Urinary catheterization in acute stroke: clinical realities. A mixed methods study.

OBJECTIVE: To determine what influences the decision to insert an indwelling urinary catheter in acute stroke patients.

DESIGN: A prospective casenote review and semi-structured interviews were conducted and corporate catheterization policy in the study sites was investigated.

SETTING: Three teaching hospitals, typical of stroke service provision in most developed countries.

SUBJECTS: Casenotes from 70 consecutive acute stroke admissions; 50 doctors, nurses and physiotherapists working in acute stroke units and medical receiving units.

RESULTS: Stroke patients were catheterized for output monitoring, relief of urinary retention or, especially for older patients, continence-related issues. Half of all catheterizations occurred in acute stroke units. Continence and catheterization were considered less important than other aspects of acute stroke care. No catheterization policy or standardized continence assessment tool was in use. Documentation was often lacking. Patients and relatives were not fully involved in the decision to catheterize. Continence assessment and catheterization practices varied widely. Complex unwritten rules relating to gender proliferated. Such rules demonstrated heuristic problem-solving could potentially cause conflict. Decisions to catheterize 'belonged' to doctors or nurses depending upon clinical indications. Clinical assessment and specialist referrals were often seen as 'not my job'.

CONCLUSIONS: Clear corporate policy on catheterization is required to direct practice. Use of standardized continence assessment tools is recommended to set and monitor standards of care. Documentation relating to urinary catheterization needs to improve.