Supplementary Material*

Transcription

1 Supplementary Material* Meddings J, Saint S, Fowler KE, Gaies E, Hickner A, Krein SL, et al. The Ann Arbor criteria for appropriate urinary catheter use in hospitalized medical patients: results obtained by using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015;162(Suppl):S1-S34. doi: /m Supplement 1. Preconference Materials for Panelists Supplement 2. Panelists' Disclosures of Interest Supplement 3. Round 3 Rating Document Summary Results * This supplementary material was provided by the authors to give readers further details on their article. The material was reviewed but not copyedited. Annals of Internal Medicine 2015 American College of Physicians

2 Supplement 1. Preconference Materials for Panelists Packet Contents Enclosed in this packet are the materials you will need for the first round of appropriateness ratings. Please confirm that your packet is complete. 1. Introductory Letter 2. Overview of the RAND/UCLA Appropriateness Method 3. Literature Search Methods 4. Instructions for Round One 5. Rating Document: Scenarios for Considering Appropriateness of Urinary Catheter Use 6. Appendixes A. Review of Catheter Types B. Examples of Appropriate and Inappropriate Indications for Indwelling Catheters Provided in the 2009 CDC Guideline for the Prevention of Catheter-associated Urinary Tract Infections C. Braden Scale for Predicting Pressure Sore Risk 7. Form W-9 Instructions* 8. Form W-9* 9. List of Possible UPS Drop Locations* 10. Return Mailing Pre-paid UPS Envelope* * Materials were mailed to panelists, but are not included in this appendix.

3 April 19, 2013 Dear «First_Name», Thank you for agreeing to serve on the expert panel that will rate the appropriateness of using urinary catheters in adult hospitalized medical patients. As previously mentioned, this panel is part of a grant that is funded by a Veterans Affairs (VA) National Center for Patient Safety, Patient Safety Center of Inquiry (PSCI), with additional support from the Agency of Healthcare Research and Quality (AHRQ) On the CUSP: Stop CAUTI project. Please read the enclosed instructions closely, fill out the rating document for Round One, and return it to us by May 7, Please make a copy of your completed rating document before mailing, so there will be a backup copy in case something gets lost in the mail. Place the original rating form in the enclosed pre-paid UPS envelope and drop it off at any UPS Store, Drop Box, or other authorized UPS shipper. In a few days, we will be contacting each of you to confirm that you have received these materials and to discuss any questions or comments you may have about the rating process. You are not required to bring any materials with you to Ann Arbor for Round Two; however, you may find it useful to bring your copy of the enclosed documents if you make any notes on them while doing the Round One ratings. At the panel conference for Round Two in Ann Arbor, June 18 th and 19 th, you will receive a new set of documents which will have your individual ratings from Round One as well as the average ratings of the panel. Should you have any questions, comments, or concerns, please contact our project manager Karen Fowler, either by at Karen.Fowler@va.gov or phone at (734) Thank you for your participation, and we look forward to welcoming you in Ann Arbor. Sincerely, Jennifer Meddings, MD, MSc Assistant Professor of Internal Medicine, University of Michigan Medical School Physician, Ann Arbor VA Medical Center Sanjay Saint, MD, MPH George Dock Professor of Internal Medicine, University of Michigan Medical School Associate Chief of Medicine, Ann Arbor VA Medical Center Director, VA/UM Patient Safety Enhancement Program

4 The RAND/UCLA Appropriateness Method (11) Background The RAND/UCLA Appropriateness Method (RAM) was developed in the mid-1980s, as part of the RAND Corporation/University of California Los Angeles (UCLA) Health Services Utilization Study, primarily as an instrument to enable the measurement of the overuse and underuse of medical and surgical procedures. In the RAM, the concept of appropriateness refers to the relative weight of the benefits and harms of a medical or surgical intervention. An appropriate procedure is one in which "the expected health benefit (e.g., increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g., mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin that the procedure is worth doing, exclusive of cost" (12, 13). Robert H. Brook, who identified the need for a tool to measure the appropriateness of care, explained that "it was motivated by the concern that the increasing complexity of medical care was resulting in some patients not undergoing procedures that they needed, and others undergoing procedures that they did not need" (122) The rationale behind the method is that randomized clinical trials the "gold standard" for evidence-based medicine often are either not available or cannot provide evidence at a level of detail sufficient to apply to the wide range of patients seen in everyday clinical practice. Although robust scientific evidence about the benefits of many procedures is lacking, physicians must nonetheless make decisions every day about when to apply them. Consequently, it was believed a method was needed that would combine the best available scientific evidence with the collective judgment of experts to yield a statement regarding the appropriateness of performing a procedure at the level of patient-specific symptoms, medical history, and test results. Overview The basic steps in applying the RAM are shown below. First, a detailed literature review is performed to synthesize the latest available scientific evidence on the procedure to be rated (please see the document entitled Literature Search Methods for more information on the literature search performed regarding urinary catheter indications). From this search, a list of specific clinical scenarios or "indications" is produced and compiled into sections based on the primary presenting symptom leading to a patient s being referred for treatment or considered for a particular procedure. (For this project this list of indications has been organized into the Rating Document: Scenarios for Considering Appropriateness of Urinary Catheter Use). 1

5 Literature review and synthesis of the evidence List of indications and definitions 1st round independently (no interaction) Expert panel rates indications in two rounds 2nd round panel meeting (as a group) Develop and share guidelines regarding appropriateness of urinary catheter use based on appropriate ratings of specific scenarios, as scored by RAND/UCLA Appropriateness Method Figure: RAND/UCLA Appropriateness Method A panel of experts is identified, often based on recommendations from the relevant medical societies. The literature review and the list of indications, together with a list of definitions for all terms used in the indications list, are sent to the members of this panel. For each indication, the panel members rate the benefit-to-harm ratio of the procedure on a scale of 1 to 9, where 1 means that the expected harms greatly outweigh the expected benefits, and 9 means that the expected benefits greatly outweigh the expected harms. A middle rating of 5 can mean either that the harms and benefits are about equal or that the rater cannot make the judgment for the patient described in the indication. The panelists rate each of the indications a total of two times. For the first round, the ratings are made individually at home, with no interaction among panelists. In the second round, the panel members meet for 1-2 days with a moderator experienced in using the method. Each panelist receives a document showing the distribution of the group s first round ratings, together with his/her own individual ratings. During the meeting, panelists discuss the ratings, focusing in particular on areas of disagreement. At this time the panelists are given the opportunity to modify the original list of indications and/or definitions, if desired. After discussing each section of indications, they re-rate each indication individually. No attempt is made to force the panel to consensus. Instead, the two-round process is designed to sort out whether discrepant ratings are due to true clinical disagreement over the use of the procedure ("real" disagreement) or misunderstanding of the scenario ("artifactual" disagreement). Finally, each indication is classified as "appropriate," "uncertain," or "inappropriate" for the procedure under review in accordance with the panelists median score and the level of disagreement among them. Indications with median scores in the 1-3 range are classified as inappropriate, those in the 4-6 range as uncertain, and those in the 7-9 range as appropriate. However, all indications rated "with disagreement," whatever the median, are classified as uncertain. "Disagreement" in this context means a lack of consensus, either because there is polarization of the group or because judgments are spread over the entire 1 to 9 rating scale. 2

6 Literature Search Methods We compiled urinary catheter indications to list as scenarios in the Rating Document using the following processes: Initial literature search strategy: Similar to prior research projects (11) assessing the appropriateness of various medical technologies (such as appropriateness of coronary revascularization) we began our literature search with a systematic review of databases (Web of Science, CINAHL, Embase, and Pubmed/MEDLINE). Each database was searched using Boolean logic (e.g. AND, OR, etc.) for various combinations of concepts including urinary catheterization, appropriate/inappropriate, protocol, indication, checklist, reminder, removal, and guideline. For example, one of the MEDLINE database searches was conducted by exploding and combining the following Medical Subject Heading (MeSH) terms: urinary tract infection, urinary catheterization, indwelling catheter, inpatient, reminder system, device removal, intervention studies. The MeSH reminder system was also searched separately. We included the following terms in a keyword search (with wildcard indicated with *): urinary tract infection; ((urin* or uret*) and cath*)) or catheter*; nosocomial or inpatient or hospital*; reminder, removal, and intervention. Example of PubMed Search Boolean Logic Steps References Step #19 Step #20 "Urinary Tract Infections/prevention and control"[mesh] or Unnecessary Procedures [MeSH] or appropriate or inappropriate [Title/Abstract] "Urinary Catheterization"[Mesh] OR catheter*[title/abstract] 340, ,760 Step #21 Conditions #19 AND #20 5,673 After excluding duplicate, non-human, pediatric, and other unrelated references by review of title and abstract, we retrieved 1,257 unique references. Next, we reviewed the titles and abstracts to identify studies where the risks and benefits of urinary catheters to patients were assessed, in comparison to patients without catheters or comparisons of patient outcomes by catheter type (such as indwelling transurethral Foley catheters compared to intermittent straight catheters) for certain clinical indications. Unfortunately most of the retrieved articles involved specialized surgical populations (such as comparing different urinary catheter protocols in the intra-operative and post-operative setting, for patients undergoing genitourinary surgeries), rather than the patient population of interest in this project the acutely ill, hospitalized, adult, medical patient. As a result, we decided to revise the literature search method. 1

7 Revised literature search strategy: Because the initial literature review strategy demonstrated a lack of evidencebased studies comparing the risks and benefits of urinary catheters in acutely ill, medical patients, a different literature search was performed as follows to obtain a comprehensive list of potentially appropriate or commonly used but inappropriate indications for indwelling transurethral Foley catheters, intermittent straight catheters and external (or condom) catheters. First, we reviewed existing guidelines (ideally generated using an evidencebased process) with recommendations regarding use or avoidance of urinary catheters, beginning with several recent guidelines focused on catheter-associated UTI prevention (from the CDC/HICPAC (8), IDSA (15, 123), APIC (16), and outside the United States (18)). We next reviewed guidelines focused on care of selected patient populations with potential needs for urinary catheters (such as patients with pressure ulcers National guideline clearinghouse (20-23), paralysis or neurologic bladder issues (24, 25), and urologic diagnoses (26) including incontinence (27-29)) that may be encountered for adult patients on acute, medical, inpatient services. From these guidelines, we abstracted appropriate and inappropriate uses of urinary catheters for conditions seen on acute, inpatient, adult medical services; we also reviewed any references that were cited as evidence supporting the catheter recommendations in these guidelines. Next, based on Dr. Meddings previous research and recent systematic literature searches (31, 124) (using similar initial literature search strategies as first described for this project) involving interventions to reduce unnecessary catheter use, we reviewed the full text of all studies involving interventions to decrease urinary catheter use for lists of appropriate and inappropriate catheter uses. For example, several studies involved catheter stop orders that functioned by requiring removal of urinary catheters if not being used for one of a specific set of reasons categorized as appropriate in the study. Specifically, we first reviewed the 14 intervention studies identified for a systematic review and meta-analysis published in 2010 (31) involving interventions to prompt removal or unnecessary urinary catheters. We next reviewed the studies identified in a more recent systematic review (30) for Chapter 9 of AHRQ s 2013 Making Healthcare Safer evidence report regarding interventions that reduced unnecessary catheter use by catheter placement restrictions or prompting removal of unnecessary urinary catheters. For these intervention studies, we also reviewed the references when provided as the evidence used to generate these lists of appropriate and inappropriate catheter uses. The most frequently cited reference for appropriateness of catheter use provided in recent studies was Table 2 from the 2009 CDC/HICPAC guideline (8), which is reproduced in its entirety in Appendix B. Starting with a comprehensive list of urinary catheter indications identified by abstraction from guidelines, intervention studies, and the accompanying reference lists, Dr. Meddings organized the list into a comprehensive table, with indications grouped by general themes of clinical scenarios. If you are interested in this complete list of indications, please contact us. In total, 118 references were abstracted to develop the final, comprehensive list of urinary catheter indications. 2

8 Finally, the comprehensive list of urinary catheter indications by category was developed into scenarios focusing on distinct clinical indications to query our expert panel in the enclosed Rating Document. These scenarios were reviewed by our research team (consisting of general medicine hospitalists, a pediatrician, a floor nurse, an ICU nurse, and an urologist). The Rating Document was reviewed further by clinicians outside our research team, including general medicine hospitalists, primary care physicians, a neurologist, and various specialists in internal medicine and surgery. Feedback from these clinicians was used to clarify the descriptions of the clinical scenarios, as well as to add some clinical scenarios that the clinicians recommended as common and/or appropriate reasons catheters are used that had not been described from the literature abstractions. 3

9 Instructions for Rating the Appropriateness of Urinary Catheter Use Round One 1. Please look over the enclosed Rating Document. You should have 35 pages. 2. Please familiarize yourself with the Rating Document s 3 sections, 9 chapters, and general structure. 3. We anticipate that it will take 3-4 hours to rate these clinical scenarios. 4. We suggest that you complete a few sections at a time, rather than completing the entire set of scenarios in one sitting. We have indicated suggested breaks in the document following chapters C and F. 5. We suggest that you use a pencil in the event that you would like to change a rating. 6. As a reminder, a procedure or treatment is considered to be appropriate if: "The expected health benefit (e.g., increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g., mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin that the procedure is worth doing, exclusive of cost" This document is intended to focus on the acutely ill, hospitalized, adult internal medicine patient (including ward, step-down, and ICU patients). A. The scenarios related to the management of urologic issues were included because they are often encountered and/or managed by non-urologists on inpatient medical units and services. B. This document is not intended to apply to patients residing in a nursing home or long term care facility, though it does address many scenarios commonly encountered in these settings. C. This document is not intended to apply to patients with clinical conditions with anatomic, peri-procedural, or treatment related needs for using catheters that are managed by specialists such as cancer specialists and surgeons (including but not limited to: urologists, gynecologists, obstetricians, orthopedists, general surgeons, and trauma surgeons). 8. This tool is not designed to assess the appropriateness of using bladder scanners. A. We understand that all facilities or clinicians do not have access to a bladder scanner. 1

10 B. For intermittent straight catheter (ISC) placement, the assumption is that if you have a bladder scanner you would use it for all scenarios except one where this is specified (Section I, question C3). C. As you complete your rating document, please note if there is a time that your rating would change as a result of using/not using a bladder scanner. 9. For each of the scenarios provided, please rate the appropriateness of using the urinary catheter type described by circling a number on a scale from 1 to 9, interpreted as: 1= highly inappropriate 5= neither appropriate nor inappropriate (neutral) OR uncertain 9= highly appropriate A. In section I we ask you to rate the appropriateness of each of three types of urinary catheters- indwelling (Foley), intermittent straight (ISC), and external (condom) catheters for each of the clinical scenarios for the reason specified. Assume that the patient has no other indication for a urinary catheter other than what is provided in the scenario. If you feel there is more information that you need to make a decision, please rate the scenario as it is and make a note on the document (near the scenario in question). B. In section II (page 30) we ask you to rate the appropriateness of using an indwelling catheter (Foley) for specific clinical scenarios as an alternative when an intermittent straight (ISC) or an external (condom) catheter could be used. C. In section III (page 33), please describe on your rating document (by writing comments) any scenarios for urinary catheter appropriateness that you feel should have been included that are important or commonly encountered in acutely ill, hospitalized patients on medical services. 10. We are not asking for the appropriateness of other urinary catheter or collection methods (such as suprapubic catheters, nephrostomy tubes, urostomies, or ileal conduits). 11. Please use your best clinical judgment (not what you perceive other experts or guidelines might recommend). 12. Consider each scenario for the average adult patient, presenting to the average healthcare provider, in an average hospital. 13. Do not consider cost in your judgment. 2

11 14. When you have completed rating the entire set of indications, please mail it back to us in the enclosed pre-paid UPS envelope. We must have these back by May 7, 2013 so that we can revise the tool based on your feedback and ratings so that it can be used for Round Two on June 18 th. 15. As optional references for you, the Appendix includes three references A. Review of catheter types B. Examples of Appropriate and Inappropriate Indications for Indwelling Catheters Provided in the 2009 CDC Guideline for the Prevention of Catheter-associated Urinary Tract Infections C. Braden Scale for Predicting Pressure Sore Risk 3

12 Table of Contents Section I: Clinical scenarios for rating the appropriateness of each of three urinary catheter types: indwelling (Foley), intermittent straight (ISC), and external (condom) A. Acute urinary retention Page 3 B. Chronic urinary retention Page 4 C. Urine collection for monitoring, evaluating, and diagnosing a condition Page 5 D. Management of other urologic problems Page 11 E. Skin wounds, pressure ulcers, and other skin irritations Page 14 F. Immobility Page 23 G. Using catheters for comfort or convenience Page 25 Section II: Section III: Clinical scenarios for rating the appropriateness of an indwelling urinary catheter (Foley) instead of an intermittent straight catheter (ISC) or external (condom) catheter Page 30 Your feedback regarding missing scenarios, bladder scanner use, and any other comments Page 33 Important Reminders: 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. 2. Assume patients would have no difficulty with catheter placement, meaning that a nurse could place an indwelling (Foley), intermittent straight (ISC), or external (condom) catheter without difficulty in the patient unless otherwise stated. Page 2 of 35

13 Instructions: Please circle your rating of the appropriateness of using an Indwelling Urinary Catheter (Foley), an Intermittent Straight Catheter (ISC), or an External Catheter (Condom) for each scenario on a scale of 1 to 9. 1 = Highly inappropriate; 5= Neutral or uncertain; 9 = Highly appropriate. A: Acute urinary retention Reminder 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. 2. Assume patients would have no difficulty with catheter placement, meaning that a nurse could place an indwelling, ISC, or external catheter without difficulty in the patient unless otherwise stated. Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If Male Patient: Appropriateness of External Catheter (Condom) Use Acute urinary retention is defined as the inability to urinate despite a full bladder. This is defined by clinical exam as painful, palpable or percussable bladder, when the patient is unable to pass any urine (126). A1. How appropriate is use of this catheter Some causes of acute urinary retention include, but are not limited to: medication side effects (anticholinergics, because a hospitalized patient has opioids, paralytics), acute neurologic injuries or inflammatory conditions of the spinal cord (trauma, disc compressions or acute urinary retention, without transverse myelitis), and some cases of bladder infection. Also, acute urinary retention can occur as exacerbations of bladder outlet obstruction, for chronic conditions associated with difficulty emptying the bladder (addressed in scenarios B1 and B2). a. less than 24 hours? b hours? c. greater than 48 hours? A2. How appropriate is use of this catheter because a hospitalized patient has acute urinary retention, due to bladder outlet obstruction, for Some conditions that cause acute urinary retention due to bladder outlet obstruction include, but are not limited to: acute prostatic hyperplasia (BPH), prostate inflammation/infection (e.g., prostatitis), newly diagnosed urethral stricture, urethrocele, newly diagnosed of bladder stones, bladder or prostatic masses, and temporary obstruction such as edema from a recent urologic procedure. a. less than 24 hours? b hours? c. greater than 48 hours? A3. How appropriate is use of this catheter because a hospitalized patient has acute urinary retention, due to bladder outlet obstruction specifically caused by urethral injury? Urethral injury can cause bladder outlet obstruction through urethral disruption, edema, and urethral blood clots. Some causes of urethral injury include, but are not limited to: patient traumatic self-removal of Foley catheter (with balloon up), straddle injuries, penetrating wounds near the urethra, and pelvic injuries. 1 = Highly inappropriate; 5= Neutral or uncertain; 9 = Highly appropriate Page 3 of 35

14 B: Chronic urinary retention Reminder 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. 2. Assume patients would have no difficulty with catheter placement, meaning that a nurse could place an indwelling, ISC, or external catheter without difficulty in the patient unless otherwise stated. Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If Male Patient: Appropriateness of External Catheter (Condom) Use Chronic urinary retention is defined as persistent or recurring difficulty emptying the bladder. B1. How appropriate is use of this catheter because a hospitalized patient has chronic urinary retention state, without bladder outlet obstruction? For example, some chronic conditions associated with chronic urinary retention without bladder outlet obstruction include, but are not limited to: neurogenic bladder due to peripheral and autonomic neuropathies (e.g., diabetes), and chronic neurologic diseases (e.g., spinal cord injury or lesions, multiple sclerosis, or Alzheimer s disease). B2. How appropriate is use of this catheter because a hospitalized patient has chronic urinary retention state, due to bladder outlet obstruction? For example, some chronic conditions associated with chronic urinary retention due to bladder outlet obstruction include, but are not limited to: benign prostatic hyperplasia (BPH), chronic bladder stones, bladder or prostatic masses, and chronic urethral stricture disease. 1 = Highly inappropriate; 5= Neutral or uncertain; 9 = Highly appropriate Page 4 of 35

15 C: Urine collection for monitoring, evaluating, and diagnosing a condition Reminder 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. 2. Assume patients would have no difficulty with catheter placement, meaning that a nurse could place an indwelling, ISC, or external catheter without difficulty in the patient unless otherwise stated. Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If Male Patient: Appropriateness of External Catheter (Condom) Use This section asks about the appropriateness of urinary catheter placement for the purpose of collecting urine to monitor, evaluate, or diagnose a condition. This section is NOT asking about the appropriateness of urinary catheter placement for any other purpose (such as patient comfort) which will be addressed in later sections. C1. How appropriate is use of this catheter in a hospitalized patient in order to obtain a random urine sample, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? Some reasons to obtain a random urine sample include, but are not limited to: urinalysis, urine culture, cytology, fractional excretion of sodium (such as in the evaluation of renal failure), and the presence of drugs. C2. How appropriate is use of this catheter in a hospitalized patient in order to obtain a 24-hour urine sample, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? Some reasons to obtain a 24-hour urine collection include, but are not limited to: the evaluation of renal diseases, urologic diseases, and malignancies. C3. How appropriate is use of this catheter to evaluate for a suspected new diagnosis of urinary retention in a hospitalized patient, who cannot be assessed otherwise using a bladder scanner or physical exam? Page 5 of 35

16 C: Urine collection for monitoring, evaluating, and diagnosing a condition Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If Male Patient: Appropriateness of External Catheter (Condom) Use NOTE: Scenarios C4-C12 ask about the appropriateness of using a urinary catheter for the purpose of measuring the VOLUME of urine output, which is commonly requested for inpatients using an order to "measure accurate I's and O's." Remember to assume the patient has no other indication for a urinary catheter other than what is described in the scenario. C4. How appropriate is use of this catheter to facilitate repeated measurements of daily urine volume in a hospitalized patient being evaluated for acute renal failure, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? C5. How appropriate is use of this catheter to facilitate measuring urine output in a hospitalized patient who is not receiving IV fluids and/or oral diuretics, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? C6. How appropriate is use of this catheter to facilitate measuring urine output in a hospitalized patient who requires IV fluids and/or oral diuretics, with a. no expected difficulty collecting urine by commode, urinal, or bedpan or obtaining daily weights? b. difficulty collecting urine by commode, urinal, or bedpan or obtaining daily weights? Page 6 of 35

17 C: Urine collection for monitoring, evaluating, and diagnosing a condition Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If Male Patient: Appropriateness of External Catheter (Condom) Use C7. How appropriate is use of this catheter to facilitate measuring urine output in a hospitalized patient who requires IV bolus (1-3 doses daily) diuretics, with a. no expected difficulty collecting urine by commode, urinal, or bedpan or obtaining daily weights? b. difficulty collecting urine by commode, urinal, or bedpan or obtaining daily weights? C8. How appropriate is use of this catheter to facilitate measuring urine output in a hospitalized patient who requires hourly titrations of IV fluid for the treatment of life-threatening lab abnormalities, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? C9. How appropriate is use of this catheter because a hospitalized patient has hemodynamic instability requiring hourly titrations of diuretics, vasopressors, inotropic agents, or IV bolus fluid resuscitation, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? Some life-threatening lab abnormalities include, but are not limited to: critical levels of glucose, calcium, potassium, sodium, and magnesium. Hemodynamic instability is defined as requiring pharmacologic or mechanical support to maintain a normal blood pressure or adequate cardiac output. Page 7 of 35

18 C: Urine collection for monitoring, evaluating, and diagnosing a condition Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If Male Patient: Appropriateness of External Catheter (Condom) Use C10. How appropriate is use of this catheter to facilitate measuring urine output in a hospitalized patient who has acute respiratory failure requiring significant oxygen by nasal cannula or facemask, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? C11. How appropriate is use of this catheter to facilitate measuring urine output in a hospitalized patient who has acute respiratory failure requiring non-invasive positive pressure ventilation, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? C12. How appropriate is use of this catheter to facilitate measuring urine output in a hospitalized patient who has acute respiratory failure requiring invasive ventilation, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? Acute respiratory failure refers to impaired oxygenation (hypoxemia) or ventilation (hypercapnia). Significant oxygen refers to nasal cannula > 5 liters per minute (LPM) or facemask > 5 LPM or >50% oxygen. Acute respiratory failure refers to impaired oxygenation (hypoxemia) or ventilation (hypercapnia). Non-invasive positive pressure ventilation includes, but is not limited to: continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BPAP). Acute respiratory failure refers to impaired oxygenation (hypoxemia) or ventilation (hypercapnia). Invasive ventilation includes, but is not limited to: endotracheal tube (ETT) and tracheostomy. Page 8 of 35

19 C: Urine collection for monitoring, evaluating, and diagnosing a condition Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If Male Patient: Appropriateness of External Catheter (Condom) Use C13. How appropriate is use of this catheter specifically because patient is located in the Intensive Care Unit without any other indications for catheter use? C14. How appropriate is use of this catheter in any hospitalized patient because turning or position changes cause unsafe changes in cardiovascular or respiratory status? 1 = Highly inappropriate; 5= Neutral or uncertain; 9 = Highly appropriate Page 9 of 35

20 We suggest you take a break Page 10 of 35

21 D: Management of other urologic problems Reminder 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. 2. Assume patients would have no difficulty with catheter placement, meaning that a nurse could place an indwelling, ISC, or external catheter without difficulty in the patient unless otherwise stated. Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use D1. How appropriate is use of this catheter to manage gross hematuria in a hospitalized patient Gross hematuria is defined as blood visual to the naked eye in the urine. a. without blood clots in the urine? b. with blood clots in the urine? c. with or without blood clots in the urine, with hematuria cause suspected to be prostatic or urethral bleeding? Section D continues on the next page Page 11 of 35

22 D: Management of other urologic problems Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use D2. How appropriate is use of this catheter to manage urinary incontinence in a hospitalized patient with a. no difficulty using commode, urinal, or bedpan when prompted/assisted with scheduled toileting (timed voiding)? b. difficulty collecting urine by commode, urinal, or bedpan, but with 1. no difficulty turning and providing skin care? 2. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? 3. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Urinary incontinence is defined as the inability to control the flow of urine resulting in involuntary urination. Section D continues on the next page Page 12 of 35

23 D: Management of other urologic problems Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use D3.How appropriate is use of this catheter to prevent urinary tract infections in a hospitalized patient with diarrhea or fecal incontinence, with a. no difficulty collecting urine by commode, urinal, or bedpan when prompted/assisted with scheduled b. difficulty collecting urine by commode, urinal, or bedpan, but with 1. no difficulty turning and providing skin care? 2. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? 3. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300lbs.)? 1 = Highly inappropriate; 5= Neutral or uncertain; 9 = Highly appropriate Page 13 of 35

24 E: Skin wounds, pressure ulcers, and other skin irritations Reminder 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. 2. Assume patients would have no difficulty with catheter placement, meaning that a nurse could place an indwelling, ISC, or external catheter without difficulty in the patient unless otherwise stated. Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use In this section, we ask about the appropriateness of urinary catheter use for the prevention and management of skin wounds, pressure ulcers, and other skin irritations in areas of skin such as the perineum and "buttock" (e.g., sacral, ischial, gluteal) that can be exposed to urine. E1. How appropriate is use of this catheter to prevent the development of incontinence-associated dermatitis in any hospitalized patient with urinary incontinence for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Incontinence-associated dermatitis is defined as irritation and inflammation of the skin from prolonged exposure to urine or stool; skin erosion is common in this condition. This condition is different than a pressure ulcer because it not related to pressure, but can increase a patient's risk for developing pressure ulcers (27). Urinary incontinence is defined as the inability to control the flow of urine resulting in involuntary urination. E2. How appropriate is use of this catheter to prevent the development of perineal or buttock pressure ulcers in any hospitalized patient with urinary incontinence for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Pressure ulcer is defined as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (27). Urinary incontinence is defined as the inability to control the flow of urine resulting in involuntary urination. Page 14 of 35

25 E: Skin wounds, pressure ulcers, and other skin irritations Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use E3. How appropriate is use of this catheter to prevent the development of pressure ulcers in a hospitalized patient assessed by a risk assessment tool to be at minimal risk for developing pressure ulcers, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? E4. How appropriate is use of this catheter to prevent the development of pressure ulcers in a hospitalized patient assessed by a risk assessment tool to be at low risk for developing pressure ulcers, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Pressure ulcer risk assessment tools (such as the Braden Scale, the Norton Scale, etc.) calculate a patient s risk for developing pressure ulcers by assessing patient risk factors such as nutrition, sensory perception, mobility, mental status, continence, and skin shear, friction, and moisture. Minimal risk is considered a score of on the Braden scale for predicting pressure sore risk (see Appendix C for The Braden Scale if interested). Pressure ulcer risk assessment tools calculate a patient s risk for developing pressure ulcers by assessing patient risk factors such as nutrition, sensory perception, mobility, mental status, continence, and skin shear, friction, and moisture. Low risk is considered a score of on the Braden scale for predicting pressure sore risk (see Appendix C for The Braden Scale if interested). Page 15 of 35

26 E: Skin wounds, pressure ulcers, and other skin irritations Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use E5. How appropriate is use of this catheter to prevent the development of pressure ulcers in a hospitalized patient assessed by a risk assessment tool to be at moderate risk for developing pressure ulcers, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? E6. How appropriate is use of this catheter to prevent the development of pressure ulcers in a hospitalized patient assessed by a risk assessment tool to be at high risk for developing pressure ulcers, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Pressure ulcer risk assessment tools calculate a patient s risk for developing pressure ulcers by assessing patient risk factors such as nutrition, sensory perception, mobility, mental status, continence, and skin shear, friction, and moisture. Moderate risk is considered a score of on the Braden scale for predicting pressure sore risk (see Appendix C for The Braden Scale if interested). Pressure ulcer risk assessment tools calculate a patient s risk for developing pressure ulcers by assessing patient risk factors such as nutrition, sensory perception, mobility, mental status, continence, and skin shear, friction, and moisture. High risk is considered a score of 0-12 on the Braden scale for predicting pressure sore risk (see Appendix C for The Braden Scale if interested). Page 16 of 35

27 E: Skin wounds, pressure ulcers, and other skin irritations Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use E7. How appropriate is use of this catheter because a hospitalized patient has mild or early incontinence-associated dermatitis, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? E8. How appropriate is use of this catheter because a hospitalized patient has moderate incontinence-associated dermatitis, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Skin affected by mild or early incontinence-associated dermatitis is described as dry, intact, not blistered, diffusely pink or red skin that may have be of a warmer temperature (27). Skin affected by moderate incontinence-associated dermatitis is described as shiny and moist skin with weeping or pinpoint areas of bleeding, that may include raised areas, small blisters and small areas of skin loss (dime size) (27). Page 17 of 35

28 E: Skin wounds, pressure ulcers, and other skin irritations Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use E9. How appropriate is use of this catheter because a hospitalized patient has severe incontinence-associated dermatitis, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 Skin affected by severe incontinence-associated dermatitis is red with areas of denudement (partial-thickness skin loss) and oozing/bleeding (27). lbs.)? For scenarios E10-E14 we are asking for the appropriateness of urinary catheter use in patients with pressure ulcers of specific stages/severity and non-pressure ulcer wounds. Because there is no staging system for wounds that are not pressure ulcers, consider the wound to be of similar severity as the pressure ulcer described in the scenario. E10. How appropriate is use of this catheter because of closed pressure ulcers (stage I) or similarly severe wounds of perineum or buttocks in a hospitalized patient without urinary incontinence, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Closed/stage I pressure ulcer is defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence (127). Patients without urinary incontinence have no expected difficulty collecting urine by commode, urinal, or bedpan. Page 18 of 35

29 E: Skin wounds, pressure ulcers, and other skin irritations Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use E11. How appropriate is use of this catheter because of closed pressure ulcers (stage I) or similarly severe wounds of perineum or buttocks in a hospitalized patient with urinary incontinence, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Closed/stage I pressure ulcer is defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence (127). Urinary incontinence is defined as the inability to control the flow of urine resulting in involuntary urination. Section E continues on the next page Page 19 of 35

30 E: Skin wounds, pressure ulcers, and other skin irritations Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use Stage II pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (127). E12. How appropriate is use of this catheter because of open pressure ulcers (stages II-IV and unstageable) or similarly severe wounds of perineum or buttocks in any hospitalized patient without urinary incontinence, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Stage III pressure ulcer is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed (127). Stage IV pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle (127). Unstageable pressure ulcer is defined as full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed (127). Patients without urinary incontinence have no expected difficulty collecting urine by commode, urinal, or bedpan. Section E continues on the next page Page 20 of 35

31 E: Skin wounds, pressure ulcers, and other skin irritations Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use E13. How appropriate is use of this catheter because of open pressure ulcers (stage II) or similarly severe wounds of perineum or buttocks n any hospitalized patient with urinary incontinence, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? E14. How appropriate is use of this catheter because of open pressure ulcers (stage III or IV) or similarly severe wounds of perineum or buttocks in any hospitalized patient with urinary incontinence, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Stage II pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (127). Urinary incontinence is defined as the inability to control the flow of urine resulting in involuntary urination. Stage III pressure ulcer is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed (127). Stage IV pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle (127). Urinary incontinence is defined as the inability to control the flow of urine resulting in involuntary urination. Page 21 of 35

32 E: Skin wounds, pressure ulcers, and other skin irritations Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use E15. How appropriate is use of this catheter because of open pressure ulcers (described as unstageable) of perineum or buttocks in a hospitalized patient with urinary incontinence for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? E16. How appropriate is use of this catheter because a hospitalized patient has other painful perineal skin conditions that would be exacerbated by contact with urine or routine toileting hygiene, for whom nursing staff has a. no difficulty turning and providing skin care? b. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? c. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? Unstageable pressure ulcer is defined as full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed (127). Urinary incontinence is defined as the inability to control the flow of urine resulting in involuntary urination. Some examples of painful perineal skin conditions include but are not limited to: vesicular or ulcerative conditions such as genital herpes simplex and Behçet s skin ulcers. 1 = Highly inappropriate; 5= Neutral or uncertain; 9 = Highly appropriate Page 22 of 35

33 F: Immobility Reminder 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. 2. Assume patients would have no difficulty with catheter placement, meaning that a nurse could place an indwelling, ISC, or external catheter without difficulty in the patient unless otherwise stated. Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use F1. How appropriate is use of this catheter because a hospitalized patient requires strict prolonged immobility? Some reasons for medically-required strict immobility include, but are not limited to: recovery from lumbar, pelvic, and sacral fractures or procedures. F2. How appropriate is use of this catheter because a hospitalized patient requires chemical paralysis for greater than 4 hours? F3. How appropriate is use of this catheter because a hospitalized patient is immobilized < 24 hours due to loss of consciousness (LOC)? F4. How appropriate is use of this catheter because a hospitalized patient is immobilized > 24 hours due to loss of consciousness (LOC)? F5. How appropriate is use of this catheter for the purpose of fall prevention (by decreasing the amount of walking) in a hospitalized patient at increased risk of falls? Chemical paralysis is defined as IV medication that makes patient completely unable to move or communicate, and is expected to cause neurogenic bladder and acute urinary retention. Some reasons for loss of consciousness include, but are not limited to: medication sedation (e.g., analgesics, anti-seizure medications, and anxiolytics), and head injuries. Some reasons for loss of consciousness include, but are not limited to: conscious sedation and head injuries. Some reasons for increased risk of falling include but are not limited to: visual impairment, frailty (e.g., weakness, aging), unsteady gait, and disorders of disequilibrium. 1 = Highly inappropriate; 5= Neutral or uncertain; 9 = Highly appropriate Page 23 of 35

34 We suggest you take a break Page 24 of 35

35 G: Using catheters for comfort or convenience Reminder 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. 2. Assume patients would have no difficulty with catheter placement, meaning that a nurse could place an indwelling, ISC, or external catheter without difficulty in the patient unless otherwise stated. Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use G1. How appropriate is use of this catheter because a patient or family requests a urinary catheter in a hospitalized patient who is not actively dying, without incontinence, and no other indication for a urinary catheter, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? Actively dying is defined as expected during this admission (with or without hospice) or shortly after hospital discharge. G2. How appropriate is use of this catheter because a hospitalized patient is on bed rest (without strict immobility) ordered by a physician, with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? Some reasons for bed rest (without strict immobility) ordered by a physician include, but are not limited to: lower-extremity injuries or vascular events (DVT, edema). Section G continues on the next page Page 25 of 35

36 G: Using catheters for comfort or convenience Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use G3. How appropriate is use of this catheter for convenience of urinary management in a hospitalized patient who will be transported for tests or procedures for greater than 4 hours a. without urinary incontinence? b. with urinary incontinence? c. with unknown continence status, but not able to communicate (e.g., loss of consciousness, aphasia/dysphasia, dementia)? G4. How appropriate is use of this catheter for convenience of urinary management in a hospitalized patient who is combative Some reasons a patient may be combative include, but are not limited to: agitation, delirium, and intoxication. a. without urinary incontinence? b. with urinary incontinence? c. with unknown continence status, but not able to communicate (aphasia/dysphasia, delirium, dementia)? Section G continues on the next page Page 26 of 35

37 G: Using catheters for comfort or convenience Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use G5. How appropriate is this catheter in a hospitalized patient who is unable to communicate their need to urinate with... a. no difficulty using commode, urinal, or bedpan when prompted/assisted with scheduled toileting (timed voiding)? b. difficulty collecting urine by commode, urinal, or bedpan, but with 1. no difficulty turning and providing skin care? 2. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? 3. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300lbs.)? G6. How appropriate is use of this catheter to address frequent, urgent, or painful urination related to urinary tract infections in a hospitalized patient? G7. How appropriate is use of this catheter for the purpose of minimizing acute, severe pain upon movement in a hospitalized patient with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? Some examples of acute severe pain include, but are not limited to: joint pain (such as acute fracture, joint infection, or gout), and post lumbar puncture headache. Page 27 of 35

38 G: Using catheters for comfort or convenience Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use G8. How appropriate is use of this catheter type to avoid exacerbating chronic pain upon movement in a patient with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? Some examples of chronic pain include, but are not limited to: chronic arthritis, fibromyalgia, lower back pain, and sciatica. Section G continues on the next page Page 28 of 35

39 G: Using catheters for comfort or convenience Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use Comfort in palliative care patient G9. How appropriate is use of this catheter type to improve comfort in an actively dying patient without urinary incontinence with a. no expected difficulty using commode, urinal, or bedpan? b. difficulties collecting urine by commode, urinal, or bedpan? G10. How appropriate is this catheter type to improve comfort in an actively dying patient with urinary incontinence with a. no difficulty using commode, urinal, or bedpan when prompted/assisted with scheduled toileting (timed voiding)? Actively dying is defined as expected during this admission (with or without hospice) or shortly after hospital discharge. Patients without urinary incontinence have no expected difficulty collecting urine by commode, urinal, or bedpan. Actively dying is defined as expected during this admission (with or without hospice) or shortly after hospital discharge. Urinary incontinence is defined as the inability to control the flow of urine resulting in involuntary urination. b. difficulty collecting urine by commode, urinal, or bedpan, but with 1. no difficulty turning and providing skin care? 2. difficulty turning and providing skin care because turning causes unsafe changes in cardiovascular or respiratory status? 3. difficulty turning and providing skin care due to excess weight from edema or morbid obesity (i.e., more than 300 lbs.)? 1 = Highly inappropriate; 5= Neutral or uncertain; 9 = Highly appropriate Page 29 of 35

40 Instructions for section II For each of the following scenarios assume the decision to use a urinary catheter has been appropriately made. For these scenarios we ask that you rate the appropriateness of specifically using an indwelling urinary catheter (Foley) to meet the patient s medical/catheter needs. The rating system is the same as for the previous scenarios: For each of the scenarios provided, please rate the appropriateness of using the indwelling urinary catheter instead of an intermittent straight (ISC) or external (condom) catheter by circling a number on a scale from 1 to 9, interpreted as: 1= highly inappropriate 5= neither appropriate nor inappropriate (neutral) OR uncertain 9= highly appropriate Important Reminders: 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. 2. We are not asking for the appropriateness of other urinary catheter or collection methods (such as suprapubic catheters, nephrostomy tubes, urostomies, or ileal conduits). Page 30 of 35

41 H: Appropriateness of using an indwelling urinary catheter instead of ISC or external catheters when a catheter is needed Reminder 1. Assume patients do not have any other indication for requiring a urinary catheter other than what is described in the scenario. Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use H1. In a hospitalized patient who required chronic ISC use prior to hospitalization, how appropriate is placement of an indwelling catheter because the patient requests a break from using ISCs while admitted? H2. In a hospitalized patient (without pre-existing catheter needs) whose current medical/catheter needs could be met by ISC or condom catheter, how appropriate is placement of an indwelling urinary catheter instead because the patient reports a history of difficult or painful catheter placement? H3. In a hospitalized patient whose current medical/catheter needs could be met by ISC or condom catheter, how appropriate is placement of an indwelling urinary catheter instead because ISC or condom catheter placement was difficult by a nurse or physician during this current admission? H4. In a hospitalized patient, how appropriate is placement of an indwelling urinary catheter instead because of inadequate/incomplete bladder drainage by ISC during this current admission? Page 31 of 35

42 H: Appropriateness of using an indwelling urinary catheter instead of ISC or external catheters when a catheter is needed Appropriateness of Indwelling Urinary Catheter (Foley) Use Appropriateness of Intermittent Straight Catheter (ISC) Use If male patient: Appropriateness of External Catheter (Condom) Use H5. In a hospitalized patient whose current medical/catheter needs could be met by ISC or condom catheter, how appropriate is placement of an indwelling urinary catheter instead because the patient is combative? Some reasons a patient may be combative include, but are not limited to: agitation, delirium, and intoxication. H6. In a hospitalized patient whose current medical/catheter needs could be met by ISC or condom catheter, how appropriate is placement of an indwelling urinary catheter instead because catheter placement is anticipated to be difficult from examination of perineal anatomy? Some examples of difficult perineal anatomy by examination include, but are not limited to: an inability to visualize the urethra to place or secure the urinary catheter due to morbid obesity, severe edema, adhesions, or scar tissue. H7. In a hospitalized patient whose current medical/catheter needs could be met by ISC or condom catheter, how appropriate is placement of an indwelling urinary catheter instead because there is documented history of difficult placement due to genitourinary tract anomalies? Some examples of genitourinary tract anomalies include, but are not limited to: urethral prolapse, urethral stricture or scar tissue. 1 = Highly inappropriate; 5= Neutral or uncertain; 9 = Highly appropriate Page 32 of 35

43 Section III I1. Are there other scenarios besides those listed where you or your team use an indwelling, intermittent straight, or external catheter? I2. Are there any scenarios that you would change your ratings for ISC appropriateness based on whether a bladder scanner was available or not? Page 33 of 35

44 I3. Do you have any comments for us that we should know before we see you in Ann Arbor? Page 34 of 35

45 THANK YOU! We look forward to seeing you in Ann Arbor! If you have any questions, comments, or concerns, please contact Karen Fowler either by at or by phone at (734) Page 35 of 35

46 Catheter Type Indwelling Urinary Catheter (Foley) Intermittent Straight Catheter (ISC) External Catheter (Condom) Appendix A Urinary catheter type definitions Urinary catheter description The Foley catheter is an indwelling trans-urethral urinary catheter that is a flexible plastic tube passed through the urethra into the bladder to drain urine from the bladder to be collected in a urine storage bag. This catheter can be placed either for temporary use (hours-days) or prolonged use (weeks-months). These catheters are most often placed by nurses, but occasionally are placed by physicians (such as urologists) when placement is challenging for anatomic reasons. Most Foley catheters are used for short periods of time while a patient is hospitalized or having an outpatient procedure, but some patients with chronic medical issues have Foley catheters in place at home, outside of the hospital. "Foley" catheters are named regarding the urologist Dr. Foley who designed them. Intermittent straight catheters (ISC) are non-indwelling catheters which are stiffer plastic tubes passed through the urethra into the bladder to drain urine from the bladder. Unlike the Foley catheter, the ISC does not remain in the bladder, and instead is used to periodically empty the bladder and in place only a few minutes (removed after flow of urine ceases), using a technique of "in-and-out" catheterization of the bladder. Patients may require use of an ISC only on an as needed basis (such as in a full bladder requiring drainage once while peri-operative medications make spontaneous bladder emptying difficult). Other patients require multiple catheterizations using an ISC per day on a scheduled basis (such as in patients with chronically enlarged prostates). ISC catheters are most often placed by nurses, but can also be placed by patients performing selfcatheterization. An external catheter is a non-indwelling urine collection device that consists of a flexible tube and urine storage bag (similar to a Foley catheter) that is attached to the patient by a condom that is fit over the penis. Although similar devices have been tested for female patients, currently external catheters are used primarily in male patients. This type of catheter is used when there is a need for urine collection but the patient has no difficulty releasing urine from the bladder. External catheters are also commonly known as "Texas catheters" because are often manufactured in Texas. Note: The appropriateness scenarios in the Rating Document DO NOT include the following types of catheters (nephrostomy, suprapubic, urostomy), for which descriptions are provided simply to clarify their differences from the Foley, ISC and condom catheters. Nephrostomy catheter Suprapubic catheters A nephrostomy catheter is a type of indwelling catheter that is a flexible tube that is placed through the skin into the kidney to drain urine that is unable to be urinated through the bladder due to a blockage in the ureter tubes which drain urine from the kidney to the bladder. Nephrostomy tubes are placed by surgical physicians or interventional radiologists, most often in operating rooms. Nephrostomies can be placed temporarily (for example, to drain urine until a kidney stone is removed) or can be placed for long-term use, including in patients being discharged home. A suprapubic catheter is a type of indwelling catheter that is a flexible tube surgically placed through the skin into the bladder to drain bladder urine which for anatomic or practical reasons cannot be managed by another type of catheter. The catheter that is placed in this suprapubic catheter can be the same a Foley catheter, but is named suprapubic to designate its location. Suprapubic catheters are initially placed and changed as needed by physicians, but after the patient has had a suprapubic catheter in place for a while, the suprapubic catheter could be changed by a nurse or the patient. Other common urine collection devices that are NOT catheters include: Urostomy: a surgically created opening in the abdominal wall to allow drainage of urine from the kidneys and ureters into the surgically created new pathway (called an ileal conduit, created using a small segment of bowel) to reach the opening on the skin. Urine is collected from the opening into an "pouch" which is a type of plastic bag attached to the skin by an adhesive, changed periodically to empty the urine.

47 Appendix B In Appendix B of the packet provided to panelists, we provided Table 2 from the 2009 Guideline for prevention of catheter-associated urinary tract infections published by the CDC, which is available on-line. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections Infect Control Hosp Epidemiol. 2010;31(4): This guideline is available in its entirety at last accessed April 24, Table 2 is provided on page 11 of this on-line document. We also provided panelists the following introductory information about this table. This table of appropriate and inappropriate indications for indwelling catheters was published in 2009 by the CDC and is currently used by many hospitals and researchers to guide appropriate use of urinary catheters. This table is provided to you (exactly as it was published) simply as a reference for what is commonly used in many hospitals and research studies to guide clinical use of urinary catheters today. You are not expected or required to agree with these indications or rate scenarios in the rating document to agree with this table. Please rate the scenarios in the rating document based on your own experience and opinion. Appendix C In Appendix C of the packet provided to panelists, we provided the Braden Scale that is a very commonly used scale for assessing a hospitalized patient s risk of developing a pressure ulcer. This scale was provided as a reminder of the components of the Braden Scale for panelists to review when considering clinical scenarios for rating urinary catheter appropriateness in which a Braden Scale score was provided to describe the patient in the scenario. The Braden Scale was introduced in the literature in the following reference: Bergstrom N, Braden B, Laguzza A, Holman V. The Braden Scale for predicting pressure sore risk. Nursing Research 1987;36: More information about the Braden Scale is available at The Braden Scale for Predicting Pressure Sore Risk is available at last accessed April 24, 2015.

48 Supplement 2. Panelists' Disclosures of Interest ~ intfpiiarional COMMITTEE of ~ MEDICAL ](J^im^ EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest 1. Given Name (First Name) Crystal 2. Surname (Last Name) Bye 3. Date 11-September Are you the corresponding author? Yes [7 No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? QYes [/] No Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? Q Yes / N o Do you have any patents, whether planned, pending or issued, broadly relevant to the work? Yes / No

49 j< b a INTERKV, iorjal ;;Oi\f U1TTEE of i! jl ''^oica^ rcur.li/v Hxroits ICMJE Form for Disclosure of Potential Conflicts of Interest Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? QYes, the following relationships/conditions/circumstances are present (explain below): [71 No other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below. Ms. Bye has nothing to disclose.! Please visit to provide feedback on your experience with completing this form.

50 INTERR 1 1 v >H' CON1 MIT TEE of MEDIOL rguknal EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest 1. Given Name (First Name) 2. Surname (Last Name) 3. Date Keith Aaronson 11-September Are you the corresponding author? [~jyes /No Corresponding Author's Name Jennifer Meddings 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method" 6. Manuscript Identifying Number (if you know it) _ Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? QYes [/] No Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? P~]Yes / No Do you have any patents, whether planned, pending or issued, broadly relevant to the work? ~J Yes / No

51 IN ;i RJ^' IONAL COMMITTEE of MEDICAL J O U R ^ L ^ L ^ T O R S ICMJE Form for Disclosure of Potential Conflicts of Interest Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? Yes, the following relationships/conditions/circumstances are present (explain below): [7] No other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below. Dr. Aaronson has nothing to disclose. Please visit to provide feedback on your experience with completing this form.

52 i y INTERNATI > OMIITTTEE"^ $jije B;i j I V ^ l L MEMCAL JOURNAL..EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest 1. Given Name (First Name) 2. Surname (Last Name) 3. Date Vineet Chopra 11-September Are you the corresponding author? ["J Yes / No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? ("HYes / No Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? \~] Yes / No Do you have any patents, whether planned, pending or issued, broadly relevant to the work? [~_] Yes No

53 U ^r J l 1 r>.ti')>i / -vl A~>M" ITT T EE of MEDICAt IOURNAL EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest Are there other relationships or activities that readers could perceive to have influenced, orthat give the appearance of potentially influencing, what you wrote in the submitted work? [~J Yes, the following relationships/conditions/circumstances are present (explain below): [/]NO other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below. Dr. Chopra has nothing to disclose. Please visit to provide feedback on your experience with completing this form. noot

54 SWtlSwl 1 I V ^ l I L MEDICAL JOURNAL EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest 1. Given Name (First Name) 2. Surname (Last Name) 3. Date Joseph Corey 05-September Are you the corresponding author? EH Yes / No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? j - J Yes [/] No Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? \~\ Yes [/] No Do you have any patents, whether planned, pending or issued, broadly relevant to the work? j - J Yes No

55 A, I INTERNATIONA! COMMITTEE of IKMPjI IV^I C MEDICAL [OURNAL EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? E] Yes, the following relationships/conditions/circumstances are present (explain below): ~/ No other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below.!dr. Corey has nothing to disclose. Please visit provide feedback on your experience with completing this form.

56 ICMJE Form for Disclosure of Potential Conflicts of Interest 1. Given Name (First Name) Heidi 2. Surname (Last Name) Haapala 3. Date 08-September Are you the corresponding author? Yes [7 No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? \~~\ Yes / N o Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? ("HYes [7] No Do you have any patents, whether planned, pending or issued, broadly relevant to the work? f - J Yes / No

57 IN 11 ^ IAL COM/'UT rvr of lfti> : 1 L journal EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? ["J Yes, the following relationships/conditions/circumstances are present (explain below): [7 No other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below. Dr. Haapala has nothing to disclose. Please visit to provide feedback on your experience with completing this form.

58 '» ' IMTrRiV-TIOMAL COMMOTEE"of i L LI'S A J jio f L if>i i ORS ICMJE Form for Disclosure of Potential Conflicts of Interest 1. Given Name (First Name) 2. Surname (Last Name) 3. Date Theodore J Iwashyna 11-September Are you the corresponding author? EZ]Yes / No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? fh Yes U~\ No Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? [~J Yes / N o Do you have any patents, whether planned, pending or issued, broadly relevant to the work? Yes / No

59 INTERNATIONAL COM MITT FT of M i ^ Q ^ J P ^ N ^ L.EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? QYes, the following relationships/conditions/circumstances are present (explain below): [7] No other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below. Dr. Iwashyna has nothing to disclose. 1 Please visit to provide feedback on your experience with completing this form.

60 I 1NTERNA'FIONAL COTS' M1TTEE of I, ^ie^^calj_oujrn^l EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest 1. Given Name (First Name) 2. Surname (Last Name) 3. Date Karen Jones 11-September Are you the corresponding author? EH Yes / No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? /Yes [ No Ifyes, please fill out the appropriate information below. If you have more than one entity press the "ADD" button to add a row. Excess rows can be removed by pressing the "X" button. University of Michigan Honoraria for time and effort for 'participating on '.he panel Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? EH Yes / No Do you have any patents, whether planned, pending or issued, broadly relevant to the work? EE] Yes / No JO nes

61 INTERNATIONAL COMMITTEE of j v i m C ^ J O U R N A L EDrrORS ICMJE Form for Disclosure of Potential Conflicts of Interest Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? [~] Yes, the following relationships/conditions/circumstances are present (explain below): [/] No other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below. Ms. Jones reports personal fees from University of Michigan, during the conduct ofthe study;. Please visit to provide feedback on your experience with completing this form.

62 I INTERNATIONAL COMMITTEE of L IhDU^L )' M> X T 1/jJL bl,<y r f] ICMJE Form for Disclosure of Potential Conflicts of Interest E Given Name (First Name) Preeti 2. Surname (Last Name) Malani 3. Date 05-September Are you the corresponding author? Yes [7 No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? [EjYes / No Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? r~]yes / No Do you have any patents, whether planned, pending or issued, broadly relevant to the work? Yes / No

63 I" INTERNA!'lONALCT3M1V«WEE~«7 i. Ai L/lC^L (Gt fill IA.L hdituks ICMJE Form for Disclosure of Potential Conflicts of Interest Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? [~JYes, the following relationships/conditions/circumstances are present (explain below): [7] No other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below. ;Dr. Malani has nothing to disclose. Please visit to provide feedback on your experience with completing this form.

64 INTERNATIONAL COMMITTEE of MEDICAL JOURNAL EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest E Given Name (First Name) 2. Surname (Last Name) 3. Date Russell Olmsted 12-September Are you the corresponding author? [^Yes _/ No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? /Yes No Ifyes, please fill out the appropriate information below. If you have more than one entity press the "ADD" button to add a row. Excess rows can be removed by pressing the "X" button. Name of Institution/Company University of Michigan Personal Non-Financial Support' Other' Comments ; Participation fee (honoraria) for peer panel that evaluated criteria for insertion of urinary catheters that rjejatesjo thi^rna^ Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? /Yes No Ifyes, please fill out the appropriate information below. Personal Fees Joint Commission Resources Premier, Inc. / / consulting services [ 'consulting services

65 INTERNATIONAL * ITT EE of ICMJE Form for Disclosure of Potential Conflicts of Interest Name of Entity Ethicon, Inc Association for Professionals in Infection Control & Epidemiology, Inc. Sage Products Avid Education, LLC Grant 1 Personal Non-Financial 1 Fees? Support* / / / / Comments [Member, advisory board Member, external faculty & technical advisory panel: on the CUSP-stop CAUTI Member, advisory board [Member, speakers bureau Do you have any patents, whether planned, pending or issued, broadly relevant to the work? FlYes [7 No Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? Yes, the following relationships/conditions/circumstances are present (explain below): [7] No other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below. Mr. Olmsted reports personal fees from University of Michigan, during the conduct ofthe study. He also consults for Joint j Commission Resources and Premier, Inc., and served on advisory boards for Ethicon, Inc, CareFusion and Sage Products and \ jspeakers bureau for Avid Education, LLC. Last he is a member of external faculty and Technical expert panel representing Association for Professionals in Infection Control & Epidemiology, Inc. all of which are outside the submitted work;. Oim

66 INTERNATIONAL COMMITTEE of URNALJpiTORS ICMJE Form for Disclosure of Potential Conflicts of Interest Please visit to provide feedback on your experience with completing this form. OSrnsied 4

67 1 1N T E RJMATICW AL"COh 1 I X I ITT EE <j/" f MrL'iC L jourhal.01 VC- 2. ICMJE Form for Disclosure of Potential Conflicts of Interest E Given Name (First Name) 2. Surname (Last Name) 3. Date David Pegues 05-September Are you the corresponding author? [^Yes / No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? [/] Yes j - J No Ifyes, please fill out the appropriate information below. If you have more than one entity press the "ADD" button to add a row. Excess rows can be removed by pressing the "X" button. Name of Institution/Company University of Michigan Personal Non-Financial Support* Other Comments Honoraria and Travel Expenses for [participating on panel Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? \~J Yes / N o Do you have any patents, whether planned, pending or issued, broadly relevant to the work? ["jyes / No 2

68 ij iriii RNAT^TONAFco:,itIITTEE!?' L, itncai. icumial on CKS ICMJE Form for Disclosure of Potential Conflicts of Interest Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? [Yes, the following relationships/conditions/circumstances are present (explain below): [/] No other relationships/conditions/circumstances that present a potential conflict of interest At the time of manuscript acceptance, journals will ask authors to confirm and, if necessary, update their disclosure statements. On occasion, journals may ask authors to disclose further information about reported relationships. Based on the above disclosures, this form will automatically generate a disclosure statement, which will appear in the box below. Dr. Pegues reports personal fees from University of Michigan, during the conduct ofthe study;. Please visit to provide feedback on your experience with completing this form.

69 INTERN\i IO 'AL COMMITTEE of MEDIC URNAL EDITORS ICMJE Form for Disclosure of Potential Conflicts of Interest E Given Name (First Name) Alexandria 2. Surname (Last Name) Radovonovich 3. Date 11-September Are you the corresponding author? Q]Yes No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at any time receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? [/]Yes No Ifyes, please fill out the appropriate information below. If you have more than one entity press the "ADD" button to add a row. Excess rows can be removed by pressing the "X" button. Name of Institution/Company Grant Personal Fees* Non-Financial Support" University of Michigan / Other Comments I I I ' ' [Honoraria and Travel expenses for participatinglonthepane[ Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? j - J Yes / N o Do you have any patents, whether planned, pending or issued, broadly relevant to the work? QYes / No

70 INTERNATIONAL COMMITTEE of ICMJE Form for Disclosure of Potential Conflicts of Interest E Given Name (First Name) 2. Surname (Last Name) 3. Date Margarita Pena, MD, FACEP 09-September Are you the corresponding author? Q^es / No Corresponding Author's Name Jennifer Meddings, MD, MSc 5. Manuscript Title The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Using the RAND/UCLA Appropriateness Method 6. Manuscript Identifying Number (if you know it) Did you or your institution at anytime receive payment or services from a third party (government, commercial, private foundation, etc.) for any aspect ofthe submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.)? Are there any relevant conflicts of interest? /Yes j No Ifyes, please fill out the appropriate information below. If you have more than one entity press the "ADD" button to add a row. Excess rows can be removed by pressing the "X" button. Name of Institution/Company University of Michigan I Grant Personal Fees* Non-Financial Support / Other^ Comments I Honoraria and Travel Expenses for participating in the panel 3 V J ^ K K. V'lM'P- Place a check in the appropriate boxes in the table to indicate whether you have financial relationships (regardless of amount of compensation) with entities as described in the instructions. Use one line for each entity; add as many lines as you need by clicking the "Add +" box. You should report relationships that were present during the 36 months prior to publication. Are there any relevant conflicts of interest? [/] Yes [~J No Ifyes, please fill out the appropriate information below. Name of Entity Roche Diagnostics Consultant/Speaker