Secondary Logo

Journal Logo

Continence Care

Interventions Post Catheter Removal (iPCaRe) in the Acute Care Setting

An Evidence- and Consensus-Based Algorithm

Gray, Mikel; Beeson, Terrie; Kent, Dea; Mackey, Dianne; McNichol, Laurie; Thompson, Donna L.; Engberg, Sandra

Author Information
Journal of Wound, Ostomy and Continence Nursing: November/December 2020 - Volume 47 - Issue 6 - p 601-618
doi: 10.1097/WON.0000000000000704
  • Free

Abstract

INTRODUCTION

While prevention is a core value of nursing and WOC specialty practice in particular, it was not an historic focus in the acute care setting that traditionally focused on management of acute and critically ill patients; specifically a concurrent emphasis on prevention of avoidable. In this context, a focus on adverse consequences of care in the acute setting was lacking.1,2 In 2006, the Centers for Medicare & Medicaid Services (CMS) announced an initiative to reduce or eliminate the frequency of hospital-acquired conditions sustained during the delivery of acute or critical care. This announcement led to the identification of “never events,” defined by the CMS as serious and costly hospital-acquired conditions attributable to medical errors that should not happen; catheter-associated urinary tract infection (CAUTI) was identified as one of the original 8 never events, along with higher stage (full thickness) pressure injuries and falls/trauma.2,3

Research indicates approximately 62,700 CAUTIs occurred in US hospitals in 2015.4 Collectively, urinary tract infections (UTIs) account for approximately 9.5% of hospital-acquired infections and 75% of these are associated with presence of an indwelling urinary catheter.4,5 Fortunately, fewer than 5% will experience bacteremia but the mortality rate among those who develop urosepsis is 10%. Multiple organizations and societies have produced guidelines or tools for prevention of CAUTI in the acute and critical care settings.6–9 All of these resources contain a bundle of preventive interventions. While the emphasis of some interventions varies based on care setting and other factors, all include a recommendation for reducing the number of indwelling catheter days in order to reduce the risk for CAUTI that rises proportionally with every day a catheter remains in place.10 Recommendations to reduce indwelling catheter days vary, but most focus on one or more of the following strategies: (1) limit indwelling catheterization to patients with appropriate (evidence-based) indications, (2) assess patients daily for appropriateness of indwelling catheter, and (3) remove indwelling catheter at the earliest possible moment (additional research demonstrates that these strategies are enhanced via implementation of a nurse-driven protocol for indwelling catheter monitoring and removal).6–9,11 Research indicates that these preventive programs are successful; for example, a study of the incidence of hospital-acquired infections compared data from 2011 to 2015; the overall incidence of hospital-acquired infections fell from 4.0% (95% confidence interval [CI], 3.7-4.4), to 3.2% (95% CI, 2.9-3.5, P = .000).5 The greatest reductions occurred in the areas of fewer UTIs and surgical site infections. While this drop provides solid evidence supporting the efficacy of CAUTI prevention programs, clinical experience clearly demonstrates that these programs may produce unintended adverse consequences related to early indwelling catheter removal such as moisture-associated skin damage and urinary incontinence.

WOC nurses are well aware of unintended consequences of preventive interventions. For example, guidelines for prevention of ventilator-associated pneumonia (VAP) include elevation of the head for bed 30° to 45° to reduce the risk for aspiration of oropharyngeal secretions.12 While this intervention reduces the likelihood of VAP,12 it is also associated with the unintended consequence of an increased likelihood of sacral pressure injury.13 Similarly, limited evidence suggests several unintended consequences may be linked to early indwelling catheter removal; resulting in an increased risk for incontinence-associated dermatitis, pressure injury, and falls.14–16 While multiple guidelines and tools are available guiding indwelling catheter monitoring and removal, guidance for bladder and incontinence management of the patient when the indwelling catheter is removed is lacking.

In order to address this gap and guide best practice, the WOCN Society appointed a Task Force to develop an evidence- and consensus-based algorithm for acute care settings focusing on assessment and selection of effective bladder and incontinence management strategies after indwelling urinary catheter removal. This algorithm, Interventions Post Catheter Removal (iPCaRe) provides an evidence- and consensus-based clinical decision-making algorithm for bladder and incontinence management post-indwelling urinary catheter removal. The intended audiences for the algorithm are bedside (or direct care, or primary care) nurses and WOC specialty practice nurses caring for patients in the acute and critical care settings. Although not explicitly developed for these settings, we anticipate many of the actions in this algorithm may be adapted for use in the postacute care setting.

METHODS

The procedures we used to develop the iPCaRe algorithm are consistent with methods used to develop previous WOCN Society clinical decision support algorithms for clinical practice.17–19 Initially, the Society appointed a Task Force to construct of the algorithm. Given the anticipated scope and complexity of this algorithm, the Task Force comprised 6 individuals with expertise in urinary incontinence and bladder management, toileting programs, intermittent catheterization, external collection devices (ECDs), body-worn absorbent products (BWAPs), support surface selection, and absorbent underpads (M.G., S.E., T.B., D.K., D.M., and D.L.T.). Task Force members were responsible for searching the literature for evidence related to bladder and incontinence management following removal of an indwelling catheter, generation of draft consensus statements, participation as voting members of the consensus panel, development and review of the algorithm, and authorship of this article.

Procedures

The procedure used to develop this clinical support decision tool was similar to that used to develop prior algorithms.16–18 Briefly, the Task Force began with a scoping review of the literature to identify existing evidence and generate statements guiding development of the decision-making algorithm. The Task Force also developed a glossary of terms to be used in the algorithm based on currently accepted definitions from the professional literature (Table 1). This task was followed by development of “Clinical Principles” statements supported by evidence. A draft of these statements was then presented to a Consensus Panel of 20 clinical experts to achieve formal consensus about each statement. Following these steps, these evidence- and consensus-based statements underwent content validation by a second, independent and interdisciplinary group of 20 experts via electronic correspondence. We used a demanding and rigorous process in order to ensure that the content of the algorithm is supported by evidence- or consensus-based statements guiding best practice and further bolstered by a process establishing the tool's content validity. The details of each step of the procedures are described in this article.

TABLE 1. - Glossary
Bladder management program Set of interventions used to assist patients with lower urinary tract dysfunction to adequately empty the bladder and minimize adverse effects. Lower urinary tract dysfunctions include urinary retention (incomplete bladder emptying) and urinary incontinence.
Coefficient of friction (CoF) dry or wet A measure of the ratio between the force necessary to move one surface (patient's skin) over another surface (an underpad) and the pressure between the 2 surfaces.
The CoF of fabrics against the skin is mainly influenced by:
  • The nature of the fabric; rougher fabrics produce higher CoF

  • Skin moisture content, moisture vapor transfer rates (MVTR), and surface wetness, which increase the CoF and are particularly relevant in the clinical context where skin may be damp from perspiration or incontinence

  • Ambient humidity, in that high humidity may increase skin moisture content or induce sweating and therefore increase CoF

Condom catheter (sheath/Texas catheter) External urinary catheter collection device; a sheath that is rolled over the penile shaft, secured with an adhesive or nonadhesive securement method, and connected to a urinary drainage bag.
Coudé tipped catheter A catheter with a slight bend or angle in it that enhances passage through the urethra and into the bladder, sometimes referred to as Tiemann tip.
Dependent toileting The need for assistance and/or prompting from a care provider to toilet.
External collection devices A group of devices that adhere or are fitted over the external genitalia or pubic area to collect urinary output; they are divided into the following categories: condom catheters, reusable body-worn urinals, non-sheath glans-adherent devices, and suction devices.
Friction (frictional force) The force that resists relative motion between 2 bodies in contact and/or material elements sliding against each other.
Friction skin injury (Fcl) External forces applied to skin resulting in separation of skin layers. This resultant injury may be either partial or full thickness in severity.
Intermittent catheterization Intermittent catheterization (sometimes referred to as straight or in-and-out catheterization) is insertion of a catheter for the purpose of draining it of urine and withdrawal of the catheter when the bladder is emptied.
Independent toileting The ability to recognize, respond to, and act upon the desire to urinate in a socially appropriate manner.
Intermittent catheterization Repeated insertion of a catheter into the bladder to drain urine of maintain patency of a urethral stricture. Refers to catheterization via the urethral or a surgical created pathway created from the appendix or bowel.
Intertriginous dermatitis An inflammatory condition of skin folds, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation, and characterized by moist erythema, malodor, weeping, pruritus, and tenderness.
Moisture-associated skin damage (MASD) Erythema or erosion of the skin due to prolonged exposure to various bodily secretions or fluids such as urine, liquid fecal matter, perspiration, wound exudate, mucus, and saliva.
Medical adhesive-related skin injury (MARSI) Erythema or other forms of skin injury that persist for ≥30 min after removal of an adhesive device; common forms of MARSI include epidermal stripping, tension injuries or blisters, skin tears, irritant contact dermatitis, allergic dermatitis, maceration, and folliculitis.
Medical device-related pressure injury (MDRPI) Localized damage to skin and underlying soft tissue attributable to use of a medical device; MDRPIs generally conform to the pattern or shape of the device and are staged using the NPIAPa staging system.
Moisture strike-through The relative amount of liquid forced back through the top layer of an underpad, brief or pad when subjected to pressure.
Moisture vapor transmission rate (MVTR) The passage of water vapor through an underpad or support surface.
Non-sheath glans-adherent External urinary collection device that uses a hydrocolloid-based adhesive attached to the glans penis. The device attaches to tubing and a urinary drainage bag.
Strict intake and output Quantitative measurement of fluid intake by mouth, feeding tube, or parenteral routes, along with quantitative measurement of liquid output from the urinary bladder and other drainage devices. Intake and output are measured over a 24-h (daily) period; values are typically measured in mL.
Toileting program Strategy to assist the patient to the toilet (toilet, bedside commode, urinal, and bedpan) as well as assisting, as needed. This strategy may include assistance with related personal hygiene and clothing management.
Urinary continence No reported or observed involuntary loss of urine.
Urinary incontinence Complaint or observation of involuntary loss of urine, includes involuntary voiding and urine loss between intermittent catheterizations.
Urinary Incontinence management strategies Interventions used to treat or manage urinary incontinence
Wound Treatment Associate (WTA) A non-WOC-certified nurse, who has completed an educational program that focuses on providing optimal care for patients with acute and chronic wounds under the direction of a WOC specialty nurse, WOC advanced practice registered nurse (APRN), or physician.
aNational Pressure Injury Advisory Panel.

Scoping Review of the Literature

In order to identify evidence guiding bladder and incontinence management in adults following removal of an indwelling urinary catheter, the iPCaRe Task Force conducted a literature search. Given the paucity of evidence found on our initial search, the Task Force conducted a scoping rather than systematic literature review. We used the approach described by Levac and refined by Colquohoun and colleagues with the aim of identifying published evidence to guide algorithm development.20,21 Consistent with scoping review guidelines, we searched for a variety of published sources of evidence including original research studies, multiple case series, systematic reviews, integrative reviews, scoping reviews, clinical practice guidelines, and best practice guidelines. The search strategy was executed by a reference librarian (informationist) using a combination of Medical Subject Heading (MeSH) terms and free text terms provided by members of the Task Force. The search was conducted in PubMed, EMBASE, and CINHAHL. The search terms were selected to represent various options for the management of bladder function following removal of an indwelling urethral catheter (Table 2). Articles were eligible for inclusion if they were published between July 2019 and January 2000, and focused on one of the following interventions after the removal of an indwelling urethral catheter in adults (age >18 years) in acute care settings: (1) behavioral interventions, (2) intermittent catheterization, (3) absorbent underpads, (4) BWAPs, (5) ECDs, or (6) pressure-redistributing support surfaces. Articles were excluded if they were not published in English, did not report results separately for adults, or if the full-text article was not available.

TABLE 2. - Search Terms Used in Scoping Review
Intervention Search Terms
Behavioral intervention Toileting OR “toileting assistance” OR bedpans OR “bed pans” OR “bathroom equipment”
ALL should be combined with acute care and subacute care
Intermittent catheterization “intermittent catheterization” OR self-catheterization OR “self catheterization” OR (“intermittent self-catheterization”) AND (“acute care” OR hospitals* OR “critical care” OR “intensive care unit”) urinary Bladder, neurogenic; spinal cord injuries
Absorbent Underpads (underpads OR “absorbent underpads” OR “bed pads” OR “urine absorbing aids” OR “incontinence pads” OR “incontinence underpads” OR “incontinence bed pads”) AND (“acute care” OR hospitals* OR “critical care” OR “intensive care unit”)
Body-worn absorbent products “containment devices” OR “incontinence products” OR “continence products” OR “containment products” OR “absorptive products” OR “body worn absorptive products” OR “incontinence briefs” OR “adult containment briefs” OR “male guards” OR inserts OR shields OR “incontinence pads” OR “adult diapers” OR “urinary incontinence” OR “fecal incontinence” OR “containment devices” OR “incontinence products” OR “absorbent products” OR “incontinence briefs” OR “male guards” OR “incontinence inserts” OR “incontinence shields”
External collection devices (“condom catheter” OR “external collection devices” OR “urinary collection device” OR catheters OR “urinary catheterization” OR “indwelling catheters”) AND (“cross infection” OR “acute care” OR hospitals* OR “critical care” OR “intensive care unit”)
Support surfaces Support surface, urinary incontinence fecal incontinence, incontinence Bed OR mattress OR sleep surface OR support surface AND: air-fluidized, active, alternating-air/pressure, bariatric, critical care, decubitus ulcer, foam, gel, high/low air loss, integrated, interactive, interface pressure, non-powered, overlay, powered, pressure redistribution, pressure reducing/reduction, pressure relief/relieving, pressure ulcer, pressure injury, reactive, specialty bed, static air, therapeutic/therapy, tissue interface pressure, tissue tolerance, treatment of pressure ulcer, and water; prevention AND: friction, heat, humidity, microclimate, pressure, pressure ulcer, shear, friction coefficient, integrated bed system, pressure redistribution, support surface, tissue tolerance Braden Sub Scales Scores moisture/mobility, acute care, hospitalization, critical care, intensive care unit

After removing duplicates and articles not published in English, 1478 articles were retrieved for additional analysis. A 2-stage screening process was used to review articles. During the first stage, titles and abstracts were reviewed by at least 2 members of the Task Force using the eligibility criteria described earlier. Articles were only excluded at this stage if all reviewers deemed them ineligible. We excluded 1416 articles that did not meet eligibility criteria. The remaining 62 articles underwent additional screening. During this stage, the full-text article was reviewed by multiple members of the Task Force using the eligibility criteria; articles that were deemed eligible by the entire Task Force were included in the scoping review. Any conflicts were resolved by discussion. None of the reviewed articles examined interventions following indwelling catheter removal in our target populations, adults in acute and critical care settings. Consequently, all were excluded (Figure 1).

Figure 1.
Figure 1.:
PRISMA flow diagram of scoping review.

Even though the scoping literature review produced no direct evidence guiding bladder or incontinence management following indwelling catheter removal, the Task Force did use the search to compose 8 statements classified as Clinical Principles. These statements were developed from consensus statements derived from prior best practice documents or clinical decision-making algorithms, or they represented widely accepted indications, contraindications, or precautions related to diagnostic or therapeutic interventions incorporated into the iPCaRe algorithm. These statements are divided according to the various pathways of this algorithm. They were reviewed by Consensus Panel members but did not go through the rigorous consensus process used to guide decision-making in the algorithm pathways. Minor revisions suggested for clarity of 2 statements were completed, otherwise no other changes in content were deemed necessary.

Development of Consensus Statements

The WOCN Society has developed 3 algorithms and this is the first time a Task Force charged with development of an algorithm was unable to identify any direct, research-based evidence guiding at least some of the interventions or decisional nodes comprising these interactive instruments. Fortunately, the process used to construct these algorithms provides a structured alternative to the use of direct evidence, consensus-based best practice guidance. Development of draft consensus statements began with development of a rough overview of the envisioned algorithm. This was followed by discussion of the major steps in the assessment of bladder and continence in the patient following indwelling catheter removal, including the main options for bladder and incontinence management from catheter removal to hospital discharge.

In order to achieve formal consensus, a Consensus Panel of 20 clinicians with expertise in bladder and incontinence management following removal an indwelling catheter was invited to participate in a 2-day consensus conference held in Philadelphia, Pennsylvania (Table 3). In addition to WOCN Society members, panelists from other professional societies and associations with a stake in this area of care were also invited; they were the Association of Rehabilitation Nurses, Society for Urologic Nurses and Associates, and the International Continence Society. The conference was facilitated by Laurie McNichol, a skilled moderator with knowledge about bladder management in the acute care setting and extensive experience in the area of developing and validating this type of algorithm. The facilitator read each of the 8 Clinical Principle statements and an initial vote was taken to determine level of agreement with the statement. Conference participants then voted through an anonymous electronic system to accept or reject the statement as written. Acceptance required approval of 80% by those in attendance. If a statement did not reach the 80% agreement criteria, there were up to 3 rounds of moderated discussion to see whether the statement could be clarified or revised in a manner that enabled it to gain consensus. Each round was followed by electronic voting. If the statement failed to meet the 80% agreement criteria on the third round of voting, it was discarded.

TABLE 3. - Consensus Panelists and Task Force Members/Consensus Panel Participants
Name Credentials Practice Setting/Affiliation
Consensus panelists
Mary Arnold-Long
Christine Berke
Tara Beuscher
Kathleen Borchert
Jynae Clapper
Dorothy Doughty
Laurie Kennedy-Malone
Marta Krissovich
Cheryl LeCroy
Catherine Milne
Mary H. Palmer
Vittoria Pontieri-Lewis
Catherine Ratliff
Susanne Quallich
Stephanie Yates
DNP, APRN, CRRN, CWOCN-AP, ACNS-BC
MSN, APRN-NP, CWOCN-AP, AGPCNP-BC
DNP, RN-BC, GCNS-BC, ANP-BC, CWOCN, CFCN
CFCN, CNS, CWOCN
MSN, RN, CRRN
MN, RN, FNP, CWOCN, FAAN
PhD, GNP-BC, FAANP, FAGHE, FGSA
ARNP, G-CNS, CWOCN-AP, CFCN
RN, MSN
MSN, APRN, BC, CWOCN-AP
PhD, RNC, FAAN, AGSF
RN, ACNS-BC, CWOCN
PhD, ARPN-BC, GNP-BC, CWOCN
PhD, ANP-BC, NP-C, CUNP, FANNP
MSN, RN, ANP-BC, CWOCN
Private Practice/Consultant, WOConsultation, LLC, Gray, Tennessee
Outpatient, Nebraska Medicine/UNMC, Omaha, Nebraska
Assisted Living, Doctors Making Housecalls, Durham, North Carolina
Hospital, University of Minnesota Hospital, Minneapolis, Minnesota
Acute Care & Faculty, University of Minnesota Hospital, Minneapolis, Minnesota
Acute Care/Education, Emory University Hospital, Atlanta, Georgia
School of Nursing, University of North Carolina at Greensboro, Greensboro, North Carolina
Community, Port Townsend, Washington
Hospital, Virginia Commonwealth University Health, Richmond, Virginia
Private Practice, Connecticut Clinical Nursing Associates, Bristol, Connecticut
Research, University of North Carolina, Greensboro, North Carolina
Acute Care, RWJUH–Nur sing, New Brunswick, New Jersey
Acute & Specialty Care, University of Virginia Health System, Charlottesville, Virginia
Academic Urology Dept., University of Michigan, Ann Arbor, Michigan
Outpatient Clinic, Duke University Hospital Cancer Center, Durham, North Carolina
Task force members/consensus panel participants
Terrie Beeson
Sandra Engberg
Mikel Gray
Dea Kent
Dianne Mackey
Donna L. Thompson
MSN, RN, CCRN, ACNS-BC,
PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN
DNP, RN, NP-C, CWOCN,
MSN, RN, CWOCN
MSN, CRNP, FNP-BC, CCCN-AP
Indiana University Health, University Hospital, Indianapolis Indiana
School of Nursing, University of Pittsburgh, Pennsylvania
Department of Urology, University of Virginia, Charlottesville, Virginia
School of Nursing, Indiana University Kokomo, Indiana
Kaiser Permanente, San Diego, California
Division of Urogynecology, Hospital of the University of Pennsylvania. Philadelphia, Pennsylvania

RESULTS: CONSENSUS STATEMENTS AND CLINICAL PRINCIPLES

As discussed earlier, the purpose of consensus statements is to provide an outline or guidance for decision-making within the algorithm. Consensus and Clinical Principle statements were divided based on major decision-making pathways within the algorithm. They are assessment, toileting, intermittent catheterization, underpads/support surfaces, ECDs, BWAPs, and indications for referral. A patient will enter the algorithm at the point the indwelling catheter is removed (Figure 2). The first step in determining options for bladder and/or incontinence management is evaluation of the patient's ability to void spontaneously and effectively empty the bladder. The first 6 consensus statements in this section of the algorithm describe steps the nurse should take to determine voiding function immediately following catheter removal (Box 1).

Box 1.
Box 1.:
Consensus Statements: Assessment
Figure 2.
Figure 2.:
Example pages from the iPCaRe algorithm.

Assessment

Assessment strategies include allowing the bladder to fill for up to 6 hours while regularly assessing the patient for a desire to urinate and spontaneous voiding. The patient is assessed for indications of an inability to urinate such as a growing sense of suprapubic pain and discomfort. If voiding occurs, bladder volume is assessed via a portable bedside ultrasound to determine the postvoid residual volume. If the patient does not void within the initial 6 hours following catheter removal, a portable bedside ultrasound is obtained to determine intravesical volume.

Task Force members discussed a postvoid residual volume indicating the need for intermittent catheterization in considerable detail. A similar discussion occurred during the Consensus Conference. Ultimately, a statement achieved consensus indicating that a postvoid residual volume exceeding 400 mL provides a reasonable cut point for considering intermittent catheterization. Nevertheless, the final statement also includes the phrase, “or per facility protocol,” acknowledging variability in local practices concerning the cut point when a postvoid residual volume is considered clinically relevant. This statement is broadly similar to guidelines from a Consensus Panel of the American Urological Association and a report from the US Department of Health and Human Services Agency for Healthcare Research and Quality acknowledging the lack of evidence pertaining to and standardization of the residual volume that indicates clinically relevant chronic urinary retention.22,23

Discussion also focused on management of patients who do not void within 6 hours of indwelling catheter removal. While members of the Consensus Panel acknowledged that reinsertion of an indwelling catheter or intermittent catheterization after catheter removal traditionally relied upon a standardized time frame, all voiced agreement that this decision should be based on assessment of several factors: intravesical volume, the patient's desire to urinate, or suprapubic discomfort combined with the inability to urinate (nociceptive urgency). Therefore, a statement was included indicating that the patient who does not void, does not perceive a strong desire to urinate, and has an intravesical volume less than 400 mL after 6 hours should be reevaluated via portable bedside ultrasound after an additional 2 hours. An additional statement indicates that this process should be repeated every 2 hours until spontaneous voiding occurs, the patient reports suprapubic discomfort, or the intravesical volume on portable bedside ultrasound exceeds 400 mL.

For patients who are able to spontaneously void, assessment shifts to evaluation of toileting ability and urinary incontinence. A single statement asserts that evaluation of toileting ability and continence status must incorporate bladder management (spontaneous voiding, intermittent catheterization, indwelling catheter, etc) and urinary incontinence management strategies (timed or scheduled toileting, ECDs, BWAPs, etc) used prior to hospitalization. The assessment of toileting ability is based on functional status (mobility and dexterity necessary to use a toilet, bedside commode, bedpan, or urinal either independently or with assistance), and cognitive status (ability to recognize, respond to, and act upon cues to urinate in a socially acceptable manner). This assessment also incorporates the extent to which pain may interfere with toileting ability and patient preference.

The assessment of incontinence recognizes the influence of care setting and context. While traditional assessment of incontinence status in an ambulatory or long-term care setting usually includes an evaluation of incontinence type (stress vs urge or mixed incontinence), a diagnosis of incontinence in the acute and critical care settings mainly focuses on the presence of incontinence, when it occurs (daytime, nighttime, or both) and volume of urine loss with a single episode of incontinence (light vs moderate to heavy). The criteria used to assess urinary incontinence were derived from work on a previous algorithm for selection, use, and evaluation of a BWAP.19

A statement was included that patients who are unable to void spontaneously should undergo intermittent catheterization every 4 to 6 hours up to 24 hours to encourage resumption of spontaneous voiding. If the patient is unable to spontaneously void, intermittent catheterization should be initiated in consultation with a provider. Refer to the subsection “Intermittent Catheterization.”

Four Clinical Principle statements were generated that apply to the assessment pathway of the algorithm (Box 2). One statement describes conditions, such as cystic masses in the abdomen or ascites, that may compromise the accuracy of bladder volume measurement using a portable bedside ultrasound.24–28 Two other statements provide contraindications for intermittent catheterization including urethral bleeding and trauma, along with precautions for intermittent catheterization such as recent urologic or urogynecologic surgery, or genital edema resulting in difficulty with catheter insertion.7,29–31 A final Clinical Principle statement advocates intermittent catheterization rather than continued use of an indwelling catheter. This principle is implied or explicitly stated in multiple guidelines for prevention of CAUTI.22,32,33

Box 2.
Box 2.:
Clinical Principles: Assessment

Toileting

Discussion around toileting initially focused on the lack of best practice guidelines or research-based evidence for its utility in the acute care setting. The first consensus statement, supported by 100% consensus among panelists, asserts that toileting is a first-line strategy for any patient able to toilet independently or with assistance. While this type of program is routinely adopted for patients who independently toilet and are continent of urine, multiple panelists reported instances where assisted toileting programs were not adequately explored for patients cared for in acute care settings, or where toileting was deemed not feasible due to cognitive impairments or urinary incontinence. Partly based on these experiences, the Consensus Panel reached consensus on a statement indicating that patients with cognitive impairments should be considered for a toileting program if they can be safely toileted and the process does not cause them undue distress. A toileting program is particularly important for patients with impaired cognition who frequently attempt to rise from bed and toilet in response to urinary urgency leading to an increased risk for falls, and limited evidence suggests that urinary incontinence is a risk factor for falls in the acute care setting.34 Therefore, a second statement asserts that lack of incontinence episodes is not essential to a successful toileting program.

Four consensus statements addressed scheduled toileting programs (Box 3). One identified essential elements of a successful scheduled toileting program that include cueing and providing assistance to the toilet, an individualized nighttime toileting program designed to maximize sleep quality, and documentation of the program ensuring consistency of care. Other consensus statements identified goals of a successful toileting program and elements to enhance success such as mobility aides, modifications in clothing to maximize donning and doffing when urinating, individual selection of a toileting device as indicated (bedside toilets, urinals, and bedpans), and consultation with physical or occupational therapy when indicated. The scheduled toileting program consensus statements incorporate language that affirms patient dignity support as much self-care and independence as possible.

Box 3.
Box 3.:
Consensus Statements: Toileting

Support Surfaces and Absorbent Underpads

Task Force members and panelists recognized that many acutely or critically ill patients have impaired mobility and other risk factors for pressure injury. Panelists were also aware of a growing body of evidence establishing urinary or fecal incontinence and incontinence-associated dermatitis a form of moisture-associated skin damage as risk factors for pressure injury.35–37 Therefore, the Task Force designed a pathway describing selection and use of pressure-redistributing support surfaces, combined with absorbent underpads for patients at risk for pressure injury. In addition to 9 consensus statements, this pathway in the iPCaRe algorithm is based on 4 Clinical Principle statements derived from the Society's first algorithm providing guidance for selection and use of support surfaces (Boxes 4 and 5).17

Box 4.
Box 4.:
Consensus Statements: Absorbent Underpads and Support Surfaces
Box 5.
Box 5.:
Clinical Principles: Absorbent Underpads and Support Surfaces

Consensus statements recognize underpads as a first-line intervention for absorption of urinary incontinence. Three consensus statements and 1 Clinical Principle statement focus on underpad selection. The Clinical Principle statement indicates that a nurse should select an underpad with a low friction coefficient (CoF) to minimize friction and skin injury, an absorbent core that rapidly contains moisture and disseminates it through the underpad, and one that prevents moisture strikethrough. A consensus statement notes that underpads should be changed as soon as possible, and a second indicates that users should consider use of an underpad with embedded technology alerting staff to episodes of urinary incontinence. A third statement reminds users that underpads should not be used for turning or repositioning patients unless specifically designed for this purpose.

Two statements inform support surface selection in patients with urinary incontinence. A consensus statement from the Society's support surface algorithm identifies support surfaces with a low air loss feature be used for patients with a Braden Scale for Pressure Sores Risk moisture subscale score of 2 (very moist) or 1 (constantly moist). An adjunctive Clinical Principle statement reflects research demonstrating that selection of this type of support surface alleviates the deleterious effects of moisture such as urinary incontinence. An additional consensus statement advises against use of plastic-backed products placed on support surfaces with a low air loss feature because they interfere with therapeutic air flow and increase rather than mitigate humidity within the microclimate, exacerbating the deleterious effects of heat and moisture between the support surface and the patient. A Clinical Principle statement focuses on the interaction between underpad and support surface, and it alerts users to minimize the number of layers (including underpads, clothing, and bed linens) between the patient and support surface. This statement was informed by the support surface algorithm that described research indicating impaired performance of the pressure-redistributing properties of support surfaces when multiple layers are placed between the surface and the patient's skin.17 A consensus statement notes that silk-like bed linens, including sheets and reusable underpads, may be used because they have a low coefficient of friction designed to reduce friction and skin damage in patients with urinary incontinence.

Finally, 2 consensus statements were included that focus on a preventive skin care program for patients with urinary incontinence and its effect on underpad performance. One notes that moisture barrier products (also referred to as skin protectants) should be applied and removed per manufacturers' directions. A second statement asserts that users should consider the potential for an increased CoF and reduced absorbent capacity of underpads when certain topical products are applied as part of a structured skin regimen for prevention of incontinence-associated dermatitis.

External Collection Devices

The most consensus statements generated for guidance of the iPCaRe algorithm (n = 20) centered on use of ECDs (Box 6). The need for this larger number of consensus statements may be attributed to several factors; the first is a paucity of guidelines concerning use of ECDs. The Task Force's scoping literature search identified a single evidence-based review for use of these devices, but none of these studies gathered data in the acute care setting.38 In addition, an important new product category has recently been developed that includes suction with the ECD. This device is the first product to gain widespread clinical use in female patients with urinary incontinence. Nevertheless, research and guidelines concerning the clinical utility of this device, non-sheath ECDs, and urinary collection pouches are sparse.39,40 As a result of these factors, the Task Force and panelists concurred that a particularly high number of consensus-based statements were needed to describe best practices related to the use of these devices in patients with urinary incontinence following indwelling urinary catheter removal.

Box 6.
Box 6.:
Consensus Statements: External Collection Devices

Given the absence of previous guidelines related to use of these devices, the first consensus statement defined the overall indication for use of ECD in patients following removal of an indwelling urinary catheter. It states that ECD should be considered for patients who are incontinent of urine, unable to engage in a toileting program, and/or require monitoring of urine output. Similar to other devices, a second statement achieved consensus that indicated these devices should not be used for staff convenience.

Based on clinically relevant differences in genital anatomy, ECDs were divided based on anatomic sex and product category. Eight consensus statements focused on use of ECDs in males. Options for males include sheath ECD, also referred to as condom or Texas catheters, non-sheath ECD, and penis pouch, also referred to as retracted penis pouch. Two consensus statements described indications for use of sheath, non-sheath ECD, and the penis pouch. Additional statements described the procedure for cleansing and inspecting skin prior to initial application and with device changes, proper technique for applying the device, and anticipated wear time. The need to consider sizing of one male ECD product category, the condom catheter, was acknowledged to ensure containment of urine and prevent medical device-related pressure injury. In addition, 2 statements explained that men with shorter penile shafts or retracted (buried) penises should use the non-sheath ECD or penis pouch. A single Clinical Principle statement guides clinical decision-making related to this device (Box 7). It is based on an article that summarized pertinent research concerning medical adhesives and the outcome of a consensus conference for setting standards for the use of medical adhesives in WOC nursing practice including prevention of medical adhesive-related skin injury.41 This statement described the need to apply gentle warming pressure to ensure an adequate seal; this advice also applies to the penis pouch that uses a similar adhesive technology.

Box 7.
Box 7.:
Clinical Principle: External Collection Devices

Twelve statements describe indication and use of external suction collection devices for use in females. The first statement states the indication for this relatively new type of device. Additional statements described inspection of the skin and external genitalia prior to application, placement and removal of the suction device, anticipated wear time, and indications for change prior to expiration of its expected wear time. Contraindications for device use were identified, along with use of suction to baffle urine away from the body. Finally a complex consensus statement was included that describes safe and effective use of the device when the patient transfers to a bedside chair.

Since the completion of the consensus conference, a male suction collection device is commercially available in the United States. At the time this article was written, no articles concerning clinical use of the device have been published and the potential use of this device has not been described in this algorithm. Fortunately, the WOCN Society's algorithms are regularly updated and information concerning this newest suction collection device is anticipated after sufficient clinical experience is gained or research is published describing its efficacy for bladder and incontinence management following removal of an indwelling urinary catheter.

Body-Worn Absorbent Products

Clinical opinions concerning the use of BWAPs in the acute care setting have evolved over time. Research has been conducted on the use BWAP and underpads for previously continent patients in acute care settings; findings at time of hospital discharge showed an increased risk for urinary incontinence when used during hospitalization.42 As a result of this and other research, evaluating the overuse of absorbent products in the acute care setting led some facilities and clinicians to champion “diaper-free” facilities. Recently, the wisdom of this strategy has come under scrutiny. Body-worn absorbent products fulfill multiple important roles in the acute care including protecting privacy and dignity of an incontinent patient when off the unit, reducing environmental contamination from urinary or fecal incontinence, and wicking away moisture from the skin. Many facilities are now considering the selective use of BWAP based on standardized indications that are informed by current best evidence for their use in all care settings.19

The body-worn absorbent pathway in the iPCaRe algorithm contains 6 consensus statements and 2 Clinical Principle statements informed by the Society's algorithm on selection, use, and evaluation of BWAP (Boxes 8 and 9).19 Indications for the use of BWAP is defined as a patient with incontinence who cannot be managed by an ECD during ambulation, therapy, or when off-unit. Assessment for use of a BWAP is based on sex, waist or hip circumference, mobility and dexterity, patient preference, goals of care, and cognitive status. Selection of a BWAP is also based on volume of incontinence (light vs moderate/heavy pathway), and timing (daytime vs nighttime) as described in the assessment pathway. An additional statement asserts that patients with chronic urinary incontinence and a history of containment with a particular BWAP should be allowed to continue wearing the preferred product. If unavailable, the user is advised to consult with the family about providing the patient with his or her preferred product if possible. An additional statement notes that patients who wear BWAP and are engaged in a toileting program should use a BWAP that enables them to continue the toileting program. A final consensus statement indicates that when creating the hospital formulary for BWAP, the nurse should advocate for multiple product types including absorbent briefs and pull-on products, pads, shields, and male guards to meet individual patient needs and preferences.

Box 8.
Box 8.:
Consensus Statements: Body-Worn Absorbent Products
Box 9.
Box 9.:
Clinical Principles: Body-Worn Absorbent Products

Two additional Clinical Principles assert that BWAP should not be used for staff convenience and change times should not be based on routine or staff convenience. These Clinical Principles are informed by the BWAP algorithm and cross-sectional research in a group of aged adults (≥65 years) cared for in a tertiary care hospital.19,43

Intermittent Catheterization

The intermittent catheterization (IC) pathway describes a safer alternative to reinsertion of the indwelling catheter in the patient who has persistent urinary retention and does not have urethral bleeding or trauma or other conditions (Box 10). Consensus statements acknowledge that, unlike IC in the ambulatory or home care setting, IC should be completed using sterile technique. Consensus statements also describe the usual frequency of catheterization should be conducted at least every 6 hours. A second consensus statement described indications for IC use in patients with higher urine output due to heart failure, kidney failure, or high-volume fluid intake who require more frequent catheterization. The recommended catheter size (14F-16F) is identified along with advice for selecting a coudé versus straight (Nelaton) catheter (Figure 3).

Box 10.
Box 10.:
Intermittent Catheterization: Consensus Statements
Figure 3.
Figure 3.:
Straight (Nealton) and coudé catheter tips.

Additional statements describe completion of bedside ultrasound for patients who exhibit signs of bladder fullness before the next scheduled IC along with consultation with a provider about changing the schedule if indicated. A consensus statement also describes strategies for management of urinary incontinence episodes between catheterizations, and the algorithm user will be guided toward pathways describing skin care and management of urinary incontinence. A final statement reminds the user that some patients may begin to spontaneously void after several days of IC and provides guidance for transitioning these patients to an alternative program such as independent or assisted toileting with ongoing incontinence management as needed.

Indications for Referral, Coordination of Care at Discharge, and Facility-wide Implementations of iPCaRe

The iPCaRe pathway comprises 5 consensus statements that provide indication criteria for consultation with a continence nurse specialist (WOC nurse, urology nurse, and rehabilitation nurse) for coordination of care at time of discharge, and strategies to overcome potential barriers to iPCaRe implementation (Box 11). The indication for referral statements identifies possible resources in the nurse's local facility, and the various conditions that should trigger consultation. Coordination of care at time of discharge, including communication with the discharge planner, is identified as essential to ensuring a seamless care plan regarding bladder and incontinence management is enacted as the patient transitions to the community, homecare, or a postacute care setting. Specific elements of discharge planning are provided for each of the bladder and incontinence management strategies identified in the algorithm. A statement concerning overcoming potential barriers to care in this area including educational needs, financial challenges, and access to needed supplies is provided.

Box 11.
Box 11.:
Consensus Statements: Indications for Referral

CONTENT VALIDATION

After reaching consensus, all statements generated from the Consensus Conference underwent an additional review process to establish content validation using the method described by Grant and Davis.43 The Society contracted with a biostatistician Susan Serieka, PhD, who is experienced in the process of content validation to guide this step of the procedure. For this phase, an independent and interdisciplinary panel of 20 international experts and 2 alternatives with expertise in bladder management accepted the invitation to participate (Table 4).

TABLE 4. - Content Validation Participants
Name Credentials Practice Setting/Affiliation
Janice Beitz PhD, RN, CS, CNOR, CWOCN-AP, CRNP, ANEF, FNAP, FAAN WOC Advanced Practice Consultant, Rutgers School of Nursing and Cooper Health System, Camden, New Jersey
Donna Z. Bliss PhD, RN, FGSA, FAAN University, University of Minnesota School of Nursing, Minneapolis, Minnesota
Christine Wanish Bradway PhD, RN, CRNP, FAAN Professor of Gerontological Nursing, University of Pennsylvania School of Nursing and Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Sue Bruch MSN, ARNP, CWOCN Homecare, Skilled Nursing, Long term Care, Web WOC Nursing Education Program, Minneapolis, MN and Unity Point Clinic, Waterloo, Iowa
Laurie Callan ARNP, MSN, FNP, CCCN, CWCN Outpatient Clinic, Mercy One Clinton Medical Center, Clinton, Iowa
Jill Cox PhD, RN, APN-C, CWOCN Acute Care, Rutgers School of Nursing, Newark, New Jersey, and Englewood Health, Englewood, New Jersey
JoAnn Ermer-Seltun MS, RN, ARNP, FNP-BC, CWOCN, CFCN Academic and Outpatient Clinic, WEB WOC Nursing Education Programs, Minneapolis, MN and MercyOne North Iowa Wound & Continence Clinic, Mason City, Iowa
Lynette Franklin APRN, MSN, ACNS-BC, CWOCN-AP, CFCN WOC Nurse Consultant, Ontario, Canada
Brandon Gates DNP, APRN, FNP-BC, RN-BC Ambulatory Care, Roper Saint Francis Healthcare, Charleston, South Carolina
David Ginsberg MD USC Department of Urology, Keck School of Medicine of USC, Los Angeles, California
Kathleen F. Hunter PhD, RN, NP, GNC(C), NCA Professor, University of Alberta Faculty of Nursing and Glenrose Hospital, Edmonton, Alberta, Canada
Adam Klausner MD Research/Academic, Division of Urology, Virginia Commonwealth University, Richmond, Virginia
Mary F. Mahoney MSN, RN, CWOCN, CFCN Homecare, Unity Point at Home, Des Moines, Iowa
Katherine Moore PhD, RN, NP, GNC(C), NCA Professor Emeritus, University of Alberta, Canada
Debra Netsch DNP, APRN, FNP-BC, CWOCN-AP, CFCN Academic, Hospital Outpatient Clinic & Acute Care, WEB WOC Nurse Education Programs, Minneapolis, MN and Ridgeview Medical Center, Waconia, Minnesota
Denise Nix MS, RN, CWOCN Acute Care, M Health Fairview Hospitals, Minneapolis, Minnesota
Janet Ramundo MSN, RN, FNP, CWOCN Acute Care, Emory University Wound Ostomy and Continence Nursing Education Center, Atlanta, GA and Methodist Hospital in Houston, Texas
Charlene Deo Singh PhD, MSN/Ed, RN, FNP, CWOCN Acute Care and Education, The Wound & Ostomy Education Program at The Valley Foundation School of Nursing, San Jose State University, San Jose, CA and HCA Regional Medical Center San Jose, San Jose, California, UC Davis BIMSON, Sacramento, California
Janet Stoia Davis RN, CWOCN, CFCN Private Practice, Stoia Consultants, Riverside, California
Adrian Wagg MB, BS, FRCP(Lond), FRCP(Edin), FHEA (MD) Research/Academic, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada

Using the collaboration software, Smartsheet version 7.4.0.280 (Smartsheet, Inc, Bellevue, Washington), an online survey for the evaluation of the 62 consensus statements was developed and distributed to the content validation experts. The biostatistician distributed a link to the online survey via e-mail to panel members with nonrespondents being sent periodic reminders to complete the online survey. Data were analyzed using SAS for Windows (version 9.4, SAS Institute, Inc, Cary, North Carolina). Content validation experts were asked to rate each statement in relation to its relevance and appropriateness, given the goal and purpose of the algorithm. Content validation panel members were asked to rate each statement's relevance on a scale of 1 (not relevant or appropriate) to 4 (very relevant). An overall content validity index (CVI) was calculated along with a CVI for each statement using the procedure described by Polit and Beck.44 Content validation indices were calculated as the proportion of panelists rating the item as relevant or very relevant where a score of 3 indicated relevant and a score of 4 indicated very relevant. A CVI cut point of 0.78 was used to select the final consensus statements.45

Table 5 summarizes the overall and individual CVI for the 62 consensus statements. Applying the recommend cut-off of 0.78, the overall CVI and all of the individual statement CVI met the threshold and were rated as “very relevant and appropriate” or “relevant and needed only minor alteration.”

TABLE 5. - Statements Reaching Consensus and Their Content Validity Index
Consensus Statement CVI
Consensus Statement CVI
Overall CVI 0.89
1. After indwelling catheter is removed:
  • Depending upon fluid intake, allow the bladder to fill up to 6 h while assessing the patient for spontaneous voiding, desire to urinate, and/or suprapubic discomfort.

  • Perform bedside portable ultrasound for bladder volume after first void or if no voiding occurs or patient expresses desire to urinate or suprapubic discomfort.

  • If bladder volume exceeds 400 mL or per facility protocol, notify provider and perform in-and-out catheterization

1.00
2. If spontaneous voiding occurs sooner than 6 h of indwelling catheter removal, record void and measure bladder volume via bedside portable ultrasound within 30 min. 0.90
3. If residual volume on portable bedside ultrasound is ≤200 mL, assess for toileting program or other bladder management strategies. 0.85
4. If patient does not void spontaneously within 6 h and bladder volume is <400 mL and patient does not report suprapubic discomfort or urge to urinate, reassess bladder volume by bedside bladder ultrasound in 2 h. 1.00
5. If patient does not void within 8 h of catheter removal and the bladder volume measured by portable bedside ultrasound is <400 mL, the patient should be assessed every 2 h with a portable bedside ultrasound until voiding occurs. If the patient reports suprapubic discomfort or bladder volume exceeds 400 mL, notify provider. 1.00
6. If patient is not voiding spontaneously, perform intermittent catheterization every 4-6 h for up to 24 h to allow time for return of spontaneous voiding. If spontaneous voiding does not occur within 24 h, start intermittent catheterization program. 0.90
7. Assessment of toileting ability should include:
  • Ability to recognize, respond to, and act upon cues to urinate in a socially appropriate manner

  • Mobility and dexterity necessary to use a toilet, bedside commode, bedpan, or urinal independently or with assistance

  • Extent to which pain interferes with independent or assisted toileting

  • Patient preference related to choice of toileting method (toilet vs bedside commode, urinal, bedpan, absorbent product, external collection device)

1.00
8. Assess voiding, incontinence, and bladder management strategies prior to catheterization to guide decision-making after catheter removal. 1.00
9. Assess patient for incontinence:
  • Volume

    • Light (dribble or drip, <100 mL)

    • Moderate/heavy (gush or involuntary void >100 mL)

  • Timing

    • Daytime

    • Nighttime


(Brought forward from BWAP scoping review and consensus)
1.00
10. Intermittent catheterization should be performed at least every 6 h in patients with normal renal function and urine output. 0.80
11. In select patients with high urine output due to edema, heart failure, kidney disease, etc, perform portable bedside ultrasound before intermittent catheterization and consider more frequent catheterizations in consultation with a provider. 0.85
12 When performing intermittent catheterization in an adult, use the smallest possible size (14F-16F) catheter; coudé tipped catheters should be available for men with prostate enlargement. 1.00
13. Sterile technique is recommended for intermittent catheterization in the acute care setting. 1.00
14. Perform portable bedside ultrasound in patients undergoing intermittent catheterization who exhibit signs of bladder fullness such as agitation, restlessness, elevated blood pressure, midline lower abdominal discomfort and distention, and, if needed, alter intermittent catheterization schedule in consultation with a provider. 1.00
15. If patient experiences urinary incontinence while on intermittent catheterization:
  • Perform portable bedside ultrasound prior to next scheduled catheterization to assess bladder volume

  • Consult with provider about altering intermittent catheterization schedule, testing for urinary tract infection or initiating other interventions for urinary incontinence

  • Implement preventive interventions for incontinence-associated dermatitis

1.00
16. If the patient starts to void (voluntarily or involuntarily), assess bladder emptying using a bedside portable ultrasound and consult with provider about intermittent catheterization schedule. 0.85
17. Toileting should be the first-line strategy for bladder management of any patient who is able to toilet independently or with assistance. 1.00
18. Patients with cognitive impairment (dementia, confusion, delirium) should be considered for a toileting program if they can be safely toileted and the toileting process does not cause undue patient distress. 1.00
19. A scheduled toileting program includes:
  • Cueing and providing assistance with toileting at fixed intervals (such as every 2-4 h when awake) or based upon individual patient needs

  • Nighttime toileting based on goals of care. Do not routinely awaken patient during the night for toileting

  • Documenting in the plan of care and sharing during hand-off to ensure consistent implementation

  • Individualization to maximize independence, preserve dignity and incorporate preference related to choice of toileting method (toilet versus bedside commode, urinal, bedpan)

1.00
20. An individualized toileting program may incorporate:
  • Mobility aides such as walkers and canes

  • Modifications in clothing such as elastic waist pants

  • Modifications to the urine/toilet receptacle such as a raised toilet seat, bedside commode, or a female/male urinal

  • Occupational therapy or physical therapy interventions

1.00
21. Patients in a toileting program who need a BWAP should use a product that promotes as much self-care and independence as possible. 1.00
22. Reasonable goals for a successful toileting program include:
  • A decrease in incontinence episodes

  • Reduced risk for skin damage

  • Improved patient satisfaction

  • Reduction in agitation in cognitively impaired persons

1.00
23. The outcome of a successful toileting program does not necessarily include absence of incontinence. 0.95
24. In the acute care setting, underpads are a first-line intervention for absorption of urinary incontinence. 0.90
25. Do not use underpads for turning and repositioning patients with incontinence unless designed for that purpose. 0.90
26. Cleanse the skin and protect it with one or more moisture barrier products after each incontinence episode. 0.90
27. Apply and remove moisture barrier products (creams, ointments, pastes, liquid barrier films) per manufacturer instructions.
Consider the potential for increased friction between the patient's skin and underpad and diminished absorbent capacity when applying topical moisture barrier products.
0.90
28. Consider using a silk-like bed linen system (sheets, underpad) with a low coefficient of friction to reduce risk of skin damage in patients with urinary incontinence. 0.90
29. Underpads should be changed as soon as possible after an incontinence episode.
Consider using underpads with embedded technology that alert care providers to episodes of urinary incontinence for patients unable or unwilling to signal for assistance or for patients with existing skin damage.
1.00
30. Consider use of a support surface with a low air loss feature and breathable underpads for patients with incontinence and a Braden Moisture subscale score of 2 (very moist) or 1 (constantly moist). 0.90
31. Do not place plastic-backed products beneath patients with urinary incontinence on support surfaces with low air loss features, as they may block therapeutic air flow. 0.95
32. Consider use of external collection devices for patients who are incontinent, unable to engage in a toileting program, and/or require monitoring of urine output. 1.00
33. External collection devices should not be used for staff convenience. 1.00
34. Consider use of condom or non-sheath glans-adherent devices in males who are unable to engage in a toileting program. 1.00
35. Consider use of condom or non-sheath glans-adherent devices in males requiring close monitoring of urine output following indwelling catheter removal. 0.95
36. When using a condom external collection device:
  • The glans penis and skin of the penile shaft should be inspected for inflammation and integrity prior to initial application or device change

  • Select an appropriately sized device based on manufacturer's sizing tool and recommendations

  • The skin should be cleansed and dried before reapplication of a condom external collection device, and the adhesive or securement mechanism applied based on manufacturer's recommendations

  • Do not apply additional adhesive securement products to the penis

  • The expected wear time of a condom external collection device is daily or every other day

1.00
37. Males with a buried or retracted penis and males with shorter penile shaft length should be considered for a non-sheath glans-adherent external collection device or a penis pouch (retracted penis pouch). 1.00
38. When using non-sheath glans-adherent external collection devices:
  • The glans penis and skin of the penile shaft should be inspected for inflammation and integrity prior to initial application or device change

  • The skin should be cleansed and pat dried before application or device change

  • Devices should be applied following manufacturers' recommendations including use of gentle, warming hand pressure to activate the adhesive

  • Do not apply additional adhesive or securement products to the penis

  • The expected wear time of non-sheath glans-adherent external collection devices is 2-3 d

1.00
39. When applying a penis pouch (retracted penis pouch):
  • The penile and suprapubic skin adjacent to the penis should be inspected for inflammation and integrity and hair clipped

  • The skin should be cleansed and pat dried before application or device change per manufacturer instruction

  • Do not apply additional adhesive or securement products to the penis or suprapubic skin

  • The penis should be placed through the pouch opening; the adherent surface should be held in place using gentle, warming hand pressure to activate the adhesive

  • The expected wear time of a penis pouch is 1-2 d

1.00
40. Consider use of external suction collection devices for females requiring close monitoring of urine output following indwelling catheter removal. 0.85
41. When applying external suction collection devices in females:
  • Inspect the skin of the genital area for inflammation, integrity, and vaginal discharge

  • Cleanse the patient's genital area from front to back

  • Visualize perineal area, gently separate the labia, and position device with the tubing connection facing up; make sure the device is touching the skin

  • Mesh briefs may be worn as a securement device. Do not apply additional adhesive or other securement products

  • Change device every 8-12 h or when absorbent fabric is soiled with feces or body fluids other than urine

0.90
42. Maintain continuous suction while an external suction collection device is in place; set minimum suction level of 40 mm Hg based on manufacturer recommendation.
Safe maximum suction levels have not been determined; follow facility protocol.
0.90
43. When changing or removing external suction collection device, follow manufacturers' recommendations or facility protocol:
  • Verify suction is at 40 mm Hg

  • Gently displace device in a manner that avoids fecal contamination

  • Assess skin integrity and perform perineal care

0.85
44. Do not use external suction collection devices in females who are:
  • Placed in prone position

  • Agitated, combative, or uncooperative

  • Experiencing frequent episodes of bowel incontinence without adequate containment

  • Exhibiting inflammation or loss of skin or mucosal integrity at the site

  • Experiencing moderate/heavy menstruation and unable to use a tampon

  • Observed to have vaginal wall outside of the vagina (prolapse)

0.90
45. When using an external female suction collection device, maintain a dedicated suction canister and tubing system. 0.95
46. Do not place an external suction collection device for females into any body orifice. 0.90
47. Reevaluate the need for external suction collection devices as mobility and cognitive function improve. 1.00
48. When using an external suction urine collection device in patients with dual incontinence, consider the use of fecal containment options such as small anal pads, external pouches, or internal containment devices. 0.95
49. Consider nighttime use of external suction collection devices to maximize sleep in patients unable to engage in a toileting program. 0.90
50. Remove external suction collection devices during out-of-bed mobilizations and transfers. 1.00
51. When transferring patients using external suction collection devices to a bedside chair:
  • Remove device

  • Position patient in chair with absorbent underpad

  • Reapply device if able to assess placement, ensure containment, and prevent medical device-related injury

  • Ensure appropriate suction and tubing length

  • Reassess device placement with routine repositioning, ensure suction tubing is not beneath patient

0.95
52. BWAPs should be used for patients with incontinence who cannot be managed by an external collection device during ambulation, therapy, or when off-unit in order to preserve dignity/privacy, prevent falls, and reduce environmental contamination. 1.00
53. When assessing incontinent patients for selecting an absorptive product, consider the following factors:
  • Gender

  • Waist or hip circumference, if these cannot be measured, use body mass index as a reference

  • Mobility and dexterity

  • Patient preference and acceptability and goals of care

  • Cognition

1.00
54. Assess incontinence severity (light or moderate/heavy) and timing (nighttime vs daytime) in order to assist in the selection of BWAP. 1.00
55. Consider continued use of patient-preferred BWAP for incontinence management.
If preferred product is not available, consult with patient and family regarding the need for them to provide preferred absorbent products.
0.90
56. When constructing facility formulary, advocate for multiple designs (briefs, pull-ons, pads, shields, and guards) and sizes of BWAP to manage incontinence. 1.00
57. Patients in toileting programs who are intermittently incontinent should be using a pull-on or an undergarment with a pad, guard, or shield vs absorbent brief. 1.00
58. Indications for referral to a continence nurse/APRN specialist (WOC nurse, urologic nurse, rehabilitation nurse), or other continence specialist:
  • Difficulty identifying optimal bladder management strategy

  • Intermittent catheterization is recommended but patient or staff is unable to perform

  • Dual incontinence (urine and fecal) with unsuccessful management plan

  • Patient, family, caregiver request

1.00
59. Consider referral to a wound care nurse/APRN specialist (WOC nurse, Wound Treatment Associate [WTA], urologic nurse, rehabilitation nurse), or other wound care specialist when any of the following are not addressed by or responsive to facility protocol:
  • Medical device-related pressure injury of skin or mucosa related to an external collection device

  • Medical adhesive-related skin injury related to an external collection device

  • Moisture-associated skin damage, including incontinence-associated dermatitis and intertriginous dermatitis

  • Friction skin injury

1.00
60. At time of discharge, care is coordinated and communicated with the discharge planner (case manager, social worker) to promote a seamless transition of care for bladder management. This plan of care may include:
  • Toileting program

  • Intermittent catheterization

  • Underpads

  • Support surfaces

  • External collection devices

  • BWAPs

  • Disposable medical supplies

  • Durable medical equipment

  • Follow-up care

1.00
61. To improve patient outcomes, identify and work to reduce barriers to implementation of iPCaRe (Interventions Post Catheter Removal) in the areas of:
  • Organization

    (policy/procedure, budgeted staff, staff mix)

  • Equipment/supplies

    (impediments to obtain, availability, malfunction)

  • Education

    (staff, patients, providers, students, and other identified stakeholders)

  • Finance

    (reimbursement, points of transition, allocation of funds)

1.00
62. Prioritize and engage in research to elevate iPCaRe from consensus-based to evidence-based practice. 1.00

DISCUSSION

The iPCaRe algorithm is the fourth promulgated by the WOCN Society, but it is the first that is entirely based on consensus-driven best practice statements. In contrast, earlier algorithms reflect a blend of evidence-based and consensus-driven statements. While our initial scoping review identified 62 articles that were read in full, all were excluded because they did not measure outcomes in the acute care setting where indwelling catheters tend to be removed after a relatively short time in place; evidence suggests most are short-term and removed within 1 to 7 days following their initial insertion.46,47 Though based entirely on consensus-based statements reflecting best practice, the algorithm was informed by research in other populations and consensus was achieved by a formalized process designed to minimize individual influence or bias. For example, we included 11 Clinical Principle statements and incorporated elements of prior algorithms and best practice guidelines that guided segments of the multiple pathways contained in this larger algorithm.16,18

Given the paucity of evidence in this area, Task Force members, consensus panelists, and content validation experts recognized and commented on the multiple areas where additional research is needed. For example, research is urgently needed to identify crucial elements for the assessment and implementation of a successful toileting program in the acute care setting. Research in this area of care may address the efficacy of individual or bundled interventions comprising an assisted toileting program, or a standardized approach to the assessment of a patient for an assisted toileting program. Additional research should address the comparative safety of an assisted toileting program to alternative bladder management strategies in acutely and critically ill patients with limited mobility.

The algorithm also provides best practice for a new class of products, external suction collection devices. These products have gained widespread use and acceptance in the United States, reflecting the need for this type of product and positive initial experiences with their use. Nevertheless, we assert that additional research is urgently needed to improve our knowledge of this product category and its use. We recommend studies focusing on how much of the individual's total urinary output is contained when the suction collection device is in place, and its potential ability to prevent incontinence-associated dermatitis.

The Task Force recognizes that the algorithm, itself, should be subjected to additional evaluation for validity and reliability when used by nurses and others in the acute care setting. Similar to all other WOCN Society clinical decision-making algorithms, iPCaRe will undergo regularly scheduled updates and revisions that will incorporate publication of new evidence and studies validating the algorithm.

CONCLUSIONS

The iPCaRe tool is a consensus-based algorithm that provides guidance for bladder and incontinence management following removal of an indwelling catheter in the acute care setting. A structured process was used to design the tool based on a scoping review of the literature to identify pertinent evidence, consensus for best practice statements when evidence was absent, and content validation of the algorithm. Similar to all WOCN Society algorithms, iPCaRe will be regularly updated and revised as evidence is published.

ACKNOWLEDGMENT

Development of the algorithm was funded through an unrestricted educational grant from Bard, who has joined Becton Dickinson.

REFERENCES

1. Centers for Medicare & Medicaid Services. Eliminating serious, preventable, and costly medical errors—never events. https://www.cms.gov/newsroom/fact-sheets/eliminating-serious-preventable-and-costly-medical-errors-never-events. Published May 18, 2006. Accessed July 8, 2020.
2. Wound, Ostomy and Continence Nurses Society Task Force. Wound, Ostomy, and Continence Nursing: Scope and Standards of WOC Practice, 2nd Edition: An Executive Summary. J Wound Ostomy Continence Nurs. 2018;45(4):36–87.
3. Centers for Medicare & Medicaid Services. Letter to State Medicaid Directors. https://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD073108.pdf Published July 31, 2008. Accessed July 8, 2020.
4. Centers for Disease Control and Prevention. Catheter-associated Urinary Tract Infections (CAUTI). https://www.cdc.gov/hai/ca_uti/uti.html.
5. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, HICPAC Healthcare Infection Control Practice Committee. Guideline for prevention of catheter associated urinary tract infections: 2009. http://scholar.google.com/scholar_url?url=https://stacks.cdc.gov/view/cdc/49910/cdc_49910_DS1.pdf&hl=en&sa=X&scisig=AAGBfm3uap3iePsk77_8Djsk9vofYRSWKg&nossl=1&oi=scholarr. Last updated February 15, 2017. Accessed July 8, 2020.
6. Centers for Disease Control and Prevention. Catheter Associated Urinary Tract Infections (2009). https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html. Accessed July 8, 2020.
7. Lawrence KG, Bliss DZ, Dailey M, Trevellini M, Pontieri-lewis V. The CAUTI Prevention Tool Kit: A Professional Practice and Collaborative Project of the Wound, Ostomy and Continence Nurses Society. J Wound Ostomy Continence Nurs. 2019;46(2):154–157.
8. World Health Organization. Advanced Infection Prevention and Control Training, May 2018 version. Prevention of catheter-associated urinary tract infection (CAUTI): student handbook. https://www.who.int/infection-prevention/tools/core-components/CAUTI_student-handbook.pdf. Accessed July 8, 2020.
9. Letica-Kriegel AS, Salmasian H, Vawdrey DK, et al. Identifying the risk factors for catheter-associated urinary tract infections: a large cross-sectional study of six hospitals. BMJ Open. 2019;9(2):e022137.
10. Tyson AF, Campbell EF, Spangler LR, et al. Implementation of a nurse-driven protocol for catheter removal to decrease catheter-associated urinary tract infection rate in a surgical trauma ICU. J Intensive Care Med. 2020;35(8):738–744.
11. Centers for Disease Control and Prevention. Guidelines for Preventing Health-Care–Associated Pneumonia, 2003. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm. Accessed July 8, 2020.
12. Chaiken N. Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing. J Wound Ostomy Continence Nurs. 2012;39(2):143–145.
13. Gates BP, Vss J, Long MA, Johnson E. Decreasing incontinence-associated dermatitis in the surgical intensive care unit: a quality improvement project. J Wound Ostomy Continence Nurs. 2019;46 (4):327–331.
14. Gupta SS, Irkulla PK, Shenoy MA, Nyemba V, Yacoub D, Kupfer Y. Successful strategy to decrease indwelling catheter utilization rates in an academic medical intensive care unit. Am J Infect Control. 2017;45(12):1349–1355.
15. Manojlovich M, Lee S, Lauseng D. A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes. J Patient Saf. 2016;12(4):173–179.
16. McNichol L, Wattsm C, Mackey D, Beitz JM, Gray M. Identifying the right surface for the right patient at the right time: generation and content validation of an algorithm for support surface selection. J Wound Ostomy Continence Nurs. 2015;42(1):19–37.
17. Ratliff CR, Yates S, McNichol L, Gray M. Compression for primary prevention, treatment, and prevention of recurrence of venous leg ulcers: an evidence- and consensus-based algorithm for care across the continuum. J Wound Ostomy Continence Nurs. 2016;43(4):347–364.
18. Gray M, Kent D, Ermer-Seltun J, McNichol L. Assessment, selection, use, and evaluation of body-worn absorbent products for adults with incontinence: a WOCN Society Consensus Conference. J Wound Ostomy Continence Nurs. 2018;45(3):243–264.
19. Levac D, Colquhoun HL, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. doi:10.1186/1748-5908-5-69.
20. Colquhoun HL, Levac D, O'Brien KK, et al. Scoping reviews: time for clarity in definition, methods, and reporting. J Clin Epidemiol. 2014;67(12):1291–1294.
21. Stoffel J, Lightner D, Peterson A, Sandhu J, Suskind A, Wei J. Non-Neurogenic Chronic Urinary Retention: Consensus Definition, Management Strategies, and Future Opportunities. AUA Guideline. https://www.auanet.org/guidelines/chronic-urinary-retention. Published 2016. Accessed July 15, 2020.
22. Brasure M, Fink HA, Risk M, et al. Chronic Urinary Retention: Comparative Effectiveness and Harms of Treatments. Comparative Effectiveness Review No. 140. (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-2007-10064-I.) AHRQ Publication No. 14-EHC041-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2014.
23. Janardanan S, Moussa AEM, James P. False positive bladder scan in ascites with anuria. Clin Case Rep. 2019;7(8):1549–1550.
24. Glanc P, O'Hayon BE, Singh DK, Bokhari SAJ, Maxwell CV. Challenges of pelvic imaging in obese women. Radiographics. 2012;32(6):1839–1862.
25. Alagiakrishnan A, Valpreda M. Ultrasound bladder scanner presents falsely elevated postvoid residual volumes. Can Fam Physician. 2009;55(2):163–164.
26. Kim TH, Kim HS, Park JW, Lim OK, Park KD, Lee JK. Falsely elevated postvoid residual urine volume in uterine myoma. Ann Rehabil Med. 2017;41(2):332–336.
27. Schowalter S, Altawil Z, Schechter-Perkins EM, Pare JR. False elevation of volume determined by bladder scanner secondary to bowel obstruction. Clin Pract Cases Emergency Med. 2020;4(2):158–160.
28. Thomsen TW, Setnik GS. Videos in clinical medicine. Male urethral catheterization. N Engl J Med. 2006;354(21):e22.
29. Gilbert B, Naidoo BL, Redwig F. Ins and outs of urinary catheters. Aust J Gen Pract. 2018;47(3):132–136.
30. American Nurses Association. Streamlined Evidence-Based RN Tool: Catheter Associated Urinary Tract Infection (CAUTI) Prevention. https://www.nursingworld.org/∼4aede8/globalassets/practiceandpolicy/innovation–evidence/clinical-practice-material/cauti-prevention-tool/anacautipreventiontool-final-19dec2014.pdf. Accessed July 17, 2020.
31. Tang MW, Kwok TC, Hui E, Woo J. Intermittent versus indwelling urinary catheterization in older female patients. Maturitas. 2006;53(3):274–281.
32. Hakvoort RA, Thijs SD, Bouwmeester FW, et al. Comparing clean intermittent catheterization and transurethral indwelling catheterization for incomplete voiding after vaginal prolapse surgery: a multicenter randomized trial. BJOG. 2011;118(9):1055–1060.
33. Najafpour Z, Godarzi Z, Arab M, Yaseri M. Risk factors for falls in hospital in-patients: a prospective nested case control study. Int J Health Policy Manage. 2019;8(5):300–306.
34. Beeckman D, Val Lancker A, Van Hecke A, Verhaeghe S. A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Res Nurs Health. 2014;37(3):204–218.
35. Gray M, Giuliano KK. Incontinence associated dermatitis, characteristics and relationship to pressure injury: a multisite epidemiologic study. J Wound Ostomy Continence Nurs. 2018;45(1):63–67.
36. Lachenbruch C, Ribble D, Emmons K, VanGilder C. Pressure ulcer risk in the incontinent patient: analysis of incontinence and hospital-acquired pressure ulcers from the International Pressure Ulcer Prevalence™ Survey. J Wound Ostomy Continence Nurs. 2016;43(3):235–241.
37. Gray M, Skinner C, Kaler W. External collection devices as an alternative to the indwelling urinary catheter: evidence-based review and expert clinical panel deliberations. J Wound Ostomy Continence Nurs. 2016;43(3):301–307.
38. Eckert L, Mattia L, Patel S, Rowena O, Reynolds P, Stuiver I. Reducing the risk of indwelling catheter–associated urinary tract infection in female patients by implementing an alternative female external urinary collection device: a quality improvement project. J Wound Ostomy Continence Nurs.2020;47(1):50–53.
39. Beeson T, Carmen D. Urinary management with an external female collection device. J Wound Ostomy Continence Nurs. 2020;47(1):50–53.
40. Yates S, McNichol L, Heinecke SB, Gray M. Embracing the concept, defining the practice, and changing the outcome: setting the standard for medical adhesive-related skin injury interventions in WOC nursing practice. J Wound Ostomy Continence Nurs. 2017;44(1):13–17.
41. Zisberg A, Sinoff G, Gur-Yaish N, Admi H, Shadmi E. In-hospital use of continence aids and new-onset urinary incontinence in adults aged 70 and older. J Am Geriatr Soc. 2011;59(6):1099–1104.
42. Fernando J, Wagg A. What wait time in a soiled pad is acceptable to older patients and their direct caregivers? J Wound Ostomy Continence Nurs. 2017;44(6):562–567.
43. Grant JS, Davis LL. Focus on quantitative methods: selection and use of content experts for instrument development. Res Nurs Health. 1997;20:269–274.
44. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health. 2007;30(4):459–467.
45. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986;35:382–385.
46. Pickard R, Lam T, MacLennan G, et al. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterization in hospital: a multicenter randomized controlled trial. Lancet. 2012;380(9857):1927–1935.
47. Saint S, Trautner BW, Fowler KE, et al. A Multicenter study of patient-reported infectious and noninfectious complications associated with indwelling urethral catheters. JAMA Intern Med. 2018;178(8):1078–1085.
Keywords:

Absorbent pads; Bladder management; External collection device; Indwelling urinary catheter; Intermittent urethral catheterization; Support surfaces; Toileting program; Urinary incontinence; Urinary retention

© 2020 by the Wound, Ostomy and Continence Nurses Society