Sanjit R. Konda, MD

AAOS Now

Published 11/1/2019
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Terry Stanton

‘No-Foley’ Trauma Initiative Demonstrates Quality/Value Benefits

A study evaluated a hospital’s implementation of a policy of using straight catherization of older orthopaedic trauma patients in lieu of indwelling Foley catheters. The authors concluded that avoiding Foley catheters significantly reduced the odds of urinary tract infection (UTI) during hospitalization and predicted a significant reduction in length of stay (LOS).

The study, presented at the Orthopaedic Trauma Society Annual Meeting by Sanjit R. Konda, MD, director of geriatric orthopaedic trauma at NYU Langone Health and vice chairman of orthopaedics for Medisys Health Network, compared rates of UTI, LOS, and cost of inpatient care among 577 patients aged 55 years or older presenting with fractures; 393 of the patients (68.1 percent) were hospitalized before the new policy was implemented, and 184 (31.9 percent) were hospitalized afterward.

Dr. Konda and his fellow investigators noted that given that urinary retention occurs in almost half of all patients undergoing hip surgery, “Urinary catheter use is unavoidable in many hip fracture patients. Therefore, the length of time that a urinary catheter is in place is a key area of focus for improving hospital-acquired UTI outcomes.”

The Centers for Disease Control and Prevention (CDC), they noted, recommends that urinary catheters be used in operative patients only as necessary and advises against their routine use. The CDC further advocates that any indwelling catheter inserted for operative intervention should be removed within 24 hours of surgery. Those recommendations have encouraged the use of intermittent catheterization as opposed to the traditional placement of indwelling catheters. “Yet, despite the knowledge about the established linkage between catheter use and UTIs, a survey of U.S. hospitals found that 56 percent of responding hospitals did not have a system for monitoring which patients had urinary catheters placed and 74 percent did not monitor catheter duration,” the authors wrote.

Before and after

At the site of the study (Jamaica Hospital Medical Center, a Level 1 trauma center within the Medisys Health Network), before the policy was implemented, the standard practice was to insert indwelling Foley catheters on admission for all middle-aged and geriatric trauma patients who presented with a fracture of the hip or femur and required surgical fixation. After the policy was implemented, an indwelling Foley catheter was not placed on admission unless requested by the patient or family and after a discussion of its risks, benefits, and alternatives. Standard practice was restructured to provide better patient monitoring and bladder scans every six hours until normal bladder function could be recaptured following surgery, the authors wrote.

If a patient was unable to urinate freely and a bladder scan demonstrated ≥ 300 mL of urinary retention, intermittent catheterization was introduced with aseptic technique and a sterile low-
friction straight catheter. If a patient had a prolonged period of urinary retention and a bladder scan demonstrated ≥ 600 mL of urinary retention, he or she was transitioned to an indwelling Foley catheter. Normal bladder function was defined as a post-micturition residual urine volume of ≤ 150 mL.

The significant findings, Dr. Konda said, were that patients without an indwelling Foley catheter had:

  • 70.0 percent lower odds of hospital-acquired UTIs
  • 9.9 times higher odds of discharge to home (as opposed to discharge to a subacute nursing facility or acute rehabilitation facility)
  • 19.8 percent decrease in time to surgery
  • 17.0 percent shorter inpatient hospitalization LOS
  • 18.0 percent lower total inpatient costs
Sanjit R. Konda, MD
Implementation of use of a standardized bladder scan and straight catheterization protocol instead of indwelling Foley catheterization (“no-Foley policy”) resulted in 70 percent lower odds of patient experiencing a hospital-acquired urinary tract infection.

Cutting CAUTIs

Dr. Konda said that catheter-associated UTIs (CAUTIs) are the most common hospital-acquired infections, accounting for approximately 80 percent of hospital infections and affecting as many as 560,000 patients per year in the United States, resulting in worse surgical outcomes, increased hospital LOS, and increased overall costs to the healthcare system.

Traditionally, he said, patients with hip and femur fractures have had an indwelling Foley catheter placed upon admission to the hospital to (1) minimize discomfort with urination, as getting up or rolling over in bed for placement of a bed pan is extremely painful when the patient has a fractured hip and (2) monitor urine output as a marker of resuscitation status. The catheter would stay in the patient for as long as 23 hours postoperatively, resulting in a CAUTI rate of approximately 15 percent nationally. “With a national initiative underway to decrease CAUTIs, establishing a protocol to decrease CAUTIs in hip and femur fracture patients seemed like the logical place to start for geriatric orthopaedic fracture patients,” he said. “These patients are generally frail and have a high comorbidity burden, making them more prone to developing a CAUTI. This cohort of patients also stood to gain the most from this intervention, given the high rate of CAUTIs seen in this group.”

One concerning finding, he said, was a weaker-than-expected effect of the no-Foley policy: Before implementation, the indwelling Foley catheter rate for the cohort of geriatric hip and femur fracture patients was 95.5 percent. After implementation, the indwelling Foley catheter rate decreased to 43.5 percent. “We expected the no-Foley catheter rate to be lower; however, we found several barriers to implementation of the policy,” Dr. Konda said. “This difficulty with policy implementation has been documented by others who have studied this issue, so we are not alone in struggling to educate other patient care [professionals] about the harmful effects of indwelling Foley catheters in this patient population. We are currently using the results of this study to educate the entire hospital staff (nurses, physician assistants, nurse practitioners, internists/hospitalists, and surgeons) about the benefits of avoiding indwelling Foley catheterization of this vulnerable cohort.”

The reasons for resistance to a no-Foley policy may include the following:

  • increased nursing time required to perform straight catheterization
  • patient uneasiness about being “straight-cathetered”
  • possibility for urethral irritation with multiple straight catheterizations
  • difficulty accessing the urethra in obese patients with hip, femur, or pelvic trauma
  • missing bladder overdistention issues in obtunded patients

Dr. Konda said the experience at his institution and the findings of the study yielded lessons for other centers adopting similar initiatives.

“A no-Foley policy is a hospital quality initiative that requires strong nursing leadership and involvement in order to carry out the day-to-day policy initiatives. It also involves strong surgeon leadership in order to establish a baseline expectation among patient care [professionals] that these patients do not require an indwelling Foley catheter. For other hospitals attempting to implement a similar no-Foley policy for their geriatric hip and femur fracture patients, I would strongly encourage them to find surgeon and nursing champions who can lead the effort to educate hospital staff about the benefits of avoiding indwelling catheter use,” he added.

Dr. Konda’s coauthors of “Pull the Foley: Improved Quality for Middle-aged and Geriatric Trauma Patients Without Indwelling Catheters” are Joseph R. Johnson, ScB; Erin A. Kelly, MS; and Kenneth A. Egol, MD.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.