Wednesday, August 1, 2012

Who should place a Foley catheter?

A nurse who understandably asks to remain anonymous writes, “In our hospital, we have an increased catheter-associated urinary tract infection (CAUTI) rate related to poor skills by medical residents. The surgical nurses want to insert the caths, but the residents jump in and do not perform the skill correctly. Feedback please.”

Thanks for the interesting query. Several thoughts come to mind. I can understand a new resident wanting to learn how to perform this procedure. But after doing a few, I think that the novelty would wear off, especially at 3:00 in the morning. Also, it is likely that the nurses would be able to do it in a much more timely way.

In my current hospital, which is non-teaching, nurses place Foley catheters without incident or opposition. I don’t know our rate of CAUTI, but I doubt it is high.

You might try the direct approach and speak to the residents when they don't do it right, but unless they've read my "Hints for new residents" blog where I mention that you can learn a lot from nurses, they may become indignant.

I assume you have some data to back up your assertions that your CAUTI rate is high and can document that the residents are not doing it correctly. Having dealt with teaching hospital politics for many years, I suggest the following to you.

Speak with your nurse manager and the nurse who does clinical education and tell them what the specific problems are. For example, are the residents not adhering to sterile technique? Are they not following the steps properly?

The nurse manager and clinical specialist should talk to your infection control nurses and their supervising physician, who should then discuss the matter with the residency program director. This will keep you out of the line of fire and not jeopardize your relationship with the residents.

This process is good way to handle any sort of conflict. In the military, it is known as following the chain of command.


  1. The rate of UTIs is always higher than expected (just read through the results of the SiSTER trial). Hospitals are always going to have more UTIs than in the community and having a Foley in any setting, but particularly in a hospital, is asking for this infection. I'm not aware of any data that endorses technique as a major contributor to UTI acquisition. Recall lots of folks do intermittent catheterization using 'clean' technique and do not, by and large, have problems with UTIs. A resident doing a 'bad' job of inserting a Foley is not likely to be so 'bad' as to not essentially mimic the technique of clean intermittent catheterization. The difference being that the later is more likely indwelling while the former is 'intermittent.' A hospitalized patient, needing a catheter, is already at risk for developing a UTI. The incremental impact of 'bad' technique on UTI acquisition seems unlikely to be high. The best defense against CAUTI is to get the "C" out as soon as possible.


    1. Agree. In fact the only "bad" job I've ever encountered with a foley was actually done by a nurse. She forgot that, "once you think you have it in you should still push it in a few more inches (it'll just coil up and the extra will slide back out once the bulb is inflated)" and prematurely inflated the bulb in a 3 year old's urethra (not cool).

    2. Thanks for the comments. I agree with both. My experience is that once you teach a nurse or a PA to do something, they usually to it well. There will always be exceptions.