Jennifer Meddings, MD, MSc; Sanjay Saint, MD, MPH; Karen E. Fowler, MPH; Elissa Gaies, MD, MPH; Andrew Hickner, MSI; Sarah L. Krein, PhD, RN; Steven J. Bernstein, MD, MPH
Presented in part by poster presentations at the Society of Hospital Medicine Annual Meeting, Las Vegas, Nevada, 25 March 2014, and the Society of General Internal Medicine 37th Annual Meeting, San Diego, California, 24 April 2014. Presented in part by teleconference for the AHRQ 50-State “On the CUSP: Stop CAUTI” Collaborative on 14 January 2014 and the Veterans Affairs National Center for Patient Safety CAUTI Breakthrough Series on 18 June 2014.
Acknowledgment: The authors thank the panelists (Table 1) for their time, expertise, and enthusiasm shared for this project. They are indebted to John Hollingsworth, MD, MSc; Milisa Manojlovich, PhD, RN, CCRN; Vineet Chopra, MD, MSc; Deborah Levine, MD, MPH; Melissa Pynnonen, MD; Lena Chen, MD, MS; Jeffrey Kullgren, MD, MS, MPH; and Jim Burke, MD, MS, for detailed feedback on the development and refinement of the urinary catheter indications rating document. The authors also acknowledge the Veterans Affairs Ann Arbor Patient Safety Center of Inquiry Strategic Advisory Board, which provided recommendations regarding the types of expertise that should be represented on the panel.
Financial Support: This research was funded by the Department of Veterans Affairs National Center for Patient Safety, Ann Arbor Patient Safety Center of Inquiry, and a contract through the Agency for Healthcare Research and Quality (AHRQ) (contract HHSA290201000025I/HHSA29032001T). Dr. Meddings' effort on this project was funded by concurrent effort from AHRQ (K08 HS19767). AHRQ provided funding for the publication of this supplement.
Disclosures: Dr. Meddings reports consultancy/honorarium with the Society for Healthcare Epidemiology of America; employment with the University of Michigan Health System; grants received from AHRQ; payment for lectures/speakers' bureaus with various professional and nonprofit organizations (including Society for Healthcare Epidemiology of America, Central Society for Clinical Research, Wound Ostomy & Continence Nurses Society) and QuantiaMD; RAND/AHRQ honorarium for preparation of AHRQ Chapter update on prevention of catheter-associated UTI (payment for manuscript preparation); and travel/accommodations/meeting expenses outside the submitted work from AHRQ and Blue Cross Blue Shield of Michigan Foundation. Dr. Saint reports grants and personal fees from Department of Veterans Affairs (VA) National Center for Patient Safety and AHRQ during the conduct of the study, as well as personal fees from Doximity and Jvion outside the submitted work. Ms. Fowler reports grants and personal fees from Department of Veterans Affairs (VA) National Center for Patient Safety and AHRQ during the conduct of the study. Dr. Krein reports grants and personal fees from Department of Veterans Affairs (VA) National Center for Patient Safety and AHRQ during the conduct of the study. Dr. Bernstein reports grants from Department of Veterans Affairs (VA) National Center for Patient Safety and a contract from AHRQ during the conduct of the study. Dr. Bernstein reports grants from Department of Veterans Affairs National Center for Patient Safety from the Agency for Healthcare Research and Quality during the conduct of the study. Dr. Bernstein is a member of the Blue Care Network Clinical Quality Committee (which reviews issues related to quality of care [although urinary catheter use has not been considered in the past, it may be reviewed in the future]) and is also Director of Quality for the University of Michigan Faculty Group Practice (if the appropriateness of urinary catheter criteria developed as part of this process are widely adopted, they could be applied to the University of Michigan by outside agencies). Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1304.
Requests for Single Reprints: Jennifer Meddings, MD, MSc, University of Michigan North Campus Research Complex Building 16, Room 427W, 2800 Plymouth Road, Ann Arbor, MI 48109; e-mail, Meddings@umich.edu.
Current Author Addresses: Dr. Meddings: University of Michigan North Campus Research Complex Building 16, Room 427W, 2800 Plymouth Road, Ann Arbor, MI 48109.
Dr. Saint: University of Michigan North Campus Research Complex Building 16, Room 433W, 2800 Plymouth Road, Ann Arbor, MI 48109.
Ms. Fowler: Ann Arbor Patient Safety Center of Inquiry Hospital Outcomes Program of Excellence Initiative, VA Center for Clinical Management Research (152), PO Box 130170, Ann Arbor, MI 48113-0170.
Drs. Gaies and Krein: VA Health Services Research and Development Service (152), PO Box 130170, Ann Arbor, MI 48113.
Mr. Hickner: Cushing/Whitney Medical Library, 333 Cedar Street, PO Box 208014, New Haven, CT 06520.
Dr. Bernstein: University of Michigan North Campus Research Complex, Building 16, Room 446E, 2800 Plymouth Road, Ann Arbor, MI 48109.
Author Contributions: Conception and design: S.J. Bernstein, K.E. Fowler, S.L. Krein, J. Meddings, S. Saint.
Analysis and interpretation of the data: S.J. Bernstein, K.E. Fowler, J. Meddings.
Drafting of the article: S.J. Bernstein, E. Gaies, A. Hickner, J. Meddings.
Critical revision for important intellectual content: S.J. Bernstein, K.E. Fowler, S.L. Krein, J. Meddings, S. Saint.
Final approval of the article: S.J. Bernstein, K.E. Fowler, E. Gaies, S.L. Krein, J. Meddings, S. Saint.
Obtaining of funding: S.L. Krein, J. Meddings, S. Saint.
Administrative, technical, or logistic support: K.E. Fowler, E. Gaies, A. Hickner.
Collection and assembly of data: K.E. Fowler, E. Gaies, A. Hickner, J. Meddings.
Interventions to reduce urinary catheter use involve lists of “appropriate” indications developed from limited evidence without substantial multidisciplinary input. Implementing these lists, however, is challenging given broad interpretation of indications, such as “critical illness.” To refine criteria for appropriate catheter use—defined as use in which benefits outweigh risks—the RAND/UCLA Appropriateness Method was applied. After reviewing the literature, a 15-member multidisciplinary panel of physicians, nurses, and specialists in infection prevention rated scenarios for catheter use as appropriate, inappropriate, or of uncertain appropriateness by using a standardized, multiround rating process. The appropriateness of Foley catheters, intermittent straight catheters (ISCs), and external condom catheters for hospitalized adults on medical services was assessed in 299 scenarios, including urinary retention, incontinence, wounds, urine volume measurement, urine sample collection, and comfort. The scenarios included patient-specific issues, such as difficulty turning and catheter placement challenges. The panel rated 105 Foley scenarios (43 appropriate, 48 inappropriate, 14 uncertain), 97 ISC scenarios (15 appropriate, 66 inappropriate, 16 uncertain), and 97 external catheter scenarios (30 appropriate, 51 inappropriate, 16 uncertain). The refined criteria clarify that Foley catheters are appropriate for measuring and collecting urine only when fluid status or urine cannot be assessed by other means; specify that patients in the intensive care unit (ICU) need specific medical indications for catheters because ICU location alone is not an appropriate indication; and recognize that Foley and external catheters may be pragmatically appropriate to manage urinary incontinence in select patients. These new appropriateness criteria can inform large-scale collaborative and bedside efforts to reduce inappropriate urinary catheter use.
Overview of the RAND/UCLA Appropriateness Method.
Summary of evidence search and selection.
APIC = Association for Professionals in Infection Control and Epidemiology; CAUTI = catheter-associated urinary tract infection; CDC = Centers for Disease Control and Prevention; HICPAC = Healthcare Infection Control Practices Advisory Committee; IDSA = Infectious Diseases Society of America.
* Some references cited as references for indication lists and reviewed from bibliographies were noted to be guidelines or intervention articles already reviewed.
Appendix Table. Synthesis of Urinary Catheter Indications From the Literature
Example of clinical scenarios from the round 1 rating document.
Scenarios B1 and B2, mentioned in figure, can be found in Supplement 3.
Table 1. Characteristics of Urinary Catheter Appropriateness Panelists
Table 2. Guide for Foley Catheter Use in Hospitalized Medical Patients*
Table 3. Guide for Intermittent Straight Catheterization in Hospitalized Medical Patients*
Table 4. Guide for External Catheter Use in Hospitalized Medical Patients*
Table 5. Summary for Most Common Uses of Foley Catheters, ISCs, and External Catheters
ICU daily checklist for appropriateness of Foley catheter.
ICU = intensive care unit; ISC = intermittent straight catheter; IV = intravenous.
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Meddings J, Saint S, Fowler KE, et al. The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015;162:S1–S34. doi: 10.7326/M14-1304
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Published: Ann Intern Med. 2015;162(9_Supplement):S1-S34.
Nephrology, Urological Disorders.
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