One of my most embarrassing moments as a young neurologist was when, as I was providing inpatient discharge instructions to a young multiple sclerosis patient, she asked the above question. It caught me totally by surprise that she had a Foley catheter in place. Later, when I first became involved in quality improvement, unnecessary Foley catheters became one of my pet peeves. You would be amazed at how often the Foley catheter appears unbeknownst to the primary physician responsible for the patient’s care and how often they are placed without legitimate medical indication. They often get put in for measuring I&O, for incontinence, or for convenience. Very often they are put in either in the emergency room or perioperatively or ordered by a covering physician who will never see that patient again. So years ago, we established “catheter rounds” and began putting a brightly-colored sticker on the order sheets of all patients with a Foley catheter, requiring the physician to indicate the reason for the Foley catheter and the expected duration of its use. Catheter use dropped about 50%!
It’s no laughing matter. Nosocomial UTI’s, still the most common nosocomial infection, are not only a safety issue for patients but they are also very costly to hospitals. The average additional cost for patients who develop nosocomial UTI’s is about $2000 due to increased length of stay and increased antibiotic and supply needs. So establishing systems to prevent unnecessary Foley use is not only good for your patient safety program, it is also very cost-effective.
The system you put in place can be low-tech or hi-tech. The simple colored sticker alert mentioned above was very effective. Adding lines for indication and duration to pre-printed order sheets can also be effective. For those facilities fortunate enough to have computerized physician order entry, add a new pop-up screen with these questions any time someone orders a Foley catheter.
Beware of unintended consequences, though. Your policy should not be so restrictive that patients who truly do need a Foley catheter are made uncomfortable. Alternatives to Foley catheters may include condom catheters or intermittent catheterization.
Also, be sure to include monitoring and measuring in your QI activities because the initial Hawthorne effect of implementing such a system often fades with time.
Update: See also Patient Safety Tips of the week for January 8, 2008 “Urinary Catheter-Associated Infections” and June 24, 2008 “Urinary Catheter-Related UTI’s: Bladder Bundles”, and our April 2008 What’s New in the Patient Safety World column “More Neonatal Incubator Fires, More on Nosocomial UTI’s, More on 1000-Fold Heparin Overdoses and our April 21, 2009 Patient Safety Tip of the Week “Still Futzing with Foleys?” and our June 9, 2009 Patient Safety Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”.