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Unintended Consequences for Patients with Spinal Cord Injury

Posted on by CDC's Safe Healthcare Blog
Matt Davis, MD
Matt Davis, MD
Matt Davis, MD, Clinical Medical Director
SCI Service Line, TIRR Memorial Hermann

The story would have been shocking, if I had not seen the precursors many times before. My patient was paralyzed by a bulging disc in her spine. In an effort to achieve “High Reliability” and reach the goal of “Zero Catheter-Associated Urinary Tract Infections,” hospital staff removed the Foley catheter used to drain her bladder. She voided into a diaper and was sent to a skilled nursing facility. She was there for 3 weeks before high bladder pressures put her into kidney failure. Her first symptom: cardiac arrest due to high potassium levels. It was not until she saw someone with training specific to spinal cord injury that she learned how this nearly-fatal episode could easily have been avoided. What would have happened if she had been at home?

Since early 2014, when I first noticed a trend to remove Foleys in a drive toward High Reliability and Zero CAUTIs, I have seen several cases of renal failure in spinal cord injury patients. In the 1950s, 40% of these patients died of kidney failure due high bladder pressures. This is easy to avoid with an indwelling catheter, not so simple with the alternatives. A bladder scanner is useful, but not sufficient for this population.

Since that time, I have also seen countless episodes of Autonomic Dysreflexia, a potentially life-threatening hypertensive urgency specific to spinal cord injury patients. Autonomic Dysreflexia presents with a unique and bewildering set of symptoms, and studies have shown that non-specialty healthcare providers receive little or no training in recognition and treatment of Autonomic Dysreflexia – nor do they see sufficient numbers of spinal cord injury patients to maintain competency once this training has been given. Fifty to ninety percent of spinal cord injury patients are susceptible to Autonomic Dysreflexia. The most common cause: bladder over-distension.

In response to these concerns, I collected data from one of my main referring hospitals. All spinal cord injury patients we admitted last November had had their Foleys removed. The busy acute hospital staff maintained safe bladder volumes only 43% of the time. Every spinal cord injury patient who was susceptible to Autonomic Dysreflexia had experienced it. There needs to be a balance between removing catheters to prevent infections and ensuring spinal cord injury patients do not suffer unintended consequences that could threaten their lives.

A program for safe Foley removal in spinal cord injury patients should contain several elements typically seen in Rehab hospitals:

  • Nursing and physician competence in recognizing/treating Autonomic Dysreflexia.
  • Competence in differentiating between voiding at safe pressure and overflow incontinence.
  • Educational programs to teach patients and families about Autonomic Dysreflexia and renal protection.
  • Discharge planning that involves a clear understanding of who will take responsibility for safe bladder management in the home.
  • Consideration of patient quality of life and independence.

Spinal cord injury organizations are working with CDC to increase awareness and educate health care providers about a rational approach to bladder management in spinal cord injury patients in acute care hospitals. I look forward to evaluating the results.

Clinical Practice Guidelines for spinal cord injuries can be downloaded here:

Matt Davis, MD, is a Spinal Cord Injury specialist with a special interest in refining Quality Improvement processes. He serves as chair of the advocacy committees for the American Spinal Injury Association and the Academy of Spinal Cord Injury Professionals.

Posted on by CDC's Safe Healthcare Blog

17 comments on “Unintended Consequences for Patients with Spinal Cord Injury”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    Thank you Dr Davis.
    As per clinical practice Guidelines for spinal cord injury patients , that you have attached , we need to look at each individual patient when deciding on the bladder management.
    This is from page 21 of the Guidelines that we recommended in 2006.
    “Consider indwelling catheterization for individuals with:
    Poor hand skills. High fluid intake.
    Cognitive impairment or active substance abuse.
    Elevated detrusor pressures managed with anticholinergic medications or other means.
    Lack of success with other, less invasive bladder management methods.
    Need for temporary management of vesicoureteral reflux.
    Limited assistance from a caregiver, making another type of bladder management not feasible.”
    Thank you.

    In response to marney smithiez:
    Without a doubt, broadening our educational efforts among nurses and Infection Preventionists will be critical. As you may see from other responses to this blog, decisions about definitive bladder management in SCI are very complicated, and probably best left to experts. According to past research, even our efforts at basic education regarding Autonomic Dysreflexia have met with poor knowledge retention in non-specialty centers.

    We do not encourage the performance of surgical procedures in parts of the hospital that lack sufficient patient volume to maintain staff proficiency in surgery. Similarly, I would suggest that we not encourage Foley removal in SCI patients outside of tertiary care centers, where there are specialty-trained physicians writing orders and specialty-trained nurses in charge of implementation.

    In response to Dr Crew:
    I agree with your comment about the importance in reducing CAUTI – with a qualification: all UTIs are important – including those related to intermittent catheterization or suprapubic catheters, which are not currently being measured.

    This is highly relevant, as there are many studies that fail to show a significant difference in UTI risk between Foley and intermittent catheterization – an observation that runs contrary to persistent dogma. In fact, the only studies that do show a UTI benefit from intermittent catheterization are, by study design, profoundly susceptible to artifact from the recently-characterized SCI-Immune Deficiency Syndrome.

    Just as the trajectory of lung cancer research was transformed by the understanding of the effects of smoking, our interpretation of past UTI research and design of future research should take this immune deficiency syndrome into account. Since most studies I have found cannot show a difference in UTI risk, it may be that we are simply trading Foley-related UTIs for UTIs related to other bladder management methods in SCI.

    Unfortunately, the notion that improvements in CAUTI rates can be achieved by improved Foley maintenance and insertion are based more on expert consensus than on high-quality evidence – as is documented in CDC and IDSA guidelines. We can all agree that it’s a good idea to adhere to basic hygiene principles. However the study by Saint, et al in the New England Journal of Medicine in 2016, failed to show an improvement in CAUTI rates in hospital units that did not remove Foleys. CAUTI surveillance, with focus on insertion and maintenance but not Foley removal, simply did not show a positive effect in that immense study.

    Thus, it is reasonable to question whether CAUTI surveillance is producing any improvement in overall UTI rates in SCI patients.

    In response to Dr Parsons:
    The SCI clinical practice guidelines are an excellent resource. While on the topic of Guidelines, it is worthwhile to bring attention to the CDC’s CAUTI guidelines from 2009. Those guidelines point out that the evidence suggesting a benefit from avoiding indwelling catheters is “very low quality” (p 34). The CDC’s weak recommendation to consider alternatives to Foleys (p 11) is a Category II recommendation. The description of a Category II designation (p. 10) implies a trade-off between benefits and harms, and thus the CDC guidelines recommend that Category II recommendations are “not intended to be enforced.” (p. 32)

    It should be noted that this Category II designation was not solely applied due to the low-quality nature of the data available. If benefits had been felt to outweigh potential harms, the recommendation for Foley removal should have received a Category IB designation (p. 10).

    As most infection preventionists are aware, Foley removal is clearly the most effective way to reduce a hospital’s CAUTI SIR. Thus, hospitals that do not remove Foleys are at increased risk of financial and public reporting penalty – in effect enforcing this provision that was “not intended to be enforced.”

    Discussions are underway with CDC and CMS to better align federal policy with Clinical Practice Guidelines from the CDC, the Consortium of Spinal Cord Medicine, and APIC.

    In response to Dr Villacorta:
    Your observation about difficulty differentiating safe bladder emptying and dangerous overflow incontinence is spot on.
    There is a common perception that checking a post-void residual (PVR) with a bladder scanner is an effective way to ensure safe bladder emptying. PVR does not provide information about pressures within the bladder, and studies of urodynamics findings in SCI have failed to show a significant effect of PVR on influencing progression to renal failure. For the majority of SCI patients, voiding by overflow incontinence, condom catheter, etc is very dangerous unless urodynamics studies demonstrate safe pressures. Unfortunately, due to the evolution of patients’ neurologic status over the initial months following SCI, it is difficult to make recommendations regarding optimal timing and frequency of urodynamic studies. These complex decisions were typically made by experienced SCI healthcare providers.

    Thanks for all the interest in this blog post!
    In response to Rhonda Reed:
    Your question about suprapubic catheters is a great one. We have seen a fair number of patients who have had suprapubic catheters placed in the early acute stage of SCI (within the first few weeks). The problem with that approach is that some patients who are profoundly paralyzed in the early acute phase will improve neurologically in upcoming weeks and months to be able to void volitionally or to become independent in self-intermittent catheterization – both of which are preferable for long-term management.

    Your experience with your local urologists is very typical of our experience as well. SCI is a relatively rare diagnosis, and it seems that urology training programs may not train their residents about potential for neurological recovery or about the potential for independence in self- catheterization according to neurological level of injury. In my experience, these competencies require constant effort to maintain even in tertiary care centers that see large numbers of SCI patients.

    I have been a registered nurse for about 40 years now and I appreciated reading the article by Dr.Davis. Most Nursing home residents are cared for by CNA’s that have no knowledge of the problems an over distended bladder can cause. My own father is in a Nursing home and has made several trips to the hospital with fevers of unknown origin and congestive heart failure, usually when I arrive I ask for them to check his urine and often the staff will ask Why? Very frustrating to see that in an assessment of a resident, the staff does not have a better understanding of how the bladder works. I was glad to read your article. I had the privilege of working with Dr. George Klauber from Tufts Medical Floating Hospital Boston Ma. He too was an excellent Urologist and a great teacher. Thank you for sharing your knowledge. Elaine McCarthy BSN

    This was very interesting. I would like to read more. This is helpful to clinicians who may not have a lot of experience with spinal cord injury patients.

    thank you so much for bringing this to peoples attention, this is still an issue in hospitals, whether nurses just don’t get any training on people w an SCI in school, or maybe very minimal. I know in the hospitals the nurses & doctors are all overworked. How can we ensure staff is more aware??

    “… data can fail to capture what it purports to quantify.”
    The Dictatorship of Data, MIT Technology Review May 31 2013.

    The failure of the CDC is to recognize CAUDI data does not quantify the danger of urinary catheters equally across all populations. This is particularly concerning for rare diseases with different pathology such as Spinal Cord Injury. The CDC has created an unfunded mandate to adopt an objectively dangerous standard for patients with rare neuromuscular diseases. Hospitals are forced to disclose aggregated CAUDI cases for disease conditions such as SCI which they may encounter less than once per year in a specific acute trauma unit. For the individual hospital, the resources required to appropriately manage patients with SCI related neurogenic bladder do not rise to the level of significance necessary to drive universal competency. However, for the individual with SCI removal of the catheter often spells acute renal insufficiency and occasionally death. The CDC should acknowledge that aggregated reporting of CAUDI is causing harm to patients with SCI and remove this condition from the current CAUDI reporting requirements.

    Dr. Davis, you are spot on in your observations and your recommendations to protect renal function and to avoid autonomic dysreflexia in recently injured patients. Thanks also for including links to the relevant clinical practice guidelines!

    Now the challenge is to get the word out to acute care hospitals and the trauma units where so many of our patients start their clinical course. Keep up the good work.

    Thank you Dr. Davis for your efforts in this area, and for your commitment to providing care to those with Spinal Cord Injury (SCI). As someone who practices at a tertiary care center and admits patients with SCI to our inpatient rehabilitation facility, I am sympathetic to this issue. Since CAUTIs have become a quality metric for inpatient care, I have noticed a trend toward the use of condom catheters for patients with SCI and neurogenic bladder who are transferred to our hospital. We have seen cases of dysreflexia and renal insufficiency from this practice. While CAUTIs should be minimized, I would advocate for a more sophisticated approach by practitioners in the case of SCI patients without volitional bladder control who are at risk for bladder spasticity, dysreflexia, and renal disease if Foleys are removed without an appropriate bladder management strategy such as intermittent bladder catheterization. Hopefully, the CAUTI dilemma in SCI can be seen as an opportunity for policy-makers to help guide appropriate clinical practice.

    With this patient population, why would a supra-pubic catheter not be an option? I do surveillance at our facility, and have lead the CAUTI reduction initiative at three hospitals. I’ve asked two urologists why this is not a better option to long term indwelling urinary catheter use, but neither had an answer. Any insight on this would be appreciated.

    I agree. Not very uncommon to receive/admit patients to inpatient rehab who feel they have been voiding on their own since Their indwelling has been removed in acute but are actually simply voiding as a result of overflow —- retaining a significant amount of urine that eventually transforms into frequent UTIs, pain ( bladder distention) and as stated above renal failure. It is scary to realize how many more patients are sent home with the same perception and may end up rehospitalized as a result of inadequate screening ( bladder scanning or even referral to urology) prior to clearance. Full heartedly support this advocacy program for more education and re considerations of more inclusive bladder management practices.

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