Preventing catheter associated UTIs in nursing homes

Catheter associated urinary tract infections in nursing homes

Catheter-associated UTIs are a preventable health problem that is common in nursing home residents.  Recent innovations designed to prevent Catheter-associated UTIs or CAUTIs are recently recommended. In today’s episode, nursing home abuse attorneys Rob Schenk and Schenk Firm discuss the hazard of Catheter-associated UTIs in nursing home residents and methods of prevention with guest Dr. Jennifer Meddings, an Associate Professor of Internal Medicine and Pediatrics at the University of Michigan Health System.

Schenk: Hello there and welcome back. My name is Rob Schenk.

Smith: And I’m Schenk Firm.

Schenk: And we are your hosts for this episode of the Nursing Home Abuse Podcast. We have a very interesting, very medical-based science health-based episode for you today talking about not just UTIs, but a huge problem in nursing homes, which is catheter-associated UTIs.

And as a guest, we actually – this is one of the ones we can’t do this by ourselves. We need someone with an advanced degree to help us. And this week, who do we have, Will?

Smith: We’re very fortunate we have Dr. Jennifer Meddings, M.D. She is a physician and she is an associate professor of medicine and pediatrics at the University of Michigan Health System, and she cares for hospitalized patients at the Ann Arbor VA Medical Center.

Much of her recent research as a physician are focused on evidence-based interventions for prevention of catheter-associated urinary tract infection. She has performed several systemic reviews involving interventions to reduce unnecessary catheter use, including meta-analyses, demonstrating that the use of urinary catheter reminders and stop orders can actually reduce catheter-associated UTIs by greater than 50 percent, which is phenomenal for those of us familiar with catheters and the prevalence of UTIs in people who have to use them.

Her work has informed the development and evaluation of educational interventions implemented in multiple international collaboratives to reduce catheter associated UTIs in the acute care and long-term care settings. She has developed and led a project using the Rand UCLA appropriateness method to formally rate the appropriateness of three types of urinary catheters – the in-dwelling urinary catheters, formally known as Foley catheters, the straight caths, and the external catheters like the condom catheters – for hundreds of clinical scenarios commonly encountered and hospitalized adults for surveillance and public reporting, and the challenges of implementing value-based purchasing programs using metrics involving urinary catheter use and pressure ulcer development.

In other words, we have somebody on here who is more than qualified to discuss what is probably one of the top five issues we face with long-term care residents, which are urinary tract infections and catheter use.

Why are catheters used in nursing homes?

All right, Jennifer, well thanks for joining us today, and one of the reasons we have you on is I know and our listeners know, because they have loved ones in nursing homes, that a lot of residents have catheters. What are some of the reasons, first of all, that nursing home residents have catheters?

Jennifer: Well actually, there are a couple of different reasons why catheters get placed in patients who are in nursing homes, and the most important thing to know is that the family should always know and ask why is it in use.

Smith: Got you.

Jennifer: Years ago, and fortunately this is not as common these days because nursing homes have actually made great strides in reducing catheter use and actually better strides in that than our hospitals have. So in the past, they were commonly used in patients that had urinary incontinence, and I think many times they were well-intended use because it was thought to increase the dignity of the patient to have their bladder emptied by a catheter rather than an adult incontinence garment or having to change their bed frequently. But we know now with experience over the years that there are actually a lot of better products for trying to manage urinary incontinence, and it should actually be the rare patient to have a catheter in place just to manage urinary incontinence.

What is an in-dwelling catheter?

Smith: And just so the people understand, because I think that some people may not understand what a catheter is, we’re talking about in-dwelling catheters, so that the type of catheter that goes up and it goes into the bladder, is that right?

Jennifer: So there are actually a couple different types of catheters, but I can just quickly review because it’s important for family members to actually know the different options. So the most common thing that people think of when they say a patient has a bladder catheter or a bladder tube is a catheter that’s commonly known for years as a Foley catheter, and that is a catheter that basically is a tube that actually goes through the outside opening where people urinate and it goes into the bladder and it actually sits there and constantly drains the urine from the bladder. So essentially, it’s purpose is primarily to keep that bladder empty, okay? So that is the in-dwelling catheter and that is used in both men and women.

But there are other types of catheters that are commonly used and really good to know about as alternatives. So in particular, there is something called a condom catheter or an external catheter that is used pretty frequently in men. It is a catheter that is a tube that actually, it’s basically the tube is connected to a bag just like that Foley catheter, but instead of being inserted into that tube that empties the bladder, it basically externally sort of attaches to the man’s penis, so it basically just collects the urine and it basically looks like a condom. That’s why they call it a condom catheter.

This catheter is safer in many respects for men who actually need it for purposes like collecting routine urine if they have severe incontinence because it doesn’t actually enter the bladder and there have been several studies showing it’s much more comfortable for men than the catheters that go inside.

There are a couple of newer products that are available for women that actually also function as an external catheter that have really come on the market really just in the past couple of years. They are not called condom catheters for women. There were condom catheters in the past but they just were kind of hard to attach.

Smith: I can imagine.

What are the different types of catheters?

Jennifer: But they did try and they tried using female condoms to do that, but they actually do have a couple of different products that really serve more of a wicking or absorption function, but they primarily work for women that really don’t move much in bed. And so there are actually those non-invasive options to address urine in both men and women, and that’s important for family members and nursing homes to know about that.

And then the other most common catheter is actually one that’s not in-dwelling. They actually call it an ISC, which is an intermittent straight cath, and in other parts of the country, it’s known as an in-and-out catheter, and that’s where the patient has a catheter placed – either the patient places it themselves, which actually can happen in some settings, they do this at home, or actually by a nurse where they sort of routinely empty that bladder when they have symptoms or on a scheduled basis. And basically that catheter goes in only for the few seconds that’s required to empty the bladder, and the catheter comes out, so that actually has several advantages for the patient because number one, that plastic is not constantly in the bladder, so it’s not getting coated with materials that increases it’s risk for infection, but it also gives that patient more dignity because they don’t have a bag and a tube stuck to them all the time.

Smith: Right. And these are the kinds that paraplegics or somebody who has some sort of issue like that may use it at home to empty their bladder, right?

Jennifer: Yeah, so intermittent catheters, although they probably have the most experience in the past for patients who did have spinal cord injuries, and that’s because with spinal cord injuries, that bladder has a nerve injury and just cannot get the muscles to sort of compress that bladder to empty.

It’s actually very commonly used in our older population in both men who have prostate issues, because that prostate, as it gets enlarged, is usually an obstruction to that bladder emptying, so some men have done this for years – they empty their bladder using an intermittent straight cath, and it actually prevents their kidneys from getting damaged from that prostate issue.

And women actually do use it. Although there are some women who have neurologic conditions besides spinal cord injuries, like multiple sclerosis happens in both men and women, and those patients often require using intermittent straight caths on a regular basis, and women sometimes need it because of certain anatomic changes that have happened as they get older, such as pelvic floor prolapse issues.

What is a UTI?

Smith: So first of all, what is a UTI? We’re going to be talking about catheter-associated UTIs, but in general, what is a UTI?

Jennifer: So a urinary tract infection, the most important thing to know about it is that it’s basically a combination. You have to have both symptoms of a urinary tract infection and a positive urine test for the infection. And this is important because years ago, and actually in some facilities it’s actually still not uncommon, is that they would diagnose a UTI just based upon a positive urine test without associating that with symptoms.

And this is really important because our older patient population, particularly those women after menopause, because of hormonal changes that happen, men particularly with prostate issues and patients with diabetes, they commonly carry bacteria in their urine that will yield a positive urine test even though they actually don’t have a clinical infection and have no symptom.

So if you’re breeding what we call a urinary tract infection that clinically requires that risk of antibiotics, you actually need to have both symptoms of an infection and a positive test.

Where does the bacteria from a UTI come from?

Smith: And just from a general perspective, it’s bacteria in the urethra? Is it in the bladder? How does it work?

Jennifer: Basically a urinary tract infection, the most common place is it’s basically bacteria that’s in the fluid that the bladder is holding, and that fluid basically empties through the opening to the outside, which is known as the urethra. That is what we call subsided, which is a lower urinary tract infection. It can be severe and actually it can go up that tube from the bladder to the kidney and actually that would cause a kidney infection, so you can have both upper urinary tract infections, which involve the kidney, and lower ones, which are more common, involving the bladder.

Smith: So it sounds like I think even most of us who don’t have medical knowledge could figure out that when you’ve got a tube that goes from the outside world into your body, there’s a chance for bacteria to get in. What are the best practices available to prevent these catheter-associated UTIs?

Schenk: The meeting of the two worlds.

Smith: Yeah.

Jennifer: Sure. So actually when we have taught at hospitals and caregivers of both hospitals and nursing homes how to do this, we actually think about what we call disrupting that life cycle of urinary catheters to try and organize our different preventive strategies. And step zero, we actually think of a stop sign. It basically means, number one, the most important strategy is to avoid placing the catheter in the first place.

Schenk: Got you.

Jennifer: And that is because once that piece of plastic is in the bladder, it is incredibly hard to prevent that catheter collecting bacteria and eventually becoming infected. So particularly they’ve done these studies where patients, if they have a catheter in and you actually check them every day, their urine, they have actually acquired bacteria, the risk actually goes up about 5 percent every day. And so you can imagine after that patient has had a catheter for one to two weeks, their risk is actually very high.

Are catheters resistant to bacteria?

We currently do not have a urinary catheter device yet that basically is resistant to infection. They have, unlike some of our – we actually have vascular or bloodstream catheters that actually do work pretty well, they’re not perfect, but they do work better, but the urinary tract, we don’t actually have any great solutions yet. They’ve actually tried a lot of different what they call anti-microbial catheters that are coated with either antibiotics or other materials that are supposed to make them resistant to urinary tract infections, but unfortunately, the larger studies when they’ve actually studied them very objectively, they actually don’t work that well. So your best protection still is to avoid that catheter in the first place.

But once you’ve decided you really need it, there are really important things to do. So step one is making sure that, number one, you are actually inserting that catheter using the best sterile technique. And there are actually very clear instructions that come from the manufacturers and also from the CDC, the Centers for Disease Prevention, with guidelines on how to do this.

And they’ve made a lot of progress in recent years putting all the materials for catheter placement in a kit with basically instructions that help people do it more intuitively the correct way the first time through, and actually it also helps, particularly in women if they have another person to help them place that catheter, because one of the problems that can happen that unfortunately is very common particularly in women and in patients that are heavier is that that catheter tip can be contaminated – even though it’s sterile when it comes out of the package, it’s easy that it can touch something like a thigh or something on the bed or something accidentally very briefly before it gets in.

And so there’s also using these catheters that are actually what they call closed – this is actually now the standard throughout the country. It wasn’t probably about a decade ago, but it helps keep that system sealed and then actually securing the device, which is they have special anchors in their adhesive to keep it from moving, because the more it moves in and out of that catheter, the more irritating it is.

Smith: Oh okay.

How are catheters kept free of bacteria?

Jennifer: Once that catheter is in, the next thing we think about is, step two, is how do we maintain that catheter from getting infected once it’s already in. And again, the most important step actually has to do with number one – somebody has to be thinking about that catheter every day, to keep asking, “Does it still need to be in?” because if you have a catheter that’s in, the most important thing to do with that catheter is to, number one, know why it’s placed in the first place and figure out if it can come out.

There are also some special care instructions to try and keep that catheter from getting infected once it’s already in. Number one, and this is important for a family to know – it’s actually important for that bag that collects the urine to be lower than that patient’s bladder so that you don’t actually get the urine flowing up back into the bladder. This is actually really important because when patients get transported say from their room to physical therapy or their room to the car to visit family, something like that, sometimes we will see people accidentally – they think they’re doing something well intentioned, to keep it off the ground, and they’ll actually hang that urine catheter bag up, and when they do that, it actually increases that patient’s risk of infection and bladder trauma. So be very careful not to change the position of that bag above that bladder if at all possible.

The other thing is to make sure that everybody is using very clean hands and gloves when they’re touching that catheter so that when they empty that catheter, they’re draining it into a container that is not being shared between patients.

Schenk: Is it common, Jennifer, to manipulate the catheter without using gloves? Is it standard to either wash the hands and use bare hands or do you have to use gloves every time.

Smith: No one – I can’t imagine anyone in a nursing home using bare hands.

What are standard practices for hygiene and catheters?

Jennifer: So the standard is of course to wash your hands and use gloves. The reason I bring this up is sometimes patients have been home with catheters and so they’re used to doing things more informal, and we have occasionally seen very well-meaning family members and visitors come in, they see that catheter bag is full and so they try to help out by emptying it themselves while they’re visiting, and they really shouldn’t do that. They should make sure the healthcare worker is emptying it and using this very clean process, particularly when you’re in a nursing home, because unlike when you’re at home, the home’s not sterile, but it certainly carries less risk of carrying some dangerous bacteria in the environment that could get in that catheter when you’re in the nursing home setting. So that’s also incredibly important.

And then just basically doing routine, daily skin care around that catheter. They’ve actually shown that using very rigorous, very strong anti-microbial cleaners around that catheter actually seems to increase the risk of infection rather than prevent, probably because it makes the skin more fragile, so just routine soap and water is just fine.

And the very third step that is most important is what we call prompting removal. So there should always be a plan that everybody knows. Either this is a catheter that is only in for a day or two until a certain problem fixes or the urologist comes to see the patient or something like that, or if it is a chronic catheter, there needs to be a reason everyone knows why that is, why the other strategies that have been tried have failed, and then what is the plan for the catheter long term.

So particularly one important thing to know is in many nursing homes around the world and actually an effective intervention they have found when patients get transferred from the hospital to the nursing home is that if a patient comes with a catheter and nobody knows why that catheter was placed, actually just doing a trial without it. Just take it out and see what happens, because otherwise people will just keep it in forever and that patient will inevitably get an infection complication.

How are chronic catheters treated?

Smith: And if you do have a chronic catheter, does it need to come out? Do you need to change it at a certain interval?

Jennifer: So this is actually a very common question that we get. So is there literature that actually shows that in a routine patient that does not have certain problems I’ll talk about in a bit that you should change it in a regular interval? And actually there is not literature supporting that. If anything, there are actually studies that show when you routinely change the catheter on a schedule such as every week, every two weeks, every four weeks without a clear reason for that, like a problem you were trying to fix with that, that increases the risk of infection and trauma to that area, because you’re basically pulling in and pulling out plastic.

I can tell you that it is a common plastic that we see in the community, that patients who have chronic catheters sometimes actually get them changed routinely every 28 days, and we’ve actually asked a lot about this. I’ve actually asked quite a lot about this because we’ll come and see this in patients whose catheters are managed by urology.

What is a catheter blocker?

There are a few patients where something like that may be clinically indicated, and these are patients that we call catheter blockers. There are some patients where simply because of their anatomy, types of chemicals in their urine, their genetics, etc., that they have that catheter more than two weeks or four weeks or something like that, the catheter actually gets blocked with sort of like crusty materials. And those types of patients are a very specific type we call a catheter blocking patient. They actually do need it changed on a more routine basis to basically avoid the catheter getting blocked, because as soon as it blocks, and it might block in the middle of the night or something like that, then their bladder will start to fill up and they can get complications.

But the patient who is not a catheter blocker, the catheter doesn’t really need to be changed for clinical reasons. I’ll tell you we have heard – I’ve asked about this, why do people do this, and there have been – we hear that many physicians do it because the Foley catheter is technically only FDA-approved as a temporary device by the FDA, meaning that it was approved for 28 days or 38 days of use, so some people change it because they’re afraid of getting in trouble for using a device beyond it’s FDA indication. But it was not really studied in that manner and actually that was years ago, and we actually think it should probably be reassessed. And there are patients who’ve had catheters for a very long time without it being changed that actually do quite fine.

So there’s one other indication where you should probably change the catheter on a not really routine, but a special basis, and this is the patient that actually has had a chronic catheter, and you actually do suspect that they do have a catheter-associated infection, and that catheter has been in for two weeks or more. And the patient who’s had that catheter in for two weeks or more, the recommendation from the CDC is actually to change out that catheter, and then allow that patient to take the old catheter out, out the new catheter in, and then allow the patient’s urine to collect in the new catheter so that your urine sample is not as likely contaminated with that previous catheter that has basically collected what we call biofilm. And so the reason is so your diagnostic test is likely a better result in a patient who’s had that chronic catheter.

But if you’re not looking for and suspecting infection and your patient is not a chronic catheter blocker, there really is no strong clinical need to change it on a routine basis, and you’re likely doing more harm than good.

Smith: Now you kind of touched on this a little bit, but how serious can UTIs be?

Are UTIs a serious infection?

Jennifer: So UTIs can actually be quite serious, particularly in our elderly population, because in general, our geriatric patients, number one, because they’re older and frail, they tend to have weakened immune systems. And so what might be a simple urinary tract infection in say a 25-year-old healthy woman that could be treated with a couple days of antibiotics and then not need to go to the hospital or ER or anything like that, the older patient actually, number one, because they’re in a healthcare facility, that bug that they get, that bacteria that they get, may not be a simple to treat bacteria. It might be a drug-resistant bacteria because it was acquired in a healthcare facility, whether it be a long-term care facility or a hospital. So they’re more likely to get a dangerous bacteria than say if they got a UTI at home.

The other thing is they are much more likely to have that bacteria spread from their bladder up to their kidney or into their bloodstream and get what we call septic, which means it could affect there, they can get fevers from it, they can get low blood pressure from it, they can get kidney failure from it, organ failure from it, and actually there is a risk of mortality from that. So it actually can be quite dangerous for our older folks.

But another thing I’d like to bring up, another reason we worry a lot about catheter-associated UTIs in our older patients is that we actually worry that our healthcare providers may think the patient has a catheter-associated UTI, check the urine because either they have a fever or confusion or something like that, check the urine – they get a positive test supporting they have bacteria in the urine, and then they diagnose that patient and treat that patient for catheter-associated UTI without really thinking about the other things that could be causing that patient’s symptoms.

And so we actually worry a lot about catheter-associated UTI diagnoses actually being incorrect and actually being a distractor from what might be the real problem, such as pneumonia or bowel obstruction or a stroke making that patient confused. So it’s really important to be really sure, number one, if you really think that patient has a UTI, there are other important things that could actually be more dangerous that you’re not thinking about. Don’t just look only for the UTI because it’s so common, convince yourself that it’s just because they have a test result without doing a more thorough physical exam and thinking about other things, because you actually could miss a pneumonia or stroke or hyperglycemia or something like that that could be causing the symptoms.

Are UTIs mistaken for other problems?

Smith: I got you, doctor. And it seems like that is something that could easily happen, because as you said before, you’re not only testing, but you’re looking for symptoms, so there could be a positive test, but the symptoms could be from something else?

Jennifer: That’s right. So for example, and we bring this up particularly because one thing that’s important to know about nursing homes as opposed to hospitals is that in many nursing homes, they actually do not function like a hospital, so they do not have a physician that is on-site 24 hours a day, and so often it’s a matter of communication between the family about their concerns, the nurses that are there and a physician who may not always be on site because they’re actually covering multiple nursing homes.

And so it’s important for say if a family member has a symptom that’s going on, like confusion is actually a very common problem that happens or decreased appetite or something like that or fever, that it’s not the only test people send. They actually have to really do a good physical exam – what else could be causing it? And probably one of the most important things for family members to know is, number one, don’t insist that – because this is another thing we hear about – is that the patient has a urinary tract sample sent because family members or friends insisted upon it being sent without really having a discussion with that family about, “Why are you worried about UTI? Really what did you notice that’s different in your family member?” and really thinking about and explaining why maybe this patient needs an X-ray rather than a urine test to sort this, because we know once those healthcare providers see that positive urine test result, it actually can be an important distractor because they may forget to think, “Oh, well did that patient have cough or did anyone listen to that patient’s lungs?”

So if they think catheter-associated UTI, usually the next question is, “So why are you convinced it’s not something else?” because usually that something else is something more serious than a catheter-associated UTI.

Always ask “Why is there a catheter in my loved one”

Smith: Got you. That’s good advice. And it sounds like at the end of the day, one of the most important questions that families of nursing home residents can ask is why is this catheter in there?

Jennifer: Exactly. Exactly.

Smith: Right. So why is this catheter and can they live without out it? At the end of the day, if you can not have a catheter, I can imagine you’re a lot less likely to develop a UTI.

Jennifer: Exactly. So some of these patients, the other thing is many of them are actually sort of at increased risk of UTIs without devices, so when you put a device in, the cervix gets even higher. So there are certain things to think about, because on the one hand, we understand it has been, we think, in many ways well intended over the years and that people will put these catheters in these frail patients because we want to keep their skin dry. We want to protect their skin from getting a rash or breakdown. It’s a dignity issue. We don’t want them to get a wet bed, things like that.

But at the same time, unfortunately we know they’re placed because it’s more convenient for staff to take care of a patient who has a catheter rather than having to change their incontinence garments and bed. So you have to balance that and make sure that it’s really for the good of the patient that the catheter’s in place and not really for convenience for either the family members or the staff.

Schenk: Well that’s fantastic information, Dr. Meddings, and we really appreciate you coming on the show to share this. Just basic information on what UTIs are, how catheter-associated UTIs are different from regular UTIs, all that information is very valuable for our listeners, and our listeners are mostly made up of family members of nursing home residents. And UTIs are a constant problem and a constant dilemma, and the more information they are armed with, the better off they are and the better off the health of the resident is.

Smith: And I think it was really interesting, as somebody who used to work in a nursing home and has dealt with healthcare in the past throughout my life, I thought it was really interesting that there’s no supporting literature that you need to change these out, because I know at the nursing homes, we just assumed that’s what you were supposed to do. We never asked. I just thought you were supposed to change them out like you were supposed to a bandage or something, but it makes a lot of sense what you were saying.

Jennifer: Right. And it could have been in these initial recommendations or these habits developed, I mean catheters were different then. They weren’t all closed so they weren’t higher risks for developing infections. And I think in many ways it was well-intended. People were trying to prevent infections.

But the other thing that we have, we only are more recently starting to appreciate, and our research is actually now focusing a lot on this now, is that everyone in the past was primarily focused on that risk of infection from the catheter, but probably something that we think actually happens more frequently and probably can be more serious is actually trauma to that urethra, to that bladder entrance, from placing and removing these catheters.

And so that’s why now we think of, even when we’re talking about routine changes and things like that, because is it really – yes, you may have less biofilm on that catheter when you change it out to a fresh one, but you’re actually now traumatizing that urinary tract again, and so every time you irritate that lining, which we call mucosa, you have these microscopic breaks in the tissue, and whenever we have – it’s almost like little scratches in that tissue, which are opening for bacteria. So trauma is actually a risk factor for getting infection, so definitely now we need to focus on is it really the infection or is it really what can we do to prevent repeated trauma in the urinary tract?

Schenk: That makes perfect sense. Again, we really appreciate the research that you’re doing. You’re on the forefront of this and I mean like that’s excellent information. And again, I want to reiterate what Will said, it’s a super misconception that you’ve got to change that catheter to get a new, clean catheter in there, you know what I mean?

Smith: Yeah, and unfortunately, like you said, these UTIs can be deadly. Anything we can do to protect our elderly is good. Dr. Meddings, we really appreciate you being on here. We really appreciate all the work that you do and we hope to keep the line open with you at some point if we ever have any questions. You’re definitely our go-to person.

Is urine color a sign of UTI?

Jennifer: Sure. And there is one more point that I think is important for families to know and this is also something that we’re trying to educate even healthcare providers about is that it is very important for a patient and family members and bedside nurses and physicians to remember that in the past, patients were thought to have urinary tract infections when they had something like a change in color in their urine, if somebody got dark, a change in odor or smell of that urine, or the urine became cloudy. And that’s actually that research has shown in the past that there is also a change in color, a change in odor or cloudiness that often prompted the family, the patient or the bedside nurse to call the doctor and say, “I need a urine test because this patient has a UTI.”

And it’s actually really important to know that those are not clinical symptoms of a urinary tract infection. There are a lot of different things that actually cause changes in color, changes in odor and changes in cloudiness, and these are actually things like medication, a lot of medications affect color, odor and cloudiness, how well hydrated they are and even the types of foods they eat, like certain types of vegetables cause a change in odor.

And so really if you ask, if you’re concerned about, for example, if a family member is concerned about a UTI, that’s why it’s always important to ask, “Why are you concerned?” And if they mention that, oh, their urine now has a slightly different color or it’s a little cloudy compared to yesterday, it’s actually the important job of the healthcare provider to say, “I hear you. I understand your concern, but let me show you some new information that we’ve been given by our inspection expert, and that is no longer considered a sign of infection.”

And so you’re really looking for more things like pain over their kidneys, chills, fevers, things like that, but don’t get too excited about a simple change in appearance. Now if they’ve suddenly started having blood in their urine, there are a lot of different things that can cause that, sometimes that’s an infection, but if it’s really just a change in color and odor, don’t be led down that path of thinking that it’s infection because that will quickly lead down to that patient getting antibiotics that they usually don’t need and can get complications from, like diarrhea, which is really morbid to our older patients.

Smith: Absolutely. Excellent, thank you Dr. Meddings.

Jennifer: Okay, thank you so much.

Schenk: Thanks, Dr. Meddings. Thank you so much.

Jennifer: Okay, bye-bye.

Schenk: Well you can certainly say Dr. Meddings has done her homework.

Smith: Yeah, and that was really interesting, because I know that, and she had mentioned that things had changed and the perspective has changed over the course of the years, but I know that when I was in the trenches in the nursing homes, it was common, and I see now, ignorant perspective that many of us had that, hey, if someone’s going to have a Foley catheter, it has to be at least changed every 28 days or something.

But what she said makes perfect sense. When you pull a catheter out or when you put one in, which let me tell you as somebody who’s had it done is the least comfortable thing you can experience as a man. It is extremely uncomfortable – not painful – uncomfortable. But having that process done over and over again leaves slight tears in your urethra, which exposes the urethra and the tract itself to infections. So that was interesting and I honestly think we could probably have a couple more episodes on UTIs and catheters. It’s interesting stuff.

Schenk: I agree. And that actually puts a good period on this episode.

Smith: Yeah. Is that a segue into the fact that it is National Punctuation Day?

Schenk: It is. You picked up what I was throwing down.

Smith: Yeah.

Schenk: September 24th is National Punctuation Day, and I guess that deserves it’s own holiday. I wonder if that includes emojis.

Smith: Yeah, that’s a good…

Schenk: Well is an emoji technically a punctuation?

Smith: No, it’s not a punctuation, so no, it doesn’t include emojis.

Schenk: Okay. So emojis then, we need to figure out when Emoji Day is.

Smith: There needs to be a National Emoji Day.

Schenk: Which I’m sure there is.

Smith: Winky face.

Schenk: Yeah.

Smith: All right.

Schenk: Well great. With that – no, how do we get the podcast? You can get the podcast every Monday as it’s delivered to you popping fresh out the oven via Stitcher, iTunes, Spotify, Google Play, wherever you get your podcast from. Or you can watch the episodes. You can watch the episodes on our website, which is NursingHomeAbusePodcast.com, or on our YouTube channel. We recommend that you do both often, every day, watch, listen, back and forth. It’s a good time. And with that, we will see you next time.

Smith: See you next time.