Sanniya Khan Ghauri  ( Department of Emergency Medicine, Shifa International Hospital, Islamabad )
Arslaan Javaeed  ( Department of Pathology, Poonch Medical College, Azad Kashmir, Pakistan )
Tabinda Abbasi  ( Final Year MBBS Student, Poonch Medical College, Azad Kashmir, Pakistan )
Abdus Salam Khan  ( Department of Emergency Medicine, Shifa International Hospital, Islamabad )
Khawaja Junaid Mustafa  ( Department of Emergency Medicine, Shifa International Hospital, Islamabad )

Objectives: To assess the knowledge and attitude of house officers, residents, specialists and nurses regarding urinary catheterisation and catheter-associated urinary tract infection in tertiary care hospitals.

Methods: The cross-sectional study was conducted from February to July 2018 at 9 hospitals in Rawalpindi and Islamabad, Pakistan, and comprised doctors and nurses. Data were collected using an interviewer-administered questionnaire. Knowledge and attitude regarding urinary catheterisation were compared between doctors and nurses. Data was analysed using SPSS 23.

Results: Of the768 individuals approached, 485(63%) agreed to participate. Of them, 358(74%) were doctors and 127(26%) were nurses. Among the doctors, 261(73%) were house officers, 58(16%) residents and 39(11%) specialists. When asked if avoiding catheter kinking was an effective way to prevent CAUTI, 194(54.19%) doctors got it correct as opposed to 102(80.31%) nurses. When the doctors and nurses were asked if the catheter should be removed whenever it is convenient for healthcare personnel, 354(98.88) doctors and 112(88.18) nurses gave the correct answer (p=0.041).

Conclusion: There was reasonable knowledge and attitude among nurses and doctors towards urinary catheterisation and preventive measures related to catheter-associated urinary tract infection.

Keywords: Health workers, Urinary catheterisation, Knowledge, Attitude, Urinary tract infection. (JPMA 69: 1843; 2019) DOI:10.5455/JPMA.8096

Introduction

Catheterisation is the procedure of introducing a urinary catheter into a patient's urinary bladder through the urethra. It can serve as a diagnostic and therapeutic tool and, in some instances, it can also be used as a tool of investigation. The broad usage of the urinary catheter makes it a frequent point of call for house officers, residents, specialists and nurses. As beneficial as urinary catheterisation can be for health staff in performing the lifesaving duties, it is not without its negatives. This procedure, if done inadvertently, can introduce a large number of pathogens into the patient's body. In fact, the patients are the ones at the receiving end of most of the positives as well as the negatives of this procedure. The significance can be comprehended by the fact that among nosocomial and hospital-acquired infections (HAIs)), the catheter-associated urinary tract infection (CAUTI), accounts for about 40%.^1-2 Among all hospital admissions, 25%require a urinary catheterisation for a host of reasons and independent of the length of stay in hospital.^3,4 A crucial area of every tertiary hospital is the intensive care unit (ICU). The frequency of urinary catheterisation in ICU is as high as 100%, ⁵ which may be due to the fact that continuous fluid balance monitoring is vital for unconscious and critically ill patients. CAUTI can cause a lot of complications. It increases morbidity and the length of hospital stay. CAUTI patients can complain of symptoms like fever, voiding discomfort and malaise. Besides, these patients would require extended courses of antibiotics use, subsequently providing a breeding ground for antibiotic-resistant which may start a problematic chain reaction of the spread of nosocomial infections. ⁶  Other CAUTI risks include catheter blockage, development of renal stones or stones along the urinary tract, and increased risk of urinary tract cancers. The worst part is that the cost of care is significantly raised in such patients, especially if it gets complicated by bacteraemia, meningitis and septic shock which significantly increase the risk of mortality in these patients. ⁷  Even though it remains an important procedure, some doctors and other healthcare personnel (HCP), like nurses, are not familiar with the true indications of catheterisation. This leads to needless catheterisation as well as unnecessarily prolonged usage of the catheter. This increases chances of CAUTI, especially because the incidence of CAUTI has a proportional relationship with the number of days a catheter remains insitu. This explains why CAUTI is higher in ICUs since the duration of catheter time is longer than in the wards. Some studies, however, have counteracted this, showing no significant difference in the rates of CAUTI among ICU and non-ICU patients. ^8,9  As such, no group of hospital patients should be specifically selected for supervision and prevention by the infection control team as there is a chance that all hospital patients carry significant CAUTI risk. Studies have supported minimising unnecessary catheterisation as the single most important modifiable risk factor in reducing CAUTI incidence. ^4,10  A good example of a preventive measure is having the catheter reminder in place which may limit the number of unnecessary catheter days. ^10,11  Many hospitals do not have strict guidelines for CAUTI prevention, which is, unfortunately, the case even among departments where urinary catheterisation is more frequently done. Therefore, it is important that HCP are well-trained as, when preventive measures are instituted and priority placed on them, the incidence of CAUTI does fall.^10,11 Not many studies in Pakistan have previously tested the knowledge and attitude of HCP regarding catheterization and CAUTI. The current study was planned to assess the knowledge and attitude of house officers, residents, specialists and nurses in tertiary care hospitals.

Subjects and Methods

The cross-sectional study was conducted from February to July 2018 at 9 hospitals in Rawalpindi and Islamabad, Pakistan, and comprised doctors and nurses. After approval from the ethics review board of Poonch Medical College, Rawalakot, Pakistan, identification numbers of all currently employed HCP were obtained from the respective human resource (HR) departments, and the numbers were fed into a computer system. For sample size calculation, n = z2 * p (1-p)/ d2 formula was used considering a prevalence rate of 50% since the actual prevalence was unknown. Assuming a response rate of 50%, HCP approached were twice as many as the required sample size. HCP were selected using the random number generator of the computer system. The only tool for data collection was an interviewer administered questionnaire. The study questionnaire was validated by two epidemiologists. The questionnaire consisted of structured 33items (Knowledge 25-items, Attitude 8-Items), and was distributed among houseofficers, residents, specialists and nurses to assess their knowledge of indications for urinary catheterisation, measures to be taken to prevent CAUTI, and attitude regarding urinary catheterisation. Demographic details, such as age and gender, were also noted. Informed written consent was obtained from each participant. Data was analysed with 95% confidence interval (CI) using SPSS 23. Categorical variables were presented as frequencies and percentages, while continuous variables were presented as mean } standard deviation (SD). Associations were checked with chi-square test and the level of significance was kept at p<0.05.

Results
 

Of the 768 individuals approached, 485(63%) agreed to participate. Of them, 358(74%) were doctors with a mean age of 34.5}8.25 years, and 127(26%) were nurses with a mean age of 30.8}7.25 years. Among the doctors, 261(73%) were house officers, 58(16%) residents and 39(11%) specialists (Table-1).



The level of knowledge among doctors increased with their rank. An example of this is regarding the question of urethral stricture being an indication for catheterisation; only 84(32.18%) house officers had the correct response compared to 22(44.82%) residents and 36(92.31%) specialists. This pattern was consistent for all the 10 questions except in two: 'neurogenic bladder due to paraplegia or quadriplegia' (255[97.70%] house officers vs 52[89.65%] residents), and 'prolonged immobilization due to unstable lumbar spine fracture' (237[90.84%] house officers vs 52[89.65%] residents). Overall, the knowledge of doctors was better than the nurses with nurses only having a superior percentage in three of the 10 items. Among these 3 items, two items were statistically significant; 'urethral stricture causing obstruction to urinary flow' (p=0.001), and 'for assisting healing of decubitus ulcers in incontinent patients' (p=0.031) (Table-2).



Specialist doctors had the highest percentage of correct answers followed by the residents and house-officers for all questions (Table-3)



but, when the overall percentage of doctors was compared with that of the nurses, the nurses knew more about CAUTI preventive measures than the doctors, scoring higher in 11 out of the 15 items (Table-4).



When asked if renewal reminders for catheters help prevent CAUTI, 225(62.84%) doctors and 80(62.99%) nurses rightly agreed. When asked if the catheter can be inserted for nursing staff's convenience, 353(98.60%) doctors and 125(98.42%) nurses rightly disagreed. When asked if the catheter should be removed whenever it is convenient for HCP, 354(98.88) doctors and 112(88.18) nurses gave the correct answer (p=0.041). Also, 305(85.19%) doctors compared to 69(54.33%) nurses believed that "maintaining a closed drainage system prevented CAUTI (p<0.05) (Table-5).



Discussion

Urinary catheters are often kept inserted even when thereis no more indication for their use.¹² This is no doubt one of the reasons why CAUTI is one of the commonest nosocomial infections. ^1,2 It has also been shown that the single most effective way to reduce the occurrence of CAUTI among hospitalised patients is to limit the use of the catheter to only cases where it is correctly indicated and to discontinue immediately after this indication is no longer present. ¹³ Of course, one of the factors that would make this possible is the knowledge level of HCP. The current study found that overall the doctors were more knowledgeable about the indications of catheterization than the nurses (p<0.05) which is similar to an earlier finding. ¹⁴ This means that educating the nurses on the indications of catheterisation would go a long way in reducing the incidence of CAUTI as they would be able to serve as reminders for doctors once the indication for the catheterisation is over. This is in tandem with studies that have shown that the nurses' zeal towards the need to have a catheter insitu helps to reduce the occurrence of CAUTI. ¹⁵When compared to a study ¹⁴ in which 79% nurses wrongly justified the use of catheters for nursing care of incontinent patients as opposed to the 21% in the current study, it is clear that there is a better knowledge on the indication of catheterisation among the nurses who participated in this study. Nevertheless, close to onethird of both doctors and nurses agreed that catheters can be used to collect the sample for culture and sensitivity testing, which is similar to the result obtained earlier.14 Even though this may appear to be a small percentage, it could lead to a significant increase in catheter usage. Hence, it is important to keep educating the doctors and the nurses on these indications as a way to check the unnecessary use of catheters. ^13,15 There was also some paucity of knowledge noted among doctors regarding the effective preventive measures for CAUTI with more than half (about 52%) of the doctors wrongly agreeing that bacteriological monitoring is an effective prevention against CAUTI. This is similar to the earlier study14 in which about 77% healthcare professionals wrongly agreed to the same proposition. This would unnecessarily lead to an increase in workload on the laboratories. Furthermore, it will increase the overall cost of patient-care. The same study¹⁴ reported that 45% HCP felt prophylactic antimicrobials for 3 days can prevent CAUTI. The current study found <25%, indicating a better knowledge among the doctors and nurses. Over 95% subjects in the current study knew that the collecting bag should be placed below the level of the bladder, but in the earlier study done, ¹⁴more than a third of nurses did not know this. All these simple measures have shown to be of great effect in CAUTI prevention and, as such, health workers must be knowledgeable.^2,10-12 The current study, unlike other studies,^14-16 showed a significant difference in the knowledge among the experience levels of the doctors, with the specialists having more knowledge than the residents and the house officers. The current study, however, is in consonance with others^10,14-16 in the fact that educating HCP regarding both the indications and preventive measures will lead to better outcomes on this front. The current  study also showed a reasonably good attitude of nurses and doctors towards urinary catheterisation. It will, however, be important to check for the incidence of  CAUTI in the hospitals studied here to have a statistical correlation between the knowledge and attitude of the  doctors and nurses to the incidence of CAUTI. This will no doubt serve as a basis for instituting protocols and other studies can be undertaken from there onwards. In terms of limitations, the current study was conducted in only two major cities, and, therefore, may not be considered a representative sample of health workers nationwide. Also, being an observational study, the temporal relationship between cause and effect could not be obtained.

Conclusion

Doctors with more experience scored better on most questions. The nurses and medical officers should also have the similar level of knowledge as most of them are directly involved with catheterisation. Proper training regarding indication, maintenance and procedure of catheterisation may lower the incidence of CAUTI.

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

References

1. Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 2001; 17:299-303.
2. Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis, prevention, and treatment of catheterassociated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society ofAmerica. Clin Infect Dis. 2010; 50:625–63.
3. Warren JW. The catheter and urinary tract infection. Med Clin North Am. 1991; 75:481-93.
4. Brennan ML, Evans A. Why catheterize: Audit findings on the use of urinary catheters? Br J Nurs. 2001; 10:580–90.
5. Datta P, Rani H, Chauhan R, Gombar S, Chander J. Health careassociated infections: Risk factors and epidemiology from an intensive care unit in Northern India. Indian J Anaesth. 2014; 58:30–5.

6. Getliffe K, Newton T. Catheter-associated urinary tract infection in primary and community health care. Age Ageing. 2006; 35:477–81.
7. Stickler DJ, Zimakoff J. Complications of urinary tract infections associated with devices used for long-term bladder management. J Hosp Infect. 1994; 28:177–94.
8. Lewis SS, Knelson LP, Moehring RW, Chen LF, Sexton DJ, Anderson

DJ. Comparison of non-intensive care unit (ICU) versus ICU rates of catheter-associated urinary tract infection in community hospitals. Infect Control Hosp Epidemiol. 2013; 34:744–7.

9. Weber DJ, Sickbert-Bennett EE, Gould CV, Brown VM, Huslage K, Rutala WA. Incidence of catheter-associated and non-catheterassociated urinary tract infections in a healthcare system. Infect Control Hosp Epidemiol. 2011; 32:822–3.

10. Fakih MG, Dueweke C, Meisner S, Berriel-Cass D, Savoy-Moore R, Brach N, et al. Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients. Infect Control Hosp Epidemiol. 2008; 29:815–9.
11. Saint S, Kowalski CP, Kaufman SR, Hofer TP, Kauffman CA, Olmsted RN, et al. Preventing hospital-acquired urinary tract infection in the United States: A national study. Clin Infect Dis. 2008; 46:243–50.

12. Apisarnthanarak A, Rutjanawech S, Wichansawakun S, Ratanabunjerdkul H, Patthranitima P, Thongphubeth K, et al. Initial inappropriate urinary catheters use in a tertiary-care center: Incidence, risk factors, and outcomes. Am J Infect Control.2007;35:594–9.
13. Elpern EH, Killeen K, Ketchem A, Wiley A, Patel G, Lateef O. Reducing use of indwelling urinary catheters and associated urinary tract infections. Am J Crit Care. 2009; 18:535–41.

14. Manisha J, Vinita D, Bibhabati M, Archana T, Poonam SL. Knowledge and attitude of doctors and nurses regarding indication for catheterization and prevention of catheterassociated urinary tract infection in a tertiary care hospital. Indian J Crit Care Med. 2015; 19:76–81.

15. Apisarnthanarak A, Thongphubeth K, Sirinvaravong S, Kitkangvan

D, Yuekyen C, Warachan B, et al. Effectiveness of multifaceted hospital wide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand. Infect Control Hosp Epidemiol. 2007; 28:791–8.

16. Drekonja DM, Kuskowski MA, Johnson JR. Internet survey of Foley catheter practices and knowledge among Minnesota nurses. Am J Infect Control.2010; 38:31–7.