Continuing Education Activity

Prevention of painful, traumatic Foley catheter removals and early identification of catheter mal-positioning can minimize pain, urinary tract infections, discomfort, and hematuria as well as eliminate long-term complications of urethral strictures and incomplete bladder emptying. It also allows for the early removal of the Foley catheter. Traumatic, unintended Foley catheter extractions, whether patient-initiated or accidental, can cause permanent urologic complications, affect hospital length of stay, decrease patient satisfaction grades, increase catheter-associated urinary tract infections (CAUTIs), and lower hospital quality scores. These injuries are usually managed with catheter replacement for 10 to 14 days (optimal) or with just observation. Rarely, they can cause severe, even life-threatening hematuria that may require pelvic arterial embolization to control. This activity reviews the prevention of inappropriate self-extraction of Foley catheters and highlights the role of the interprofessional team in minimizing this event.

Objectives:

• Explain why it is important to avoid traumatic Foley catheter removal.
• Describe the treatment required if traumatic Foley catheter removal occurs.
• Summarize tips on early recognition of malpositioned Foley catheters.
• Outline the prevention of inappropriate self-extraction of Foley catheters and describe the role of the interprofessional team in minimizing this event.

Introduction

Prevention of painful, traumatic Foley catheter removals and early identification of catheter mal-positioning can minimize pain, urinary tract infections, discomfort, and hematuria as well as eliminate long-term complications of urethral strictures and incomplete bladder emptying. It also allows for the early removal of the Foley catheter.[1]

Traumatic, unintended Foley catheter extractions, whether patient-initiated or accidental, can cause permanent urologic complications, affect hospital length of stay, decrease patient satisfaction grades, increase catheter-associated urinary tract infections (CAUTIs), and lower hospital quality scores. These injuries are usually managed with catheter replacement for 10 to 14 days (optimal) or with just observation. Rarely, they can cause severe, even life-threatening hematuria that may require pelvic arterial embolization to control.[2]

The following guidelines will help prevent such events by early identification of patients at risk and reasonable steps that nursing services can then initiate and perform on their own without specific physician orders. Tips on early recognition of mal-positioned Foleys are included so that these painful and potentially dangerous conditions can be identified and corrected more quickly. 

The use of a larger (30 mL) balloon Foley to minimize unintended self-extraction is controversial. While the 30 mL balloon is certainly much larger and therefore more resistant to being pulled out while inflated, it would do more damage to the urethra if a determined patient manages to extract it. Also, larger catheter balloons may be more stimulating and increase an at-risk patient's attempts to remove the catheter. For that reason, it is not routinely recommended. However, it may be reasonable to use a larger balloon initially for new suprapubic tubes.[3]

Issues of Concern

Interventions to Reduce Traumatic and Inappropriate Self-Extraction of Foley Catheters

Identify Patients at Risk

Every patient with a Foley catheter who has delirium or dementia is potentially at risk of a traumatic Foley catheter removal. This would include patients recovering from anesthesia, procedures, or sedation and particularly if the Foley catheter is new. Patients with head injuries are at particular risk. Often these patients are in the recovery room or intensive care unit (ICU) settings, but this may not always be the case. Other patients at risk include:

• Any patient with delirium or dementia, particularly an elderly nursing home patient with a recently placed Foley catheter or one who has a prior history of traumatic self-extraction of catheters.
• Patients who are constantly pulling or tugging on their Foley catheters.
• Patients with a history of agitation from brain injury, medications, or other illnesses.
• Patients admitted for mental status changes whose degree of confusion is unclear, and their tolerance of the new Foley catheter is not yet known.
• Patients with newly inserted Foley catheters who are just waking from anesthesia and may become agitated.
• Any patient being transferred where the catheter may become caught and accidentally pulled or tugged.
• Patients with a history of prior Foley catheter self-extractions.[4]

Be Suspicious of a Possible Malpositioned Catheter

• Minimal or no urine output while the bladder scan shows the bladder is full or distended despite the Foley.
• When flushed, fluid can be injected but not aspirated, cannot be injected, or simply leaks out around the Foley catheter.
• The Long Catheter Sign: In males, this refers to one-half or more of the catheter being exposed outside of the penis. Be aware that, occasionally, usually with urethral strictures,  the catheter can double back on itself, or a male patient's urethra may be exceptionally long, giving a false impression of normalcy.
• Verify Foley positioning with a bladder ultrasound if suspicious. Try readjusting or replacing the Foley if necessary.
• A simplified cystogram can also be used to check the Foley catheter position. A small amount of contrast (3 mL) is added to the Foley catheter balloon, and about 30 mL of diluted contrast is added to the bladder through the main Foley catheter lumen so both the bladder and the Foley balloon can be easily visualized on x-ray. This simplified cystogram approach can be done at the bedside, requires minimal expertise to perform, and gives a clearer image of the anatomical situation than ultrasound which will often only show the absence of the Foley balloon in the bladder. Therefore, this technique is preferred over bladder ultrasound when possible.[2][5]

Use Standard Preventive Measures

All patients with Foley catheters should include a properly placed Foley stabilization device as well as additional observation by staff if patients appear confused or agitated. Do not use a Foley stabilization device on suprapubic catheters.

Reposition the Foley Catheter Under the Thigh, Tape and Cover it

In higher-risk patients, reposition the catheter by directing it under the thigh and then taping it directly to the skin without a gap. Leave no space under the tubing or the catheter for the patient to use his fingers to grab it. Being unable to encircle the catheter and tubing makes it much harder for the patient to secure purchase on the Foley and pull it out. The catheter needs to be completely secured with tape, starting almost at the level of the meatus and continuing as the catheter is secured underneath the thigh. Then wrap a large, wide elastic bandage around the patient’s thigh, completely covering the tape and Foley catheter. TED hose or similar anti-edema leg wraps may also be used to cover the Foley catheter and tubing. These measures should obscure the majority of the Foley catheter, making it even more difficult for the patient to get his fingers under and around the catheter as both the wrappings and the tape would need to be dislodged first. This delay will often give staff sufficient time to intervene. Additional tape or a plastic roll also may be used to cover the wrap if additional security measures are desired.

Use a Diaper or Mesh Underwear with Pads

When in place, these coverings make it a little harder for patients to reach their catheters as they will have to get past the diaper and padding to grasp and pull on the Foley. This is particularly helpful when used together with the decoy catheters described below.

Add Decoy Foley Catheters

Decoy catheters are a greatly underutilized resource and are particularly useful as they are not only effective but can be immediately initiated by nurses for any patient identified as being at risk without waiting for a specific physician’s order. The decoy catheter can be taped to the upper thigh or just over the diaper and secured sufficiently to prevent easy removal with simple pulling. If it comes off too easily, the patient may lose interest and go looking for the real Foley. Benzoin or similar adhesive agents can be used to help fasten the tape and decoy catheter more securely to the skin or over their pants/diaper. Multiple decoy catheters can be used if necessary to keep confused patients occupied. This has proven to be a very simple and effective technique for protecting Foley catheters from even the most persistent patients who seem determined to pull out their Foleys traumatically.[6]

Consider Additional Preventive Measures

These include restraints, mitts, sedation, or constant monitoring with a sitter for the highest risk patients. The decision on which to use will need to be individualized on a case-by-case basis and is usually best determined by the primary attending physician or team. It is important to ask the physician if it appears that the patient is at risk for pulling his catheter out and other measures are insufficient. The benefits of the previously described techniques are that nursing staff can initiate them without any individual physician's order or input.

If Trauma, Check the Foley Balloon for any Missing Pieces or Fragments

In such situations, carefully inspect the extracted Foley and make clear documentation regarding whether the Foley balloon is fully intact. Physicians may want to examine the catheter, particularly the balloon, to determine if any pieces are missing that could still be in the bladder and might require surgical removal with cystoscopy. Such fragments left in the bladder can become calcified and eventually develop into stones.[7][8]

Clinical Significance

By instituting these measures, unplanned traumatic Foley catheter removals can be minimized:

• Identify patients at risk, especially those with new Foley catheters, delirium, dementia, agitation, mental status changes, confusion, or a prior history of traumatic Foley catheter extractions.
• Increase monitoring and observation of patients identified as being at risk.
• Pay extra attention to Foley catheters during patient transfers.
• Look for signs of a mal-positioned Foley such as high bladder residuals on bladder scan, decreased urinary drainage, low urine output, new gross hematuria, or a "long catheter" sign. 
• Use Foley stabilization devices properly. 
• In higher-risk patients, add more of the following Foley catheter security measures early.
• Secure the catheter by repositioning the Foley to pass under the patient’s thigh, then secure with tape directly to the skin without leaving any gaps and cover with a wide elastic wrap.
• Diapers and mesh underpants can be placed over a taped, secured catheter and make it even harder for confused patients to grab their catheters. May also use anti-edema stockings such as TED hose and similar.
• Use “decoy” catheters when appropriate for extra protection.
• If the Foley is pulled out anyway, check the catheter carefully to see if the balloon is intact and chart it appropriately. Keep the old catheter for examination by the physician.

Using these measures, one might expect similar results to those reported at Creighton University Medical Center in Omaha (unpublished data) where the traumatic Foley catheter extraction rate decreased from 1 or even 2 per week to almost none.[9]

Enhancing Healthcare Team Outcomes

Prevention of patient self-mutilation and injury by reducing the likelihood of traumatic Foley catheter extractions is beneficial to hospitals and patients by reducing hospital days and avoiding urological complications. This has been hampered in the past by the need for specific physician orders for either a sitter, restraints, or sedation. These precautions are costly, require a physician's order, use valuable resources better utilized elsewhere, and may not even be very effective. Making traumatic Foley removals a nurse-initiated program greatly facilitates its implementation and effectiveness. In particular, the nurses liked using the decoy catheters and found them particularly effective, even in the most difficult cases. Newer devices have been developed for difficult catheterizations to prevent malpositioning as well.[10][11]

The key, however, is to have a collaborative interprofessional team identifying the patients at risk for a traumatic Foley removal and implementing safety measures to prevent this occurrence. A nursing-driven risk assessment for every patient on admission or after Foley catheter insertion to identify patients at high risk for inappropriate extractions and communicating these findings with the medical provider can greatly reduce the risk. Nurses and clinicians must coordinate the care of Foley catheters so that appropriate protective measures may be undertaken. The nurse can also assist the medical provider in identifying when a patient is no longer in need of a Foley catheter. Communicating this finding with the provider will lead to the early safe removal of the catheters and prevent traumatic self-extraction by the patient. An integrated interprofessional team can greatly reduce the incidence of this troublesome problem with improved patient safety, reduced urethral trauma, increased quality, and better outcomes. [Level V]