Accepted Manuscript

Failed Removal of Indwelling Urinary Catheters in Acute Stroke Patients: Incidence

and Risk Factors

Frederick S. Frost

PII: S1934-1482(17)30697-4
DOI: 10.1016/j.pmrj.2017.06.022
Reference: PMRJ 1935

To appear in: PM&R

Received Date: 18 May 2016

Revised Date: 3 March 2017
Accepted Date: 27 June 2017

Please cite this article as: Frost FS, Failed Removal of Indwelling Urinary Catheters in Acute Stroke
Patients: Incidence and Risk Factors, PM&R (2017), doi: 10.1016/j.pmrj.2017.06.022.

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 ACCEPTED MANUSCRIPT

Failed Removal of Indwelling Urinary Catheters in Acute Stroke Patients:

Incidence and Risk Factors

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1 Failed Removal of Indwelling Urinary Catheters in Acute Stroke Patients:

2 Incidence and Risk Factors

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3 Abstract

4 Background: Reducing the incidence of indwelling urinary catheter (IUC) use and early

5 removal of the devices that are inserted are appropriate priorities for quality patient

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6 care. Just like symptomatic bacteriuria, failed catheter removal as a complication of

7 IUC use is associated with considerable morbidity. In the ideal setting, patients that

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8 need IUCs have them, and patients that do not need them will have them safely

removed, with the goal of reducing medical complications and facilitating the

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10 rehabilitation phase of care.

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11 Objective: To determine the incidence of failed removal of indwelling urethral catheters
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12 (IUCs) and the factors associated with failed removal in persons hospitalized with acute

13 stroke.
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14 Design: Retrospective review of medical records and associated clinical data collection
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15 platforms.
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16 Setting: Comprehensive stroke center at a tertiary care hospital

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17 Patients: The study cohort included 175 stroke patients admitted to the hospital and

18 managed with IUCs. Mean age was 66.1 years (Standard Deviation = 15), 55% were
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19 female.
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20 Methods: Univariable and multiple logistic regression analyses were performed.

21 Variables assessed included age, gender, race, duration of hospital stay, stroke

22 subtype, National Institutes of Health Stroke Scale and 6-Clicks Scale, which is a

23 measure of functional status.

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24 Main Outcome Measurements: The dependent variable was occurrence of a failed

25 attempt at removal of an IUC – defined as removal followed by a catheter reinsertion.

26 Results: Over the study period, 175 of 432 patients with acute hospital admission for

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27 new stroke had an IUC removal event. Of these patients, 46 (26%) experienced a failed

28 catheter removal. On univariate analysis, factors significantly associated with failed

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29 removal included presence of a hemorrhagic stroke (p = .005), lower level of physical

function (by 6-Clicks and NIHSS scores), hospital length of stay (p < .001) and

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31 discharge location (p = .005). Bedside bladder ultrasound testing by nursing staff was

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32 more frequently utilized in the group of patients who had failed IUC removals (95%
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33 confidence interval: 4.561 - 21.669, p<.001). Length of stay (p < .001), white race (p =

34 .001), and hemorrhagic stroke (p = .009) were independently associated with failed
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35 catheter removal after adjustment for other clinical variables

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36 Conclusions: This single site study identified a high incidence of failed urinary catheter
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37 removal in stroke patients, along with factors associated with failed removal. This is the

38 first step in developing a predictive model that could reduce the incidence of this
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39 adverse event. Policies, penalties and protocols designed to reduce catheter days must

40 be sensitive to the special situations where IUCs are medically necessary and equal
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41 consideration given to identifying the patients for which catheter removal poses a
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42 greater risk than continued catheter use.

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44 Introduction

45 Considerable attention has been drawn to the problem of catheter-associated

46 urinary tract infection (CAUTI), particularly since the Centers for Medicare and Medicaid

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47 Services (CMS) in the United States, in conjunction with the Center for Disease Control

48 (CDC), mandated financial penalties, such a 1% pay reduction, for hospitals linked to

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49 the diagnosis of urinary tract infection in catheterized hospital patients.1,2 While the use

of indwelling urinary catheters (IUCs) is a significant risk factor for the development of

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51 symptomatic bacteriuria, the association of IUCs with morbidity in hospitalized patient is

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52 a complex issue. 3,4 The IUCs are employed in the sickest hospital patients, and their
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53 presence serves as much as a marker for burden of illness as a predictor of subsequent
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54 complications.2 5,6 Urinary catheterization is commonly employed in patients with stroke,
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55 who often fulfill multiple criteria for their placement, such as bladder dysfunction and

critical illness (Table 1).7 The problem of failed IUC removal crosses venues of care, as
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57 patients move from acute care to rehabilitation settings, making it difficult to study.
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58 Management of failed IUC removal, defined as the need for IUC reinsertion, often
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59 comes under the purview of rehabilitation clinicians; as a non-surgical issue it may

60 receive limited attention by urologists.

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61 Reduction of “catheter-days” is a laudable goal and draws attention to frivolous

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62 and unnecessary use of these devices.8 Studies link catheter use with the development

63 of significant increases in urine bacteria concentration. The extent of this bacteria

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64 growth has been directly linked to duration of catheter use. For some patients,

65 bacteriuria will cause symptomatic infection and even urosepsis.11 In general, reducing

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66 the incidence of IUC use and early removal of the device are thus appropriate priorities
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67 for quality patient care. There are, however, subpopulations of patients for which

68 catheters should be left in place – short term and long term.13 Unlike an intravenous

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69 line, when the time to remove the device is heralded by the intake of oral fluids and

70 medications, the only way to determine whether the patient will be able to empty their

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71 bladder successfully after using an IUC is to remove the catheter.14

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72 This study aimed to identify risk factors for failed removal of IUCs in stroke

73 patients. Just like symptomatic bacteriuria, failed catheter removal as a complication of

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74 IUC use is associated with considerable morbidity.3 Patients who cannot empty their
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75 bladder are prone to bladder over distension even under the most conscientious nursing

76 surveillance.15 Urine that is colonized with bacteria poses a much greater risk to the
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77 patient with high bladder pressures (when the patient experiences urinary retention)

than colonized urine under low pressure with an indwelling catheter.16 The detrusor
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damage brought about by an episode of bladder over distension can lead to re-insertion
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80 of the IUC, instrumentation trauma, and an entirely new episode of unnecessary

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81 prolonged catheter use.17 Incontinence, especially in female patients who cannot use

82 external collecting devices (condom catheters), is a major risk factor for soft tissue
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83 ulcers – themselves a major determinant of morbidity in the acute and post-acute

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84 setting.18,19 In the ideal setting, patients that need IUCs have them, and patients that

85 don’t need them will have them removed, with the goal of reducing medical

86 complications and facilitating the rehabilitation phase of care2021.

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88

89 Methods:

90 This was a retrospective cohort study of 175 patients admitted to a Joint

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91 Commission certified Comprehensive Stroke Center from August 2012 to April 2014.

92 Eligibility criteria included: (1) a first hospital admission during the study period with the

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93 principal diagnosis of ischemic or hemorrhagic stroke, (2) evaluation by physical

therapist as part of the hospital stroke carepath, (3) IUC inserted during current

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95 admission, and (4) evidence of an IUC removal event. Exclusion criteria included:

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96 patients who had a urinary catheter already in place at the time of current admission
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97 (e.g. nursing home patients with a chronic indwelling catheter), patients who died after

98 admission, and those patients for whom there was no attempt at IUC removal. Clinical
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99 data was obtained from review of the medical record. Administrative data and 6-Clicks

100 scores were electronically extracted from an institutional rehabilitation database. All
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101 patients were treated under a stroke care path that guides clinical decision and assists
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102 in adherence to processes that are considered standard of care.22 Under this care path,

103 physical therapy assessments are mandated by the third hospital day for all stroke
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104 patients except those that were critically ill or whose management focus was providing
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105 comfort care. The emphasis on detailing consistent measurement of global physical
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106 function in this study was related to an a priori assumption that such function is

107 associated with voiding success after catheter removal. No specific criteria or protocol

108 was in place to prompt IUC removal. IUC removal was carried out as part of clinical

109 judgment by nursing and medical staff, guided by the general catheter use concepts

110 adopted by the health care organization, as reflected in Table 1. Information on

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111 neurologic impairment and functional status are collected as part of standard practice

112 using National Institutes of Health Stroke Scale (NIHSS) and 6-Clicks scale. The

113 NIHSS measures neurological impairment in stroke patients and is comprised of 15

114 items with higher scores indicating greater impairment23. The 6-Clicks tool is a valid

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115 and reliable measure of basic mobility and self-care function that is used in the acute

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116 care setting to inform therapy resource utilization and discharge

117 recommendations.24,25,26 Scores on the 6-clicks tool are normalized along a 100 point

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118 scale, with mean = 50 and standard deviation (SD) = 10. Higher scores reflect lower

119 physical impairment.

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120 Clinical characteristics were summarized using descriptive statistics. Univariate

121 analysis was first performed to separately evaluate the association of clinical factors
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122 with failed IUC removal. The need to replace an IUC was considered a failure. If the

123 patient had multiple attempts to remove the IUC, only the first event was counted.
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124 Univariate odds ratios with 95% confidence intervals were obtained using logistic
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125 regression.
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126 To evaluate the clinical factors independently associated with failed IUC removal,

127 multiple variable logistic regression models were constructed using forward stepwise
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128 variable selection. The dependent variable was failed removal of an IUC. The following
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129 variables were evaluated for inclusion: marital status (married, single, other) length of

130 hospital stay (days), stroke subtype (ischemic, hemorrhagic) and initial and final 6-

131 clicks and NIHSS scores. The significance level for entry into and exit from the model

132 was .15. The variables age (unit = 10 years), sex and race (white/non-white, ascribed

133 by the patient or family member, not by staff) were forced into the model regardless of

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134 their inclusion in the stepwise selection process. The Hosmer and Lemoshow

135 Goodness of Fit test was calculated to evaluate fit of the model. 2728 A separate model,

136 which included only the variables that were known before the IUC removal, was created

137 using similar methods. All analyses were conducted with SAS Version 9.4 (SAS

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138 Institute, NC). A significance level of alpha=.05 was applied.

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139

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140 Results:

141 During the 20-month time period of the study, 175 patients met eligibility criteria

142

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including attempt at IUC removal. Characteristics of the study cohort are described in
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143 Table 2. Mean age was 66.1 years (SD 15.1) and mean admission NIHSS was 12.8

144 (SD 8.1). Over half (55%) were female. Forty-six patients (26.3%) had an unsuccessful
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145 catheter removal. Factors available prior to IUC removal attempts that were associated
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146 with an unsuccessful removal on univariate analysis included white race (p = .020),
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147 hemorrhagic stroke (p = .005), and lower level of physical function as measured by

148 initial 6-Clicks score (p = .003) (Table 2). Additional factors associated with failed
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149 catheter removal that were only available at hospital discharge included total acute care

150 hospital length of stay (p < .001), worse discharge NIHSS Score (p = .015), and
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151 discharge to a destination other than home (p = .04, p = .002). Among patients who
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152 had a successful IUC removal, the average number of catheter days prior to successful

153 removal was 3.7 days (SD = 3.3). Among patients who had a failed IUC removal, the

154 average number of catheter days preceding the failed IUC removal was 3.8 days (SD =

155 4.5). These two averages were not significantly different (P = 0.92). As expected,

156 patients with failed IUC removal were more likely to have ultrasound scanning at the

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157 bedside following initial catheter removal in order to determine urine retention (OR 9.94,

158 95% confidence interval 4.56 - 21.67, p<.001).

159 Results of the multiple logistic regression (Table 3) demonstrate that the longer

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160 length of stay (p < .001), white race (p = .001) and hemorrhagic stroke (p = .009) were

161 independently associated with failed catheter removal. For the model limited to

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162 variables available at the time of the IUC removal, we found that initial 6-clicks score (p

= .003), white race (p = .006) and hemorrhagic stroke type (p = .005) were

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164 independently associated with a failed catheter removal. The Hosmer and Lemoshow

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165 Goodness of Fit test showed acceptable fit for both models (p = > .44 for either model).
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166
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167 Discussion:

168 Failed IUC removal was a common adverse event in our study of patients
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169 admitted to a Comprehensive Stroke Center. The push to reduce catheter days is based
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170 largely upon a self-evident concept that a foreign body in the bladder provides a “nidus

for infection”. In the medical literature, a handful of clinical studies propose that the
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172 catheter is the problem, although these studies have not controlled for the patient’s
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173 primary burden of illness and define urinary tract infections in variable ways.2 It has
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174 been well documented that urinary bacteria colonization is very common in older

175 patients, with or without catheters.29 In fact, the long held notion that normal urine is

176 sterile has recently been challenged as investigators reframe the concept of a normal

177 human microbial biome. Using bacterial DNA measurements and more sensitive

178 microbiological techniques, bacteria are found in up to 70 percent of urine samples

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179 taken from normal individuals.30,31 In all of our study patients, the catheter was placed

180 on the basis of physician admitting orders, either in the emergency department or

181 intensive care unit. It is impossible to determine retrospectively which patients would

182 have entered the hospital with substantial bacteriuria, or which patients would have

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183 developed clinically important levels of bacteriuria during their stay even if a catheter

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184 was not used. There was no other documentation

In the acute care setting, IUCs are used out of necessity, when better bladder

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186 emptying options are not practical (Table 1).32 Intermittent catheterization is not

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187 medically advisable in critically ill patients.32 Fluid intake and renal output is widely
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188 variable in critically ill patients, (heightening the risk of bladder over-distension in

189 patients who may not be able to void), and urine output must be accurately measured.
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190 Repeated instrumentation of the lower genitourinary tract is not a benign intervention;

191 intermittent catheterization heightens the risk of urethral trauma and may introduce
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192 debris and skin bacterial flora into the bladder. In men, condom catheters pose their
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193 own risks especially in older men with prostatic hypertrophy.33,34,35 Although the urine

194 collection bag hanging at the bedside may be full, the patient’s bladder may be full as
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195 well. A sedated, highly medicated, and cognitively impaired male patient may be simply
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196 “overflow voiding” through a condom catheter with very high bladder pressures and
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197 over-distension. The confused patient with a distended bladder may not use the

198 nursing call-light and attempt to climb out of bed to access the bathroom. In fact, most

199 falls in the hospital setting are associated with toileting concerns.36,37 These problems

200 can be mitigated somewhat by increased nursing attention and easy accessibility of

201 bladder ultrasound scanners, made available to the bedside nurses.38 In our study,

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202 utilization of bladder scanning was associated with failed IUC removal, indicating that

203 nursing staff used this technology as a method of identifying removal failures.39

204 In this retrospective study, we were not able to determine the reasons why

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205 catheters were reinserted. Use of electronic medical record nursing flow sheets gave

206 us precise information about removal and reinsertion, but this form of documentation

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207 lacked the narrative to explain the reasoning that went into the decision. Likewise,

physician documentation regarding the reasons for ordering catheter reinsertion was

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209 uniformly absent. It is our suspicion that most of the catheter reinsertions came as a

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210 result of failure to void and urinary retention – incontinence is usually managed by adult
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211 diapers. The diagnosis of urinary retention can be made clinically, without bladder

212 ultrasound measurement, so bladder scanning was not deemed an accurate marker for
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213 identifying the condition in our patients.

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214 An episode of urinary retention is not a trivial matter, although more is known
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215 about the risk factors for failed trial without catheter (TWOC) after an episode of urinary

216 retention than the risk factors for failed catheter removal after an IUC insertion for
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217 medical reasons, like stroke. Risk factors for failed TWOC after an episode of acute

218 retention include age greater than 75 years, urine volume drained more than one liter,
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219 and a previous history of lower urinary tract symptoms.40 In their multicenter review,
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220 Emberton noted that trials of IUC removal at 3 days after an episode of urinary retention

221 were only successful 20-43% of the time.41 Patients who fail with catheter removal are

222 thus often subjected to an extended period of continued IUC use. Taking the catheter

223 out in a patient who cannot empty their bladder is likely to greatly increase the number

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224 of catheter days. Establishing accurate accounting and accountability for these

225 additional days is difficult as patients are transferred to rehabilitation centers.

226 Urinary retention or bladder outlet obstruction is considered to be a legitimate

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227 reason for IUC use (Table 1). This indication is paradoxical, however. In most

228 instances, the diagnosis of retention can only be made if the catheter is removed. In

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229 this study, chart history was collected regarding pre-hospitalization use of bladder or

voiding medications. Logging of these medications was done as a means of identifying

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231 patients with a history of prostate obstruction or voiding dysfunction prior to stroke.

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232 Prior use of these medications was not found to be associated with failed catheter
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233 removal in our study. Numbers were small in these categories, however, and a study

234 that included more patients may yield different results. Some clinicians advocate for
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235 patients be given alpha blocker medications prior to catheter removal to improve the

236 likelihood of successful voiding by reducing outlet resistance.42 Further study of this
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237 tactic would be helpful. Drugs used to reduce bladder outlet resistance may have an
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238 impact on blood pressure, a special concern for patients who have had a recent stroke.
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239 As death – coincident with removal of life support – was an exclusion criteria for

240 the study, none of the patients in this study had IUC placed for “comfort care”.
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241 Nonetheless, there are selected situations where IUCs may be the best compromise
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242 choice. For terminally ill patients, IUCs may ease the pain, inconvenience, and hygiene

243 issues related to uncontrolled voiding.43,44 In addition, certain patients with neurogenic

244 bladder may reasonably choose to employ a suprapubic catheter or IUC over the long

245 term.45 For these patients, especially those with impaired hand function unable to void

246 utilizing other methods, intermittent catheterization would require the engagement of a

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247 24 hour caregiver. An IUC offers the independence and freedom to work, attend

248 school, or get a full night’s sleep46.

249 In our study, factors that were independently associated with failed IUC removal

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250 could be stratified into two categories. The first category consisted of factors that were

251 known prior to catheter removal and included white race, greater impairment in

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252 admission functional status (as measured by 6-Clicks scores) and intracerebral

hemorrhage (rather than ischemic infarct). The latter two factors may measure the same

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254 phenomenon. Patients with intracerebral bleeding are on the average more

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255 neurologically impaired than those with ischemic infarcts upon admission.47 Although
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256 mean Functional Independence Measure (FIM) score may not vary upon discharge from

257 the rehabilitation unit, a study by Kelly et al. showed a higher percent of ischemic stroke
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258 patients achieve a score consistent with functional independence than do patients with

259 an intracerebral hemorrhage.47 The association between greater functional impairment

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260 and failure to void after IUC removal is intuitive. Micturition is a complex process, and
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261 involves integration of spinal reflexes with the central nervous system, especially the

262 pons.48 A greater functional impairment is likely to indicate a more extensive

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263 neurological deficit, and a higher risk for neurological voiding dysfunction. In addition,
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264 successful voiding may also be contingent on the patient’s body positioning, and use of
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265 neuroactive medications may reduce voiding function or level of alertness. Patients with

266 more severe functional restrictions may be unable to trigger a void using a bedpan or

267 urinal.

268 The finding that those patients in the white race category were at higher risk for

269 IUC removal failure is difficult to explain but may be due to differences in unmeasured

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270 clinical characteristics. The number of patients in the study cohort with nonwhite race is

271 small and these findings should be interpreted with caution.

272 The second category consists of variables that were available after the catheter

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273 was removed. Variables in this category that were independently associated with failed

274 IUC removal were white race, hemorrhagic stroke, and longer lengths of stay and

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275 discharge destination. The length of stay factor may also represent a proxy for severity

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276 of functional impairment.

277 Once a failed removal occurs, there is little to do but reinsert the catheter, watch

278

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and wait – often waiting for an extended time while a mechanically-damaged distended
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279 bladder recovers.49 As a non-surgical condition, the patient may receive little attention

280 from urology consultants. These events discourage the patient and family, and the
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281 presence of an IUC becomes a source of fear for family members who are being asked
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282 to assist the patient after discharge home.49 Broadly defined, incontinence is a
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283 predictive factor for discharge to a nursing facility, rather than home. It is plausible that

284 the presence of a urinary catheter may impact decisions about discharge setting.
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285 The term “catheter associated urinary tract infection” (CAUTI) correctly states

286 what science has shown, that catheters are associated with bacteriuria at a level that
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287 meets an arbitrary definition of the term. In practice, the term has come to be
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288 understood as “catheter caused urinary tract infection”, even though cause and effect is

289 difficult to determine in a patient with acute medical illness. When financial penalties

290 are imposed in concert with clinical practice guidelines, it is not surprising that the

291 pendulum may swing to overly enthusiastic implementation of clinical protocols. In this

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292 setting, even patients who may meet criteria for exclusion from catheter removal may

293 suffer from an overwhelming push to meet a metric.

294 Protocols designed to reduce catheter days must be sensitive to the special

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295 situations where IUCs are medically necessary and equal consideration given to

296 identifying the patients for which catheter removal poses a greater risk than continued

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297 catheter use. This point is difficult to emphasize in the setting of a quality management

narrative that is financially incentivized to focus on IUC removal. The problem may be

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299 underestimated, because many patients with failed IUC removal are quickly discharged

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300 to a rehabilitation facility. These facilities thus assume responsibility for catheter days at
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301 the upstream hospital. The chances of avoiding these adverse events will be improved

302 as we learn more about the clinical scenario and timing that would predict successful
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303 removal of the catheter. It is probable that delaying catheter removal in selected

304 patients could result in an overall decrease in catheter-days. Rehabilitation

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305 professionals, adept at managing bowel and bladder care in patients with disabilities,
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306 can take an active role in the acute care setting by educating staff on the implications of

307 unsuccessful IUC removal. Acute care physicians may be unaware of the long-term
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308 consequences of a failed IUC removal.

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309 Strengths of this study are the detailed clinical information available including
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310 patients’ functional status and medication for urination. Limitations of this study include

311 its sample size, lack of data on reasons for reinsertion, lack of follow up as patients

312 were discharged to a variety of post- acute venues, and its retrospective, single-site

313 design. The high incidence of catheter reinsertions found in this study emphasize the

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314 need for better chart documentation by physicians and nurses, detailing the thought

315 processes and clinical decision making behind these orders.

316 Conclusions:

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317 The failed removal of an IUC is a common and significant adverse medical event

318 that is potentially preventable. This study identified a high incidence of failed IUC

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319 removal, along with factors associated with failed removal in stroke patients. This is the

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320 first step in developing a predictive model that can be used to inform IUC removal

321 decisions, although many more observations than those included in this study will be

322

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needed. Given our findings, we believe larger, prospective multi-center studies are
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323 warranted.
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324

325 Acknowledgements: The authors thank Vinoth Ranganathan MS MBA, and Erica
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326 Yates BSN, for their support and advice on study implementation and manuscript
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327 preparation.
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Table 1

Examples of Appropriate Clinical Situations for Indwelling Urinary Catheter Use11

The patient has acute urinary retention or bladder outlet obstruction.

The patient is critically ill and accurate measurements of urine output are needed.

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The patient requires prolonged immobilization (e.g. spine fractures, polytrauma).

Perioperative management in selected patients:

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o urological surgery patients

o patients undergoing prolonged surgery

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o patients expected to receive large volume infusions during surgery

o patients who need intraoperative monitoring of urine output

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The patient requires incontinence management in the setting of wound management.

The patient is hospitalized with a history of neurogenic bladder.

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The patient is undergoing end-of-life comfort care.
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Table 2 Failed IUC Successful IUC

All Patients OR (95% CI) P-value
Study Descriptors Removal Removal

N 175 46 129

Age, mean (SD) 66.1 (15.0) 65.9 (14.8) 66.1 (15.1) 0.99 (0.79, 1.24) † .92

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Gender, N (%)

Female 96 (54.9%) 22 (47.8%) 74 (57.4%) Reference

Male 79 (45.1%) 24 (52.2%) 55 (42.6%) 1.47 (0.75, 2.90) .27

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Race, N (%)

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White 133 (76.0%) 41 (89.1%) 92 (71.3%) Reference

Black/Other 42 (24.0%) 5 (10.9%) 37 (28.7%) 0.30 (0.10, 0.77) .02

Marital Status, N (%)

Married 80 (45.7%)

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Single 40 (22.9%) 10 (21.7%) 30 (23.3%) 0.94 (0.38, 2.20) .88

Divorced/Widowed 55 (31.4%) 15 (32.6%) 40 (31.0%) 1.05 (0.48, 2.28) .89

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Median Income (x $1,000),

46.4 (39.3-62.5) 48.3 (42.6-61.7) 45.8 (39.1-62.7) 1.14 (0.92, 1.42) ‡ .24
median (IQR)

Stroke Type, N (%)

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Ischemic 157 (89.7%) 36 (78.3%) 121 (93.8%) Reference

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Hemorrhagic 18 (10.3%) 10 (21.7%) 8 (6.2%) 4.2 (1.55, 11.78) .005

Admission Glascow Coma Score,

12.8 (2.7) 12.6 (3.0) 12.9 (2.5) 0.95 (0.84, 1.08) .43
mean (SD)
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Admission NIHSS Score,

12.7 (8.0) 13.2 (9.0) 12.6 (7.7) 1.01 (0.97, 1.05) .67
mean (SD)
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Initial Six-Clicks Score,

36.1 (9.9) 32.4 (7.7) 37.5 (10.2) 0.94 (0.89, 0.98) .003
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mean (SD)

Medication for Urination, N (%) 7 (4.0%) 1 (2.2%) 6 (4.7%) 0.46 (0.02, 2.77) .47

IUC Days, median (IQR) 2 (1-4) 2 (1-5) 2 (1-4) 1.00 (0.91, 1.10) .96

Length of Stay, median (IQR) 9.0 (5.4-13.4) 13.3 (9.0-20.9) 7.6 (4.9-11.2) 1.14 (1.08, 1.21) < .001

Discharge NIHSS Score,

10.1 (7.8) 12.5 (7.6) 9.2 (7.7) 1.06 (1.01, 1.10) .01
mean (SD)
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Final Six-Clicks Score,

36.0 (7.8) 34.2 (8.1) 37 (7.6) 0.95 (0.90, 1.00) .09
mean (SD)

Discharge Disposition, N (%)

Home 28 (16.0%) 2 (4.3%) 26 (20.2%) Reference

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IRF 69 (39.4%) 18 (39.1%) 51 (39.5%)
4.74 (1.32, 30.37) § .04
SNF 62 (35.4%) 17 (37.0%) 45 (34.9%)

LTAC 16 (9.1%) 9 (19.6%) 7 (5.4%) 16.71 (3.41, 128.09) .002

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Bladder Scan after IUC Removal, N
50 (28.6%) 29 (63.0%) 21 (16.3%) 9.94 (4.65, 22.23) < .001
(%)

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† - Odds ratio based on 10 year increase in age

‡ - Odds ratio based on $10,000 year increase in median income

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§ - IRF and SNF were combined into one group for the odds ratio
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IUC: Indwelling Urinary Catheter

IQR: Interquartile Range

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NIHSS: National Institute of Health Stroke Scale

IRF: Inpatient Rehab Facility

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SNF: Skilled Nursing Facility

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LTAC: Long-term Acute Care Hospital

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Table 3. Multivariate analysis of factors associated with failed removal of indwelling urinary catheter
removal using forward stepwise selection where, initially, candidate predictors were all variables in
Table 2 (Model 1) or limited to variables known before catheter removal (Model 2).

Model 1 Model 2

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Odds Ratio (95% CI) p-value Odds Ratio (95% CI) p-value

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Age (per 10 years) 1.05 (0.79, 1.40) .74 0.86 (0.66, 1.10) .24

Male Gender (vs. Female) 0.78 (0.33, 1.79) .56 1.09 (0.51, 2.30) .83

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Non-White Race (vs. White) 0.11 (0.02, 0.36) .001 0.21 (0.06, 0.59) .006

Hemorrhagic Stroke (vs.

6.18 (1.65, 25.46) .008 5.28 (1.68, 17.94) .005

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Ischemic)
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Length of Stay (per day) 1.18 (1.11, 1.27) < .001 -- --

Initial 6-Clicks Score (per 1 unit) -- -- .93 (0.88, 0.97) .003

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CI: Confidence Interval

Model 1: Hosmer-Lemeshow Goodness of Fit Test: p = .95

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Model 2: Hosmer-Lemeshow Goodness of Fit Test: p = .44

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