No Catheter. No CAUTI: Urine Management with External Catheters

Urinary catheters are one of the most frequently used medical devices in hospitals and long-term care facilities. With the placement of an indwelling urinary catheter, comes the potentially lurking introduction of pathogens into the urinary tract. Approximately, 75% of urinary tract infections (UTIs) acquired in the hospital are associated with a urinary catheter. Appropriate indications for indwelling catheter placement and continued use can significantly prevent morbidity and mortality in the inpatient population.

The use of external catheters in men and women is a noninvasive substitution for collecting and containing urine in patients with urinary incontinence. The 2009 CDC Guidelines for Prevention of Catheter-Associated Urinary Tract Infections recommended that “clinicians should consider external catheters as an alternative to an indwelling urinary catheter in cooperative male patients without urinary retention or bladder outlet obstruction.” These guidelines reflect that in 2009, external catheters were being recommended for physicians to consider in the male population. An update to these guidelines is anticipated to also reflect the emergence of newer external catheters that include the anatomically female population. External catheters can also be extremely beneficial to females needing a urinary management device especially since women are more prone to develop CAUTIs. There is literature available regarding the use of external female urinary catheters as alternatives to indwelling urinary catheters.

External devices can also be recommended to other patients with risk factors for developing CAUTI such as history of UTIs, the elderly, and immunocompromised patients. Remember, with no catheter, we eliminate the risk of developing a CAUTI.

External urinary management products have vastly expanded in the last few years. The traditional condom catheters were predominantly the only external catheter available to patients and were limited to the anatomically male population. The growing diversification of urinary management now includes products such as BD’s PureWick and Stryker’s PrimaFit and PrimoFit. Emerging literature and guidelines have provided a glance into external collection devices as alternatives to indwelling and suprapubic catheters for urine collection. Literature states that these devices are safe for use and promote CAUTI reduction efforts.

More literature is still needed whether these devices can measure accurate intake and outtake, some of these devices have not been fully tested to take these measurements. This should be considered in a patient’s plan of care if intake and outtake need to be strictly measured. This is a limitation to some external catheters in comparison to Foleys.

External catheters can be considered more comfortable and with less movement restriction compared to indwelling catheters. External catheters are also available for home use and can be properly placed without a physician or nurse. They can support and provide a more independent lifestyle for qualifying patients. In some facilities, these external products are predominately managed by medical/nursing assistants and techs, which can also be useful for the nursing workload.

If an infection preventionist’s (IP’s) facility uses external urinary management devices, they should consider generating data related to external device utilization for their facility’s CAUTI prevention efforts. IPs can look into their external catheter days to determine if there is a relationship between external catheter days and indwelling catheters days and CAUTIs. With an increase in external device utilization, it is expected that CAUTIs should decrease. An increase in external catheter days can indicate that alternatives to foley catheters are being considered for urinary management.

A health care facility’s urinary management protocol should include the use of alternatives to indwelling urinary catheters such as external catheters for patient candidates with urinary incontinence. If patients meet the appropriate criteria in the clinical setting to use these alternatives, it could be an option in their plan of care. Appropriate criteria for external catheters include urinary incontinence, frequent urination, difficulty walking or immobility, pressure ulcers, incontinence-associated dermatitis, and bedrest orders. More indications are provided by Agency for Healthcare Research and Quality. Contraindications should be detailed in a facility’s urinary management protocol or policy and includes urinary retention and urethral blockages. External catheters should also be used with cautions if patients have altered mental status. Skin irritation and breakdown can occur from using external catheter, primarily because of friction associated from the device or any of its adhesive. Skin integrity should be assessed before and after external catheter placement. Some external catheters also include latex; therefore, it is imperative to be aware of any allergies that a patient may have prior.

Patients and their health care teams have more options available to them for bladder care than ever before.