What's your excuse for Foley use?

Efforts to prevent catheter-associated urinary tract infection (CAUTI) are underway worldwide. Reducing indwelling urinary catheter (or ‘Foley’) use is a key component of most prevention initiatives, which makes sense given the evidence showing its effectiveness in reducing CAUTI rates. Such an approach, however, requires a specific focus on promoting the use of appropriate indications for a Foley at the time of insertion and throughout the duration of catheterisation. Unfortunately, data show substantial variability in both interpreting and applying such indications. The article by Murphy and colleagues uses robust qualitative methods to provide insights into decision-making about Foley insertion, including indications for use and the clinical context. This focus corresponds with what we and others have characterised as the socioadaptive aspects of CAUTI prevention, including behaviour change and unit culture, as compared with the technical components, such as urinary catheter reminders or stop orders. Murphy et al’s work supports the use of certain strategies to promote more appropriate Foley use, such as better education about and availability of alternatives, including bladder scanning and external catheters (referred to as urinary sheaths in the paper). It also reinforces current wisdom about some of the presumed reasons why clinicians use Foley catheters, including issues related to workload and perceived convenience for clinicians (or patients) and other safety concerns (ie, pressure ulcer prevention). A multicenter study conducted in the USA focusing on CAUTI prevention practices similarly found that nursing convenience was perceived as a driving force underlying inappropriate urinary catheter use. As one of the nurses in that study stated: “convenience, unfortunately, is a high priority, and that is another factor, and especially with urinary catheters, yes, the workload will be increased if you have to take them to the bathroom or you have to change their bed a little more often....” Likewise, Harrod and colleagues—also using qualitative methods— reported that hospital staff felt they had to choose between what they viewed as competing safety priorities (eg, effect of urinary catheter use on patients’ risk of falls) when it comes to improvement initiatives to limit urinary catheter use. Other results reported by Murphy and colleagues highlight some emerging issues and approaches for addressing inappropriate or potential ‘overuse’ of Foleys. For example, the knee-jerk reaction illustrated by the emergency department physician who said “I really don’t think about the decision at all” and the apparently unreflective favouring of Foley use to monitor urine output both suggest a need for better cognitive tools and strategies. This could include encouraging more mindful practice and better criteria and guidance for defining appropriate use, such as when hourly output monitoring might truly be required. On the other hand, concerns about avoiding contingencies and the use of combined weak indications and goals are more insidious and difficult to address, perhaps serving as fallback rationalisations or ‘excuses’ for actions rather than true decisions. Among the several strengths of this paper is the in-depth nature of the findings and the focus on the insertion decision, highlighting specific attitudes or potential knowledge gaps that serve as points for intervention. Understanding how attitudes and perceptions related to Foley use differ across clinical settings (eg, emergency department vs medical ward) is also important in developing effective strategies to promote appropriate use. However, while generalisability in the statistical sense is not in question, the transferability of these findings to other hospitals and settings is of note. Specifically, at this hospital physicians were primarily responsible for urinary catheter insertion and this appeared to be EDITORIAL