Unintended Consequences for Patients with Spinal Cord Injury

December 11, 2018 by CDC's Safe Healthcare Blog

Matt Davis, MD, Clinical Medical Director
SCI Service Line, TIRR Memorial Hermann

The story would have been shocking, if I had not seen the precursors many times before. My patient was paralyzed by a bulging disc in her spine. In an effort to achieve “High Reliability” and reach the goal of “Zero Catheter-Associated Urinary Tract Infections,” hospital staff removed the Foley catheter used to drain her bladder. She voided into a diaper and was sent to a skilled nursing facility. She was there for 3 weeks before high bladder pressures put her into kidney failure. Her first symptom: cardiac arrest due to high potassium levels. It was not until she saw someone with training specific to spinal cord injury that she learned how this nearly-fatal episode could easily have been avoided. What would have happened if she had been at home?

Since early 2014, when I first noticed a trend to remove Foleys in a drive toward High Reliability and Zero CAUTIs, I have seen several cases of renal failure in spinal cord injury patients. In the 1950s, 40% of these patients died of kidney failure due high bladder pressures. This is easy to avoid with an indwelling catheter, not so simple with the alternatives. A bladder scanner is useful, but not sufficient for this population.

Since that time, I have also seen countless episodes of Autonomic Dysreflexia, a potentially life-threatening hypertensive urgency specific to spinal cord injury patients. Autonomic Dysreflexia presents with a unique and bewildering set of symptoms, and studies have shown that non-specialty healthcare providers receive little or no training in recognition and treatment of Autonomic Dysreflexia – nor do they see sufficient numbers of spinal cord injury patients to maintain competency once this training has been given. Fifty to ninety percent of spinal cord injury patients are susceptible to Autonomic Dysreflexia. The most common cause: bladder over-distension.

In response to these concerns, I collected data from one of my main referring hospitals. All spinal cord injury patients we admitted last November had had their Foleys removed. The busy acute hospital staff maintained safe bladder volumes only 43% of the time. Every spinal cord injury patient who was susceptible to Autonomic Dysreflexia had experienced it. There needs to be a balance between removing catheters to prevent infections and ensuring spinal cord injury patients do not suffer unintended consequences that could threaten their lives.

A program for safe Foley removal in spinal cord injury patients should contain several elements typically seen in Rehab hospitals:

Nursing and physician competence in recognizing/treating Autonomic Dysreflexia.
Competence in differentiating between voiding at safe pressure and overflow incontinence.
Educational programs to teach patients and families about Autonomic Dysreflexia and renal protection.
Discharge planning that involves a clear understanding of who will take responsibility for safe bladder management in the home.
Consideration of patient quality of life and independence.

Spinal cord injury organizations are working with CDC to increase awareness and educate health care providers about a rational approach to bladder management in spinal cord injury patients in acute care hospitals. I look forward to evaluating the results.

Clinical Practice Guidelines for spinal cord injuries can be downloaded here:

Matt Davis, MD, is a Spinal Cord Injury specialist with a special interest in refining Quality Improvement processes. He serves as chair of the advocacy committees for the American Spinal Injury Association and the Academy of Spinal Cord Injury Professionals.

December 11, 2018 by CDC's Safe Healthcare Blog