Running Head: URINARY RETENTION LITERATURE REVIEW
Capstone Project
Jennifer Cameron
The Pennsylvania State University
2
Background/Significance
Hospital acquired infections, HAIs, are a perpetual problem the healthcare industry faces
each and every day. Based on a large sample of U.S. acute care hospitals, on any given day,
about 1 in 25 hospital patients has acquired at least one HAI on each hospital stay. There were an
estimated 722,000 HAIs in U.S acute care hospitals in 2011, and about 75,000 patients with
HAIs died during their hospitalization (Magill et al., 2014). Urinary tract infections are currently
one of the most prevalent HAIs, representing approximately 30%-40% of all infections,
especially in the intensive care setting, where the presence of urinary catheters are more common
(Marra et al., 2011). Catheterization is typically done by the use of either an intermittent catheter,
which is inserted each and removed each time the bladder is emptied, or an indwelling catheter,
which stays in place for a longer period of time. Generally, the use of catheters are associated
with an inappropriately high incidence of catheter-associated urinary tract infections, (CAUTI),
(Shumm & Lam, 2008). According to one study in particular, CAUTI can be contributed to
approximately 34% of all nosocomial infections in the United States, (Chenoweth, 2013).
Furthermore, a particularly high number of patients seem to have had a catheter put in place
without sufficient clinical indication as to why it may be needed (Burton, 2011). This largely
preventable infection rate can lead to an increased patient morbidity as well as higher health care
costs for everyone involved (Fink, et al, 2012).
A considerable amount of research has been done in the past, and is currently underway
in order to determine evidence-based, best practice guidelines for the use of catheters. Collective
approaches to preventing CAUTI incidence are the adherence to strict aseptic technique, proper
hand hygiene, as well as a reduction in the duration of use, (Newman & Willson, 2011).
However, CAUTI could potentially be eliminated or greatly minimized with simple and cost-
3
effective preventive approaches via the implementation of multidimensional infection control
programs aimed at a general reduction of HAI rates and wider acceptance of universal infection
control programs.
Suggested Evidence-Based Practice Literature Review
After reviewing abstracts of numerous research studies conducted worldwide, some
studies proved to be at the forefront of examination. In one specific prospective cohort study, the
research was conducted in seven separate intensive-care units in four specific hospitals, in urban
areas of China, between August 2008 and July 2010. All four of the hospitals were governmentowned teaching hospitals. All patients admitted to one of the seven ICUs were included in this
study, and all patients were followed until discharge. This study not only took into consideration
the rate of CAUTI, but it also measured rates of other HAI such as central line-associated blood
stream infections, CLASBI, and ventilator-associated pneumonia, VAP. In particular, this study
measured the incidence per 1,000 cases of each nosocomial infection. The results yielded overall
CLABSI rate at 7.66 per 1,000, the VAP rate was 10.46 per 1,000, and the CAUTI rate was 1.29
per 1,000. Mortality rates were also calculated as these HAI demonstrated an increased death
rate. Across the entire study, 5.4% of the patients admitted into one of the intensive-care units
died. Mortality was 18% in patients with CLABSI, 26% in those with VAP, 47% in those with
CAUTI, and only 4% in patients without a hospital acquired infection, (Hu, et al., 2013).
In another interesting study, a quasi-experimental interrupted time series study was
conducted in a 38-bed medical-surgical intensive care unit and in two, 20-bed step-down units.
Both SDUs had a similar physical layout and were located in a private tertiary care hospital in
Sao Paulo, Brazil. All rooms in the ICU and the SDUs are single-bed rooms. The SDU patients
are transferred from the ICU, from various step-down wards, and from the emergency
4
department. The study was carried out in two phases. In the first phase, which took place from
June 2005-December 2007, urinary catheters were inserted using aseptic technique with a 2%
chlorhexidine preparation for skin asepsis. The catheters were not regularly replaced as they
were kept in place until it was no longer needed or until adverse events mandated the removal of
the catheter, (Marra et al., (2011).
The second phase of the experiment took place from January 2008-July 2010. The same
process that was carried out in phase one continued, however the catheters were inspected once
monthly at random intervals. A bladder bundle was implemented at the beginning of the second
phase consisting of a urinary catheter insertion cart, hand hygiene, chlorhexidine skin prep, a
sterile field, and sterile gloves. Only one attempt at insertion was permitted for each catheter,
requiring a new catheter to be used for each attempt. The bundle also incorporated sufficient
urinary catheter balloon inflation and daily review of the need for a catheter with prompt
removal if no longer indicated. The bundle was implemented for use in all ICU and SDU patients
requiring a catheter. Before the start of phase two, a mandatory seminar was provided to all staff
involving techniques of CAUTI prevention, while reviewing the study protocol, and encouraging
participation in the urinary catheter bundle program. Feedback to staff was provided on
compliance with the bundle components through email. Lastly, posters were displayed on the
units with bar graphs revealing compliance with the progression of care measures and CAUTI
rates, (Marra et al., (2011).
In phase one, in the ICU, there were 24,820 patient-days and 15,500 urinary catheter
days, for a catheter utilization ratio of 0.62. In the ICU in phase two, there were 27,584 patientdays and 14,577 urinary catheter days, for a catheter utilization ratio of 0.53. In the SDU in
phase one, there were 36,454 patient-days and 6,633 urinary catheter days, for a catheter
5
utilization ratio of 0.18, and in SDU phase two, there were 34,661 patient-days and 4,041 urinary
catheter days, for a utilization ratio of 0.12. In the second phase, compliance was evaluated per
the urinary catheter checklist in 90.5% (2,105/2,327) of catheter insertions in the ICU and in
89.0% (1,744/1,959) of those in the SDUs. The results yielded a statistically significant reduction
of CAUTI rate in the ICU, from 7.6 per 1,000 catheter-days (95% confidence interval [CI], 6.68.6) before the intervention to 5.0 per 1,000 catheter-days (95% CI, 4.2-5.8) after the
intervention (P= 0.001). A statistically significant reduction of CAUTI rate in the SDUs was
found, from 15.3 per 1,000 catheter-days (95% CI, 13.9-16.6) before the intervention to 12.9 per
1,000 catheter-days (95% CI, 11.6-14.2) after the intervention (P=0.014), (Marra et al., 2011).
One article of particular interest, took a fairly different approach. The authors noted that
tremendous evidence-based research and quality initiatives, both public and private, aimed at
decreasing CAUTI along with associated cost, morbidity and mortality, have been published
over the last thirty years. The guidelines all point to one preponderant principle: to minimize
unnecessary urinary catheter use. A number of strategies in support of this notion can be found in
the literature, from the use of condom catheters in replace of indwelling catheters, to the use of
bladder ultrasound scanners to identify or rule out urinary retention, to the utilization of
computerized reminders, stop orders, or nurse-driven protocols to certify catheters are
discontinued as soon as they are no longer indicated. Over time, a standard basis has been
solidified for CAUTI prevention program and policies, however, an insufficient amount of
research has followed up with preceding studies regarding if the particular programs and policies
are actually being implemented and executed in ICUs across the nation (Conway et at., 2012).
The aim of this study is to evaluate the incidence and adherence to CAUTI prevention
policies in ICUs in hospitals in the US, to isolate disparities in policies based on facility and
6
department characteristics, infection prevention and control, as well as organizational support.
Lastly, the authors expect to determine if a relationship exists between prevention guidelines and
CAUTI rates. The approach integrates data obtained from a large nation-wide, cross-sectional
survey of infection prevention and control departments designed to ascertain the costeffectiveness of infection prevention and control practices. The methodology of the experiment
was reviewed and accepted by institutional review boards at Columbia University, and the
Centers for Disease Control and Prevention, (CDC), (Conway et at., 2012).
In order to obtain an unbiased and equitable study sample, the National Healthcare Safety
Network (NHSN) was used. The NHSN is a system of hospitals that readily, or by state mandate,
confidentially surrenders data on HAI at their given facility. Criteria included at least 500
device-days per year in at least one ICU. The sample was comprised of 441 hospitals nationwide.
An online questionnaire was conducted in the spring of 2008. Questions included facility
characteristics such as region, number of beds, teaching status, ICU type, and state mandatory
reporting of all HAI. Infection prevention and control department characteristics were assessed
with questions about the number and roles of professional staff, board certification in infection
prevention and control, and hours dedicated to the infection prevention and control department,
followed by questions regarding presence of CAUTI prevention policies, adherence to policies,
and CAUTI incidence rates. Lastly, the questionnaire assessed for the presence of policies for
four specific CAUTI prevention strategies: the use of condom catheters for men, the use of
portable bladder ultrasound scanners for determining post-void residual volume, the use of
urinary catheter reminders or stop orders, and nurse-initiated urinary catheter discontinuation.
Adherence to the policy was assessed by asking respondents what proportion of time each policy
7
was appropriately implemented: all of the time (95%-100%), usually (75%-94%), sometimes
(25%-74%), rarely/never (<25%), or do not know, (Conway et at., 2012).
At the completion of the study, 250 hospitals responded to the survey and data was
provided for 415 ICUs nationwide, the majority, 71% were considered teaching hospitals, and
43% of the ICU included were in hospitals where over half of the infection prevention and
control personnel were board certified. The outcome was a bit disturbing considering the highly
regarded status of most of the hospitals included in the study. According to the results section of
the study, CAUTI prevention policies were not common in the majority of ICUs surveyed.
Guidelines supporting the use of portable ultrasound were in place in 25.9% of ICUs (n=106),
recommendations encouraging the use of condom catheters for men were in place in just 20% of
ICUs, (n=82). Urinary catheter reminders or stop orders and nurse-initiated urinary catheter
discontinuation were rarely in place with just 9.5%, (n=39). A mere 31% of ICUs with urinary
catheter reminders or stop orders in place tracked them, and less than half the ICUs in the study
reported having at least one of the four CAUTI policies in place, 42.2%, (n=174), (Conway et at.,
2012).
Given the results of the study, the researchers were able to conclude a considerable
amount of additional information relevant to the assumption of the authors. Ultimately, the
authors indicate that only one other large-scale study of CAUTI prevention practices in US
hospitals had been conducted prior, and results were similar in that there was no evidence of one
single, widely used CAUTI prevention method, along with low adherence to any of the specific
prevention guidelines assessed for in the questionnaire. Interestingly, the results of the study
revealed that ICUs of larger hospitals generally have higher CAUTI rates and were significantly
less likely to have adopted at least one CAUTI prevention policy, (Conway et at., 2012).
8
Action Plan
One of the most common disorders regarding patients on a medical-surgical acute care
unit is the inability to void, known as ischuria or simply, urinary retention, (UR). This occurs
when the bladder is unable to empty itself completely. There are several causes of urinary
retention, ranging from obstruction as seen in benign prostatic hyperplasia, and urinary stricture,
to nerve problems and medications, although post-operative urinary retention (POUR) is one of
the most common causes found on a typical acute care floor (National Kidney and Urologic
Diseases). UR is a common complication seen daily by healthcare professionals at Hershey
Medical Center on the acute care floors 4AC and 5AC. While, the problem seems to be a bit
more widespread on the 4th floor, a predominately a post-operative orthopedic and urology floor,
it has been noted that UR and the decision of whether or not to catheterize a patient is an ongoing
and debatable topic prevalent on both units. Since catheterization is a common procedure done in
nearly all hospitals and healthcare centers, CAUTI, are among the most prevalent HAI in the
United States, (National Kidney and Urologic Diseases).
An overwhelming increase of CAUTI rate over the last several decades has driven a
nationwide initiative for research and implementation of new and improved evidence-based
interventions aimed at raising awareness in hospitals and other healthcare facilities. Prior to the
implementation of the CAUTI prevention action plan revealed in this paper, it was not apparent
that Hershey Medical Center had any specific guidelines in place consistent among all hospital
units in order for staff to methodically and meticulously perform catheter care. With the
execution and introduction of a standardized hospital-wide CAUTI guideline protocol, the rate of
infection could systematically be tracked and analyzed while allowing healthcare professionals
9
the opportunity to provide the most advanced, cutting-edge, utmost care to all hospitalized
patients.
As noted, at Hershey Medical Center, HMC, the 4th floor and 5th floor, both acute care,
medical-surgical floors, have a high influx of patients, the majority are post-operative patients,
exhibiting signs of urinary retention post-surgical procedure. Healthcare professionals, mainly
nurses on that particular unit, are left with making a series of hasty decisions, and more often
than not, ultimately necessitating to catheterize the patient. After spending a great deal of clinical
time on both floors, it is determined that there be a need for an implementation of a standardized
“bladder bundle,” proposed to allow nurses and other members of the healthcare team to follow a
specific protocol each and every time a catheter is inserted or removed. In terms of healthcare, a
bundle is considered a collection of processes needed to effectively and safely care for patients
undergoing a particular treatment or procedure with an inherent risk. Several interventions are
“bundled” together and, when combined, significantly improve patient care outcomes, (Society
for Healthcare Epidemiology of America/Infectious Disease Society of America, 2008).
After spending hours systematically reviewing a great deal of evidence-based research
and collaborating with preceptors on both units, it was determined that the implementation of a
bladder bundle would be an effective and operational approach to demonstrate the findings of
this project, and ultimately anticipate a unit-wide, improved awareness and understanding of
CAUTI and the necessary steps to support reduction and prevention. Since the nursing process is
the fundamental core of practice for a nurse to deliver holistic, patient-focused care, it was
unanimously ascertained that the nursing process must be utilized for proper initiation and
implementation this project (American Nurses Association, 2015). At this point, the first step,
assessment of the problem, including collection of data, and identification of specific patient
10
problems and needs, had been completed, as well as the second step, diagnosis, in which the
individual analyzes assessment data and searches for evidence.
With the collective assistance of a group of individuals, the planning phase, step three of
the nursing process, was subsequently completed over a period of several weeks after
analyzation and interpretation of the data. It was of utmost importance to pay particular attention
to by what means the bladder bundle could have a prospective positive patient outcome while
being adjusted and tweaked to adhere to the customs of each unit respectively. After careful
consideration, the development of the bladder bundle began to take shape. Due to obvious
financial limitations as well as a time-sensitive deadline, presenting a clever and eye-catching
poster appeared to be an ideal method to display throughout both units. A collaborative effort to
choose and agree what would be displayed on the poster did not generate any controversy, and a
simple mnemonic, with a catchy and colorful design was decided upon within a short amount of
time. In accordance with the poster, the letters “ABCDE” were listed and with each letter, a
tactic or approach to CAUTI reduction and prevention following:
Adherence to general infection control policies such as hand
hygiene, aseptic insertion, proper maintenance, education is
important
Bladder ultrasound may avoid indwelling catheterization
Condom catheters or other alternatives such as intermittent
catheterization should be considered in appropriate patients
Do not use the indwelling catheter unless you must!
Early removal of the catheter using a reminder, stop-order, or
nurse-initiated removal protocol is warranted
Saint S, et al. Translating Hospital-Associated Urinary Tract Infection Prevention Research into
Practice via the Bladder Bundle. Joint Commission Journal on Quality and Patient Safety 2009;
25:449-55.
The posters were displayed in each of the three hallways in both units, as well as other common
areas throughout the units. These included the breakrooms, locker rooms, pantries and offices as
well all of the staff bathrooms. Since the initial launch of the action plan, the posters have been
11
displayed for approximately eight weeks. Unfortunately, as many nurses had mentioned that they
noticed the poster to group members, it is virtually impossible in terms of this class project, to
track the effectiveness and ultimately determine if over the course of a period of several months,
there had actually been an evident reduction in the rate of CAUTI, (Saint et al., 2009).
It was acknowledged that implementation of the bladder bundle would not come without
a series of limitations. Primarily, as mentioned before, finances were a critical barrier to
providing an innovative, evidence-based, bladder bundle to the staff on the fourth and fifth
floors. Without the addition of any other prevention strategies, had there even been a small
amount of monetary resources, a more pleasing and attractive poster could have been developed.
Moreover, if it were possible, it would have benefited to authorize a unit-wide seminar or
continuing education colloquium with required attendance for all staff. Awareness of the issue at
hand could have been raised with more confidence. Following the educational session, an
evaluation of knowledge of each attendee would gage the ability of individuals to recall
important information regarding the most current and established guidelines. Lastly, the short
time restriction on this project prevents a proper evaluation of implementation. While both units
currently track CAUTI rates and post the most up-to-date statistics, as did they prior to the start
of this assignment, the length of the project will not allow for a period of proper implementation
and execution, followed by another period of evaluation and assessment of new knowledge
gained through required CAUTI sessions.
Conclusion
Upon completion of the capstone project, tremendous knowledge and understanding has
been gained by all individuals involved in the development of this project. In the beginning of
the semester, after spending only a few days on the two particular medical-surgical floors
12
discussed above, it was apparent that urinary retention was an extremely common complication
managed very frequently with the use of catheters. Still being in school, and with very little prior
experience or knowledge regarding parameters of when and when not to catheterize a patient, it
was profoundly evident that nurses on both units were occasionally unsure or hesitant to follow
orders regarding catheters, whether it be to insert, or discontinue. After discussion of the topic
with several fellow nurses on the floor, this topic continued to be troubling in that there did not
seem to be any specific guidelines or protocol for unit nurses to follow when in fact they were
faced with a decision that could ultimately affect the overall outcome of the patient. In an effort
to potentially alleviate some hesitation or reluctance to confront the subject at hand all together,
the basis for this project was formulated after some careful consideration and deliberation with
corresponding group members and research was underway almost immediately.
According to a recent study, more than one hundred million indwelling urinary catheters
are used annually across the globe, while more than a quarter of these are used in the United
States. About 15% of patients admitted to acute care hospitals in the United States receive an
indwelling urinary catheter at some point during their hospital stay. CAUTI count for
approximately 40% of all HAI whereas roughly 80% of health care-associated UTI are caused by
a urinary catheter. The cost in healthcare is outrageous, with each occurrence of suggestive
CAUTI costing at least six-hundred dollars. In recent years, CAUTI has become even more
costly for hospitals because the Centers for Medicare & Medicaid Services no longer reimburses
hospitals for the extra cost of caring for patients who develop CAUTI (Meddings et al., 2012).
CAUTI are a health care complication with simple and cooperative methods to
preventing its development and progression. If time were not of the essence, and evaluation of
the executed bladder bundle proves to be ineffective and unsuccessful, there are a few minor and
13
inconsequential yet essential strategies such as adherence to strict asepsis and well as proper
hand hygiene that all healthcare professionals absolutely must follow independently in an effort
to encourage reduction and subsequent cessation of this largely preventable complication.
14
References
American Nurses Association, Nursing World. The Nursing Process (2009). American Nurses
Association. http://www.nursingworld.org.
Baldini, G., Bagry, H., Aprikian, A., Carli, F., & Phil, M. (2009). Postoperative urinary retention.
Anesthesiology, 110(5), 1139-57.
Bhatia, N., Daga, M. K., Garg, S., & Prakash, S. K. (2010). Urinary Catheterization in Medical
Wards. Journal of Global Infectious Diseases, 2(2), 83–90
http://doi.org.ezaccess.libraries.psu.edu/10.4103/0974-777X.628700
Burton, Deron C DC (2011). "Trends in catheter-associated urinary tract infections in adult
intensive care units - United States, 1990-2007.". Infection control and hospital
epidemiology (0899-823X), 32 (8), p. 748.
Chenoweth, C., & Saint, S. (2013). Preventing catheter-associated urinary tract infections in the
intensive care unit. Critical Care Clinics, 29(1), 19.
Conway LJ, Pogorzelska M, Larson E, Stone PW. Adoption of policies to prevent catheterassociated urinary tract infections in United States intensive care units. American Journal
of Infection Control. 2012;40(8):705-710. doi:10.1016/j.ajic.2011.09.020.
Fink, R., Gilmartin, H., Richard, A., Capezuti, E., Boltz, M., & Wald, H. (2012). Indwelling
urinary catheter management and catheter-associated urinary tract infection prevention
practices in nurses improving care for healthsystem elders hospitals. American Journal of
Infection Control, 40(8), 715. doi:10.1016/j.ajic.2011.09.017 t;40(8):715-20. doi:
10.1016/j.ajic.2011.09.017. Epub 2012 Jan 31.
Hu, B., Tao, L., Rosenthal, V. D., Liu, K., Yun, Y., Suo, Y., & ... Saunders, C. L. (2013).
Device-associated infection rates, device use, length of stay, and mortality in intensive
15
care units of 4 Chinese hospitals: International Nosocomial Control Consortium
findings. American Journal of Infection Control, 41(4), 301-306.
Magill et al., (2014). Multistate Point-Prevalence Survey of Health Care-Associated Infections.
New England Journal of Medicine, 2014; 370:1198-208.
Marra et al., (2011), Preventing catheter-associated urinary tract infection in the zero-tolerance
era, American Journal of Infection Control, Volume 39, Issue 10, December 2011, Pages
817-822, ISSN 0196-6553.
Meddings J,Rogers MAM, Krein SL, et al., (2014). Reducing unnecessary urinary catheter use
and other strategies to prevent catheter-associated urinary tract infection: an integrative
review. BMJ Quality and Safety; 23:277-289
Mohammadi-Fallah, M., Hamedanchi, S., & Tayyebi-Azar, A. (2012). Preventive effect of
tamsulosin on postoperative urinary retention. Korean Journal of Urology, 53(6), 419423. doi:10.4111/kju.2012.53.6.419
Newman, D. K., & Willson, M. M. (2011). Review of intermittent catheterization and current
best practices. Urologic Nursing, 31(1), 12.
Saint, S., Olmsted, R. N., Fakih, M. G., Kowalski, C. P., Watson, S. R., Sales, A. E., & Krein,S.
L. (2009). Translating Health Care–Associated Urinary Tract Infection Prevention
Research into Practice via the Bladder Bundle. Joint Commission Journal on Quality and
Patient Safety / Joint Commission Resources, 35(9), 449–455.
Schumm, K., & Lam, T. B. L. (2008). Types of urethral catheters for management of short-term
voiding problems in hospitalised adults. The Cochrane Database of Systematic Reviews,
(2), CD004013.
16
Society for Healthcare Epidemiology & Infectious Disease Society of America. Clin Infect Dis.
(2008) 46 (2): 155-164. doi: 10.1086/524891