Review of difficult foley catheterization: Why the use of Coudé catheters are not standard nursing protocol

Abstract

Difficult and traumatic urethral catheterizations are common consultations among urologists. Traumatic catheterizations lead to patient morbidity and increased healthcare costs. Coudé tip catheters were initially created in the 18^th and 19^th century and are used for difficult catheter insertion, mostly in males with enlarged prostates. We designed a prospective study to implement a protocol at our institution for catheterizations; however this was declined due to the inclusion of Coudé catheter use by nursing staff. This opinion review aims to summarize current protocols to combat difficult Foley catheter insertions and future implementation of protocols for healthcare providers. This study will highlight the current literature of managing difficult Foley catheter insertions and the impact this poses on healthcare costs for the hospitals and the patients. There is more research needed surrounding nursing and provider education when addressing difficult catheterization. Through continued urologic research and protocol implementation, there will ideally be more studies published surrounding catheter troubleshooting. One such solution will ideally be a more standard and accepted use of Coudé catheters. Multiple quality improvement projects have been published surrounding the education of nurses with placement of Coudé catheters. Our survey-based pilot study showed a need for a protocol and education regarding catheterizations for nurses at our institution. Subsequently, a retrospective study at our institution found that majority of consultations for difficult urethral catheterizations did not require urology consultation to place the catheter. We designed a prospective study and hoped to propose a protocol for which nursing staff when difficult urinary catheters are encountered to promote improved patient care. A current protocol at our institution, states that nurses are “not approved to place Coudé catheters”. Therefore, the prospective study was declined due to inclusion of Coudé catheter placement as one option for troubleshooting difficult catheters by nurses. Overall, we find the use of a Coudé catheter as an area of interest in nursing and urological care. However, there seems to be a difference in nursing practice across institutions regarding the comfort and ability to use Coudé catheters. We hope this discussion can continue to bring education and decreased patient cost and morbidity through quality improvement.

Key Words: Healthcare costs; Urinary catheterization; Coudé catheter; Urethral injury; Quality improvement; Education

Core Tip: Difficult and traumatic urethral catheterizations are common consultations among urologists. Coudé tip catheters were initially created in the 18^th and 19^th century and are used for difficult catheter insertion, mostly in males with enlarged prostates. Multiple quality improvement projects have been published surrounding the education of nurses with placement of Coudé catheters. Overall, we find the use of a Coudé catheter as an area of interest in nursing and urological care. However, there seems to be a difference in nursing practice across institutions regarding the comfort and ability to use Coudé catheters. We hope this discussion can continue to bring education and decreased patient cost and morbidity through quality improvement.

INTRODUCTION

A common consultation to the urology service in a hospital setting is for a difficult Foley catheter insertion. Urinary catheters can relieve bladder outlet obstruction, urinary retention and provide adequate drainage in the setting of neurogenic bladder[1]. In male patients, a difficult Foley insertion is usually secondary to an anatomic or structural abnormality. The most common culprit is an enlarged prostate leading to difficulty with standard Foley catheter insertion. Coudé tip catheters were initially created in the 18^th and 19^th century and are used for difficult catheter insertion in men with enlarged prostates[2]. In general, Foley catheterization is a very common procedure, with 10%-25% of hospitalized patients undergoing catheterization[3]. Successful management of catheter insertion depends on a careful urologic history, review of systems, and physical examination[1]. In some cases, a risk prediction model can be used to predict difficult Foley catheterizations and when to use specific urologic instrumentation[4]. With continued failed attempts at successful catheterization, there may be a risk of traumatizing the urethra. The most common areas of urethral injury are the bulbous and posterior urethra. These are usually caused by forceful catheterization as well as improper balloon inflation within the urethra[5,6]. Complications of this may include future development of urethral strictures[7] as well as a risk of infection[8], bladder distension, permanent scarring, and prolonged hospitalization[9]. This translates to an associated healthcare cost of iatrogenic urethral injuries translates to $371790 (US Dollars) per patient in some studies[10]. Urology consultation is ordered when a Foley catheter is difficult to insert based on nursing and other provider evaluation. Studies report an average of 1.6 Foley catheter attempts by healthcare providers prior to urology consultation[6]. Urologists may be able to insert the Foley with additional surgical training techniques or different Foley catheter types when prior placement is unsuccessful. When assessed by urologist, most difficult catheterizations in male patients can be resolved with the use of different catheter types such as a Coudé tipped catheter. In this case, prior studies show the most common approach to a difficult catheter among urology residents is the use of a Coudé catheter[11]. Otherwise, procedures such as cystoscopy or suprapubic tube insertion will be needed to be performed by a trained urologist to place the Foley catheter[12]. However, most consultations can be successfully managed without special interventions or maneuvers required by a trained urologist[13].

Overall, Foley catheter placement is commonly performed by nurses and other healthcare providers in hospitalized patients. However, education for nursing surrounding difficult urinary catheter insertion is sparse[14]. Based on our institutional experience, Foley catheters are usually placed and triaged by either nursing staff or the urology service. Educational sessions for all healthcare providers should be implemented to assist with the placement of routine Foley catheters. This will ideally improve patient outcomes and decrease healthcare costs and consultation burden[10,15]. Being able to train nursing staff on Coudé catheter placement may improve burden to urology healthcare and be able to improve use of healthcare resources[16]. Specific research regarding specialty catheter use such as a Coudé is needed and not otherwise present in the existing literature. There are differences across institutions and policies that may limit the ability of nursing staff to troubleshoot difficult catheterization. Nursing protocols that are implemented to improve traumatic catheterization outcomes may lead to a decreased incidence of urethral injuries in patients. This is highlighted in prior studies where protocols that combine education programs and catheter insertion algorithms showed a reduction in catheter trauma and subsequent required procedures[17].

At our institution, we first investigated this topic through a retrospective study, as education at our institution surrounding catheterization was lacking. This study reviewed consultations placed to the urology service for difficult and traumatic catheterizations. The study found that most consultations were able to be triaged without the need for urological procedures. Patients with a history significant for difficult catheterizations and those who had multiple catheter attempts prior to urological evaluation were more likely to be a true difficult catheterization[18]. The findings of this study conclude that either a lack of education or improper technique led to more difficult catheterization consultations. From the findings of this study, we proposed a protocol in which nursing staff and clinicians will have education and algorithms available when triaging difficult catheterizations, especially in male patients. This would ideally translate to improvement in healthcare costs by having less traumatic catheter insertions and the complications that result.

We designed a prospective study to implement this protocol. A current hospital protocol at our institution, states that nurses are “not approved to place Coudé catheters”. Therefore, the prospective study was declined due to inclusion of Coudé catheter placement as one option for troubleshooting difficult catheters by nurses, especially for the use in male patients. This is similar to other institutions where nurses are not trained with Coudé catheter insertion[19], thus emphasizing a need for further research and outreach in this area.

This opinion review aims to summarize current protocols to combat difficult Foley catheter insertions and future implementation of protocols for healthcare providers. This study will highlight the current literature of managing difficult Foley catheter insertions and the impact this poses on healthcare costs for the hospitals and the patients. There is more research needed surrounding nursing and provider education when addressing difficult catheterization. Through continued urologic research and protocol implementation, there will ideally be more studies published surrounding catheter troubleshooting. One such solution will ideally be a more standard and accepted use of Coudé catheters. We hope to address the current evidence on how to improve patient outcomes and training surrounding catheter insertion techniques. This study will add to the existing literature surrounding catheterization to improve patient care through exploring standard protocols, education and the use of Coudé catheters across institutions.

WHAT IS A COUDÉ CATHETER AND WHEN IS IT USED?

In 1836, Louis Auguste Mercier invented the Coudé catheter. This catheter is curved at the tip to minimize the risk of urethral injury when inserted in male patients[2] (Figure 1). In our experience, the hospital nursing staff is usually first to evaluate and attempt Foley catheter placement in patients for a range of clinical indications[14]. Insertion of a Coudé catheter is ideally used to negotiate the acute angle of the prostatic urethra in cases of benign prostatic hyperplasia, incorrect technique cases and the anxious patient[20]. The standard Foley catheter insertion kits come equipped with a 16-Fr latex or silicone catheter. These kits are used for the general Foley catheter insertion in male and female patients. If the first attempt at Foley catheterization is unsuccessful, providers should use a Coudé catheter in the next attempt in a male patient[6]. Urology is usually consulted in the setting of a difficult catheter or traumatic catheter insertion. If Foley catheters can be successfully placed prior to consult to the urology service, the patients will avoid multiple catheter attempts and ideally a reduction in urethral trauma and associated healthcare costs. As shown in our retrospective study, those patients with a history of difficult Foley placement were more likely to require urology consultation for catheter placement[18]. When a catheter is needed for a patient, the nursing team will attempt insertion with a standard catheterization tray. If an initial catheter attempt is unsuccessful, an additional attempt can be made by a different nurse however other tools may be required. For example, if the patient is an older man with a history of an enlarged prostate, a Coudé catheter can be used for successful placement. If there is return of blood after catheterization or additional catheter attempts are unsuccessful, urology consultation is warranted. The use of Coudé catheters, can be used by healthcare providers to better triage difficult catheter scenarios, especially in older male patients.

Figure 1 Example of a Coudé Foley catheter. This catheter is curved at the tip to minimize the risk of urethral injury when inserted in male patients. Insertion of a Coudé catheter is ideally used to negotiate the acute angle of the prostatic urethra in cases of benign prostatic hyperplasia, incorrect technique cases and the anxious patient[30].

WHY ARE COUDÉ CATHETERS DIFFICULT TO USE AND IMPLEMENT?

Although Foley catheterization is a routine procedure, improper insertion of catheters continues to increase healthcare costs. This leads to added hospitalization, interventions and complexity of patient follow up visits[5]. After institutional analysis, Villanueva and Hemstreet report that 41%-54% of patients requiring a urology consultation for difficult Foley insertion were managed with an 18-Fr Coudé catheter[6]. Therefore, the authors in that study conclude that incorrect technique or an enlarged prostate were the most common causes of difficult catheterization[6]. Consultations placed to the urology service for difficult Foley catheterization are often done without organ pathology and usually when improper catheter insertion technique has led to urethral injuries[6]. A prior study by Bacsu et al[13] showed that forty-one percent of consultations for difficult catheterization were classified as inappropriate by a urologist. Liu et al[21] found in their study of 81 consultations, in most cases (70%), successful catheter placement was performed by the urology resident with only a minority requiring cystoscopic (20%) placement or suprapubic tube placement (9%). Only 20% of consults required cystoscopy and 9% required suprapubic tube insertion. Therefore, most consults were managed with standard catheter insertion. We believe, based on this data, in an index patient without urological history of lower urinary tract pathology, an initial placement of a Foley catheter by the primary team or nursing staff prior to urology consultation is warranted[22].

Based on the reviewed researched discussed, the authors here conclude that the use of Coudé catheters should be taught in education for healthcare providers, especially in the hospital setting. In older male patients where Foley catheterization is difficult, the use of a Coudé catheter can be a standard option for nursing staff, with appropriate confidence and education. We believe this would lead to better patient outcomes through decreased catheter attempts and decrease burden to the urology consultation service. Institutions have different polices for catheter types used across different states and countries to treat patients who require catheterization. The authors here conclude that with improved education and training, nursing and other medical staff can be equipped to use these catheters to treat patients during difficult catheterization scenarios.

HOW DO WE AS PROVIDERS BETTER UTILIZE CATHETERIZATION PROTOCOLS?

Implementation and creation of protocols require multidisciplinary and institutional support for providers. To avoid iatrogenic complications from catheterization, further improvements in catheter training protocols are needed. This may additionally improve patient morbidity and health care costs from urethral catheter injuries[6].

Protocols and infrastructure exist to allow for nursing care teams to learn catheter triage and proper insertion in difficult scenarios. Laborde et al[23] reported on a nurse-driven protocol for Foley catheter usage that decreased the overall catheter associated trauma to 0.97 per month. Overall, this study showed that nurse driven protocols can decreased catheter trauma after implementation. Some studies, such as one by Hackett et al[24], have recommended a rapid response nursing training program to assist with decreasing complications from catheter placement. They showed that using rapid response nurse practitioners and a 2-step training program, there was a reduction in catheter-related complications and hospital length of stay. Price and McKeon[25] examined retrospective outcomes of a difficult urinary catheter team lead by nurses. This resulted in a 92% successfully insertion rate for the nurse team. They found that a comprehensive program for a nurse team handling difficult catheters improved insertion technique, eliminated urology consults, and reduced catheter associated infections.

If appropriate nursing care and teaching is implemented, patient care can be improved through proper catheter placement and better technique. Bhatt et al[26] reported a survey-based study distributed to hospital staff regarding Foley catheter management. A majority (51%) of responders felt they needed more support with urethral catheter management as well as 64% of responders requesting changes in catheter education. This study is an additional example of catheter training needing to focus on different types of catheter and management of difficult catheter scenarios. Bhatt et al[22] additionally designed a prospective study to calculate incidence, morbidity, and costs associated with iatrogenic catheterization injury at their institution. They reviewed current forms of education and training interventions to reduce urethral catheterization injuries. They found that current forms of education and training protocols at their institution did not change morbidity or costs of urethral injuries but did decrease incidence of these complications. Improved and intense training protocols are necessary to avoid urethral injuries in patients requiring catheterization. Vigran et al[27] studied the outcomes of a 1-hour urinary catheter educational session which detailing topics such as management and troubleshooting of difficult catheters. This was shown to reduce the incidence of unsuccessful catheterization and eliminated the need for additional urology consultations. Ingram et al[28] studied incoming nursing residents at their institution who prospectively participated in a Foley catheter curriculum. Through this educational initiative between the urology department and nursing department, nursing trainees reported increase content knowledge and confidence with catheter placement that was statistically significant before and after the curriculum was implemented. This can also translate and be implemented among resident and attending physicians who are encountered with a difficult urethral catheterization. Manalo et al[29] found that among medical residents, more thorough training is needed with urinary catheterization to reduce the risk of catheter complications urethral injuries.

Therefore, protocols designed for nursing staff should focus on reducing patient morbidity and healthcare costs surrounding difficult and traumatic Foley catheterizations. There are programs that exist for nurses to use Coudé catheters in difficult catheterization cases. Prior studies suggest that the use of Coudé catheters can be taught to nursing staff to triage difficult Foley catheter insertion through proper educational channels. If a patient is an older male with baseline urinary symptoms, the use of a Coudé catheter prophylactically may improve traumatic catheter insertions by allowing for a better catheter attempt due to patient factors such as prostate anatomy. At our institution, although Coudé catheters are not listed to be used by nursing staff, we hope to continue to build educational trainings to encourage a decreased burden in consultations to the urology service and improve catheter insertion techniques. The proposed educational sessions would ideally be performed by the urology residents and staff to nursing units within the medical floor, operating room, and emergency room. The target audience would be nurses and physicians who work in these parts of the hospital. The educational training session would review step-by-step proper Foley catheter insertion techniques. Additionally, education would be given to the placement of Coudé catheters in situations, such as men with enlarged prostates, where this troubleshooting would be utilized.

CONCLUSION

Overall, we find the use of a Coudé catheter as an area of interest in nursing and urological care. However, there seems to be a difference in nursing practice across institutions regarding the comfort and ability to use Coudé catheters. We believe most difficult Foley catheter insertions at our institution can be triaged using better education and the possible use of a Coudé catheter. The authors created difficult Foley algorithms to be provided at our institution for nurses and physicians. This allows nursing staff a troubleshooting checklist when inserting a catheter in a male patient. The provider will be able to follow the steps needed for a difficult Foley in a male patient from an enlarged prostate. Based on the algorithm, if a patient is an older male with baseline urinary symptoms, the use of a Coudé catheter may improve traumatic catheter insertions by allowing for a better catheter attempt due to patient factors such as prostate anatomy, as these catheters were created for these clinical scenarios[2]. Although our prospective study was declined due to the recommendation of a Coudé catheter in the algorithms, we hope to continue education at our institution to improve patient care and comfort. From the prior research highlighted here, we believe there is a need to implement institution-specific policies to handle difficult Foley catheterizations. These may impact patient care through nurses and physicians alike but will ultimately decrease the morbidity associated with Foley catheterization. Additionally, we hope this discussion can continue to bring education surrounding catheters and decreased patient cost and morbidity through quality improvement. Within our institution, we hope to continue to build educational trainings to encourage a decreased burden in consultations to the urology service and improve catheter insertion techniques. Overall, the need and use of urology consultations will not go away as there are scenarios where these are needed. Instead, we hope that catheter algorithms and educational sessions will allow nursing staff to be better equipment with techniques for catheter placement. This discussion and research will ideally lead to better patient care and decrease morbidity from this commonly faced problem.