Hypothesis / aims of study
Long-term indwelling urinary catheters are often used in elderly patients with severe functional dependence in rehabilitation and chronic care hospitals, sometimes without clear indications. In such settings, urinary catheters inserted during acute hospitalization are sometimes continued without systematic reassessment of their indication. Prolonged catheterization increases the risk of urinary tract infections and other complications. This study aimed to evaluate the effectiveness of a nurse-led catheter removal pathway designed to de-implement unnecessary long-term catheterization.
Study design, materials and methods
The study consisted of three sequential phases: phase 1 (usual care), phase 2 (implementation of the catheter removal pathway), and phase 3 (pathway combined with a multidisciplinary continence care team as part of a national urinary independence program). During phase 1, only infection surveillance data were available.
This single-center retrospective cohort study included 526 hospitalized patients managed using a standardized catheter removal pathway during phases 2 and 3 between 2011 and 2023 in a Japanese rehabilitation and chronic care hospital. Before pathway implementation, decisions regarding catheter removal and post-removal management were typically made on an ad hoc basis by non-urologist physicians, primarily geriatric physicians. After implementation, the pathway—initially proposed by a part-time urologist—was carried out by geriatric ward nurses without specialist continence training, under a standardized protocol with supervision by part-time urologists (1–1.5 days per week in total). Under the pathway, nurses performed catheter removal, bladder ultrasound assessment, and protocol-based intermittent catheterization. Intermittent catheterization frequency was determined using a stepwise residual urine–based protocol. Most patients were unable to perform self-catheterization because of severe functional dependence. Nurse-assisted intermittent catheterization was generally continued for about two weeks after catheter removal unless post-void residual (PVR) decreased to <100 mL, at which point intermittent catheterization was discontinued.
Results
The median age was 83 years (40–105 years). Stroke was present in 33% of patients and dementia in 18%. The main reasons for catheterization were general deterioration (38.1%), urinary retention (22.0%), and fever (14.2%). Notably, the indication for catheterization was undocumented in nearly one-fifth of patients (19.5%). Approximately 76% of patients had indwelling catheters for ≥2 weeks and 53% for ≥4 weeks before removal. Spontaneous voiding occurred in 18% of patients on the day of catheter removal, increasing to 69% by day 3 and 84% by day 14.
Ultimately, 88% of patients achieved catheter-free spontaneous voiding despite prolonged catheterization and severe functional dependence. Catheter reinsertion was required in 12% of patients. During identical six-month observation periods across implementation phases, febrile urinary tract infections were observed in 14 cases before pathway implementation, compared with 3 and subsequently 1 case in later phases.
Interpretation of results
These findings suggest that bladder function can recover in many functionally dependent elderly patients even after prolonged indwelling catheterization. Immediate catheter reinsertion after failure to void may therefore be unnecessary in many cases if intermittent catheterization and bladder monitoring are appropriately performed.