More care is not always better care. And often times, the things we do for convenience for the patient and nurse can backfire and lead to medical complications. We see this with PICC line complications. More commonly though, we see it with the convenient Foley catheter.
Many patients would much rather have the convenience of a Foley catheter during their hospital stay than experience the perceived embarrassment of incontinence. Many nurses would much rather have the convenience of a Foley catheter so they can call the hospitalist at 2 am with decreased urine output.
If I actually have a patient I'm concerned about with low urine output, it's because they aren't passing any urine at all. It's called anuria. If you donate one kidney, you can live a long and healthy life with just the other. That means, to get anuria, you must have failure of both kidneys or the inability to pass the urine your body is making out the genitourinary tract.
For the internists in training out there, remember your three general causes of acute renal failure.
- Prerenal
- Intrinsic
- Post obstructive.
If you are able to work through your differential diagnosis using this as the foundation of your thought process, you can manage 95% of all cases of renal failure without invoking the diagnostic skills of a nephrologist. You're an internist. This is what you do for a living. Like this case a reader sent me of an 88 year old demented, bed bound nursing home patient who presented to the ER with extremis:
- Tachycardia
- Fever
- Hypertension
- Leukocytosis
She had all the signs of sepsis, except for the hypertension. These nursing home folks always have a Foley catheter, even if it's a difficult Foley catheter insertion. There's something about nursing homes and Foley catheters. You can't have one without the other.
If you're an internist in training, understand that having a nurse obtain a straight cath or Foley sample of urine can help you accelerate your diagnostic evaluation. Any old person from a nursing home with any of the following symptoms
- It doesn't matter what they presented with
Should get a urine sample. In this situation, the 88 year old patient wasn't making urine, even with her Foley catheter securely in place. How is that possible? When the Foley catheter isn't draining, that's how.
What you see in the first CT image cut is bilateral hydronephrosis (obstructed kidneys).
Note the bilateral nature of the dilated ureters and kidneys involved in the hydronephrosis. To get both kidneys obstructed, the obstructing lesion must be somewhere distal to both ureters in order to obstruct fluid flow out of both kidneys. Unless you had the unfortunate bad luck to get big obstructing stones trying to pass down the ureters of both kidneys at the same time, the lesion must be distal to the ureters to obstruct flow. In a man, bilateral hydronephrosis is often the result of an enlarged prostate. For men and women, this can also mean the presence of a bladder tumor or clot obstructing both ureters. In this case, it was an obstructed Foley catheter that caused a massive pooling of urine in the bladder. See the CT cut below. That little white dot in the middle of that giant round thing, that's the Foley catheter in a bladder filled with urine.
It's as if we plugged the drain hole in the sink and turned on the faucet.
No wonder this lady had hypertension and tachycardia. Her demented little soul was probably writhing in pain, for days, at the nursing home. She probably had a rip roaring bladder infection too from the accumulation of static urine in this post obstructive cause of hydronephrosis.
In order to get anuria ( no urine output) from hydronephrosis, you must obstruct urine flow from both kidneys. You see, a hydronephrotic kidney will still often produce urine. But the obstructing lesion is what prevents the urine from being eliminated and the back pressure causes the kidneys to dilate.
This gives the illusion that the patient isn't making urine, when in fact they are. The urine just can't exit the body. What would cause this in a patient with a Foley catheter? Why, an obstructed or malfunctioning Foley catheter, that's how.
Sometimes the easiest explanation is the most likely explanation. In the case of no urine output, I am often given the run around from nurses when I ask them to please manipulate the Foley position and flush it clear. Too many times in my seven years as a hospitalist I have seen this solve the problem of low or no urine output. Yet I still constantly get aggravated responses from nurses who can't believe their catheter could possibly be the problem. It's almost as if they take it personally at my suggestion that the catheter needs to be flushed or manipulated. It's not personal. It's science. And these pictures prove it.
As a side note, this is the population of patients that rides the Medicare-Merry-Go-Round. We tune them up. We ship them out. And we wait for them to bounce back for their next DRG. Starting in 2013, Medicare will start taking back 1% (to increase in future years) of ALL Medicare DRG payments to a hospital if they experience a higher 30 day readmission rate than allowed (formula yet to be determined) for any one of these three primary DRGs ( to be expanded in future years)
- Heart failure
- Pneumonia
- Acute myocardial infarction.
That means if a hospital has a zero % 30 day readmission rate on 10,000 non heart failure Medicare admissions worth $10,000 each, or one hundred million dollars in hospital revenue, but that same hospital has a 20% 30 day readmission rate for 100 congestive heart failure DRG admissions and Medicare determines the acceptable readmission rate is only 15%, the hospital will have to give back 1% of all one hundred million dollars, or one million dollars because an extra five heart failure patients got admitted in a year.
Those five heart failure bounce backs will have cost the hospital one million dollars, or $200,000 each. With that said, If we can't keep nursing homes from sending helpless demented patients with obstructed Foley catheters to the ER, how do we expect nursing homes to check daily weights?
Good luck America. This is the reality of your new Medicare. Eventually, I think, many hospitals will simply close their ERs, politely tell the Medicare and Medicaid National Banks to shove it and implement their own community wide regional self insured community insurance plans through partner relationships with local businesses and charities. And the Medicare patients will be left in the dust, or at least be given directions to the nearest county hospital. When you buy votes by promising everything, eventually, you end up delivering on nothing.
