Research: The Prevalence and Implications of Foley Catheter Dependent Loops

Full text

SOURCE: FOLEY, F. E. B. (1 9 3 7). A SE L F -
R E TA I N I N G B A G C AT H E T E R FO R U S E A S A N
I N D W EL LI NG C AT H E T E R FO R C O NS TA N T D RA I N AG E
O F T H E B L A D D E R . J UROL, 38, 1 4 0- 3.
THE PREVALENCE & IMPLICATIONS OF
FOLEY CATHETER DEPENDENT LOOPS
PHIL WUTHIER, RN BSN OCN BS/MSME PE

L A ND M AR K S T UD I E S :
A P R OS PE C TI VE S T UD Y OF PAT HO GE N ES IS O F CAT HE T ER -
ASSO CI AT ED U RI NARY TRAC T I N FE CT I ON S
T A M B Y A H P . A . , H A L V O R S O N , K . T . , & M A K I , D . G . ( 1 9 9 9 ) . M A Y O C L I N P R O C . 7 4 ( 2 ) , 1 3 1 -
136.
Researchers Conclusions:
INTRALUMINAL CONTAMINATION still an important avenue of transmission in spite of the nearly
universally utilized “closed catheter system” (since mid 1960’s)
GREATEST DANGER OF CAUTI: silent bacteriuria provides a huge reservoir of antibiotic
resistant organisms in the bladder
34% INTRALUMINAL: mean 7.9 days (SD=8.0) Presumed Cause:
* breaks in closed system or reflux of urine
* mechanism of transmission -- unstated
BACTERIURIA RESULTS:
66% EXTRALUMINAL in Origin: Cause:
EARLY OCCURENCE mean 1.0 day (SD=0) * non-aseptic insertion
LATE: mean 6.3 days (SD=5.0) * mucous film (biofilm) growing and
ascending outside of catheter
1,497 newly catheterized patients - 235 cases (15.7%) of new-onset bacteriuria found
Daily urine sample taken from catheter bag and patient bladder
90% of bacteriuria cases were asymptomatic

F O L L O W U P D I S CU SS I O N I N L I T ER AT UR E :
I N T RA LU M I NAL B A C TE RI U R I A:
A N O N- B I OFI L M D RI V E N R OU T E O F T R A NS MI S S IO N
( M A K I , D . G . 2001)
I D E NT I F I ED O R G AN I S M S CO NS I S TEN T WI TH C O NTA M I NAT I O N
F R O M T HE H A ND S OF H E A LT H C A R E W O RKE R S
( S H U M A N & C H E N O W E T H , 2 0 1 0 )
Exact Mechanism of Intraluminal Transmission: not formally identified in
literature.
S U M M ARY S TATE M E N T I N 20 0 9 I NT E R N ATI O N AL C L I NI CA L
P R AC TI C E G UI D E L I NE S F R O M T H E I N F E C TIO U S D I SE AS ES SO C I ETY
O F AM E R ICA :
“ B O T H A N I M A L A N D H U M A N S T U D I E S H AV E D E M O N S T R AT E D T H A T
B A C TE RI A T HAT E N TE R TH E DR A I NAG E BAG AR E S O ON FO U N D IN
T H E B L A D D E R ” ( H O O T E N , E T A L . , 2 0 1 0 , P . 6 3 4 )

L A ND M AR K S T UD I E S :
RI SK FACTO RS F OR CAT HE TER - ASSO CI AT ED U RI NARY
TR AC T I NF E CT IO NS: A PR OS PEC TI VE ST UD Y
SH OWI NG TH E M IN IMAL EF FE C TS O F C ATH E TE R C AR E
VI OLAT IO NS O N T HE RI SK OF C AU TI .
M A K I , D . G . , K N A S K I N K I , V . & T A M B Y A H , P . A . ( 2 0 0 0 ) . I N F E C T I O N C O N T R O L A N D
H O S P I T A L E P I D E M I O L O G Y , 21( 2 ) , 1 6 5 .
CURRENT SUMMARY:
2012 published review of the current study-based directives on reducing CAUTI:
“ALL GUIDELINES AGREE THAT ENSURING DEPENDENT DRAINAGE SIGNIFICANTLY
REDUCED THE RISK OF CAUTI (THE DRAINAGE TUBING SHOULD BE BELOW THE LEVEL
OF THE PATIENT’S BLADDER BUT ABOVE THE LEVEL OF THE COLLECTION BAG)”
(Tambyah & Oon, 2012, p. 368)
RESULTS:
“THE ONLY CATHETER-CARE VIOLATION PREDICTIVE OF AN INCREASED RISK FOR
CAUTI WAS THE DRAINAGE TUBE SAGGING BELOW THE LEVEL OF THE COLLECTION
BAG.”
(Maki, Knaskinki & Tambyah, 2000, p. 165 )
850 newly catheterized patients - 158 (18.6%) developed bacteriuria
Purpose: Evaluation of Impact of nursing interventions & mistakes
Daily urine samples; daily research nurse evaluation of catheter care

Air-Lock Evaluation:
Assertion: A dependent loop (A-C) of greater than 18 cm in depth cannot be overcome by a
catheterized bladder.
Probable Air-lock defined as dependent loop depth >18 cm,
and fluid not cresting at the bag (A>B)
Possible Air-lock defines above, except fluid cresting (A=B)
Cause: Entrapped column of air
D E P E N D E N T L O O P S : S T U D Y P R E L I M I N A R Y D E T A I L S
TY PE 1: GREAT ER P ROXIMAL PRESS URE
N O T E : DI M E N S I ON B H I GH E R TH A N D
( D I M E N S I O N S T O F L O O R L E V E L )
IMPEDED OR ARRESTED FLOW

Cause: Blocked Catheter Tip Openings AND Entrapped column of air
D E P E N D E N T L O O P S : S T U D Y P R E L I M I N A R Y D E T A I L S
TY PE 2: REDUCED PROXIMAL PRE SSURE
N O T E : DI M E N S I ON D HI GH E R TH A N B
( D I M E N S I O N S T O F L O O R L E V E L )

D E P E N D E N T L O O P S : S T U D Y P R E L I M I N A R Y D E T A I L S
“F ” : T H E 6 TH ME ASU RE D DIM EN S IO N: AIR -URIN E INTERFAC E

P E N RO SE H O SP I TAL DEP E N DEN T L OO P O BSE RVAT I ON A L S TU DY
2015
Research Question: On two given audit days at the 244 bed hospital in question, what is the
prevalence of indwelling catheter dependent loops, and what can be concluded about the impact of
dependent loops on impeded urine flow?
Sample Characteristics (N = 78)
Data collected on 55 of 78 patients
Nursing Dept.
Review / Approval IRB Approval Coordination with
Audit Team Patient Consent
METHOD:
Audit
DAY 1
Audit
DAY 2
Overall
Percentage
Patients
Evaluated
29 26 70.5%
Refusal of
Consent
3 2 6.4%
Unable to
Consent
6 8 18.0%
Off unit
4 0 5.1%
TOTAL
42 36

P E N RO SE H O SP I TAL DEP E N DEN T L OO P O BSE RVAT I ON A L S TU DY
2015
28 cases (58.3%) stable Type 1 configuration
14 (29.2%) stable Type 2
4 (8.3%) no pressure differential
2 (4.4%) unstable
SUMMARY POINTS OF STUDY
48 of 55 examined catheters (87.3%) had dependent loops
Type 1 Dependent Loops
Average 11.0 cmWC pressure differential
Probable cases of air lock: 3
Possible cases of air lock: 9
Type 2 Dependent Loops
Average 17.9 cmWC pressure differential
Probable cases of air lock: 14
Dimension “F”: 61.8% of cases had the urine-air interface downstream of transitional
fitting sample port

P E N RO SE H O SP I TAL DEP E N DEN T L OO P O BSE RVAT I ON A L S TU DY
2015
CONCLUSIONS / IMPLICATIONS:
* Results given credence to anecdotal experience of nurses:
Dependent loops are very common
& difficult to avoid consistently over time
* Further work needed: hypothesis of 18 cmWC maximum catheterized
bladder pressure
* 3 Outliers: 3 of 28 Type 1 dependent loops had pressure differentials
> 18 cmWC (19, 21, 27 cm)
* Clinical Staff: keep dependent loops under 18 cm in depth & provide careful
protection of the catheter bag
* Complete & continual elimination of dependent loops may not be a
realistic clinical goal

PR OPO SE D I NN OVATIO N: E LI MIN ATE D EP END EN T LO OP S
Stoller, M., & Garcia, M. (2005). U.S. Patent Application 11/251,560.

PR OPO SE D I NN OVATIO N: E LI MIN ATE D EP END EN T LO OP S
Tomes, J. E., Zyburt, S. C., Burgess, J. E., & Kutsch, J. H. (2011). U.S. Patent Application
13/009,613.

PR OPO SE D I NN OVATIO N: E LI MIN ATE D EP END EN T LO OP S
Lampotang, S., Gravenstein, N., Schwab, W. K., Lizdas, D. E., & Enneking, F. K.
(2011). U.S. Patent Application 13/821,611.

PR OPO SE D I NN OVATIO N: E L I M I N AT E T H E “ P O W E R ” O F
DE P EN DE NT LO OP S
Moghe, A. K., Elliott, C., & Patel, H. A. (2013). U.S. Patent Application 13/951,781.
VENTED TRANSITIONAL FITTING

PR OPO SE D I NN OVATIO N: E L I M I N AT E T H E “ P O W E R ” O F
DE P EN DE NT LO OP S
Wuthier, P. (2014). U.S. Patent Application 14/532,728.
CLOSED SYSTEM INTERNAL VENT

SUMMARY AND QUESTIONS

References
Barford, J.M.T., & Coates, A.R.M. (2009). The pathogenesis of catheter-associated urinary tract infection.
Journal of Infection Prevention, 10(2), 50-56.
Bi, Q.C., & Zhao, T.S. (2001). Taylor bubbles in miniaturized circular and noncircular channels. International
Journal of Multiphase Flow, 27(3), 561-570.
Danek,G., Gravenstein, N., Lizdas, D.E., & Lampotang, S. (2015). Prevalence of dependent loops in urinary
drainage systems in hospitalized patients. Journal of Wound, Ostomy and Continence Nursing, 42(3), 273-278.
Feneley, R.C., Kunin, C.M., & Stickler, D.J. (2012). An indwelling urinary catheter for the 21st century. BJI
International, 109(12), 1746-1749.
Foley, F. E. B. (1937). A self-retaining bag catheter for use as an indwelling catheter for constant drainage of the
bladder. J Urol, 38, 140-3.
Funada, T., Joseph, D.D., Maehara, T., & Yamashita, S. (2005). Ellipsoidal model of the rise of a Taylor bubble in
a round tube. International Journal of Multiphase Flow, 31(4), 473-491.
Garcia, M.M., Gulati, S., Liepmann, D., Stackhouse, G.B., Greene, K., & Stoller, M. L. (2007). Traditional Foley
Drainage Systems – Do they drain the bladder? Journal of Urology, 177(1), 203-207.
Gibson, A. H. (1913). The motion of long bubbles in a vertical tube. Philosophical Magazine, 6(26), 952-965.
Hooten, T.M., Bradley, S.F., Cardenas, D.D., Colgan, R., Geerlings, S.E., Rice, J.C., … Nicolle, L.E. (2010).
Diagnosis, prevention, and treatment of catheter-associated urinary tract infections in adults: 2009 International
Clinical Practice Guidelines from the Infectious Disease Society of America. Clinical Infectious Disease. 50(5),
625-663.
Maki, D.G. (2001). Engineering out the risk of infection with urinary catheters: revisiting the issue. Infection
Control Resource, 3(2), 3-7.

References
Maki, D.G., Knaskinki, V. & Tambyah, P. A. (2000). Risk Factors for catheter-associated urinary tract infections: a
prospective study showing the minimal effects of catheter care violations on the risk of CAUTI. Infection Control
and Hospital Epidemiology, 21(2), 165.
Maki, D.G., & Tambyah, P. A. (2001) Engineering out the risk for infection with urinary catheters. Emerging
Infectious Diseases, 7(2), 342-347.
Schwab, W. K., Lizdas, D. E., Gravenstein, N., & Lampotang, S. (2014). Foley drainage tubing configuration
affects bladder pressure: a bench model study, Urologic Nursing, 34(1), 33-37.
Shosho, C.E. & Ryan, M.E. (2001). An experimental study of the motion of long bubbles in inclined tubes.
Chemical Engineering Science, 56, 2191-2204.
Shuman, E.K., & Chenoweth, C.E. (2010). Recognition and prevention of healthcare-associated urinary tract
infections in the intensive care unit. Critical Care Medicine. 38(8), S373-S379.
Tambyah P.A., Halvorson, K.T., & Maki, D.G. (1999). A prospective study of pathogenesis of catheter-associated
urinary tract infections. Mayo Clin Proc. 74(2), 131-136.
Tambyah, P. A., & Oon, J. (2012). Catheter-associated urinary tract infection. Current Opinion in Infectious
Diseases, 25(4), 365-370.
Referenced U.S. Patent Application Publications:
Lampotang, S., Gravenstein, N., Schwab, W. K., Lizdas, D. E., & Enneking, F. K. (2011). U.S. Patent Application
13/821,611.
Moghe, A. K., Elliott, C., & Patel, H. A. (2013). U.S. Patent Application 13/951,781.
Stoller, M., & Garcia, M. (2005). U.S. Patent Application 11/251,560.
Tomes, J. E., Zyburt, S. C., Burgess, J. E., & Kutsch, J. H. (2011). U.S. Patent Application 13/009,613.
Wuthier, P. (2014). U.S. Patent Application 14/532,728.

I WOULD WELCOME
FURTHER DISCUSSION OR
QU ESTIO NS …
PHILWUTHIER@YAHOO.COM
Be on t he l o ok ou t i n Fe br u ar y 2 0 1 6? ? ?:
Wu t h i er, P. E . , Su b le t t, K . L ., & R i eh l , L. ( 20 1 6) . Ur in a ry
ca t he t e r d ependent loops as a potential contribution cause
of b a ct e ri ur i a – a n o bs er v at io n al s tu d y. U r ol o gi c Nu r si n g

ADDENDUM: Quick “Engineering Talk:”
Dimensionless Parameters for Defining Flow in Small Diameter Tubing
Eo = ∆ρ g d2 / σ (Eӧtvos Number)
EO < 40 surface tension effects dominate: impeded liquid flow &
“pseudo-stable” conditions sometimes occur
Critical Eo = 3.37 there exists a minimum diameter below which an air bubble will not rise
under gravitational / buoyancy forces alone
(Funada, T., Joseph, D.D., Maehara, T., & Yamashita, S. (2005)
Catheter tip internal diameter < critical value
Drainage tube diameter > critical value
IMPLICATION: The diameter change at the transitional fitting provides a natural barrier
against reflux flow – but can be overcome when a pressure differential is applied across it.