The Ann Arbor Criteria For Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using The RAND/UCLA Appropriateness Method

Annals of Internal Medicine SUPPLEMENT
The Ann Arbor Criteria for Appropriate Urinary Catheter Use in

Hospitalized Medical Patients: Results Obtained by Using the
RAND/UCLA Appropriateness Method
Jennifer Meddings, MD, MSc; Sanjay Saint, MD, MPH; Karen E. Fowler, MPH; Elissa Gaies, MD, MPH; Andrew Hickner, MSI;
Sarah L. Krein, PhD, RN; and Steven J. Bernstein, MD, MPH
Interventions to reduce urinary catheter use involve lists of “ap- ing and catheter placement challenges. The panel rated 105
propriate” indications developed from limited evidence without Foley scenarios (43 appropriate, 48 inappropriate, 14 uncertain),
substantial multidisciplinary input. Implementing these lists, 97 ISC scenarios (15 appropriate, 66 inappropriate, 16 uncer-
however, is challenging given broad interpretation of indica- tain), and 97 external catheter scenarios (30 appropriate, 51 in-
tions, such as “critical illness.” To refine criteria for appropriate appropriate, 16 uncertain). The refined criteria clarify that Foley
catheter use— defined as use in which benefits outweigh risks— catheters are appropriate for measuring and collecting urine
the RAND/UCLA Appropriateness Method was applied. After re- only when fluid status or urine cannot be assessed by other
viewing the literature, a 15-member multidisciplinary panel of means; specify that patients in the intensive care unit (ICU) need
physicians, nurses, and specialists in infection prevention rated specific medical indications for catheters because ICU location
scenarios for catheter use as appropriate, inappropriate, or of alone is not an appropriate indication; and recognize that Foley
uncertain appropriateness by using a standardized, multiround and external catheters may be pragmatically appropriate to
rating process. The appropriateness of Foley catheters, intermit- manage urinary incontinence in select patients. These new ap-
tent straight catheters (ISCs), and external condom catheters for propriateness criteria can inform large-scale collaborative and
hospitalized adults on medical services was assessed in 299 sce- bedside efforts to reduce inappropriate urinary catheter use.
narios, including urinary retention, incontinence, wounds, urine
volume measurement, urine sample collection, and comfort. The Ann Intern Med. 2015;162:S1-S34. doi:10.7326/M14-1304 www.annals.org
scenarios included patient-specific issues, such as difficulty turn- For author affiliations, see end of text.
C atheter-associated urinary tract infection (CAUTI)

and unnecessary urinary catheter use remain im-
portant patient safety problems in 2015, despite non-
Affairs (VA) hospitals, urinary catheter use varies widely,
even among clinicians and hospitals trying to imple-
ment similar appropriateness criteria (9). Specifically, in
payment for hospital-acquired CAUTI since 2008, na- the “On the CUSP” project, urinary catheter use ap-
tionwide public reporting of CAUTIs since 2011, and pears highest among hospitals in the Western United
increasing adoption of interventions to reduce catheter States (10). Hospitals in this region used “accurate mea-
use (1– 4). National reports of urinary catheter use have surement of urinary output in critically ill patients” out-
remained relatively unchanged since 2009, with cathe- side of the ICU setting and “urinary incontinence with-
ter utilization ratios (catheter-days/patient-days) in out a sacral or perineal pressure ulcer” as indications
2013 reported as 0.60 for intensive care units (ICUs) for urinary catheter use more than did hospitals in other
and 0.17 for non-ICU wards (5). Even within the large regions (10). Hospitals in the Midwestern United States
“On the CUSP: Stop CAUTI” collaborative funded by had the highest rates for using other conditions, such
the Agency for Healthcare Research and Quality as morbid obesity, transfer from the ICU, immobility,
(AHRQ), which uses many interventions to remove un- dementia, and patient request, as indications for use
necessary urinary catheters, the catheter use ratios (10). A recent national survey of catheter placement
from June 2014 were 0.56 for ICUs and 0.18 for non- practices in acute care hospitals demonstrated that
ICUs (6, 7). many hospitals reported placing catheters for reasons
Key tools for reducing urinary catheter use are lists beyond the HICPAC list of appropriate indications, in-
of appropriate and inappropriate catheter indications, cluding for patient request and urinary incontinence
which restrict use to appropriate indications and without obstruction (9).
prompt catheter removal when catheters are no longer In summary, although the 2009 HICPAC CAUTI
appropriate. In the United States, hospitals implement- guideline about appropriate catheter indications was
ing interventions to prevent CAUTI and reduce catheter instrumental for informing many interventions to re-
use, including hospitals in the “On the CUSP” project,
generally rely on the 2009 Guideline for Prevention of
Catheter-Associated Urinary Tract Infections from the See also:
Healthcare Infection Control Practices Advisory Com-
CME/MOC activity . . . . . . . . . . . . . . . . . . . . . . . . . S31
mittee (HICPAC) for guidance regarding appropriate
Editorial comment . . . . . . . . . . . . . . . . . . . . . . . . . S35
and inappropriate catheter indications (8).
In our experience as team members of the “On the Web-Only
CUSP” project and bedside clinicians caring for medi-
Supplements
cal patients in university and Department of Veterans
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SUPPLEMENT Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients
duce catheter use, implementation of appropriate and increased life expectancy, relief of pain, reduction in
inappropriate indication lists has been challenging for anxiety, improved functional capacity) exceeds the ex-
3 reasons: 1) broad interpretation of such indications as pected negative consequences (e.g., mortality, morbid-
“critical illness”; 2) bedside clinician concerns that prag- ity, anxiety, pain, time lost from work) by a sufficiently
matic patient-specific issues, such as incontinent pa- wide margin that the procedure is worth doing, exclu-
tients who are very difficult to turn for skin care, are not sive of cost” (12, 13). The goal of the method is to com-
addressed; and 3) the need for more specific guidance bine the best available scientific literature with the col-
on use of alternatives to indwelling catheters, such as lective judgment of experts to yield a statement on the
external condom catheters and intermittent straight appropriateness of a procedure with regard to specific
catheters (ISCs). patient characteristics, such as symptoms, medical his-
To address these concerns, we applied a well- tory, or test results. This list of indications may be used
established method for evaluating appropriateness of retrospectively to assess the appropriateness of proce-
medical technology—the RAND/UCLA Appropriateness dures received or prospectively as a clinical decision
Method—to more rigorously define the appropriateness aid for improving the use of the procedure.
of 3 types of urinary catheters (indwelling Foley cathe- As illustrated in Figure 1, the first step of the
ter, ISC, and external condom catheter). Our objective RAND/UCLA Appropriateness Method is a literature re-
was to develop a list of catheter indications assessed as view to synthesize the latest available scientific evi-
appropriate, inappropriate, or of uncertain appropri- dence on the procedure to be rated. From the litera-
ateness for these urinary catheter types that can guide ture search, a list of specific clinical scenarios or
nurses and physicians considering catheters in hospi- indications is produced, from which a rating document
talized medical patients. We focused on indications for for assessing appropriateness is generated. A panel of
urinary catheters most commonly considered on med- experts is identified, often on the basis of participation
icine services and excluded perioperative care because in or recommendation by various relevant medical so-
we expected the literature review and clinical expertise cieties. In a modified Delphi process, the panelists as-
required for perioperative indications to be different. sess the benefit-to-harm ratio of the procedure for each
indication in the rating document on a 1 to 9 scale; 1
means the expected harm greatly exceeds the ex-
METHODS pected benefit, and 9 means the expected benefit
Overview of the RAND/UCLA Appropriateness greatly outweighs the expected harms. Panelists per-
Method form the first round of ratings independently without
The RAND/UCLA Appropriateness Method was de- interaction with other panelists.
veloped to enable measuring the overuse of medical For the next round or rounds of rating, panelists
and surgical procedures in the RAND Corporation/Uni- meet at a conference led by a moderator experienced
versity of California, Los Angeles, Health Services Utili- in the method. During the conference the panelists dis-
zation Study (11). For procedures that may be over- cuss the ratings, focusing on areas of disagreement or
used, this method assesses the procedure as uncertainty, and have the opportunity to modify the in-
“appropriate” when the “expected health benefit (e.g., dication list as needed. No attempt is made to force
consensus. Following the discussion at the conference,
Figure 1. Overview of the RAND/UCLA Appropriateness the panelists individually re-rate the appropriateness of
the indications by using the same 1 to 9 scale. Each
Method.
indication's final assessment is classified by the RAND
/UCLA Appropriateness Method according to the pan-
Literature review and synthesis of the evidence el's median score and level of disagreement among
regarding urinary catheter use panelists. Disagreement represents a wide difference
of opinion by the panelists. For our panel of 15 mem-
bers, disagreement existed if at least 5 panelists rated
the appropriateness of an indication from 1 to 3 and at
Develop a list of potential indications least 5 panelists rated the appropriateness from 7 to 9.
with definitions If disagreement is found, those indications are consid-
ered to be of “uncertain” appropriateness. For indica-
tions without disagreement, median panel score
ranges are used to classify indications as follows: 1 to 3,
Expert panel rates the appropriateness of indications using rating
inappropriate; 4 to 6, uncertain appropriateness; and 7
tool in at least 2 rounds:
Round 1: panel members rate without interaction (by mail) to 9, appropriate.
Round 2: panel members rate after group discussion, clarifications
RAND/UCLA Appropriateness Method Versus
the Method Used for the 2009 HICPAC CAUTI
Guideline
Develop and share guidelines regarding Literature Search
appropriateness of urinary catheter use Similar to the method used to generate the 2009
HICPAC guideline, the RAND/UCLA Appropriateness
S2 Annals of Internal Medicine • Vol. 162 No. 9 (Supplement) • 5 May 2015 www.annals.org

Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients SUPPLEMENT
Method began with a literature search for guidance re- 4-member external expert group. The HICPAC method
garding urinary catheter use. The literature search was applied a grade for level of evidence and strength of
used to generate a list of potentially appropriate indi- recommendation for individual recommendations pro-
cations for indwelling urinary catheters for consider- vided in the guideline text regarding appropriate uri-
ation by experts with diverse clinical and research ex- nary catheter use and catheter alternatives (HICPAC
pertise. However, both the HICPAC team and our team guideline pages 10 to 11, 34 to 35, and 37 to 38). The
found very little in the literature with which to estimate quality of evidence cited was graded as “low” and “very
risks and benefits of urinary bladder drainage strate- low”; the strength of recommendations ranged from
gies by clinical indication in order to guide develop- “strong” (for using catheters only as necessary instead
ment of an appropriate indications list. As a conse- of routinely for operative patients and avoiding cathe-
quence, both the HICPAC team and our team reviewed ters to manage incontinence) to “weak” (for use of al-
the literature for other types of guidance on appropri- ternatives to indwelling catheters for some neurogenic
ate and inappropriate uses of catheters. The HICPAC bladder conditions). The table of appropriate and inap-
CAUTI working group started with the indications dis- propriate indications for indwelling catheters was pro-
cussed in the original 1981 Centers for Disease Control vided and cited as primarily selected by expert consen-
and Prevention CAUTI prevention guideline (14) and sus; this is the table of general indications used
consulted other major CAUTI guidelines being devel- currently by most interventions for reducing catheter
oped around the same time (15, 16) to develop a draft use. No systematic scoring system was applied for rat-
list of indications (Gould C. Personal communication. ing and selecting the indications for this table (Gould C.
12 September 2014). Personal communication. 12 September 2014). The en-
Similarly, because our team's initial systematic tire HICPAC CAUTI guideline went through several
search of the literature (Figure 2, Strategy 1) did not levels of review, including by the larger HICPAC com-
yield articles quantifying risks and benefits of urinary mittee, which discussed the available data and recom-
catheters by clinical indication (although it did yield 9 mendations in the entire guideline for approval before
articles discussing indications), we also reviewed CAUTI sending it to the Centers for Disease Control and Pre-
guidelines (Figure 2, Strategy 2), including the HICPAC vention with a prepublication period of public com-
guideline and guidelines focused on clinical conditions ment review (109).
for which urinary catheters are commonly considered, In summary, the HICPAC method clearly has sub-
such as pressure ulcers, paralysis or neurologic bladder stantial strengths, including multiple levels of review,
issues, and urologic diagnoses (including incontinence) and yielded an important general list of appropriate
(8, 14 –29). In addition, because we had recently per- and inappropriate indications that are guiding catheter
formed 2 systematic reviews of controlled intervention use in hospitals nationwide. However, the list does not
studies to reduce CAUTI or urinary catheter use (30, account for common clinical patient characteristics that
31), we reviewed the 30 studies and the references make the current list incomplete and difficult to imple-
(Figure 2, Strategy 3) yielded by these systematic re- ment. The need for a more critical review of how clinical
views. We sought guidance from these studies because characteristics affect the appropriateness prompted
implementation of many interventions required a list our selection of the RAND/UCLA Appropriateness
of appropriate and inappropriate urinary catheter Method.
indications. The strengths of the RAND/UCLA Appropriateness
From the articles identified through the search Method for this project are derived from the methodi-
strategies listed in Figure 2, a comprehensive table of cal review of detailed clinical patient characteristics that
indications by article (8, 14, 32–108, 115–120) was de- affect urinary catheter benefits, risks, and the potential
veloped and categorized by themes (such as “urinary to use alternatives. For example, the HICPAC table in-
retention and/or obstruction”), as detailed in the Ap- dicates that indwelling catheters are inappropriate “as
pendix Table (available at the end of this article). This a substitute for nursing care of the patient or resident
table of indications was used to develop clinical scenar- with incontinence,” which is certainly sound general ad-
ios for the rating document. The rating document was vice. However, this recommendation can be frustrating
first refined by additional multidisciplinary input from for bedside clinicians. These practitioners are tasked
other clinicians before being sent to panelists to rate with managing incontinence without catheters when
the appropriateness of urinary catheters for each caring for patients for whom providing routine, fre-
scenario. quent skin care is challenging, such as patients who are
difficult to lift and turn because of severe edema, mor-
bid obesity, or pain.
Generating Recommendations for Appropriate For these reasons, the detailed rating document of
Urinary Catheter Use indications used in our study asked clinicians to con-
A key difference between the HICPAC method and sider the appropriateness of catheter use for inconti-
the method used for this study is how the recommen- nence in multiple clinical scenarios, including patients
dations were generated regarding the indications. The with and without common clinical characteristics that
initial HICPAC appropriate indications went through affect the ability and resources required for nurses to
several levels of review and refinement, starting with provide skin care for incontinence. Our list of indica-
the 4-member HICPAC CAUTI subcommittee and a tions for evaluation was generated by the detailed liter-

Figure 2. Summary of evidence search and selection.
Strategy 1: Systematic review for quantitative evidence for urinary catheter risks/benefits by clinical indication
Records identified using PubMed/MEDLINE, Web of Science, CINAHL, Embase (n = 340 000)
Records remaining after exclusion of duplicates and by title/abstract (n = 1257)
Records remaining after applications of inclusion criteria: human, adult, acute care hospital, and exclusion criteria:
perioperative setting, children, not involving urinary catheters (n = 13)
Records including discussions of catheter indications (15, 32–39) (n = 9)

Records providing quantitative data regarding risks/benefits of urinary catheters with respect to specific clinical indications (n = 0)
Because Strategy 1’s systemic search did not yield the quantitative data comparing risks and benefits of urinary catheters for
specific clinical indications, the literature search strategy was revised to be a comprehensive review of urinary catheter
indications cited in guidelines (Strategy 2) and intervention studies focused on prevention of CAUTI, as previously identified in
2 systematic reviews (Strategy 3)
References reviewed from bibliographies,

Strategy 2: Guideline review
cited for indication guidance*
a. CAUTI guidelines reviewed: 8, 14, 18, 40–78

• 1981 CDC CAUTI guideline (14)
• 2009 HICPAC CAUTI guideline (8)
• 2008 and 2010 IDSA CAUTI guidelines (15, 17)
• 2008 APIC CAUTI guidelines (16)
• 2008 European and Asian CAUTI guidelines (18)
• 2012 European guidelines for urinary catheter use (19)
b. Other clinical guidelines anticipated to contain guidance on use of No additional supporting references or new
urinary catheters in management of specific conditions: indications identified from these guidelines
• Pressure ulcers (20–23)
• Paralysis or neurogenic bladder (24, 25)
• Urologic diagnoses (26) or Incontinence (27–29)
Strategy 3: Review of intervention studies focused on reducing CAUTI or References reviewed from bibliographies,
urinary catheter use, anticipated to describe catheter indications as part cited for indication guidance*
of intervention
14 studies (56–58, 79–89) identified from systematic review (31) our 14, 57, 59, 60, 62, 63, 89–96
team performed in August 2008
16 studies (32, 33, 35–39, 97–105) identified in updated systematic 8, 17, 49, 59, 61, 62, 79, 106–108
review (30) our team performed in October 2012
Summary of literature reviewed for urinary catheter indications and contraindications:

• 17 guidelines (8, 14–29)
• 79 other articles reviewed (30–108)
APIC = Association for Professionals in Infection Control and Epidemiology; CAUTI = catheter-associated urinary tract infection; CDC = Centers for
Disease Control and Prevention; HICPAC = Healthcare Infection Control Practices Advisory Committee; IDSA = Infectious Diseases Society of
America.
* Some references cited as references for indication lists and reviewed from bibliographies were noted to be guidelines or intervention articles
already reviewed.

ature review as well as other indications suggested by pulmonary, anesthesia, emergency medicine, urology,
members of our research team and other clinicians rep- and epidemiology. Several panelists worked in infec-
resenting hospital medicine, internal medicine, neurol- tion control.
ogy, urology, other surgical specialties, and nursing. The panel discussion was facilitated by method
Also in contrast to the methods used for generat- and clinical content experts who focused on areas of
ing the indications in the 2009 HICPAC guideline, the disagreement or uncertainty in order to clarify whether
RAND/UCLA Appropriateness Method applies system- the disagreement or uncertainty could be resolved by
atic, reliable, and reproducible rating and scoring of clarifying the clinical scenario or resulted from clinical
appropriateness for individual clinical indications (11, uncertainty due to insufficient research. Of note, the
110, 111). The rating documents are generated in a RAND/UCLA Appropriateness Method does not re-
standard fashion that requires clear instructions, read- quire or aim for consensus; there is no voting, and the
ability, and clinical definitions. This process also ratings are done independently and submitted pri-
prompts clinician input to improve and expand the sce- vately in writing. The method for scoring the ratings as
narios being considered on the basis of clinical experi- appropriate, inappropriate, or uncertain is standard-
ence, including pragmatic challenges. Figure 3 illus- ized (11).
trates the format, instructions, definitions, and clinical In summary, our study used the RAND/UCLA Ap-
examples provided to panel members to query the appropriateness Method to begin where the HICPAC
propriateness of each catheter type for specific clinical 2009 guidance for catheters left off. We recognized
scenarios. that the literature available for informing risks and ben-
The panel discussion focused on the single task of efits for urinary catheter use is limited; therefore, the
assessing appropriateness of urinary catheter use and previously applied HICPAC method for grading the ev-
took place with all 15 expert panelists (nurses, physi- idence to inform the strength of recommendations had
cians, and an infection preventionist) from 7 facilities limited potential to differentiate appropriateness of
(most in the metro Detroit area in Michigan) in 4 states catheter use for common clinical scenarios not yet stud-
in the same room. As detailed in Table 1, the panel's ied. In addition to considering available quantitative ev-
nurses had expertise in wound care, medical-surgical idence from the literature, the RAND/UCLA Appropri-
ward care, critical care, and emergency medicine. The ateness Method used a standard method for rigorously
physicians' expertise included cardiology, neurology, applying clinical expertise to rate “appropriateness” for
hospital medicine, geriatrics, infectious disease, physi- detailed clinical indications beyond grading the quality
cal medicine and rehabilitation, critical care medicine, of evidence in the literature.
Table 1. Characteristics of Urinary Catheter Appropriateness Panelists

Name Title Affiliation* Specialty
Keith Aaronson, MD, MS Medical Director, Heart Transplant Program University of Michigan (UM), Ann Arbor, MI Cardiology
Crystal Bye, BSN, RN Wound Care Nurse VA Ann Arbor Healthcare System Wound care nursing
(VAAAHS), Ann Arbor, MI
Vineet Chopra, MD, MSc Clinical Assistant Professor, Internal Medicine VAAAHS; UM; Ann Arbor, MI Hospital medicine
Joseph Corey, MD, PhD Assistant Professor, Neurology and Biomedical VAAAHS, Geriatric Research, Education, Neurology
Engineering and Clinical Center; UM, Ann Arbor, MI
Heidi Haapala, MD Instructor, Physical Medicine and Rehabilitation VAAAHS; UM, Ann Arbor, MI Physical medicine and
rehabilitation
Theodore J. Iwashyna, Associate Professor, Internal Medicine VAAAHS; UM, Ann Arbor, MI Pulmonary and critical
MD, PhD care medicine
Karen Jones, RN, BSN Project Coordinator, Infection Prevention and St. John Hospital and Medical Center, Emergency medicine
Control Detroit, MI nursing
Preeti Malani, MD, MSJ Associate Professor, Internal Medicine VAAAHS, Geriatric Research, Education, Infectious diseases
and Clinical Center; UM, Ann Arbor, MI and geriatric
medicine
Russell Olmsted, MPH, Director, Infection Prevention and Control Services St. Joseph Mercy Healthcare System, Ann Infection prevention
CIC Arbor, MI
David Pegues, MD Professor of Medicine; Medical Director, Healthcare Hospital of the University of Pennsylvania, Healthcare
Epidemiology, Infection Prevention and Control Philadelphia, PA epidemiology and
infectious diseases
Margarita E. Pena, MD, Medical Director, Clinical Decision Unit, Assistant St. John Hospital and Medical Center, Emergency medicine
FACEP Program Director, Emergency Medicine Detroit, MI
Aleksandra Clinical Nurse Specialist Critical Care Richard L. Roudebush VA Medical Center, Critical care nursing
Radovanovich, MSN, Indianapolis, IN
RN, CCRN, CCNS
Ted Skolarus, MD, MPH Assistant Professor, Urology VAAAHS; UM, Ann Arbor, MI Urology
Andrea Starnes, RN Charge Nurse VAAAHS, Ann Arbor, MI Medical-surgical
nursing
Hannah Wunsch, MD, Herbert Irving Assistant Professor, Anesthesiology Columbia University, New York, NY Critical care medicine
MSc and Epidemiology
* Affiliation at time of panel participation.

Figure 3. Example of clinical scenarios from the round 1 rating document.
Instructions: Please circle your rating of the appropriateness of using an indwelling urinary catheter (Foley), an intermittent straight catheter (ISC), or an
external catheter (condom) for each scenario on a scale of 1 to 9. 1 = highly inappropriate; 5 = neutral or uncertain; 9 = highly appropriate.
A: Acute urinary retention
Reminder
1. Assume patients do not have any
other indication for requiring a urinary
catheter other than what is described
in the scenario. If Male Patient: Appropriateness
2. Assume patients would have no Appropriateness of Indwelling Appropriateness of Intermittent
Urinary Catheter (Foley) Use Straight Catheter (ISC) Use of External Catheter (Condom)
difficulty with catheter placement,
Use
meaning that a nurse could place an
indwelling catheter, ISC, or external
catheter without difficulty in the
patient unless otherwise stated.
Acute urinary retention is defined as “the inability to urinate despite a full bladder. This is defined by clinical exam as ‘painful, palpable or
percussable bladder, when the patient is unable to pass any urine.’” (126).
A1. How appropriate is use of this Some causes of acute urinary retention include: medication adverse effects (anticholinergics, opioids,
catheter because a hospitalized patient paralytics), acute neurologic injuries or inflammatory conditions of the spinal cord (trauma, disc compres-
has acute urinary retention, without sions or transverse myelitis), and some cases of bladder infection. Also, acute urinary retention can occur
bladder outlet obstruction, for… as exacerbations of chronic conditions associated with difficulty emptying the bladder (addressed in
scenarios B1 and B2).
a. less than 24 hours? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
b. 24–48 hours? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
c. greater than 48 hours? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
A2. How appropriate is use of this Some conditions that cause acute urinary retention due to bladder outlet obstruction include:
catheter because a hospitalized patient acute prostatic hyperplasia, prostate inflammation/infection (e.g., prostatitis); newly diagnosed urethral
has acute urinary retention, due to stricture; urethrocele; newly diagnosed bladder stones; bladder or prostatic masses; and temporary
bladder outlet obstruction, for… obstruction, such as edema from a recent urologic procedure (addressed in scenarios B1 and B2).
a. less than 24 hours? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
b. 24–48 hours? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
c. greater than 48 hours? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
Scenarios B1 and B2, mentioned in figure, can be found in Supplement 3 (available at www.annals.org).
Rating of the Urinary Catheter Indications The panel discussion for each catheter indication
To facilitate round 1 of the ratings, panelists were was moderated by a methods expert (S.J.B.) and a
mailed a packet of preconference materials in April CAUTI clinical content expert (J.M.). The catheter indi-
2013 (Supplement 1, available at www.annals.org), in- cation list and associated definitions were modified
cluding an introductory letter, an overview of the during the conference on the basis of discussion by
RAND/UCLA Appropriateness Method, a summary of using a standard method in the RAND/UCLA Appropri-
the literature review (including a review of urinary cath- ateness Method for annotating the revised indications
eter types), the 2009 HICPAC list of appropriate and and ratings. For example, when it became apparent
inappropriate indications for indwelling catheters, the that panelists had disagreed on an indication's appro-
Braden Scale for Predicting Pressure Sore Risk (112), priateness because they were considering 2 distinct pa-
and the round 1 rating document with instructions on tient populations, the clinical indication was revised to
how to complete it. Panelists' disclosures of interest are allow the panelists to assess appropriateness for pa-
available in Supplement 2 (available at www.annals tient population “X” (by marking an “X” on the rating for
.org). that population) and to separately assess appropriate-
The Ann Arbor Panel of Urinary Catheter Appropri- ness for patient population “O” (by marking an “O” on
ateness met on 18 and 19 June 2013. The 15 panelists the rating for that population).
were provided summary round 1 rating documents, in- For the round 2 ratings, panelists were asked to
cluding their own individual ratings from round 1 and re-rate the appropriateness of each catheter indication
the median ratings of the panel for each catheter indi- using the same 1 to 9 scale after discussing each cath-
cation. After panelist introductions, an overview of the eter indication. Because of the many modifications to
conference schedule was provided, along with a brief the catheter indications made during round 2, revised
clinical review of the function and infectious and nonin- rating documents incorporated the revised catheter in-
fectious risks of the 3 types of urinary catheters of dication text for panelists to use in a confirmatory
interest. Panelists were oriented to the round 2 rating round 3. During the round 3, panelists were simply led
document and reminded of the definition of appropri- by the moderator (J.M.) through a quick review of the
ateness; rating instructions were reviewed. catheter indications in order to confirm panelists' un-

derstanding of the revisions made to the rating docu- Catheter Appropriateness, by Clinical Indication
ment in round 2. Tables 2 to 4 summarize appropriate and inappro-
priate uses of Foley catheters, ISCs, and external con-
Data Processing and Statistical Analyses dom catheters, respectively. Table 5 provides side-by-
Data from the rating documents from each round side summaries of the appropriateness of each catheter
were entered into a Microsoft Access Database in du- for the 5 most common clinical reasons to consider a
plicate and checked for discrepancies. Analyses were urinary catheter: urinary retention, incontinence, mea-
conducted by using SAS software, version 9.3 (SAS In- suring volume, specimen collection, and comfort or
stitute). Descriptive statistics were calculated for all vari- convenience. Detailed results summarizing the median
ables. Summary result documents listing the frequency scores and frequencies of the panel ratings for each
of responses, median response, and each individual clinical scenario for round 3 are provided in Supple-
panelist's response were created. Each indication was ment 3 (available at www.annals.org) as an example of
classified as “appropriate,” “uncertain,” or “inappropri- the raw data yielded by this type of method; these
ate” in accordance with the panelists' median score and dense tables are not intended as clinical references.
the level of disagreement among them, as described in
the overview of the RAND/UCLA Appropriateness Highlights of Important Discussion Points From
Method. the Panel Conference
Urinary Retention or Obstruction
Role of the Funding Source The HICPAC guideline states that indwelling cath-
This study was funded by the Veterans Affairs Na- eter use is appropriate for “acute urinary retention or
tional Center for Patient Safety and through a contract bladder outlet obstruction” and that “intermittent cath-
from AHRQ. The funding sources were not involved in eterization is preferable to indwelling urethral or supra-
the conduct, interpretation, or reporting of the results pubic catheters in patients with bladder emptying dys-
or the decision to submit the manuscript for function.” Overall, panelist ratings for appropriateness
publication. of Foley catheters or ISCs did not vary by duration of
urinary retention (<24 hours, 24 to 48 hours, or >48
hours). Some individual panelists rated Foley catheters
with higher appropriateness for short time frames and
RESULTS ISCs for longer time frames, whereas other panelists
Overall Results, by Catheter Type rated ISCs with higher appropriateness for shorter time
Overall, in round 3, the panel rated catheter appro- frames and Foley catheters for longer time frames.
priateness for a total of 299 scenarios. This included 97 Three issues discussed reflected concern that 1) per-
clinical scenarios rated for appropriateness of each of forming ISC multiple times may be uncomfortable for
the 3 urinary catheter types (Foley, ISC, external) and 8 patients with no experience with ISCs; 2) an indwelling
clinical scenarios rated for the appropriateness of Foley Foley catheter poses an increased risk for CAUTI over
catheters instead of ISCs or external catheters due to time; and 3) the risk for infection with repeated ISC use
common issues, such as a patient's request to use a may be similar to that with indwelling catheters, partic-
Foley catheter while admitted instead of the ISC used ularly for short time periods or with suboptimal ISC
at home. Of the 299 scenarios, 88 (29.4%) were rated sterile technique by nurses without much experience
as appropriate, 165 (55.2%) were rated as inappropri- using ISCs. Of note, even in our panel of experienced
ate, and 46 (15.4%) were rated as uncertain (14 be- clinicians, not all recognized that external catheters are
cause of disagreement). absolutely inappropriate for management of urinary re-
Of the 105 clinical scenarios for which the panel tention because this type of catheter simply collects
was asked to rate appropriateness of Foley catheter urine that is spontaneously voided by the bladder.
use, 43 were rated as appropriate, 48 were rated as Scenarios of acute urinary retention with bladder
inappropriate, and 14 were rated as uncertain (4 be- outlet obstruction prompted much discussion among
cause of disagreement). Of the 97 clinical scenarios for the panelists. The appropriateness of Foley catheters or
which panelists rated appropriateness of ISCs, 15 were ISCs varied according to the reason for the obstruction.
rated as appropriate, 66 as inappropriate, and 16 as Examples discussed included bladder outlet obstruc-
uncertain (2 because of disagreement). Of the 97 clini- tion without inflammation or infection, such as acute
cal scenarios for which panelists rated appropriateness prostatic hyperplasia, newly diagnosed urethral stric-
of external catheters, 30 were rated as appropriate, 51 tures, urethroceles, bladder stones, or bladder or pros-
as inappropriate, and 16 as uncertain (8 because of dis- tatic masses. Examples of bladder outlet obstruction
agreement). Many of the evaluated clinical scenarios with inflammation or infection included urethral inflam-
included common patient characteristics, which al- mation in the setting of urinary tract infection, recent
lowed us to consolidate the appropriateness recom- urethral trauma, or prostatitis. The urologist on the
mendations into fewer clinical scenarios. For example, panel felt strongly that recommendations regarding
we found that it was a specific patient characteristic catheter placement and removal in the setting of acute
(such as a nurse's inability to turn the patient in order to prostatitis were beyond the scope of this panel, given
provide skin care) that influenced the panelist decision both the potential for catheterization to cause compli-
rather than the broader clinical scenario. cations in prostatitis (such as sepsis) and the fact that

Table 2. Guide for Foley Catheter Use in Hospitalized Medical Patients*
Appropriate indications
Acute urinary retention without bladder outlet obstruction
Example: medication-related urinary retention
Acute urinary retention with bladder outlet obstruction due to noninfectious, nontraumatic diagnosis
Example: exacerbation of benign prostatic hyperplasia
Caution: consider urology consultation for catheter type and/or placement for conditions, such as acute prostatitis and urethral trauma
Chronic urinary retention with bladder outlet obstruction†
Stage III or IV or unstageable pressure ulcers or similarly severe wounds of other types that cannot be kept clear of urinary incontinence despite wound
care and other urinary management strategies‡
Urinary incontinence in patients for whom nurses find it difficult to provide skin care despite other urinary management strategies‡ and available
resources, such as lift teams and mechanical lift devices
Examples: turning causes hemodynamic or respiratory instability, strict prolonged immobility (such as in unstable spine or pelvic fractures), strict
temporary immobility after a procedure (such as after vascular catheterization), or excess weight (>300 lb) from severe edema or obesity
Hourly measurement of urine volume required to provide treatment
Examples: management of hemodynamic instability, hourly titration of fluids, drips (e.g., vasopressors, inotropes), or life-supportive therapy
Daily (not hourly) measurement of urine volume that is required to provide treatment and cannot be assessed by other volume§ and urine collection
strategies
Examples: acute renal failure work-up, or acute IV or oral diuretic management, IV fluid management in respiratory or heart failure
Single 24-h urine sample for diagnostic test that cannot be obtained by other urine collection strategies
Reduce acute, severe pain with movement when other urine management strategies are difficult‡
Example: acute unrepaired fracture
Improvement in comfort when urine collection by catheter addresses patient and family goals in a dying patient
Management of gross hematuria with blood clots in urine
Clinical condition for which ISC or external catheter would be appropriate but placement by experienced nurse or physician was difficult or patient for
whom bladder emptying was inadequate with nonindwelling strategies during this admission
Inappropriate uses
Urinary incontinence when nurses can turn/provide skin care with available resources, including patients with intact skin, incontinence-associated
dermatitis, pressure ulcers stages I and II, and closed deep-tissue injury
Routine use of Foley catheter in ICU without an appropriate indication
Foley placement to reduce risk for falls by minimizing the need to get up to urinate
Post-void residual urine volume assessment
Random or 24-h urine sample collection for sterile or nonsterile specimens if possible by other collection strategies
Patient¶ or family request when no expected difficulties managing urine otherwise in nondying patient, including during patient transport
Patient ordered for “bed rest” without strict immobility requirement
Example: lower-extremity cellulitis
Preventing urinary tract infection in patient with fecal incontinence or diarrhea or management of frequent, painful urination in patients with urinary tract
infection
ICU = intensive care unit; ISC = intermittent straight catheter; IV = intravenous.
* This table provides guidance for Foley catheter use in the medical patient, excluding both appropriate and inappropriate uses in the perioperative
setting.
† It is unclear whether a Foley catheter is appropriate for chronic urinary retention without bladder outlet obstruction (e.g., neurogenic bladder)
when an ISC is feasible and adequate; appropriateness may vary according to reason for urinary retention and level of difficulty or discomfort
inserting an ISC.
‡ Other urinary management strategies: barrier creams, absorbent pads, prompted toileting, nonindwelling catheters.
§ Other volume assessment strategies: physical examination, daily weighing.
Other urine collection strategies: urinal, bedside commode, bedpan, external catheter, ISC.
¶ It is unclear whether a Foley catheter is appropriate for a patient with long-term ISC use who requests a “break” from the ISC by using a Foley
catheter while admitted; transition to Foley catheter may lead to difficulties returning to an outpatient ISC regimen, but a patient's clinical capabil-
ities to perform self-catheterization may be reduced depending on the reason for admission. In addition, a patient with self-catheterization history
may prefer to avoid catheterization by others.
prostatitis can be a complication of catheterization. Al- that ISCs and Foley catheters were both appropriate for
though Foley catheter insertion and use may be appro- chronic urinary retention with bladder outlet obstruc-
priate for prostatitis with acute urinary retention, the tion but were uncertain by disagreement about the ap-
decision to use a catheter for prostatitis (or suspected propriateness of a Foley catheter for chronic retention
prostatitis) needs to be highly individualized for the pa- without bladder outlet obstruction when an ISC was
tient; consultation with a urologist should be consid- feasible; discussion focused on concerns for risks of
ered to guide catheter use (which may include a Foley long-term indwelling catheters and the potential dis-
catheter or suprapubic drainage). In addition, the deci- comfort or caregiver burden of long-term ISC use.
sion to place or remove urinary catheters for a patient
with urinary retention who has recently had a urologic
procedure or urethral trauma should be made only in Urinary Incontinence or Skin Issues
consultation with the urologist. Foley catheters can be The HICPAC guideline states that indwelling cath-
used therapeutically to address hematuria in patients eter use is appropriate to “assist in the healing of open
with urethral trauma (for example, due to accidental sacral or perineal wounds in incontinent patients” but is
removal of the Foley catheter with the balloon inflated), inappropriate “as a substitute for nursing care of the
yet replacement of a Foley catheter after urethral patient or resident with incontinence.” Panelists ex-
trauma may require expert placement. Panelists agreed pressed the challenges of balancing the risks of cathe-

Table 3. Guide for Intermittent Straight Catheterization in Hospitalized Medical Patients*
Appropriate indications†
Acute urinary retention without bladder outlet obstruction, if bladder can be emptied adequately by a maximum frequency of ISC every 4 h
Example: medication-related urinary retention
Acute urinary retention with bladder outlet obstruction due to noninfectious, nontraumatic diagnosis
Example: exacerbation of benign prostatic hyperplasia
Caution: consider urology consultation for catheter type and/or placement for such conditions as acute prostatitis or urethral trauma
Chronic urinary retention with or without bladder outlet obstruction
Stage III or IV or unstageable pressure ulcers or similarly severe wounds of other types that cannot be kept clear of urinary incontinence despite
wound care and other urinary management strategies‡ if ISC is adequate to manage the type of incontinence (i.e., overflow)
Urinary incontinence that is treated and can be managed by ISC (i.e., overflow incontinence)
Urine volume measurements (not hourly) or sample collections in patients using ISC for urinary retention/obstruction or overflow incontinence
Random urine sample collection for sterile or nonsterile specimens if impossible by other collection strategies§
Management of urine in patients with strict temporary immobility if ISC does not require excessive movement
Post-void residual urine volume assessment if bladder scanner is unavailable or inadequate and more detail than suprapubic fullness is needed
Inappropriate uses
Random urine sample collection for sterile or nonsterile samples if possible by other strategies‡
ISC = intermittent straight catheter.
* This table provides guidance for ISC use in the medical patient, excluding both appropriate and inappropriate uses in the perioperative setting.
† It is unclear whether ISC is an appropriate option for urinary management in distressed patients, such as those with dyspnea or those at the end
of life, because of concerns that potential discomfort from an ISC could add to distress.
‡ Other urinary management strategies: barrier creams, absorbent pads, prompted toileting, external catheters.
§ Other urine collection strategies: urinal, bedside commode, bedpan, external catheter.
Table 4. Guide for External Catheter Use in Hospitalized Medical Patients*

Appropriate indications
Stage III or IV or unstageable pressure ulcers or similarly severe wounds of other types that cannot be kept clear of urinary incontinence despite
wound care and other urinary management strategies†‡
Moderate to severe incontinence-associated dermatitis‡ that cannot be kept clear of urine despite other urinary management strategies†
Urinary incontinence in patients for whom nurses find difficult to provide skin care despite other urinary management strategies† and available
resources, such as lift teams and mechanical lift devices
Examples: turning causes hemodynamic or respiratory instability; strict prolonged immobility, such as in unstable spine or pelvic fractures; strict
temporary immobility after procedure, such as after vascular catheterization; or excess weight (>300 lb) from severe edema or obesity
Daily (not hourly) measurement of urine volume that is required to provide treatment and cannot be assessed by other volume§ and urine collection
strategies
Examples: acute renal failure work-up, or acute IV or oral diuretic management, of IV fluid management in respiratory or heart failure
Single 24-h or random sterile¶ or nonsterile urine sample for diagnostic test that cannot be obtained by other urine collection strategies
Reduction in acute, severe pain with movement when other urine management strategies are difficult†
Example: acute unrepaired fracture
Patient request for external catheter to manage urinary incontinence while hospitalized
Improvement in comfort when urine collection by catheter addresses patient and family goals in a dying patient
Inappropriate uses
Any use in an uncooperative patient expected to frequently manipulate catheters because of such behavior issues as delirium and dementia
Any type of urinary retention (acute or chronic, with or without bladder outlet obstruction)
Urinary incontinence in patients with intact skin when nurses can turn/provide skin care with available resources when the patient has not requested
the external catheter
Routine use in ICU without an appropriate indication
External catheter placement to reduce risk for falls by minimizing the need to get up to urinate
Post-void residual urine volume assessment
24-h or random sample collection for sterile¶ or nonsterile specimens if possible by noncatheter collection strategies
Foley catheter placement for convenience of urinary management in patient during transport for tests and procedures
Patient or family request when there are no expected difficulties managing urine by commode, urinal, or bedpan in nondying patient
To prevent urinary tract infection in patient with fecal incontinence or diarrhea or to manage frequent, painful urination in patients with urinary tract
infection
ICU = intensive care unit; IV = intravenous.
* At time of this publication, external catheters are primarily developed and used for male patients in the form of condom catheters. However, these
indications would also apply to female patients after development of external catheters appropriate and adequate for such patients.
† Other urinary management strategies: barrier creams, absorbent pads, prompted toileting.
‡ It is unclear whether external catheters are appropriate for early/mild incontinence-associated dermatitis or incontinence with early-stage pressure
ulcers (stage I or II ulcers or closed deep-tissue injury) because of the increased risk for infection even with external catheters and availability of
noncatheter strategies to manage urinary incontinence.
§ Other volume assessment strategies: physical examination, daily weighing.
Other urine collection strategies: urinal, bedside commode, bedpan.
¶ Sterile sample collection that involves external catheter is feasible and appropriate, but ability to perform depends on clinician experience.

Table 5. Summary for Most Common Uses of Foley Catheters, ISCs, and External Catheters
Is This Reason an Appropriate Clinical Foley Indwelling Urinary ISC External Condom Noncatheter Options
Indication for Catheter Use? Catheter Catheter
1. Patient cannot urinate due to urinary
retention
Acute retention WITHOUT bladder outlet Yes Yes, if bladder can be No, cannot address urinary Bladder scanner, to avoid
obstruction emptied by 4- to 6-h retention catheterizing when no
Examples: medication-related (opioids, ISC or little urine seen in
anticholinergics, paralytics) bladder
Acute retention WITH bladder outlet Foley/ISC appropriateness vary by obstruction type No, cannot address urinary Bladder scanner, to avoid
obstruction Consider urology consultation for prostatitis, retention catheterizing when no
urethral trauma. or little urine seen in
bladder
Chronic urinary retention WITHOUT Uncertain* Yes No, cannot address urinary Bladder scanner, to avoid
bladder outlet obstruction retention catheterizing when no
or little urine seen in
bladder
Chronic urinary retention WITH bladder Yes Yes No, cannot address urinary Bladder scanner, to avoid
outlet obstruction retention catheterizing when no
or little urine seen in
bladder
2. Patient cannot stop or control

urination due to incontinence
Incontinence (no skin issue), nurses can No No No Barrier creams, prompted
turn/provide skin care toileting, garments can
often manage
incontinence-related
skin issues
Incontinence (no skin issues), nurses can No No Yes Barrier creams, prompted
turn but patient requests catheter toileting, garments can
often manage
skin issues
Incontinence (no skin issues), difficulty Yes No Yes Barrier creams, prompted
turning due to: toileting, garments can
Excess weight (>300 lb) from obesity or often manage
edema incontinence-related
skin issues
Turning causes hemodynamic or Yes No, because of Yes Barrier creams, prompted
respiratory instability concerns that ISC toileting, garments can
may add often manage
unnecessary distress incontinence-related
to an unstable skin issues
Strict temporary immobility after Yes. All catheters appropriate if cannot manage urine otherwise. Barrier creams, prompted
vascular procedure toileting, garments can
often manage
skin issues
Incontinence with mild/early No No Uncertain* Barrier creams, prompted
incontinence-associated dermatitis toileting, garments can
often manage
skin issues
Incontinence with moderate/severe No No Yes Barrier creams, prompted
incontinence-associated dermatitis toileting, garments can
often manage
skin issues
Incontinence with closed pressure ulcer: No No Uncertain* Yes, if use of noncatheter
stage I, deep tissue injury options would not
worsen ulcer
Incontinence with open pressure ulcer: No Yes, if ISC is adequate Uncertain* Yes, if use of noncatheter
stage II to manage the options would not
incontinence worsen ulcer
Incontinence with open pressure ulcer: Yes Yes, if ISC is adequate Yes Yes, if use of noncatheter
stage III, stage IV, or unstageable to manage the options would not
incontinence worsen ulcer
Continued on following page

Table 5—Continued
Is This Reason an Appropriate Clinical Foley Indwelling Urinary ISC External Condom Noncatheter Options
Indication for Catheter Use? Catheter Catheter
3. Clinician requests catheter to measure
urine volume†
Hourly urine volume is required to Yes No No No
provide treatment.
Example: manage hemodynamic
instability, hourly titrate IVF, drips
Daily (not hourly) urine volume required Yes, if cannot be Uncertain* Yes, if cannot assess Exam/daily weight, urinal,
to guide treatment. collected/assessed without catheter bedpan, etc.
Examples: acute renal failure work-up, without catheter
IVF or oral/IV bolus diuretics, fluid
management in respiratory failure
Post-void residual urine volume No Yes, if no bladder No Bladder scanner
scanner
4. Urine specimen collection is needed to

perform a diagnostic test‡
Sterile sample for urine culture No Yes Uncertain*¶ No
Nonsterile random urine sample No Yes Yes No
24-hour urine sample Yes Uncertain§ Yes No
5. Urine catheter is requested to provide

comfort and/or convenience
Improve comfort (address patient/family Yes Uncertain§ Yes Yes, for all options
goals) in dying patient
Family or patient request in nondying No No No Yes, for all options
patient with no incontinence or
difficulties using commode, urinal, or
bedpan
Chronic ISC patient requests a “break” Uncertain§ Yes No Bladder scanner to
from ISC while admitted reduce frequency of
ISC by avoiding if no or
little urine in bladder
ISC = intermittent straight catheter; IV = intravenous; IVF = intravenous fluid.
* Uncertain due to disagreement between panelist ratings.
§ Uncertain due to panelist ratings having median score of 4 – 6.
† It is inappropriate to use a urinary catheter simply because the patient is being cared for in an intensive care unit; an appropriate medical
indication is required.
‡ When cannot be collected by noncatheter means.
ISC can be appropriate for daily/24-h urine volume collections if all the urine can be obtained using ISC, such as patient using for urinary retention
or obstruction.
¶ External catheters can be used to collect sterile samples if the staff has been trained for applying external catheters for this purpose.
ters with the desire to address how incontinence and by position changes. However, panelists also recog-
catheters affect patient dignity. The use of urinary cath- nized that because not all hospitals have these types of
eters to manage urinary incontinence when nurses had resources readily available, pragmatic challenges
difficulty turning a patient due to morbid obesity or se- should be acknowledged in providing incontinence
vere edema prompted much discussion. Panelists care for patients who are difficult to turn. Some panel-
agreed that ambulatory obese or edematous patients ists expressed concern that encouraging catheter use
who did not require catheters before hospitalization to manage incontinent obese patients could be harmful
should have noncatheter strategies prioritized. How- because patients with catheters may not have their po-
ever, the panelists recognized that the functional status sitions changed, which could place them at risk for
of patients can change when they are ill enough to be pressure ulcers. Other panelists, however, felt that in-
hospitalized, and they may not be able to assist with adequate management of incontinence in patients who
turning in bed or with noncatheter strategies. are difficult to turn can also be harmful as a risk factor
Different options or thresholds were proposed to for skin breakdown.
describe morbid obesity or edema severe enough to In conclusion, use of a Foley or external catheter
make turning too difficult; these options included body was assessed as appropriate to manage incontinence
mass index and different weight thresholds. In the end, in a patient difficult for nurses to turn with their avail-
panelists agreed that 300 pounds was a reasonable able resources because of morbid obesity or severe
weight threshold because this weight may increase the edema.
risk for injury to nurses trying to turn the patient. Such More discussion than was anticipated occurred for
resources as mechanical lifts and lift teams were noted use of catheters to address incontinence-associated
to be important resources in providing care to patients dermatitis, defined as “irritation and inflammation of
who are challenging to turn. These resources can, in the skin from prolonged exposure to urine or stool;
turn, facilitate skin care and reduce pressure ulcer risks skin erosion is common in this condition; this condition

is different than a pressure ulcer because it not related When the panel discussed use of catheters for re-
to pressure, but can increase a patient's risk for devel- peated daily urine volumes, it recommended that uri-
oping pressure ulcers” (27). Definitions of mild, moder- nary catheters should be considered only if the daily
ate, and severe dermatitis were provided verbally and urine volume (or patient's overall volume status) could
in the rating document. Panel discussion was led by not be assessed adequately by noncatheter methods,
nurses explaining that noncatheter strategies can be ef- such as daily weighing; physical examination; and urine
fective for prevention and management of incontinence- collection by urinal, bedpan, hat, or commode. Panel-
associated dermatitis. For patients with incontinence- ists also discussed examples of when it is clinically suf-
associated dermatitis, neither Foley catheters nor ISCs ficient to know that the patient is making large amounts
were assessed as appropriate to manage incontinence of urine (such as noted by incontinence with large
regardless of severity; panelists were uncertain by dis- amounts of urine) but the exact volume of urine is not
agreement about external catheters for mild dermatitis needed. Yet if these noncatheter methods to collect or
but assessed external catheters as appropriate for assess urine production do not address the need, both
moderate or severe dermatitis. Foley and external catheters were assessed as appro-
Pressure ulcer was defined as “a localized injury to priate; ISC appropriateness was uncertain by disagree-
the skin and/or underlying tissue usually over a bony ment. Panelists expressed concerns that ISCs may be
prominence, as a result of pressure, or pressure in com- inadequate to assess an accurate daily urine volume in
bination with shear” (27). Definitions for pressure ulcers most patients in whom urine collection by other means
by stage as defined by the National Pressure Ulcer Ad- is difficult.
visory Panel were provided in the rating document Of note, panelists uniformly rated urinary catheters
(113). Routine tools for assessing pressure ulcer risk for urine volume monitoring simply because the patient
were also discussed, with a copy of the Braden Scale is located in an ICU as inappropriate (median score, 1);
provided as an example (112). Panelists rated all cath- even patients in an ICU require an appropriate medical
eter types as inappropriate (median scores, 1 to 2) for indication given the risks associated with any urinary
preventing pressure ulcer development in an inconti- catheter use.
nent patient for whom nurses had no difficulty turning
to provide skin care, regardless of the patient's as-
sessed risk for pressure ulcers by a risk-assessment
tool, such as the Braden Scale. Catheter appropriate- Urine Specimen Collection
ness for incontinent patients with pressure ulcers varied The HICPAC guideline states that indwelling cath-
by ulcer stage, as detailed in Tables 2 and 4. eter use is inappropriate “as a means of obtaining urine
for culture or other diagnostic tests when the patient
can voluntarily void.” Consistent with this guidance, as
summarized in Tables 2 to 4, panelists rated catheters
Measuring Urine Volume as inappropriate if urine could be obtained by other
The HICPAC guideline states that an appropriate means. However, they also rated scenarios providing
use of an indwelling catheter is “for accurate measure- guidance as to which catheter types may be appropri-
ments of urinary output in critically ill patients.” Our ate for specific urine sample types when urine collec-
panel assessed multiple scenarios to clarify when urine tion is difficult, based on the type of urine specimen
output volume measurement by a urinary catheter is needed (random versus 24-hour sample, sterile versus
appropriate to deliver care to ICU and non-ICU pa- nonsterile).
tients. As summarized in Tables 2 to 4, when hourly
urine volumes are required to provide treatment, the
Foley catheter is appropriate because it is the only
method that can provide hourly measurements. Of Urinary Catheter Use for Comfort
note, even among our panel of experienced clinicians, The HICPAC guideline states that indwelling cath-
not all recognized that external catheters cannot be eter use is appropriate “to improve comfort for end of
used to assess hourly urine production because this life care if needed.” Panelists agreed with this indica-
type of catheter simply collects urine that is spontane- tion, rating Foley and external catheters as appropriate
ously voided by the bladder. The panel discussed the when the catheter addressed the goals of the dying
following examples of scenarios requiring hourly urine patient and the family. Panelists noted that catheters
output: 1) management of hemodynamic instability re- can both address incontinence and preserve precious
quiring hourly titrations of medications, such as vaso- time that would be needed for incontinence care. How-
pressors, inotropes, diuretics, and intravenous fluid bo- ever, catheters may be uncomfortable, hazardous, and
luses; 2) acute respiratory failure requiring invasive embarrassing for patients and thus are not always help-
ventilation with hourly titrations of medical and respira- ful or desired.
tory therapies; and 3) hourly measurement for urine The panel addressed several scenarios of patient
studies or urine volumes to manage life-threatening and family requests for urinary catheters. In brief, all
laboratory abnormalities (for example, critical hypergly- catheters were assessed as inappropriate when re-
cemia or abnormal levels of electrolytes, such as cal- quested for a patient with no incontinence and no dif-
cium, potassium, and sodium). ficulties using the commode, urinal, or bedpan; in fact,

the particular hazard of Foley catheters and external DISCUSSION
catheters as the “one-point restraint” (114), with in- Our 15-member multidisciplinary panel of experts
creased potential harms related to falls and immobility, applied the RAND/UCLA Appropriateness Method to
informed the panel's decision. generate refined appropriateness criteria for Foley
Panelists were uncertain by disagreement regard- catheters, as well as new criteria for appropriateness of
ing the use of a Foley catheter instead of an ISC as a ISC and external catheters for hospitalized adult medi-
requested “break” from ISCs for patients with long-term cal patients. Tables 2 to 4 summarize the refined ap-
ISC use at home during their hospitalization. Some pan- propriate and inappropriate indications for Foley
elists acknowledged that patients with long-term ISC catheters, ISCs, and external condom catheters, respec-
may be unable to perform their usual ISC while admit- tively. We believe these tables will be useful as guides
ted and may prefer to avoid insertion of an ISC by oth- for clinical selection of urinary catheters. We believe
ers. Other panelists noted that use of a Foley catheter that, similar to the widely used table of indwelling uri-
in a patient managed by long-term ISC use can impair nary catheter indications from the 2009 HICPAC CAUTI
the patient's long-term bladder function, leading to dif- guideline, these tables will also be useful in adapting,
ficulties transitioning back to an ISC after discharge, implementing, and assessing interventions to reduce
particularly if use of a Foley catheter is prolonged. Foley catheter use. For example, many hospitals cur-
Panelists considered catheter use as a means to rently use the 2009 HICPAC example list of appropriate
avoid pain-provoking movements and discussed that indications as pull-down options in electronic orders
using a catheter to avoid movement is associated with for urinary catheters; our refined list can be imple-
immobility hazards. In brief, panelists rated Foley cath- mented in a similar way. Likewise, the 2009 HICPAC list
eters (median score, 7) and external catheters (median of example appropriate indications for indwelling uri-
score, 8) as appropriate for urine management to min- nary catheters has been used in retrospective medical
imize acute severe pain associated with movement. Ex- record reviews and practice surveys to assess and pro-
amples included a severe unrepaired fracture and a vide feedback on appropriateness of Foley catheter
joint infection. All catheters were assessed as inappro- use; our refined indication list can be used in the same
priate (median score, 1 to 3) for avoiding movement to manner. Tables 3 and 4 are new resources to guide
avert an exacerbation of chronic pain given the antici- appropriate use of ISC and external catheters, similar to
pated duration or frequency of catheter use that would how the 2009 HICPAC guideline has been used for
be needed for this purpose. guiding Foley catheter use.
Panelists rated all urinary catheters as inappropri- Compared with the HICPAC examples of catheter
ate (median score, 1 to 2) for decreasing the need to indications, panelists agreed that Foley catheters were
appropriate for many scenarios that could be generi-
get out of bed in order to prevent falls in patients at
cally described by the HICPAC terminology. Yet panel-
increased risk for falls. All catheter types were assessed
ists also often assessed ISC or external catheters as ap-
as inappropriate to manage incontinence for combat-
propriate or requested more detailed clinical criteria,
ive patients. This assessment stems from the risk for
such as severity of illness and challenges with using
catheter-related harm associated with an inability to
noncatheter means to justify using a Foley catheter. We
safely place a catheter in an uncooperative patient and
anticipate that these refined urinary catheter criteria will
excessive manipulation or accidental removal of the
allow physicians and nurses to feel more comfortable
catheter by the patient. implementing interventions to restrict catheter use be-
The panel also assessed the appropriateness of cause the criteria address practical challenges regard-
Foley catheters for patients for whom other catheters ing catheter use and urinary management.
would be appropriate but are anticipated to be difficult Panel discussions revealed unexpected but impor-
to place. Panelists assessed Foley catheters as appro- tant key issues involving selection of different types of
priate instead of ISC when an experienced nurse or urinary catheters. Even experienced clinicians may not
physician has difficulty with ISC insertion during the be aware that external catheters are inappropriate for
hospitalization or when there is a documented history urinary retention or measurement of hourly urine out-
of difficult placement due to genitourinary tract anom- put and are associated with an increased risk for infec-
alies. Panelists were uncertain regarding appropriate- tion (although lower than that seen with a Foley cathe-
ness of using a Foley catheter when the patient re- ter). The development of an external catheter for
ported previous difficulty with ISCs. Panelists noted that female patients is also critically needed to reduce use
a single painful ISC experience should not preclude of Foley catheter use in these patients. Clinicians often
use of an ISC in the future because it may be the most worry about the discomfort ISC may cause some pa-
appropriate and safest method for the patient's urinary tients and expressed uncertainty about deciding when
problem. Panelists did discuss the importance of rec- an ISC is adequate for managing urinary issues. Despite
ognizing the patient's anxiety and choosing experi- the first HICPAC indication of Foley catheters to man-
enced clinicians to attempt the ISC with all comfort pre- age “acute urinary retention or bladder outlet obstruc-
cautions, such as lidocaine gel and a size and style of tion,” our panel's urologist clarified that the appropri-
straight catheter appropriate for the patient's clinical ateness of Foley catheter, ISC, or suprapubic catheter
situation. for acute retention with bladder outlet obstruction var-

Figure 4. ICU daily checklist for appropriateness of Foley catheter.
Is the Foley catheter still appropriate for your ICU patient? If your patient does not have one of the following criteria, remove Foley catheter.
1. Urine volume measurement:
a. Is HOURLY urine volume measurement being used to inform and provide treatment?
Examples: Hemodynamic instability requiring hourly or multiple daily titrations per day of ongoing bolus fluid resuscitation, vasopressors,
inotropes, or diuretics
Acute respiratory failure requiring invasive ventilation with hourly titrations of diuretics
Hourly measurement of urine studies or urine volumes to manage life-threatening laboratory abnormalities
b. Is DAILY urine volume measurement being used to provide treatment AND volume status CANNOT be adequately or reliably assessed without a
Foley catheter, such as by daily weight or urine collection by urinal, commode, bedpan, or external catheter?
Examples: Management of acute renal failure, IV fluids, or IV or oral bolus diuretics
Fluid management in acute respiratory failure requiring large volumes of oxygen (≥5 L/min or >50%)
2. Does patient have a urologic problem that is being treated with a Foley catheter?
Examples: Urinary retention that cannot be adequately monitored or addressed by bladder scanner or ISC
Urinary retention anticipated because of treatment with paralytic medications
Recent urologic or gynecologic evaluation or procedure with Foley catheter not recommended to be removed yet, such as:
− Acute urinary retention with bladder outlet obstruction due to acute prostatitis or urethral edema
− Gross hematuria with blood clots in the urine
− Hematuria suspected to be prostatic or urethral bleeding being managed with Foley catheter
3. Urine sample collection for a laboratory test when CANNOT be collected by non catheter method
What type of sample is needed? Use Foley Catheter? Use ISC? Use External Catheter?
Sterile sample for urine culture No Yes Yes, if staff trained for sterile application
Nonsterile random urine sample No Yes Yes
24-hour urine sample Yes If all urine can be collected by ISC Yes, preferred option in cooperative males
4. Does the patient have urinary incontinence that cannot be addressed by noncatheter methods (barrier creams, incontinence garments and absorbent
pads, prompted toileting, straight catheterization if overflow incontinence) because nurses cannot turn and provide skin care with specialty resources
(such as lift teams and lift machines) or transition to external catheter (for cooperative males)?
Examples: Turning causes hemodynamic or respiratory instability
Strict temporary immobility postprocedure, such as from a vascular procedure if patient cannot manage urine otherwise
Incontinence with open pressure ulcers (stage III or IV) or “unstageable” ulcers
5. Foley catheter is providing comfort from severe distress related to urinary management that cannot be addressed by noncatheter options, ISC, or
external catheter.
Examples: Difficulty voiding due to severe dyspnea with position changes required for managing urine without an indwelling catheter
Address patient and family goals in a dying patient
Acute, severe pain upon movement (e.g., unrepaired fracture) WITH demonstrated difficulties using noncatheter options or external
catheter
ICU = intensive care unit; ISC = intermittent straight catheter; IV = intravenous.
ies by the reason for obstruction, such as prostatitis or ters, provides examples tailored to the ICU, and in-
urethral injury; other panelists agreed with this caution. cludes alternatives to consider, with the goal of de-
Given the persistently high rate of Foley catheter creasing the risk for infectious and noninfectious
use in the ICU, along with the growing hazard of complications of Foley catheters.
multidrug-resistant organisms in nosocomial urinary Our study has several limitations. Nine of our 15
tract infections and increasing rates and morbidity of experts came from the University of Michigan, Ann Ar-
Clostridium difficile infection, we hope our results will bor Veterans Affairs Medical Center, or both; 3 other
encourage decreased placement and earlier removal experts came from the Ann Arbor or Detroit area.
of Foley catheters in the ICU. Perhaps the simplest but Therefore the appropriateness ratings may better re-
potentially most powerful panel assessment was that flect institutional or regional views than national exper-
urinary catheters are inappropriate for monitoring urine
tise. Although we sought a broader representation of
solely because the patient is in an ICU; even ICU pa-
experts across the United States, our selection of pan-
tients should have an appropriate medical reason to
elists was limited by availability for a 2-day meeting
justify the risk for a urinary catheter.
We developed a daily checklist as a potential tool (which is easier to obtain for local panelists) and the
for reviewing Foley catheter appropriateness for ICU need to replace 2 nonlocal panelists with local panelists
patients (Figure 4). This checklist focuses on Foley cath- because of last-minute emergencies limiting their avail-
eter use rather than all catheters because Foley cathe- ability. Our panel was diverse, but we could not include
ters remain the most commonly used and pose the all specialists who use urinary catheters to manage
highest risk to ICU patients. Although this tool certainly medical patients. However, although the panel did not
cannot address all medical indications for Foley cathe- include nephrologists or bariatric specialists, it did in-
ters (and is undergoing refinement by clinical testing), it clude many clinicians who routinely evaluate and man-
focuses on the most common requests for Foley cathe- age acute renal insufficiency and obese patients.

Our panel's recommendations regarding the use Board, which provided recommendations regarding the types
of catheters in morbid obesity also reflects the reality of expertise that should be represented on the panel.
that not all hospitals in the United States have special-
ized resources for caring for morbidly obese patients, Financial Support: This research was funded by the Depart-
such as lift teams and mechanical lifts. Issues in the care ment of Veterans Affairs National Center for Patient Safety,
of bariatric patients also included anatomical chal- Ann Arbor Patient Safety Center of Inquiry, and a contract
lenges with placement of all urinary catheter types for through the Agency for Healthcare Research and Quality
patients with severe adiposity; in such patients, clini- (AHRQ) (contract HHSA290201000025I/HHSA29032001T).
cians cannot visualize the urethral meatus to safely Dr. Meddings' effort on this project was funded by concurrent
place or secure catheters. effort from AHRQ (K08 HS19767). AHRQ provided funding for
This project's findings are also limited to indica- the publication of this supplement.
tions for urinary catheters most commonly considered
on medicine services and not for perioperative indica- Disclosures: Dr. Meddings reports consultancy/honorarium
tions because the literature review and clinical exper- with the Society for Healthcare Epidemiology of America; em-
tise required for perioperative indications were ex- ployment with the University of Michigan Health System;
grants received from AHRQ; payment for lectures/speakers'
pected to be different.
bureaus with various professional and nonprofit organizations
Despite these limitations, we believe the Ann Arbor
(including Society for Healthcare Epidemiology of America,
Criteria for Appropriate Urinary Catheter Use in Hospi-
Central Society for Clinical Research, Wound Ostomy & Con-
talized Medical Patients will inform both small- and tinence Nurses Society) and QuantiaMD; RAND/AHRQ hono-
large-scale interventions for avoiding placement and rarium for preparation of AHRQ Chapter update on preven-
prompting removal of unnecessary urinary catheters. tion of catheter-associated UTI (payment for manuscript
They may be particularly helpful for units, such as ICUs, preparation); and travel/accommodations/meeting expenses
that have not seen a meaningful reduction in urinary outside the submitted work from AHRQ and Blue Cross Blue
catheter use, possibly related to broad and varied in- Shield of Michigan Foundation. Dr. Saint reports grants and
terpretation of the 2009 HICPAC criteria. National sur- personal fees from Department of Veterans Affairs (VA) Na-
veillance measures of “appropriate” urinary catheter tional Center for Patient Safety and AHRQ during the conduct
use are needed as a next step for comparing and mo- of the study, as well as personal fees from Doximity and Jvion
tivating safer catheter use. The detailed criteria involve outside the submitted work. Ms. Fowler reports grants and
the identification of patients for whom catheter use is personal fees from Department of Veterans Affairs (VA) Na-
appropriate, taking into account patient-specific chal- tional Center for Patient Safety and AHRQ during the conduct
lenges, and can aid in developing a standardized de- of the study. Dr. Krein reports grants and personal fees from
vice use ratio for comparing hospital performance. Al- Department of Veterans Affairs (VA) National Center for Pa-
though the criteria developed by this method are more tient Safety and AHRQ during the conduct of the study. Dr.
complex and will be more challenging to implement Bernstein reports grants from Department of Veterans Affairs
(VA) National Center for Patient Safety and a contract from
and monitor, the complexity mirrors the hard decisions
AHRQ during the conduct of the study. Dr. Bernstein reports
that clinicians are already making each day when de-
grants from Department of Veterans Affairs National Center
ciding to place or remove Foley catheters. for Patient Safety from the Agency for Healthcare Research
From the University of Michigan Medical School and Veterans and Quality during the conduct of the study. Dr. Bernstein is a
Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, member of the Blue Care Network Clinical Quality Committee
and Cushing/Whitney Medical Library, Yale University, New (which reviews issues related to quality of care [although uri-
Haven, Connecticut. nary catheter use has not been considered in the past, it may
be reviewed in the future]) and is also Director of Quality for
Presented in part by poster presentations at the Society of the University of Michigan Faculty Group Practice (if the ap-
Hospital Medicine Annual Meeting, Las Vegas, Nevada, 25 propriateness of urinary catheter criteria developed as part of
March 2014, and the Society of General Internal Medicine this process are widely adopted, they could be applied to the
37th Annual Meeting, San Diego, California, 24 April 2014. University of Michigan by outside agencies). Authors not
Presented in part by teleconference for the AHRQ 50-State named here have disclosed no conflicts of interest. Disclo-
“On the CUSP: Stop CAUTI” Collaborative on 14 January 2014 sures can also be viewed at www.acponline.org/authors/icmje
and the Veterans Affairs National Center for Patient Safety /ConflictOfInterestForms.do?msNum=M14-1304.
CAUTI Breakthrough Series on 18 June 2014.
Requests for Single Reprints: Jennifer Meddings, MD, MSc,
Acknowledgment: The authors thank the panelists (Table 1) University of Michigan North Campus Research Complex
for their time, expertise, and enthusiasm shared for this proj- Building 16, Room 427W, 2800 Plymouth Road, Ann Arbor,
ect. They are indebted to John Hollingsworth, MD, MSc; MI 48109; e-mail, [email protected].
Milisa Manojlovich, PhD, RN, CCRN; Vineet Chopra, MD, MSc;
Deborah Levine, MD, MPH; Melissa Pynnonen, MD; Lena Current Author Addresses: Dr. Meddings: University of Mich-
Chen, MD, MS; Jeffrey Kullgren, MD, MS, MPH; and Jim igan North Campus Research Complex Building 16, Room
Burke, MD, MS, for detailed feedback on the development 427W, 2800 Plymouth Road, Ann Arbor, MI 48109.
and refinement of the urinary catheter indications rating doc- Dr. Saint: University of Michigan North Campus Research
ument. The authors also acknowledge the Veterans Affairs Complex Building 16, Room 433W, 2800 Plymouth Road, Ann
Ann Arbor Patient Safety Center of Inquiry Strategic Advisory Arbor, MI 48109.

Ms. Fowler: Ann Arbor Patient Safety Center of Inquiry 2009. Infect Control Hosp Epidemiol. 2010;31:319-26. [PMID:
Hospital Outcomes Program of Excellence Initiative, VA Cen- 20156062] doi:10.1086/651091
ter for Clinical Management Research (152), PO Box 130170, 9. Greene MT, Kiyoshi-Teo H, Reichert H, Krein S, Saint S. Urinary
catheter indications in the United States: results from a national sur-
Ann Arbor, MI 48113-0170.
vey of acute care hospitals. Infect Control Hosp Epidemiol. 2014;35
Drs. Gaies and Krein: VA Health Services Research and Devel- Suppl 3:S96-8. [PMID: 25222904] doi:10.1086/677823
opment Service (152), PO Box 130170, Ann Arbor, MI 48113. 10. Greene MT, Fakih MG, Fowler KE, Meddings J, Ratz D, Safdar N,
Mr. Hickner: Cushing/Whitney Medical Library, 333 Cedar et al. Regional variation in urinary catheter use and catheter-
Street, PO Box 208014, New Haven, CT 06520. associated urinary tract infection: results from a national collabora-
Dr. Bernstein: University of Michigan North Campus Research tive. Infect Control Hosp Epidemiol. 2014;35 Suppl 3:S99-S106.
[PMID: 25222905] doi:10.1086/677825
Complex, Building 16, Room 446E, 2800 Plymouth Road, Ann
11. Fitch K, Bernstein SJ, Aguilar MS, Burnand B, LaCalle JR, Lazaro
Arbor, MI 48109. P, et al. The RAND/UCLA Appropriateness Method User's Manual.
Santa Monica, CA: RAND; 2001.
12. Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE.
Author Contributions: Conception and design: S.J. Bernstein,
A method for the detailed assessment of the appropriateness of
K.E. Fowler, S.L. Krein, J. Meddings, S. Saint. medical technologies. Int J Technol Assess Health Care. 1986;2:53
Analysis and interpretation of the data: S.J. Bernstein, K.E. -63. [PMID: 10300718]
Fowler, J. Meddings. 13. Park RE, Fink A, Brook RH, Chassin MR, Kahn KL, Merrick NJ,
Drafting of the article: S.J. Bernstein, E. Gaies, A. Hickner, J. et al. Physician ratings of appropriate indications for six medical and
Meddings. surgical procedures. Am J Public Health. 1986;76:766-72. [PMID:
3521341]
Critical revision for important intellectual content: S.J. Bern-
14. Wong ES. Guideline for prevention of catheter-associated urinary
stein, K.E. Fowler, S.L. Krein, J. Meddings, S. Saint. tract infections. Centers for Disease Control and Prevention. 1 Feb-
Final approval of the article: S.J. Bernstein, K.E. Fowler, E. ruary 1981. Accessed at http://wonder.cdc.gov/wonder/prevguid
Gaies, S.L. Krein, J. Meddings, S. Saint. /p0000416/p0000416.asp on 1 June 2014.
Obtaining of funding: S.L. Krein, J. Meddings, S. Saint. 15. Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE,
Administrative, technical, or logistic support: K.E. Fowler, E. Rice JC, et al; Infectious Diseases Society of America. Diagnosis,
prevention, and treatment of catheter-associated urinary tract infec-
Gaies, A. Hickner.
tion in adults: 2009 International Clinical Practice Guidelines from the
Collection and assembly of data: K.E. Fowler, E. Gaies, A. Infectious Diseases Society of America. Clin Infect Dis. 2010;50:625
Hickner, J. Meddings. -63. [PMID: 20175247]
16. Greene L, Marx J, Oriola S. An APIC guide to the elimination of
catheter-associated urinary tract infections (CAUTIs): developing and
applying facility-based prevention interventions in acute and
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Appendix Table. Synthesis of Urinary Catheter Indications From the Literature
Reference: First Author: Title of Guideline, Other References If Indication for Indwelling Urinary Catheter Use Type of Material Cited
Cited for Catheter Indications
Theme 1: Urinary retention and/or obstruction
Adams et al (32); additional references: (17, 106) Obstruction Original research report
Apisarnthanarak et al (79); additional references: (57, 59, 62, 90–92) Urinary retention due to obstructive uropathy or drugs Original research report
Obstruction to the urinary tract distal to the bladder
Bruminhent et al (33); additional references: (8, 17, 79) Urinary tract obstruction Original research report
Neurogenic bladder or urinary retention
Dumigan et al (81); additional reference: (93) Any patient with inability to void for relief of urinary Original research report
obstruction when intermittent catheterization is
difficult
Elpern et al (98) Urinary tract obstruction Original research report
Urinary retention
Neurogenic bladder dysfunction
Fakih et al (34, 82); additional reference: (14) Urinary tract obstruction Original research report
Neurogenic bladder dysfunction
Urinary retention
Fakih (115); additional references: (14, 17) In ED setting: Original research report
Neurogenic bladder
Urinary obstruction
Fuchs et al (35) Inability to void as documented by bladder scanning Original research report
Long-term catheterization (>28 d) has already been
initiated
Gardam et al (94); additional reference: (116) Obstruction of urinary tract distal to the bladder Original research report
Geng et al (19); additional references: (8, 18, 60, 63–78) Relief of acute or chronic retention Evidence-based
Long-term indwelling catheterization may be needed guidelines
for: 1) bladder outlet obstruction when unsuitable
for surgical relief, 2) chronic retention (often as a
result of neurologic injury or disease) where
intermittent catheterization is not possible
Bladder outlet obstruction, in patients who are
unsuitable for surgical relief
Gokula et al (59); additional references: (92, 93, 117) Obstruction of the urinary tract distal to the bladder Original research report
To permit urinary drainage in patients with neurogenic
bladder dysfunction and urinary retention
Gotelli et al (99) Relief of urinary retention not managed with Original research report
intermittent catheterization
Gould et al: 2009 Healthcare Infection Control Practices Advisory Acute urinary retention or bladder outlet obstruction Evidence-based
Committee Guideline to Prevent Catheter-Associated Urinary guidelines
Tract Infection (8); additional references: (14, 17, 40–58, 87, 118)
Hooton et al: Diagnosis, Prevention, and Treatment of Clinically significant urinary retention if medical Evidence-based
Catheter-Associated Urinary Tract Infection in Adults: 2009 therapy is not effective and surgical correction is not guidelines
International Clinical Practice Guidelines from the Infectious indicated
Diseases Society of America (14); additional references:
(15, 61, 62)
Huang et al (57); additional reference: (62) Urinary retention that could not be relieved by Original research report
alternate measures
Jain et al (62) Managing urinary retention due to obstructive Original research report
uropathy or drugs
Knoll et al (36); additional reference: (61) Urinary retention Original research report
Lo et al: Strategies to Prevent Catheter-Associated Urinary Tract Acute urinary retention and urinary obstruction Evidence-based
Infections in Acute Care Hospitals (17); additional references: guidelines
(59, 60)
Loeb et al (84); additional references: (62, 91, 94) Urinary tract obstruction Original research report
Neurogenic bladder
Urinary retention
Reilly et al (86); additional references: (59, 60, 63) Acute neurogenic bladder Original research report
Inability to void
Robinson et al (100); additional references: (59, 61, 62, 107, 119) Provide relief of urinary tract obstruction not Original research report
manageable by other means
Permit drainage in patients with neurogenic bladder
dysfunction and urinary retention that is not
manageable by other means (with clean intermittent
catheterization)
Roser et al (37) Acute urinary retention or obstruction Original research report
Rothfeld and Stickley (38) Inability to void spontaneously (usually because of Original research report
obstruction)
Saint et al (56); additional references: (62, 95) Urinary retention Original research report
Titsworth et al (39); additional reference: (120) Neurogenic bladder or retention only if I&O Original research report
catheterization fails

Appendix Table—Continued
Topal et al (88); additional references: (14, 96) Bladder outlet obstruction Original research report
Acute urinary retention
Voss (104); additional references: (49, 108) Chronic history of prolonged catheterization or Original research report
suprapubic catheter
Weitzel (89) To relieve urinary tract obstruction, neurogenic Original research report
bladder, hydronephrosis, urinary retention that
cannot be drained by other means such as ISC
Wong: Guideline for prevention of catheter-associated urinary tract To relieve urinary tract obstruction Evidence-based guideline
infections (14) To permit urinary drainage in patients with neurogenic
bladder dysfunction and urinary retention
Theme 2: Accurate measurement of urinary output

Adams et al (32); additional references: (17, 106) Input and output measurement Original research report
Apisarnthanarak et al (79); additional references: (57, 59, 62, 90–92) Fluid challenge in patient with acute renal insufficiency Original research report
Close monitoring of urine output as indicated for
incontinent patients, uncooperative patients (e.g.,
because of intoxication), or critically ill patients.
Critical illness was defined as hypoxemia,
hypotension, or congestive heart failure, need for
inotropic support, repeated administration of
diuretics, suggesting need to closely monitor urine
output on an hourly basis
Bruminhent et al (33); additional references: (8, 17, 79) Urinary output measurement in critical patients Original research report
Dumigan et al (81); additional reference: (93) Any patient requiring monitoring of acute renal Original research report
insufficiency or failure
Patient requiring strict I&O and is unable to cooperate
with bathroom, bedpan, or urinal use. Need for
strict I&O should be assessed after 72 h, and
documentation should include reason for strict I&O
after 72 h
Any neurosurgery patient being monitored for
syndrome of inappropriate antidiuretic hormone
secretion
Elpern et al (98) Frequent monitoring (every 1-2 h) of urinary output Original research report
required
Need to obtain accurate measurements of urinary
output in critical illness
Fakih et al (115); additional references: (14, 17) In ED setting: Original research report
Output monitoring in intensive care
Non-intensive care with ≥6 L/min oxygen
Intubated
Fuchs et al (35) Urinary incontinence and strict fluid input/output Original research report
monitoring required
Monitoring of urinary output because of
hemodynamic instability
Gardam et al (94); additional reference: (116) Alteration in BP or volume status requiring continuous, Original research report
accurate urine volume measurement
Need to measure urine output accurately in
uncooperative patient (e.g., intoxication)
Geng et al (19); additional references: (8, 18, 60, 63–78) Need for accurate measurements of urinary output in Evidence-based
critically ill patients guidelines
Gokula et al (59); additional references: (92, 93, 117) Alteration in the blood pressure or volume status Original research report
requiring continuous, accurate urine volume
measurement
A need to measure urine output accurately in an
uncooperative patient (e.g., intoxication)
Gotelli et al (99) Aggressive treatment with diuretics or fluids Original research report
Accurate monitoring of intake and output
Gould et al: 2009 Healthcare Infection Control Practices Advisory Need for accurate measurements of urinary output in Evidence-based
Committee Guideline to Prevent Catheter-Associated Urinary critically ill patients guidelines
Hooton et al: Diagnosis, Prevention, and Treatment of Accurate urine output monitoring required, when Evidence-based
Catheter-Associated Urinary Tract Infection in Adults: 2009 frequent or urgent monitoring needed, such as with guidelines
International Clinical Practice Guidelines from the Infectious critically ill patients, when patient unable or
Diseases Society of America (15); additional references: (14, 61, unwilling to collect urine
62)
Huang et al (57); additional reference: (62) Need for precise monitoring of urine output Original research report
Fluid challenge in patient with acute renal insufficiency

Jain et al (62) Close monitoring of urine output in the critically ill Original research report
patient needing intensive monitoring. The presence
of hypoxemia, hypotension, congestive heart failure,
and the need for inotropic support or repeated
administration of diuretics suggested the need for
close monitoring or urine output on an hourly basis.
Close monitoring of urine output in the patient no
longer critically ill and in whom hourly urine record
of urine output did not prompt any change in
therapy only when a reasonable record of urine
output could not be maintained due to urinary
incontinence or lack of patient cooperation
Knoll et al (36); additional reference: (61) Fluid challenge in acute renal insufficiency Original research report
Intake and output monitoring and patient critically ill
or unwilling/unable to collect urine
Lo et al: Strategies to Prevent Catheter-Associated Urinary Tract Urine output monitoring in critically ill Evidence-based
(59, 60)
Loeb et al (84); additional references: (62, 91, 94) Fluid challenge in patient with acute renal failure Original research report
Patrizzi et al (68) Hemodynamic instability Original research report
Reilly et al (86); additional references: (65, 60, 63) 24-h urine collection in an ICU Original research report
Hourly intake and output monitoring in an ICU
Hemodynamically unstable needing accurate I&O
monitoring in an ICU
Strict I&O monitoring required and patient incontinent
in an ICU
Robinson et al (100); additional references: (59, 60, 62, 107, 119) Obtain accurate intake and output in critically ill Original research report
patients
Roser et al (37) Critically ill patient requiring strict output monitoring Original research report
(ICU)
Rothfeld and Stickley (38) Physician order for hourly urine output reporting Original research report
Saint et al (56); additional references: (62, 95) Very close monitoring of urine output and patient Original research report
unable to use urinal or bedpan
Titsworth et al (39); additional reference: (120) Urine output monitoring in critically ill patients for a Original research report
finite period
Topal et al (88); additional references: (14, 96) Urinary output monitoring if the patient was unable to Original research report
collect urine
Voss (110); additional references: (49, 108) Aggressive treatment with diuretic medications or Original research report
fluids
Weitzel (89) To measure accurate intake and output in critically ill Original research report
patients
Wenger (105) The patient has received IV inotropic agents within the Original research report
last 24 h
There is an order for IV diuretics to be given every 6 or
fewer hours
The patient is undergoing ultrafiltration
Acute or worsening renal failure is evident (that is,
there has been a creatinine level increase of 1
mg/dL or more above the admission or baseline
level)
Wong: Guideline for prevention of catheter-associated urinary tract To obtain accurate measurements of urinary output in Evidence-based guideline
infections (14) critically ill patients
Theme 3: Peri-procedural
Adams (32); additional references: (17, 106) Urologic surgery Original research report
Apisarnthanarak et al (79); additional references: (57, 59, 62, 90–92) Patient at risk of contaminating the site of a recent Original research report
surgical procedure
Preoperative insertion for patients going direction to
the operation room
Bruminhent et al (33); additional references: (8, 17, 79) Urologic surgery or other surgery on contiguous Original research report
structures

Dumigan et al (81); additional reference: (93) Any patient undergoing a urologic procedure, until Original research report
blood clears from urine
Plastic surgery procedure for repair of pressure ulcer
until flap is healed
Any gynecologic procedure, usually for duration of
surgery but no more than 24 h postoperative (72 h if
vesicourethral suspension)
Patient with prolonged cardiac procedure anticipated
(e.g., complex angioplasty). Discontinue
immediately postoperative.
Any patient undergoing a prolonged (>2 h) surgical
procedure (e.g., vascular, cardiac, or extensive
bowel procedures). Orders for catheter
discontinuation should be written when orders are
written for the patient to be allowed out of bed.
Any obstetrics patient with postpartum vulvar edema
until resolution, or receiving magnesium sulfate for
pre-eclampsia
Elpern et al (98) Patient to undergo prolonged (>2 h) procedure Original research report
Epidural catheter in place
Recently underwent surgical/invasive procedures
Urologic surgeries
Fakih et al (37, 82); additional reference: (14) Need to undergo urologic procedures, or urologic Original research report
surgery or surgery on contiguous structures
Emergent pelvic ultrasound
Acute hip fracture until surgical correction
Patients undergoing emergency surgery
Urologic procedures
Fuchs et al (35) Immobilization due to surgical procedure such as Original research report
pelvic/hip fracture necessitating immobilization
Pre- or postoperative order according to surgical
protocols
Long-term epidural catheter in place
Gardam et al (94); additional reference (116) Preoperative catheter insertion for patients going Original research report
directly to the operating room
Geng et al (19); additional references: (8, 18, 60, 63–78) Perioperative use for selected surgical procedures Evidence-based
Need for intraoperative monitoring or urinary output guidelines
Urologic surgery or other surgery on contiguous
structures of genitourinary tract
Anticipated prolonged duration of surgery
Gokula et al (59); additional references: (92, 93, 117) Preoperative catheter insertion for patients going Original research report
directly to the operating department
Gotelli et al (99) Catheter placed by urology for procedure/surgery Original research report
Gould et al: 2009 Healthcare Infection Control Practices Advisory Patients undergoing urologic surgery or other surgery Evidence-based
Committee Guideline to Prevent Catheter-Associated Urinary on contiguous structures of genitourinary tract guidelines
Tract Infection (8); additional references: (14, 17, 40–58, 87, 118) Anticipated prolonged duration of surgery (catheters
inserted for this reason should be removed in the
PACU)
Patients anticipated to receive large-volume infusions
or diuretics during surgery
Need for intraoperative monitoring or urinary output
Hooton et al: Diagnosis, Prevention, and Treatment of Catheter- During prolonged surgical procedure with general or Evidence-based
Associated Urinary Tract Infection in Adults: 2009 International spinal anesthesia guidelines
Clinical Practice Guidelines from the Infectious Diseases Society of Selected urologic and gynecologic procedures in the
America (15); additional references: (14, 61, 62) perioperative period
Huang et al (57); additional reference: (62) Recent abdominal or pelvic surgery Original research report
Knoll et al (37); additional reference: (61) Prolonged surgery with general or spinal anesthesia Original research report
Lo et al: Strategies to Prevent Catheter-Associated Urinary Tract Perioperative use for selected surgical procedures Evidence-based
(59, 60)
Loeb et al (84) ; additional references: (62, 91, 94) Urologic surgery Original research report
Reilly et al (86); additional references: (59, 60, 63) Gastric bypass surgery Original research report
Renal surgery
Crush injury
Pelvic fracture
Spine radiography not cleared
Epidural catheter

Robinson et al (100); additional references: (59, 61, 62, 107, 119) Within 48 h after surgery Original research report
Aid in urologic surgery or other surgery on contiguous
structures
Roser et al (37) Selected surgeries: genitourinary tract, abdomen Original research report
Saint (56); additional references: (62, 95) Perioperative use recent surgery Original research report
Stéphan et al (87); additional references: (14, 92) Perioperative use for patients in OR getting total knee Original research report
replacement, if patient met at least 1 of following
conditions: 1) age >80 y; 2) obesity; 3) urinary
incontinence
On the wards: catheter was removed on postoperative
day 1 (2nd day of catheterization) after total knee
replacement
Perioperative use in PACU: catheter could be placed
by the following criteria: 1) decision required clinical
judgment by a physician; 2) no routine use of
urination before discharge; 3) no routine
determination of bladder volume by ultrasound and
no decision for catheterization based on bladder
volume measurement; 4) urinary catheter inserted
because of long duration must be removed before
discharge from unit
Perioperative use for patients in OR getting total hip
replacement or related surgery if patient meets at
least one of following conditions: 1) age >75 y; 2)
ASA class ≥3; 3) obesity; 4) urinary incontinence
On the wards: catheter was removed on postoperative
day 2 (3rd day of catheterization) after total hip
replacement or related surgery
Perioperative use for patients in OR with interventions
with expected surgery duration >5 h
Note: urinary catheter placed because of
long-duration surgery must be removed before
discharge from the unit
Titsworth et al (39); additional reference: (120) Perioperative use for selected surgical procedures Original research report
>3 h
Topal et al (88); additional references: (14, 96) Postoperative requirements in specific urologic or Original research report
gynecologic procedures or on contiguous
structures of the genitourinary tract
Weitzel (89) To aid in urologic surgery or other surgery in Original research report
contiguous structures
For the first 48 h after surgery
Wenger (105) Surgery performed within last 24 h Original research report
Wong: Guideline for prevention of catheter-associated urinary tract To aid in urologic surgery or other surgery on Evidence-based guideline
infections (14) contiguous structures
Theme 4: Urology: for diagnosing or delivering treatment for

urologic issues
Adams et al (32); additional references: (17, 106) Hematuria Original research report
Bruminhent et al (33); additional references: (8, 17, 79) Gross hematuria with clots Original research report
Fuchs et al (35) Bladder irrigation is required (e.g., for chemotherapy Original research report
or blood clots)
Gardam et al (94); additional reference: (116) Continuous bladder irrigation for urinary tract Original research report
hemorrhage
Geng et al (19); additional references: (8, 18, 60, 63–78) Allow bladder irrigation/lavage Evidence-based
Instillation of medication directly in the bladder guidelines
Gokula et al (59); additional references: (92, 93, 117) Continuous bladder irrigation for urinary tract Original research report
hemorrhage
Gotelli et al (99) History of being difficult to catheterize Original research report
Hematuria within the prior 24 h
Knoll et al (36); additional reference: (61) Trauma, to allow for urethral or bladder healing Original research report
Patrizzi et al (68) Urinary requirement for indwelling catheter Original research report
Robinson et al (100); additional references: (59, 67, 62, 107, 119) Following prescription of urologist for special purpose Original research report
or difficult insertion
Bladder irrigation and/or instillation of medication
Titsworth et al (39); additional reference: (120) Management of acute urologic conditions when I&O Original research report
catheterization is not prudent
Topal et al (88); additional references: (14, 96) Clinically significant hematuria Original research report
Voss (104); additional references: (49, 108) History of being difficult to catheterize Original research report
Having a Foley catheter placed by urologist

Wenger (105) A urologist is on the case; the catheter cannot be Original research report
removed without the urologist's approval
Weitzel (89) For special purpose or difficult insertion Original research report
To irrigate bladder or instill medication
Theme 5: Perineal wounds including pressure ulcers and/or

incontinence as indication
Adams et al (32); additional references: (17, 106) Decubitus ulcer Original research report
Apisarnthanarak et al (79); additional references: (57, 59, 62, 90–92) Manage incontinence that poses a risk to the patient Original research report
(e.g., because of major skin breakdown such as
sacral or perineal wounds or a nearby surgical site)
Bruminhent et al (33); additional references: (8, 17, 79) Stage III or IV sacral decubitus in incontinent patients Original research report
Dumigan et al (79); additional reference: (93) Perioperative use for plastic surgery procedure for Original research report
repair of pressure ulcer until flap is healed
Elpern et al (98) Stage III or IV skin ulcers Original research report
Surgical repair of decubitus ulcer
Fakih et al (34, 82); additional reference: (14) Incontinent patients with stage III or IV sacral pressure Original research report
ulcers
Stage III or IV sacral decubitus ulcers with
incontinence
Fuchs et al (35) Incontinence with skin breakdown in the sacral/groin Original research report
area
Gardam et al (94); additional reference: (116) Urinary incontinence posing a risk to the patient (e.g., Original research report
major skin breakdown or protection of nearby
operative site)
Geng et al (19); additional references: (8, 18, 60, 63–78) To assist in healing of open sacral or perineal wounds Evidence-based
in incontinent patients guidelines
Management of intractable incontinence
Facilitate continence and maintain skin integrity (when
conservative treatment methods have been
unsuccessful)
Long-term catheterization may be necessary in
debilitated, paralysed, or comatose patients in
presence of skin breakdown and infected pressure
ulcers–only as a last resort when alternative
noninvasive approaches are unsatisfactory or
unsuccessful
Gokula et al (59); additional references: (92, 93, 117) Urinary incontinence posing a risk to the patient (e.g., Original research report
major skin breakdown or protection of nearby
operative site)
Gotelli et al (99) Management of urinary incontinence with stage III or Original research report
greater pressure ulcerations
Gould et al: 2009 Healthcare Infection Control Practices Advisory To assist in healing of open sacral or perineal wounds Evidence-based
Committee Guideline to Prevent Catheter-Associated Urinary in incontinent patients guidelines
Huang et al (57); additional reference: (62) Open wounds in the sacral or perineal areas Original research report
Management of urinary incontinence
Jain et al (62) Management of urinary incontinence in patients with Original research report
sacral or perineal decubitus ulcers
Management of urinary incontinence at patient's
request
Management of urinary incontinence in terminally ill
patients
Knoll et al (36); additional reference: (61) Incontinence AND either open sacral or perineal Original research report
wound or patient request
Lo et al: Strategies to Prevent Catheter-Associated Urinary Tract Assistance in pressure ulcer healing in incontinent Evidence-based
Infections in Acute Care Hospitals (17); additional references: (59, residents guidelines
60)
Loeb et al (84); additional references: (62, 91, 94) Open sacral wound care for incontinent patients Original research report
Patrizzi et al (68) Incontinence with skin breakdown Original research report
Reilly et al (86); additional references: (59, 60, 63) Skin breakdown in sacral area Original research report
Robinson et al (100); additional references: (59, 61, 62, 107, 119) Management of urinary incontinence in persons with Original research report
stage III or IV pressure ulcer
Roser et al (37) Healing of sacral/perineal wound (stage III or IV) Original research report
Rothfeld and Stickley (38) Active UTI in patients with stage III or IV sacral Original research report
decubitus ulcer
Obvious inflammation of the perineum unlikely to
respond to barrier precautions as determined by
the wound care nurse

Saint et al (56); additional references: (62, 95) To assist in healing of open sacral or perineal wounds Original research report
in incontinent patients
Titsworth et al (39); additional reference: (120) Assistance in severe pressure ulcer healing (non Original research report
healing stage III or IV
Topal et al (88); additional references: (14, 96) Urinary incontinence with open sacral or perineal Original research report
wounds
Voss (104); additional references: (49, 108) Wound care management with incontinence Original research report
Weitzel (89) To manage incontinence in a patient with a stage III or Original research report
IV pressure ulcer
Wenger (105) A pressure ulcer might be soiled if the catheter is Original research report
removed and the patient is incontinent
Theme 6: Immobility-related issues

Adams et al (32); additional reference: (17, 106) Immobility Original research report
Fuchs et al (35) Immobilization due to 1 or more of the following: Original research report
Surgical procedure such as pelvic/hip fracture
necessitating immobilization
Sedation/paralysis/decreased level of
consciousness
Geng et al (19); additional references: (8, 18, 60, 63–78) Patient requires prolonged immobilization (e.g., Evidence-based
potentially unstable thoracic or lumbar spine, guidelines
multiple traumatic injuries such as pelvic fractures)
Gould et al: 2009 Healthcare Infection Control Practices Advisory Patient requires prolonged immobilization (e.g., Evidence-based
Committee Guideline to Prevent Catheter-Associated Urinary potentially unstable thoracic or lumbar spine, guidelines
Tract Infection (8); additional references: (14, 17, 40–58, 87, 118) multiple traumatic injuries such as pelvic fractures)
Jain et al (62) Difficulty in voiding due to bed rest Original research report
Patrizzi et al (68) Uncleared spinal radiographs in female patients only Original research report
Reilly et al (86); additional references: (59, 60, 63) Spine x-rays not cleared, crush injury, pelvic fracture Original research report
Roser et al (37) Required activity restriction from trauma, surgery, or Original research report
other physical condition (i.e., unstable spine,
fracture, and hemodynamics)
Theme 7: Comfort, end of life, patient request, sedated

Adams et al (32); additional reference: (17, 106) Nursing end-of-life care Original research report
Apisarnthanarak et al (79); additional references: (57, 59, 62, 90–92) Comfort care in terminally ill patient Original research report
To manage difficulty voiding in patients for whom bed
rest has been ordered
Bruminhent et al (33); additional references: (8, 17, 79) Hospice care Original research report
Dumigan et al (81); additional reference: (93) Any patient who is chemically paralyzed Original research report
Elpern et al (98) Deep sedation/paralysis Original research report
Movement intolerance due to terminal illness or
severe impairment
Fakih et al (34, 82); additional reference: (14) To improve comfort for end-of-life care if needed Original research report
Fuchs et al (35) Sedation/paralysis/decreased level of consciousness Original research report
Geng et al (19); additional references: (8, 18, 60, 63–78) Intractable urinary incontinence where catheterization Evidence-based
enhances the patient's quality of life, only as a last guidelines
resort when alternative noninvasive approaches are
unsatisfactory or unsuccessful
To improve comfort for end-of-life care if needed
Cases where patient insists on this form of
management after discussion of the risks
Fakih et al (34, 82); additional reference: (14) End-of-life care, hospice Original research report
Gokula et al (59); additional references: (92, 93, 117) Palliative care for terminally ill Original research report
Gotelli et al (99) Management of incontinence in those with conditions Original research report
that would experience clinically significant pain with
frequent movement
Management of incontinence in the terminally ill
Gould et al: 2009 Healthcare Infection Control Practices Advisory To improve comfort for end-of-life care if needed Evidence-based
Committee Guideline to Prevent Catheter-Associated Urinary guidelines
Hooton et al: Diagnosis, Prevention, and Treatment of Catheter- For comfort in a terminally ill patients; if less invasive Evidence-based
Associated Urinary Tract Infection in Adults: 2009 International measures (e.g., behavioral and pharmacologic guidelines
Clinical Practice Guidelines from the Infectious Diseases Society of interventions or incontinence pads) fail and external
America (15); additional references: (14, 61, 62) collecting devices are not an acceptable alternative
Huang et al (57); additional reference: (62) Chemical paralysis Original research report
Terminal comfort care

Jain et al (62) Management of urinary incontinence at patient's Original research report
request
Management of urinary incontinence in terminally ill
patients
Knoll et al (36); additional reference: (61) Palliative care for terminally ill Original research report
Lo et al: Strategies to Prevent Catheter-Associated Urinary Tract As an exception, at patient request to improve comfort Evidence-based
(59, 60)
Knoll et al (36); additional reference: (61) Incontinence AND patient request Original research report
Comfort care for the terminally ill
Loeb et al (84); additional references: (62, 91, 94) Comfort care for urinary incontinence in terminal illness Original research report
Patrizzi et al (68) Deep sedation Original research report
Intubated and deeply sedated
Reilly et al (86); additional references: (59, 60, 63) Any patient who is chemically paralyzed and sedated Original research report
Neurological head injury
Robinson et al (100); additional references: (59, 61, 62, 107, 119) Comfort care in terminally ill patients Original research report
Roser et al (37) End-of-life care Original research report
Saint et al (56); additional references: (62, 95) Patient too ill or fatigued to use any other type of Original research report
urinary collection strategy
Management of urinary incontinence on patient
request
Titsworth et al (39); additional reference: (120) Comfort during end of life Original research report
Topal (88); additional references: (14, 96) End-of-life care Original research report
Voss (104); additional references: (49, 108) End-of-life care Original research report
Weitzel (89) To provide comfort care in terminally ill patients Original research report
Wenger (105) The patient is receiving palliative or hospice care Original research report
The patient is unresponsive or comatose
The patient has received IV sedation within the last
12 h
Theme 8: Miscellaneous: Decreased level of consciousness,

chronic Foley use, etc.
Short-term use for unresponsive or severely agitated
patients
Severe hypoxia requiring ≥ 6 L/min oxygen (or 40%
O2)
Voss (104); additional references: (55, 108) Chronic history of prolonged catheterization or Original research report
suprapubic catheterization
Wenger (105) A physician has ordered that the catheter not be Original research report
removed (the medical reason to continue or criteria
for removal should be documented)
A physician has documented “medical necessity” within
the last 24 h
Theme 9: Inappropriate indications for using indwelling catheters

from the literature
Apisarnthanarak et al (79); additional references: (57, 59, 62, 90–92) No longer needed for monitoring of urine output: Original research report
patient no longer critically ill or when hourly record
of urine output did not prompt any change in
therapy
Unclear indication in patients for whom catheter serves
no useful purposes
Urinary incontinence without clinically significant skin
breakdown
Neurogenic bladder for which intermittent
self-catheterization is possible
Convenience of care
For administration of amphotericin B bladder irrigation
Staff are too busy to remove catheter
Staff forgot to remove catheter

Dumigan et al (81); additional reference: (93) Any incontinent patient if no other indications for Original research report
catheter are present.
Any patient with diarrhea if no other indications for
catheter are present.
The administration of a diuretic, as this does not
necessarily require strict monitoring of I&O
Catheters are inappropriate if used for any invasive
cardiac procedure anticipated to be of average
duration, such as elective or routine angioplasty or
intracoronary stent procedure
Any presence of a decubitus ulcer unless in immediate
postprocedure period of a surgically repaired site.
Diapers and routine care are adequate.
Elpern et al (98) Incontinence without any of the appropriate Original research report
indications
As a substitute for nursing care of the incontinent
patient
Incontinence without clinically significant loss of skin
integrity
ICU patients without sufficient justification; review and
define daily purpose for catheter continuation
Convenience of the personnel providing patient care
Diuresis
Frequent, but nonessential, determination of urinary
output
Nurse's concern about patient's discomfort
Diarrhea, without any of the appropriate indications
Patient's preference
Fakih et al (34, 82); additional reference: (14) Nonobstructive renal insufficiency Original research report
Transferred from intensive care
Patient request
Confusion
Incontinence
Postoperative day 2 or later
Morbid obesity
Immobility
Urine specimen collection when patient able to void
No clear reasons
No clear reason for urinary catheter
Oxygen supplementation <6 L/min
Dementia
Urine specimen collection
Incontinence
Patient request
Output monitoring outside intensive care
Gardam et al (94); additional reference (116) New onset or worsening renal failure (unless Original research report
obstruction distal to the bladder)
Pelvic or hip fractures (unless stable fracture or pain
precludes use of diapers or bedpan)
Mild congestive heart failure, cerebral vascular
accidents or abdominal pain (unless other
appropriate indications are present)
Geng et al (19); additional references: (8, 18, 60, 63–78) To insert a catheter only for the comfort of the nursing Evidence-based
personnel is irresponsible guidelines
Avoid use of urinary catheters in patients and nursing
home residents for management of urinary
incontinence
Contraindicated use of catheters: acute prostatitis,
suspicion of urethral trauma
Gould et al: 2009 Healthcare Infection Control Practices Advisory As a substitute for nursing care of patient or resident Evidence-based
Committee Guideline to Prevent Catheter-Associated Urinary with incontinence guidelines
Tract Infection (8); additional references: (14, 17, 40–58, 87, 118) As a means of obtaining urine for culture or other
diagnostic tests when patient can voluntarily void
For prolonged postoperative duration without
appropriate indications (e.g., structural repair of
urethra or contiguous structures, prolonged effect
of epidural anesthesia, etc.)
Hooton et al: Diagnosis, Prevention, and Treatment of Catheter- Indwelling catheters should not be used for urinary Evidence-based
Associated Urinary Tract Infection in Adults: 2009 International incontinence except in exceptional cases when all guidelines
Clinical Practice Guidelines from the Infectious Diseases Society over approaches have not been effective and may
of America (15); additional references: (14, 61, 62) be considered at patient request

Jain et al (62) Close monitoring of urine output when patient was no Original research report
longer critically ill and in whom the hourly record of
urine output did not prompt any change in the
therapy unless cannot obtain reasonable record of
urine output due to incontinence or lack of patient
cooperation
Urinary incontinence without open sacral/perineal
wound, terminal illness, or patient request
Neurogenic bladder where intermittent
self-catheterization is possible
Nursing staff convenience is not an acceptable
indication
Patrizzi et al (68) Convenience to avoid frequent transfers to a bedpan Original research report
or a bedside commode
Convenience to accurately measure a patient's urine
output
Robinson et al (100); additional references: (59, 61, 62, 107, 119) Those who cannot communicate their need to void Original research report
Those who are hemodynamically stable
Those who are incontinent
Those who have urinary retention that can be
managed by other means
Roser et al (37) Chronic Foley use Original research report
Topal et al (88); additional references: (14, 96) Order to maintain chronic catheter Original research report
Wong: Guideline for prevention of catheter-associated urinary tract Should not be used solely for the convenience of Evidence-based guideline
infections (14) patient care personnel
Discouraged as a means of obtaining urine for culture
or certain diagnostic tests, such as urinary
electrolytes, when the patient can voluntarily void
van den Broek (103); additional references: (59, 62, 91, 94) Monitoring of urine production in patients who can Original research report
micturate on request
Incontinence of urine unless open perineal or sacral
wounds are present or patients are immobile with
enhanced risk of getting bed sores
Weitzel (89) Collecting output if patient capable of using bedpan, Original research report
commode, or toilet
Managing incontinence
Efficiency (such as urinalysis collection in emergency
department)
Automatic use by diagnosis (such as always inserting
Foley for worsening heart failure)
Wenger (105) Convenience of either nurses or patients Original research report
Theme 10: Indications in the literature for use of other types of

urinary catheters
Apisarnthanarak et al (79); additional references: (57, 59, 62, 90–92) ISCs as preferable to chronic indwelling urethral or Original research report
suprapubic, in patients with bladder emptying
dysfunction

Geng et al (19); additional references: (8, 18, 60, 63–78) Use of a male external catheter in cooperative male Evidence-based
patients without urinary retention or bladder guidelines
outlet obstruction
Intermittent catheterization is preferable in patients
with bladder emptying dysfunction
Suprapubic catheterization:
Acute and chronic urine retention that is not able to
be adequately drained with a urethral catheter
Preferred by patient due to patient needs (e.g.,
wheelchair user, sexual issues)
Acute prostatitis
Obstruction, stricture, abnormal urethral anatomy
Pelvic trauma
Complications of long-term urethral catheterization
When long-term catheterization is used to manage
incontinence
Complex urethral or abdominal surgery
Fecally incontinent patients who are constantly
soiling urethral catheter
Contraindications suprapubic catheterization:
Known or suspected carcinoma of the bladder
Absolutely contraindicated in the absence of an
easily palpable or ultrasonographically localized
distended urinary bladder
Previous lower abdominal surgery
Coagulopathy (until the abnormality is corrected)
Ascites
Prosthetic devices in lower abdomen (e.g., hernia
mesh)
Gould et al: 2009 Healthcare Infection Control Practices Advisory Consider using external catheters as an alternative to Evidence-based
Committee Guideline to Prevent Catheter-Associated Urinary indwelling urethral catheters in cooperative male guidelines
Tract Infection (8); additional references: (14, 17, 40–58, 87, 118) patients without urinary retention or bladder outlet
obstruction
Consider alternatives to chronic indwelling catheters,
such as intermittent catheterization, in spinal cord
injury patients
ISCs are preferable to indwelling urethral or
suprapubic catheters in patients with bladder
emptying dysfunction
Consider ISCs in children with myelomeningocele and
neurogenic bladder, to reduce risk of urinary tract
deterioration
Hooton et al: Diagnosis, Prevention, and Treatment of External catheters in cooperative male patients Evidence-based
Catheter-Associated Urinary Tract Infection in Adults: 2009 without urinary retention or bladder outlet guidelines
International Clinical Practice Guidelines from the Infectious obstruction
Diseases Society of America (15); additional references: (14, 61, ISCs as preferable to chronic indwelling, in spinal cord
62) injury patients
ISCs as preferable to chronic indwelling urethral or
suprapubic, in patients with bladder emptying
dysfunction
Mentions challenges of ISC in patients with upper
extremity weakness in cervical spinal cord or other
abnormality, obesity, spasticity, and discomfort in
sensate patients, and unwillingness of patients to
perform frequent ISC due to comorbid conditions
or urethral anatomy
Titsworth et al (39); additional reference: (120) Routine bladder scanning and I&O catheterization are Original research report
preferred over indwelling catheters for treatment of
failure to void due to lower UTI risk
Topal et al (88); additional references: (14, 96) Initiate straight catheterization if spontaneously voids Original research report
in 2–4 h and PVR >250 mL
Initiate straight catheterization if no void in 4-6 h and
total bladder volume is >400 mL
Wong: Guideline for prevention of catheter-associated urinary tract Condom catheter drainage may be useful for Evidence-based guideline
infections (14) incontinent male patients without outlet obstruction
and with an intact voiding reflex
ISCs in patients with bladder emptying dysfunction,
such as those with spinal cord injuries
ASA = American Society of Anesthesiologists; BP = blood pressure; ED = emergency department; I&O = in-and-out; ICU = intensive care unit;
ISC = intermittent straight catheter; IV = intravenous; OR = operating room; PACU = postanesthesia care unit; PVR = post-void residual; UTI =
urinary tract infection.

Continuing Medical Education/Maintenance of Certification Activity

In addition to CME credit, physicians enrolled in the American Board of Internal Medicine’s (ABIM) Maintenance
of Certification (MOC) program can earn 8 medical knowledge self-assessment points for successful completing the
following module online. To earn 5 CME credits, please take this quiz at www.annals.org/article.aspx?doi=10.7326/
M14-1304. To earn MOC points, you must take the MOC quiz at www.acponline.org/urinarycathetermoc; successful
completion qualifies for 8 MOC points, and this information will be transferred to the ABIM.
These CME and MOC activities are free to ACP members and individual subscribers to Annals of Internal
Medicine. Others who are interested in completing this MOC activity can learn more about ACP membership and
individual subscriptions to Annals of Internal Medicine at www.acponline.org.
Question 1: In this project, a multidisciplinary panel of experts rated the appropriateness of indwelling Foley cath-
eters for 105 clinical scenarios. Which of the following clinical indications were rated as appropriate uses for Foley
catheters?
A: Post-void residual volume assessment
B: Collection of urinalysis sample to expedite work-up and treatment
C: Hourly measurement of urine volume is required to provide treatment
D: Foley placement to reduce risk for falls by minimizing the need to get up to urinate
E: Measurement of urine output in a patient after admission to the ICU
Question 2: In this project, a multidisciplinary panel of experts rated the appropriateness of external condom cath-
eters for 97 clinical scenarios. Which of the following clinical indications were rated as appropriate uses for external
catheters?
A: Manage urinary incontinence in a delirious, uncooperative elderly male
B: Single 24-hour or random urine sample for diagnostic test when cannot be obtained by other urine collection
strategies
C: Chronic urinary retention without bladder outlet obstruction
D: External catheter placement to reduce risk for falls by minimizing the need to get up to urinate
E: Hourly measurement of urine volume is needed to provide treatment
Question 3: In this project, a multidisciplinary panel of experts rated the appropriateness of intermittent straight
catheterization (ISC) for 97 clinical scenarios. Which of the following clinical indications were rated as appropriate
uses for ISC?
A: Management of overflow urinary incontinence
B: Hourly measurement of urine volume is needed to provide treatment
C: Random urine sample collection for sterile or nonsterile samples if possible by other strategies
D: Acute urinary retention with bladder outlet obstruction due to acute bacterial prostatitis
E: Management of gross hematuria with blood clots in the urine
Question 4: Which of the following skin issues are appropriate uses for Foley catheters?
A: Management of incontinence-associated dermatitis
B: Stage II sacral pressure ulcer
C: Stage III, stage IV, or unstageable pressure ulcers or similarly severe wounds of other types that cannot be
kept clear of urinary incontinence despite other urinary management strategies
D: Prevention of pressure ulcer in patients assessed to be at high risk for pressure ulcers by the Braden Scale.
E: Prevention of incontinence-associated dermatitis in an elderly patient immobilized due to weakness
Question 5: Which of the following catheters increase a patient’s risk for urinary tract infection?
A: External condom catheter
B: Intermittent straight catheter
C: Suprapubic catheter
D: Foley catheter
E: All urinary catheters are associated with an increased risk for urinary tract infection
Question 6: Which of the following are infectious complications of Foley catheters?
A: Cystitis
B: Bacteremia
C: Septic arthritis
D: Clostridium difficile infection
E: All of the above are infectious complications that can occur due to urinary catheters

Question 7: What of the following conditions would be anticipated to cause acute urinary retention without bladder
outlet obstruction?
A: Exacerbation of benign prostatic hypertrophy
B: IV infusion with paralytic medication, such as cisatracurium, for patient on a mechanical ventilator
C: Inability to urinate after a urologic procedure
D: Bladder stones
E: Acute prostatitis
Question 8: What of the following are noninfectious complications of Foley catheters?
A: Accidental removal
B: Hematuria
C: Urethral stricture
D: False passage
E: All of the above are noninfectious complications that can occur with Foley catheters
Question 9: What is the relationship between incontinence-associated dermatitis and pressure ulcers?
A: Incontinence-associated dermatitis is a type of pressure ulcer
B: Incontinence-associated dermatitis that is considered moderate or severe has eroded skin, and thus is con-
sidered an open pressure ulcer
C: Incontinence-associated dermatitis can increase a patient’s risk for developing pressure ulcers
D: Incontinence-associated dermatitis in the sacrum is a “localized injury to the skin and/or tissue usually over a
body prominence”
E: Because a Foley catheter can prevent incontinence-associated dermatitis, Foley catheters are effective and
appropriate for prevention of pressure ulcers
Question 10: Which of the following statements are true regarding payment and/or public reporting for catheter-
associated urinary tract infections (CAUTIs)?
A: U.S. hospitals receive a fine for each hospital-acquired CAUTI that occurs
B: Hospital rates of CAUTI that are reported on Medicare’s Hospital Compare Web site are from diagnoses
submitted by physicians for billing in administrative discharge data
C: Removal of payment for hospital-acquired CAUTI as a payable comorbidity in October 2008 resulted in large
reductions in hospital payment
D: Nonpayment and public reporting of CAUTIs has successfully eliminated CAUTI as an important patient safety
problem
E: Hospital rates of CAUTI from the National Healthcare Safety Network are reported on Medicare’s Hospital
Compare Web site
Question 11: Which of the following is an appropriate indication for using a Foley catheter for a patient located in the
ICU?
A: Monitoring of urine output because the patient was transferred to the ICU
B: Monitoring of hourly urine output is required to guide the titration of vasopressor intravenous medication for
a patient with sepsis
C: Prevention of hospital-acquired pressure ulcers because ICU patients are often at increased risk for pressure
ulcers
D: All dying patients receiving “comfort care” need a Foley catheter
E: Convenience to manage urine during patient transport for tests
Question 12: Which of the following statements are true regarding catheter-associated complications?
A: Many noninfectious complications of short-term Foley catheterization are at least as common as clinically
significant urinary tract infections
B: CAUTIs are common but are easily treated with antibiotics
C: Dysuria in a catheterized patient is a symptom of urinary tract infection
D: External urinary catheters are not associated with any noninfectious complications
E: Patients with urinary catheters should be screened regularly with urine tests to detect and prompt early
treatment of CAUTI
Question 13: Which of the following is a strategy to reduce unnecessary placement of Foley catheters?
A: Nurse-empowered catheter removal protocols
B: Removing payment for placement of Foley catheters as a procedure
C: Restrict Foley catheter ordering by requiring physicians to identify the indication for placement from a list of
appropriate indications
D: Require documentation of the reason for Foley placement
E: Placing catheter orders in admission order sets for patients admitted to the ICU

Question 14: A patient with a history of spinal cord injury 10 years ago is admitted to the hospital for treatment of
osteomyelitis in the setting of a pressure ulcer. He performed self-catheterization at home and is unable to void without
catheterization. Which of the following are appropriate strategies for urinary management while he is admitted?
A: Place an external catheter because he has a pressure ulcer
B: Place a Foley catheter because he has a pressure ulcer
C: Place a Foley catheter after first ISC attempt is noted to be difficult
D: Continue intermittent straight catheterization while admitted unless he develops a condition that requires
hourly urine output measurements to guide treatment (such as hypotensive sepsis)
E: External catheter because it will allow for more complete monitoring of urine output, but has a lower risk for
infection than a Foley catheter
Question 15: A patient with a history of urinary incontinence and dementia is admitted to the hospital for influenza
and dehydration. At home, his wife manages his urinary incontinence using incontinence garments (“adult diapers”)
and absorbent bed pads. His skin is in good condition, and he is admitted to a non-ICU bed. Which of the following
are appropriate strategies for urinary management while he is admitted?
A: Noncatheter strategies, such as barrier creams, incontinence garments, absorbent bed pads
B: Foley catheter to manage urinary incontinence while admitted
C: External catheter to manage urinary incontinence while admitted
D: Bladder scanner and ISC protocol
E: Foley catheter to manage urine while being transported for tests
Question 16: A patient is admitted for surgery on a chronic heel wound to the ICU because he has a tracheostomy
and requires chronic mechanical ventilation that cannot be provided in a non-ICU unit in this hospital. He lives in a
long-term acute care hospital, and his urine management plan includes adult diapers and careful attention to skin
care. What is the most appropriate urinary management strategy for this patient during his ICU stay?
A: Foley catheter
B: External catheter
C: Incontinence garments (“adult diapers”) with careful attention to skin care
D: Intermittent straight catheterization
E: Suprapubic catheter
Question 17: A patient admitted to the ICU for the acute respiratory distress syndrome (ARDS) requires mechanical
ventilation and paralytic medications. What is the most appropriate urinary management plan?
A: External catheter
B: Catheter-free strategies, such as incontinence garments
C: Foley catheter
D: Intermittent straight catheterization
Question 18: A man with a history of benign prostatic hyperplasia is admitted for surgical repair of broken tibia and
is noted to have urinary retention. Which of the following is the most appropriate strategy to address the urinary
retention?
A: Monitoring for retention with bladder scanner protocol and use of ISC or Foley catheter as needed to address
retention
C: Bedside urinal
D: Prompted toileting
E: Suprapubic catheter
Question 19: A female patient is admitted with end-stage cancer and urinary incontinence and is transitioned to a
palliative care plan, including hospice care, during admission. Which urinary management strategy is most appro-
priate?
A: Foley catheter is appropriate because the patient’s status has been changed to “comfort care”
C: Intermittent straight catheterization
D: Foley catheter is appropriate when consistent with the patient’s goal of care of minimizing position changes
needed for urination and linen changes, which are uncomfortable for the patient
E: Foley catheter in order to provide hourly urine measurements

Question 20: A thin elderly man with dementia and dehydration is admitted to a non-ICU bed while awaiting
placement in a nursing home. He has urinary incontinence, and his nurses are frustrated because he keeps pulling
his IVs and is not the easiest person to turn for skin care because he is confused. Which urinary management strategy
is most appropriate?
A: Foley catheter
C: Intermittent straight catheter
D: Noncatheter strategies, such as prompted toileting and incontinence garments or pads
Question 21: A patient is going to be transported to radiology for a chest CT scan, and the nurse requests a Foley
to prevent urinary incontinence while away from his room. Which of the following statements regarding urinary
management strategies is NOT appropriate to address the concern for urinary incontinence while transporting for a
radiology test?
A: Foley catheters are appropriate to improve convenience of the patient and/or transport staff when off the
floor for radiology tests, even when the patient does not require a Foley catheter while in their patient room
B: Incontinence garment or pads
C: Prompted toileting using urinal, bedpan, or commode
D: External catheter
Question 22: Mrs. Smith is admitted for a work-up for syncope. She assessed to be at increased risk for falls based
on unsteady gait and recent syncope. A Foley catheter is requested by her nursing team to reduce her risk for falls
by minimizing the need for the patient to get out of bed to urinate. Which of the following statements correctly
describe a potential risk and/or benefits of the Foley to the patient?
A: Foley catheter placement would be beneficial because patients with urinary catheters are less likely to fall
than patients without urinary catheters
B: Foley catheters are important patient safety devices because they keep patients in bed that should stay in bed
C: Foley catheters can increase the patient’s risk of falling (by tripping over the catheter), and other risks of
immobility, such as venous thromboembolism and pressure ulcers, because the catheter can serve as a
“one-point restraint”
D: Foley catheter–associated UTIs are not serious compared with the risk for a fall, so Foley catheter placement
is appropriate
E: Males are at increased risk from mechanical injury related to placement of a urinary catheter, unlike females
Question 23: Mr. Williams is admitted for sepsis, and is being treated with large quantities of IV fluids, vasopressors,
and antibiotics. He has not voided since admission and has no history of renal failure or anuria. Which of the
following are appropriate urinary management strategies?
A: External catheter
B: Intermittent straight catheter
C: Noncatheter strategies, such as urinals, bedside commodes, and prompted toileting
D: Foley catheter
Question 24: Which of the following is NOT a possible complication from use of an external urinary catheter?
A: Urinary tract infection
B: Skin irritation
C: Urethral stricture
D: Allergic reaction
E: Skin necrosis, penile strangulation, and urethrocutaneous fistula

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Annals of Internal Medicine SUPPLEMENT

The Ann Arbor Criteria for Appropriate Urinary Catheter Use in

C atheter-associated urinary tract infection (CAUTI)

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Figure 2. Summary of evidence search and selection.

Records remaining after exclusion of duplicates and by title/abstract (n = 1257)

Records including discussions of catheter indications (15, 32–39) (n = 9)

References reviewed from bibliographies,

a. CAUTI guidelines reviewed: 8, 14, 18, 40–78

Summary of literature reviewed for urinary catheter indications and contraindications:

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Table 1. Characteristics of Urinary Catheter Appropriateness Panelists

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Figure 3. Example of clinical scenarios from the round 1 rating document.

A: Acute urinary retention

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Table 2. Guide for Foley Catheter Use in Hospitalized Medical Patients*

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Table 3. Guide for Intermittent Straight Catheterization in Hospitalized Medical Patients*

Table 4. Guide for External Catheter Use in Hospitalized Medical Patients*

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2. Patient cannot stop or control

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4. Urine specimen collection is needed to

5. Urine catheter is requested to provide

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Figure 4. ICU daily checklist for appropriateness of Foley catheter.

ICU = intensive care unit; ISC = intermittent straight catheter; IV = intravenous.

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Appendix Table. Synthesis of Urinary Catheter Indications From the Literature

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Theme 2: Accurate measurement of urinary output

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Theme 4: Urology: for diagnosing or delivering treatment for

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Theme 5: Perineal wounds including pressure ulcers and/or

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Theme 6: Immobility-related issues

Theme 7: Comfort, end of life, patient request, sedated

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Theme 8: Miscellaneous: Decreased level of consciousness,

Theme 9: Inappropriate indications for using indwelling catheters

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Theme 10: Indications in the literature for use of other types of

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