Quality

10 Things Urologists Think Hospitalists Should Know


 

10 Things Urologists Think Hospitalists Should Know Dr. Danella

10 Things: At A Glance

  1. Take out urinary catheters as soon as possible.
  2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
  3. Beware certain types of medications in vulnerable patients.
  4. Don’t discharge patients who are having difficulty voiding.
  5. Broach sensitive topics, but do so gently.
  6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
  7. Diabetic patients require extra attention.
  8. Practice good antibiotic stewardship.
  9. Determine whether the patient can be seen as an outpatient.
  10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.1

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”2

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.3

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”


Tom Collins is a freelance writer in South Florida.

Catheters: More than Meets the Eye

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says. —Thomas R. Collins

References

  1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
  2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
  3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
  4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

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