Persistent Barriers to Timely Catheter Removal Identified from Clinical Observations and Interviews

Abstract

Background: Indwelling urinary and vascular catheters are valuable devices in patient care, but prolonged or unnecessary use increases the risk of infectious and noninfectious catheter harms.

Methods: To understand persistent barriers to detecting and removing unnecessary catheters, researchers conducted a multimethod qualitative study that included observations and in-person interviews with clinicians working on a progressive care unit of a large hospital. Observations consisted of shadowing nurses during shift change and while admitting patients, and observing physicians during morning rounds. Observational data were gathered using unstructured field notes. Interviews were conducted using a semistructured guide, audio-recorded, and transcribed. Qualitative content analysis was conducted to identify main themes.

Results: Barriers to timely removal identified during 19 interviews with clinicians and 133 hours of field observations included physicians not routinely reviewing catheter necessity during rounds, catheters going unnoticed or hidden under clothing, common use of "Do Not Remove" orders, and little or no discussion of catheters among clinicians. Five overall themes emerged: (1) Catheter data are hard to find, not accurate, or not available; (2) Catheter removal is not a priority; (3) Confusion exists about who has authority to remove catheters; (4) There is a lack of agreement on, and awareness of, standard protocols and indications for removal; and (5) Communication barriers among clinicians create challenges.

Conclusion: To address barriers and facilitate detection and timely removal, clinicians need ready access to accurate catheter data, more clearly delineated clinician roles for prompting removal, effective tools to facilitate discussions about catheter use, and standardized catheter removal protocols.

Figure 1.

Setting and Sample

Figure 2.

Common Barriers to the Steps to Catheter Removal Identified during Observations and Clinician Interviews. Blue circles indicate where barriers are most likely to interfere with steps to removal (1-4) *Steps to Removal excerpted from Meddings & Saint, 2011 in Disrupting the Life Cycle of the Urinary Catheter in CID 2011:52 1 June, 1291–1293 **While some barriers have the potential to affect several steps, we highlight the steps where the primary impact is most likely to be found. Abbreviations: O= noted in observations; I= stated during interviews