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Study Finds Doctors Often Unaware That Hospital Patients Have Urinary Catheters

Patient Safety May Be at Risk From Infections

ANN ARBOR, Mich. - Hospital doctors have a lot to remember about each patient as they make their rounds. But many of them could use some reminding about a common and risky source of hospital-acquired infections that lies just under the bed covers: urinary catheters.

So finds a multi-center study led by University of Michigan researchers and published in the Oct. 16 issue of the American Journal of Medicine. Overall, the authors report, doctors in the study weren't sure of patients' catheter status more than a quarter of the time. And, perhaps as a result, the researchers found that nearly one-third of patients using catheters didn't need them - putting them in needless discomfort and at unnecessary risk for urinary tract infections.

"If out of sight means out of mind, as these findings suggest, then we must find a way to prompt physicians to check each patient's catheter use and make sure it's necessary," says Sanjay Saint, M.D., MPH, assistant professor of internal medicine at the U-M Health System and leader of the study. "We will likely cut infection risk by reducing inappropriate catheterization."

Catheters are often left in when a patient comes a hospital floor from surgery, the emergency room or the intensive care unit. But their use can lead to patient discomfort and urinary tract infections - which make up 40 percent of hospital-acquired infections - and can extend hospital stays.

Saint and his colleagues studied 256 doctors - from medical students to attending physicians - working in teams on the general medicine floors of four teaching hospitals. They surveyed the professionals without warning before morning rounds, giving them a list of the patients in their care and asking which ones had catheters the previous day, and why. The authors then checked the patients to see if they actually had catheters the previous day and whether they were needed.

Overall, 25 percent, or 117, of the 469 patients had catheters, a rate typical of U.S. hospitals. Physicians and medical students, overall, were unaware of catheter status 28 percent of the time, and 31 percent of the catheters were found to be unneeded.

The more senior the doctor, the less likely they were to be aware that a patient was using a catheter, the study found. Attending physicians were unaware 38 percent of the time, while medical students were incorrect in their answers 21 percent of the time, probably because they have fewer patients in their care and are more focused on the patient's immediate status than his or her "bigger picture."

The study also found that more likely a doctor was to be incorrect about a patient's catheter status, the more likely it was that the catheter was not needed. And, correspondingly, a patient was almost four times as likely to have an appropriate catheter if his or her providers knew about it.

Overwork may also play a role in the problem. Providers were 20 percent more likely to be unaware of catheters if they took care of large numbers of patients.

"These forgotten catheters are often left in until the patients develop painful complications from them or are preparing to leave the hospital," Saint says. "They may have been needed earlier in the hospital stay, but often aren't questioned as the patient improves, and then may become inappropriate and even risky."

In general, unneeded catheterizations likely result from a desire for convenience from doctors and nurses, without a real medical need. But adult diapers and less-invasive catheters can cut down on bedwetting and other problems without putting the patient in the same kind of discomfort and perhaps reduce the risk of infection, Saint says. Only patients whose urine needs to be closely monitored, or who have medical reasons for being unable to use a bathroom or other options, should be on catheters.

"The best prevention is to discontinue catheter use as soon as possible, and that may mean prompting the physician to check catheter status and justification often," Saint explains. "The placement and continuation of an unnecessary catheter has potentially serious consequences and thus jeopardizes the safety of a patient by needlessly exposing him or her to conditions that may cause harm.

Saint and his colleagues say more study is needed to see which methods will prove to be effective in preventing unnecessary urinary catheterization. To this end, UMHS is currently examining the possibility of instituting an automatic stop to catheter use after 48 hours in the hospital, unless a medical reason exists to keep the device in.

Urinary Tract Infections

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