for a total of 2,306.3 days of catheterization (46.2%). The mean age was 63.3 years; 355 patients (77%) had underlying chronic diseases, mainly neoplasms (175 [49.2%]), heart failure (51 [14.5%]), and chronic obstructive pulmonary disease (37 [10.5%]). Most patients were admitted to the urology ward (124 [26.9%] of 461 patients), the gynecology ward (100 [21.7%]), and the general surgery ward (94 [20.4%]), and most underwent a surgical intervention (345 [74.8%]). For all patients with an IUTC, an open drainage system was used. The most frequent indication for catheterization was surgical intervention (281 patients [61%]), the second most frequent indication was management of urinary incontinence for nursing convenience (75 [16.3%]), and the third was urinary obstruction (28 [6.1%]). The number of patients with an inappropriately used IUTC was high (138 [30%]). The most common reasons that IUTC use was inappropriate were excess duration of catheterization for surgical interventions (in 37 [13.2%] of 281 patients), and use for the purpose of obtaining urine and managing urinary incontinence, for nursing convenience (in 101 patients [100%]). The most common appropriate indication was surgical intervention.

In univariate analysis, inappropriate urinary catheterization was significantly associated with ward of admission ( and ), greater age ( and ), a greater number of chronic comorbidities ( and ), no surgical intervention ( and ), and longer duration of urinary catheterization ( and ).

In the multivariate analysis, inappropriate use of an IUTC was significantly associated with greater age, with not having undergone a surgical intervention, with having a good state of consciousness, with a greater number of chronic comorbidities, with a longer duration of catheterization, and with ward of admission (Table). No significant associations were found with patient sex and greater length of hospital stay.

Table.  Multivariate Logistic Regression Findings for Inappropriate Use of an Indwelling Urinary Catheter

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Discussion

The proportion of patients with inappropriate IUTC use found in the present study (138 [30%] of 461 patients) was higher than that reported by Jain et al.⁸ (41 [21%] of 202 patients), similar to that reported by Hartstein et al.⁹ (36 [33%] of 108 patients), and lower that reported by Gokula et al.⁷ (155 [54%] of 285 patients, during the first 24 hours after admission), Gardam et al.¹⁰ (12 [50%] of 24 patients, in an emergency department), and Munasinghe et al.⁶ (34 [38%] 89 patients, during the first 24 hours after admission).

The most frequent reason that IUTC use was inappropriate was excess duration of catheterization after surgical intervention, and, indeed, in the present study, the mean duration was 5 days, which is 2 days longer than that found by Gokula et al.,⁷ and results of the multivariate analysis revealed that longer duration of catheterization was significantly associated with inappropriate IUTC use. Although one of the most effective measures for prevention of infection in patients with an IUTC is use of a closed drainage system,⁴ we found that open drainage is still in use, which is unacceptable. Similar concern has been stated by Bouza et al.,⁵ who reported open drainage systems were used for 39 (21.5%) of 181 catheterized patients.

We found a significant difference in inappropriate IUTC use according to ward, which emphasizes the large heterogeneity in prescription practices regarding IUTC utilization, and indeed no written guidelines were available in the wards surveyed. Appropriate IUTC use was also significantly more likely in patients with a more deteriorated mental status and in those who had undergone a surgical intervention, compared with medical patients, and these findings are expected because treatment of an uncooperative patient and surgical interventions are appropriate indications for IUTC insertion.

Our results clearly indicate substantial potential for improvement in the use and management of urinary catheterization, and emphasize the need for written guidelines and monitoring.