Misplaced Catheter Causes Significant Urological Damage

On the date of the incident in question, the patient was admitted to the hospital undergo a hip replacement. Pre-surgery, the patient was anaesthetized, and the nurse attempted to place a Foley catheter. However, the Foley catheter balloon was inflated in the patient’s urethra instead of his bladder. The balloon remained in the urethra for hours, despite not producing a good return of urine, and the patient did not recieve a urology consultation. This misplacement necessitated a surgical procedure to implant a temporary suprapubic tube and additional surgery of the urethra. Due to this misplacement, the patient ultimately spent multiple days in intensive care and suffered permanent disability and disfigurement.

Question(s) For Expert Witness

1. Are you able to address standard of care/ongoing complications as it relates to using a Foley catheter improperly?

Expert Witness Response E-014220

I am very familiar with current standard of care for Foley catheter placement and management (especially for inpatients) and catheter related complications, such as trauma related complications and catheter associated UTIs (CAUTIs). I'm familiar with risk factors associated with catheter related complications (i.e. traumatic catherizations) which include but not limited to prior lower urinary tract surgery/procedure (ex. TURP, RRP/RALP etc), presence of urinary tract device, such as sphincter or sling, and prior lower urinary tract trauma or infections. In 2012 I was a member of a multidisciplinary committee at my institution addressing catheter associated complications, such as UTIs and traumatic injury due to placement of Foley catheter. Our committee's findings led to significant changes in urethral catheter management in inpatients. Protocols were created for placement and subsequent management of Foley catheters for all inpatients. This included, specific to minimizing risk of traumatic catheterization, that the catheter balloon should not be inflated until the catheter is completely in and there is return of urine. Also, if the patient has risk factors for catheter related complications (as described above), developed blood per urethra upon initial attempts to catheterize, or requires a Coude cath (specialized catheter) Urology should be consulted.

These are typically patients on trauma service, ICU/CCU, and surgical services. This often involves urgent or semi-urgent placement of a Foley catheter by a nurse or intern/junior resident in the ER, trauma unit, resuscitation bay, ICU or operating room. The malposition is not recognized for hours or days (and sometimes week(s)) later. The subsequent history usually involves blood/urine bypassing around the catheter and poor drainage/urine output via catheter. Significant number of these patients has encountered long term sequelae from the injury due to the inflation of the balloon within the urethra. This injury inevitably leads to a urethra stricture which typically requires treatment either endodcopically, i.e. urethral dilation and/or DVIU (incising the stricture) or surgical repair/reconstruction, what is known as urethroplasty.