Prevalence and Appropriateness of Indwelling Urinary Catheters in Japanese Hospital Wards: A Multicenter Point Prevalence Study

Kohta Katayama (  pine77717@gmail.com ) International University of Health and Welfare Narita Hospital Jennifer Meddings VA Ann Arbor Healthcare System Sanjay Saint VA Ann Arbor Healthcare System Karen Fowler VA Ann Arbor Healthcare System David Ratz VA Ann Arbor Healthcare System Yasuaki Tagashira Tokyo Metropolitan Tama Medical Center Yumi Kawamura Mimihara General Hospital Tatsuya Fujikawa Mitoyo General Hospital Sho Nishiguchi Shonan Kamakura General Hospital Naomi kayauchi Mito Kyodo General Hospital Nobumasa Takagaki Nobumasa Clinic Yasuharu Tokuda Muribushi Okinawa Center for Teaching Hospitals Akira Kuriyama Kurashiki Central Hospital


Introduction
Indwelling urinary catheters are commonly used in hospitalized adults, including approximately 20% of hospitalized patients in Western countries. 1 Urinary catheter complications are also common, including catheter-associated urinary tract infection (CAUTI) with a reported prevalence of 6% of hospital-associated infections (HAIs) in the United States 2 as well as causing patient discomfort from urethral trauma, immobility, and inadvertent removal. 3 The most effective intervention to prevent both infectious and non-infectious harms is avoiding inappropriate indwelling urinary catheter use. 4,5 Limited reports on the appropriateness of urinary catheter use exist in Asia. 6 One study from Japanese intensive care units (ICUs) reported that the point prevalence of urinary catheters was 76% with only 54% of those catheters considered appropriate. 7 Urinary catheter use in Japanese non-ICU wards has not been previously studied.
We thus sought to estimate the prevalence and appropriateness of indwelling urinary catheters, and to determine the incidence of CAUTI in non-critical care units in Japanese hospitals.

Methods
This prospective study was conducted at multiple hospitals in Japan from October 2017 to June 2018. We enrolled 7 wards from 6 community hospitals. The participating hospitals included one university-a liated community hospital (Hospital A), and a variety of public (Hospitals B & C) and private (Hospitals D, E, & F) hospitals. Each participating unit had between 40 and 60 adult beds. Additional participating hospital and unit characteristics can be found in the Supplementary Appendix. Only Hospital B employed physicians specializing in infectious diseases. The ethics committee of each participating hospital approved the study protocol.
The study teams at each hospital evaluated urinary catheter prevalence through in-person bedside evaluation, appropriateness of catheter use via chart review, and CAUTI incidence at least 5 days of each week for 3 months.

Study observers -either physicians or research nurses -used the 2009 Healthcare Infection Control Practice
Advisory Committee (HICPAC) guidelines and the Ann Arbor Criteria for Appropriate Urinary Catheter Use to determine catheter appropriateness. 6,9 Indwelling urinary catheters in critically ill patients were deemed appropriate when medical staff required hourly urine volume measurement. Even in non-ICU wards, appropriate urine output monitoring by an indwelling urinary catheter was sometimes felt to be required to manage patients with electrolyte abnormalities or decompensated heart failure. Urinary catheters in patients who required prolonged strict immobilization for therapeutic purposes, such as pelvic fracture and unstable thoracic or lumbar spine, were also considered appropriate. The beside nurses were asked for their assessment of catheter indication. Study observers in all hospitals, except for Hospital C, also independently assessed the indication for every urinary catheter through medical record review.. The medical records were reviewed for orders for urinary catheter placement as well as documentation of urinary catheter presence.

STATISTICAL ANALYSES
The primary outcomes were: 1) proportion of patients in non-ICU wards with an indwelling urinary catheter; 2) proportion of patients with a urinary catheter that had an appropriate indication based on independent assessment; and 3) CAUTI incidence. We also assessed how often the urinary catheter's use was documented in the medical record, and if there was a physician order for placement of the urinary catheter. Data analysis was conducted through SAS software, version 9.4 (Cary, North Carolina).

Results
Data were assessed for 710 catheter-days over 5528 patient-days. The prevalence of urinary catheters was 13% (range: 5-19%). Table 1 lists urinary catheter utilization by hospital. One hospital (Hospital C) did not conduct an independent review of urinary catheter indication and therefore their data on catheter appropriateness were excluded. Based on the observers' independent assessment, urinary catheters were deemed appropriate in 371 of the 586 catheter-days (63%; range: 17-81%). The total incidence of CAUTI was 9.86 per 1000 catheter-days. *Independent assessment of indication by observer (i.e., research team physician or nurse) was not collected in Hospital C.
The most common indication for urinary catheter use was acute urinary retention or bladder outlet obstruction (as assessed by bedside nurses (38%) and observers (35%)), followed by need for accurate measurement of input and output in critically ill patients (19% bedside nurses, 18% observers). Common indications for urinary catheters that were deemed inappropriate included monitoring input and output in non-critically ill patients (15% bedside nurses, 12% observers) and no apparent reason for catheter use (2% nurses, 12% observers). Although urinary catheters were documented in the medical record in 91% of patients, a physician's order for catheter placement was present in only 10% of records for catheterized patients.

Discussion
Our multicenter study found that urinary catheters were present in 13% of patients, with only 63% of assessed catheter-days meeting appropriate indications for use. The prevalence of urinary catheters in this study was similar to that in the US. 1,2 Urinary catheter prevalence in our study was much lower than that reported in Japanese ICUs (76%), 8 likely due to lower acuity of illness.
The proportion of inappropriate urinary catheter use and CAUTI incidence in our study (9.86 infections per 1000 catheter-days) was higher than reports from the US (1.54-2.28 infections per 1000 catheter-days). 1 Similar to prior studies, 7 many of these inappropriate catheters either had no apparent reason for use, or were used for urine output management in non-critically ill patients. Interventions such as catheter reminders and stop orders have been reported to be effective in other countries, 5 and the same strategies may be effective in Japan.
Our study has some important limitations. While participating wards in this study represent a small sample of Japanese hospitals, these hospitals were located in various parts of Japan. Second, one hospital was unable to provide an objective assessment of urinary catheter appropriateness and was thus excluded from appropriateness calculations.
Despite its limitations, this national prospective study provides epidemiological information about the appropriate use of urinary catheters in Japanese non-ICU wards. Inappropriate use of urinary catheters is high. That a physician's order for placing the urinary catheter was present in only 10% of the patients evaluated is one key opportunity for improvement. A multimodal intervention may also help improve the appropriate use of urinary catheters in this setting, as such an approach has been successful elsewhere. 1,10 Declarations Ethics approval and consent to participate All study methods were carried out in accordance with relevant guidelines and regulations (declaration of Helsinki). This is an observational study conducted within the usual practice. Therefore, the Institutional Review Board of Mito Kyodo General Hospital has waived the informed consent from the patients (17-21). This study protocol was also

Consent for publication
Not applicable Availability of data and materials The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.