https://orcid.org/0009-0008-1950-7318
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Abstract
Objective
To develop evidence-based audit indicators for urinary leakage prevention and management in ICU patients with indwelling catheters, to evaluate current clinical compliance with these indicators, and to analyze barriers and facilitators for evidence implementation using the JBI Clinical Evidence Application Model as a theoretical framework.
Methods
Using the Clinical Evidence Application Model from the Joanna Briggs Institute(JBI)Centre for Evidence in Healthcare in Australia as the theoretical framework,clinical nursing issues were identified.Literature searches were conducted,evidence was evaluated and synthesised,and review criteria and methods were established.Using convenience sampling,39 nurses and 75 indwelling catheterised patients in the General ICU(North Campus) of Wuxi Second People's Hospital, Wuxi, Jiangsu Province, China were selected for baseline review between April and May 2025.Barriers were analysed and change strategies developed based on baseline findings.
Results
A total of 22 pieces of evidence on urinary leakage prevention and management for ICU patients with indwelling urinary catheters were introduced,leading to the formulation of 21 review indicators. And among those,16 showed that compliance rate was less than 60%. There were 27 barriers and 17 facilitators found by analysis. 25 change strategies were made according to this.
Conclusion
There are big differences between what we know from research about how to stop or deal with urine leaking in intensive care patients who have a tube in their bladder and what doctors and nurses do in hospitals right now. We need special sets of rules called “evidence-based practice protocols” that use tricks from studies to help doctors and nurses give better care to sick people in the hospital.
Citation: Bian H, Zhou Z, Yan J, Yang Z, Yu P (2026) Implementing evidence-based practices for urinary leakage prevention in ICU patients with indwelling catheters: A JBI-guided baseline review. PLoS One 21(7): e0351406. https://doi.org/10.1371/journal.pone.0351406
Editor: Hussam sami Awayid, Middle Technical University, IRAQ
Received: November 17, 2025; Accepted: May 27, 2026; Published: July 10, 2026
Copyright: © 2026 Bian et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data underlying this study contain sensitive patient information and cannot be made publicly available due to ethical restrictions imposed by the Ethics Committee of Wuxi Second People’s Hospital (Approval No. 2024-Y341). Requests for data access should be directed to the Ethics Committee of Wuxi Second People’s Hospital (Email: wxeyzzjd@163.com; Tel: +86 510 66618534).
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
1. Introduction
Urinary leakage is the most common non-infectious complication,occurring at a rate of 10.6%in short-term catheterization and 52.1%in long-term patients [1]. ICU patient is critically ill, so it’s necessary to precisely monitor urine output by routine observation. To ease physical and mental discomfort for people who have urinary incontinence or retention,indwelling catheterization is frequently used.Long term catheterization will cause many different problems which seriously affect the quality of patients'life.Surveys show [2,3] That catheter leakage happens in 20% to 30% of cases. Leakage results in macerated perineal skin and higher chances of pressure injury. It could lead to CAUTI, longer hospital stays and more healthcare cost. According to research [4] That is, patients who have leakage have 2.5 times the risk of CAUTI than those without leakage.Furthermore, the frequent catheter changes needed because of leakage cause more damage to the urethra mechanically, making a bad circle. Despite there being clear guidelines on catheter management from both domestic and foreign experts [5,6], There’s still quite a gap between what we do clinically and what is best based on evidence.Surveys show [7] only 35% of ICU nurses stick to standard catheter size and balloon inflation procedures.Leakage is mostly handled with guesswork (such as pressure setting), without specific tests and treatment plans.The special ICU environment with patients who can’t stop moving around, constant changing positions, and lots of different tubes at once makes it much harder to handle leaks. In light of these points, we adopt the JBI Center for Evidence-based Healthcare in Australia’s Clinical Evidence Application Model from the Joanna Briggs Institute (JBI) as our theoretical framework.A multidisciplinary team was formed to apply evidence-based methods in identifying optimal evidence for preventing and managing urinary leakage in indwelling catheter patients.Review criteria were established to identify barriers to applying best evidence,and action strategies were formulated to facilitate the translation of evidence into clinical practice.
2. Materials and methods
2.1. Build a team
Form a multidisciplinary evidence-based practice team comprising 12 members, including experts in clinical management,specialized nursing,and evidence-based support.Invite one senior researcher from Fudan University's Evidence-Based Nursing Center to serve as the project's chief consultant,providing guidance on evidence-based methodology,overseeing protocol design,and ensuring quality control throughout the process; Co-lead the initiative with one Deputy Director of Nursing and one ICU Department Director to coordinate medical decision integration,process standardization,and cross-departmental resource coordination,ensuring decision management.Operational coordination was entrusted to a Head Nurse, who served as Team Leader and was responsible for strategic project planning and timeline governance. Two ICU Ward Nurse Managers were appointed as Deputies to oversee the standardisation of competencies, implementation of protocols, and quality monitoring. The main implementation team consisted of four clinical nurse specialists who were purposefully selected from different backgrounds. Two had formal certification in EBP, and another had 10 years’ worth of urological experience. They were supposed to take these guidelines and turn them into real interventions, then lead the change in practice. To guarantee smooth patient management, attending doctors from Urology and Intensive Care Medicine were included in the team so that both therapeutic and nursing approaches would be consistent right from the start.A nursing postgraduate student was responsible for evidence acquisition,the development of audit criteria,and barrier factor analysis.
2.2. Identify evidence-based nursing problems
Based on an analysis of the current practices for preventing and managing urinary leakage in patients with indwelling catheters in the ICU of a tertiary hospital in Wuxi,Jiangsu Province,China,several gaps between clinical practice and evidence-based standards were identified.These include a lack of standardized assessment during catheterization,fragmented interventions with poor coordination across key aspects such as catheter size selection,fixation methods,and balloon management,and weak collaborative decision-making between medical and nursing staff.Additionally,knowledge regarding urinary leakage management is insufficient,and preventive measures against catheter blockage are inadequate.To address these gaps,this study aims to establish an evidence-based practice protocol for the prevention and management of urinary leakage in ICU patients with indwelling catheters.
All the staff signed the informed consent.This study was approved by the Ethics Committee of Wuxi Second People's Hospital(No.2024-Y341).The study was conducted in accordance with the Declaration of Helsinki(as revised in 2013).
2.3. Literature retrieval
Based on the PIPOST Model from the JBI Centre for Evidence-Based Healthcare [8],identify evidence-based nursing questions. Conduct searches top-down according to the 6S Pyramid Model,constructing search terms by combining subject headings and free-text keywords. The search timeframe spans from January 2014 to December 30,2024. Systematically searched relevant databases:UpToDate,BMJ Best Practice,the Joanna Briggs Institute(JBI)Evidence-Based Healthcare Centre database,Cochrane Library,PubMed,Embase,Web of Science,the National Institute for Health and Care Excellence(NICE),the Registered Nurses'Association of Ontario(RNAO),the National Guideline Clearinghouse(NGC),MedlinePlus,the American Urological Association(AUA),and the European Association of Urology(EAU).UpToDate,JBI Centre for Evidence-Based Healthcare,Cochrane Library,RNAO,Scottish Intercollegiate Guidelines Network,International Guidelines Network,NICE Guidelines Library,New Zealand Guidelines Group,Critical Care Specialty Committee,Diabetes Specialty Committee,China Guidelines Network,Dutch Medical Abstracts Database,PubMed,China Biomedical Literature Database,China National Knowledge Infrastructure(CNKI),etc. The following Chinese search keywords were used:“Critical illness/Severe illness/ICU(Intensive Care Unit)/ Intensive Care Unit”,“Urinary catheter/Catheter/Indwelling urinary catheterization/Urinary catheter insertion”,“Urine leakage/Leakage/”.The following English search keywords were used:ICU/Critical illness*/critically ill/Critical care/Intensive Care unit”“Indwelling catheterization/Indwelling urinary catheterization/Urinary catheter/Catheterization/Urinary catheter insertion”“Urinary leakage management/Leakage control.” A total of 8 articles were ultimately included [9–16]. Among these, 2 were clinical decision aids [9,10], 2 were guidelines [11,12], 1 was an expert consensus [13], and 3 were randomized controlled trials [14–16].
2.4. Evaluate and summarize the best evidence
(1) Literature Quality Assessment.Two evaluators trained in evidence-based practice independently assessed the guidelines using the Appraisal of Guidelines for Research and Evaluation(AGREE II)tool [17].Expert consensus statements were evaluated according to the JBI Center for Evidence-Based Healthcare criteria [18].Clinical decision aids and evidence summaries were assessed using tools appropriate to their evidence type [19].In cases of disagreement, third-party adjudication is sought.(2)Evidence item evaluation.During evidence item extraction,researchers systematically collate evidence items from included literature.When evidence conflicts arise,strict adherence to a four-tier screening principle ensures evidence authority and applicability:evidence-based evidence takes precedence,high-quality evidence takes precedence,most recently published evidence takes precedence,and domestic guidelines take precedence.The JBI Evidence Recommendation Level System(2014 Edition)is applied to determine the recommendation level for included evidence.The evidence-based practice team convenes group meetings involving five stakeholders:one ICU attending physician,one senior ICU nurse with 20 years of experience,one head of the nursing department's catheterization team,one urologist,and one ICU patient who has undergone catheter removal and is in the recovery phase with sufficient consciousness for communication.Recommendations are made based on the feasibility,appropriateness,clinical significance,and effectiveness of evidence application,as well as the clinical implications and effectiveness of evidence translation.One urologist and one ICU patient who had undergone catheter removal and was in the recovery phase with sufficient consciousness to communicate.Based on the feasibility,appropriateness,clinical significance,and effectiveness of evidence application,combined with the clinical context of evidence translation and ICU resource allocation,evidence is scored using a 1–10 point scale.
2.5. Review criteria development and baseline assessment
Guided by principles of scientific rigor, credibility, effectiveness, and the evidence's measurability, the evidence-based team convened core members to discuss and develop 21 review criteria based on 22 best-evidence items. Review criterion compliance rate = Number of practitioners adhering to the criteria / Total number of practitioners surveyed × 100%.Recruitment Period and Informed Consent:April 1, 2025 – May 31, 2025: Using convenience sampling, 39 nurses and 75 indwelling catheter patients from the General ICU (North Campus) of a tertiary hospital in Wuxi were selected as baseline review subjects. All participants provided written informed consent to voluntarily engage in this study.Patient Inclusion Criteria: Currently indwelling catheterized; age ≥ 18 years; voluntary participation with written informed consent.Patient Exclusion Criteria: Critically ill patients with an anticipated hospital stay < 24 hours; those transferred or deceased during the study period; those unable to cooperate due to illness or other reasons.Nurse Inclusion Criteria: Possession of a valid nursing license; ≥ 1 year of ICU work experience; voluntary participation with written informed consent.Nurse Exclusion Criteria: Nurses on advanced training, rotation, internship, or maternity/paternity leave.Based on the included best evidence, theSurvey Questionnaire on Evidence Awareness for Urine Leakage Prevention and Management in ICU Patients with Indwelling Catheters was independently designed for nurse review. Five experts evaluated the questionnaire's content validity index (CVI), yielding a CVI of 0.822.
2.6. Barrier analysis and action strategy development
For review indicators with compliance rates<60%,the Integrated Action Promotion Framework for Research Implementation in Health Services (i-PARIHS) [20]was applied.Focusing on three dimensions—innovation(I), recipient(R),and context(C)—barriers were.
3. Results
3.1. Included evidence
Initial searches yielded 25 evidence items.Three were excluded due to poor feasibility and clinical applicability:"Recommendation of male standard-length catheters for specific female patient groups,”“Prohibition of female-length catheters for male catheterization,"and"Control of balloon filling volume and catheter curvature."Consequently,22 best evidence items were synthesized across five domains:catheter selection,balloon management,urinary catheter obstruction prevention,medication strategies,and personnel training(Table 1).
3.2. Baseline evaluation results
This study established 21 review indicators,grouped as follows based on compliance:3 indicators(10,11,16)achieved 100%compliance;14 indicators (1,2,3,4,5,6,7,8,14,15,17,18,19,20)had a compliance rate of 0%;2 indicators(9,21) showed compliance rates below 60%;and the remaining 2 indicators(12,13)had compliance rates above 60%.Table 1 presents the evidence included for urinary leakage prevention and management in ICU patients with indwelling urinary catheters,along with the corresponding review indicators,review methods,and results.The low compliance rates across multiple indicators reveal substantial gaps between current clinical practice and best evidence. These gaps increase the risk of urethral injury, catheter-related infection, leakage, pressure injury, and prolonged hospital stay. Improving adherence to evidence-based protocols is critical to enhancing patient safety and care quality in the ICU.
3.3. Analysis of barriers and facilitators
Based on the baseline audit results, a multi-discipline team consisting of a department manager, 2 critical care CNS, urologist, and 2 EBP specialists carried out structured brainstorming sessions to find out how to implement it. Using i-PARIHS framework, the team looked at what affected adopting it; they checked if the evidence fit and was possible, if nurses and patients liked it, and about the place, having enough things and people working well together. These talks went round and round, helping pick out big obstacles and work on plans just for them,as shown in Table 2.
4. Discussion
4.1. Development of evidence-based audit criteria for the prevention and management of catheter-associated urinary leakage in ICU patients
Scientific audit criteria should be applied so as to close the evidencetopractice gap for managing catheterassociatedurinary leakage in the ICU, which is a clinically relevant problem that can negatively affect patient comfort, increase the risk of infection, and lead to longer hospital stays [21,22].And those kinds of indicators have to take into account the best available evidence along with what’s feasible clinically and among professionals too [21]. Based on the JBI Evidence Translation Framework, we formed a panel consisting of nursing leaders, ICU clinicians, and urological experts. After the panel performed a systematic search and synthesis of all the available evidence, they used the FAME principles to generate 21 audit criteria. These criteria cover five major areas: catheter choice, balloon handling, obstruction avoidance, drug use, and staff education, creating a useful way to check if people follow good nursing ideas based on facts. To make sure everything was the same, all the people looking at things got the same training about how to do it before they started checking at the beginning.
4.2. Conduct standardized clinical reviews of urinary leakage prevention and management for ICU patients with indwelling urinary catheters to provide a basis for analyzing barriers
Successfully carrying out Evidence Based Care depends on correctly finding the differences between what we know from evidence and how nurses actually do things. Our audit shows there’s a big difference between what’s happening now and the best evidence for stopping and dealing with urine leaking out in ICUs when people have a tube inside their bladder all the time. Out of 21 indicators checked, only 3 reached full compliance; 14 had none. In total, 16 indicators showed compliance rates under 60%, which means there are many chances to get better at doing things right, especially when it comes to choosing catheters, handling balloons, and teaching staff. (1) Systemic Level: There’s no department with its own group, procedures, standardised methods, unified urinary symptom evaluation scales, or criteria for choosing catheters to prevent and handle leakage. This takes away clear directions from nursing workers when it comes to checking on and choosing catheters. Therefore, before translating clinical evidence, multidisciplinary teams need to establish organisational structures. This could be done in different ways by using the projects teams previous evidence based practice such as [23]such as online meetings,video education [24], Hands-on demonstrations,small group discussion.(2) Urinary Catheter Selection: Audit indicators 1–6 all have 0% compliance rate, which shows that there’s no uniform assessment tool and procedure for urinary catheter selection among health care providers, also indicating a lack of knowledge about best evidence. Field interview results showed that most healthcare workers had a vague idea about how smaller catheters can reduce the risk of urethral injuries and infections. Moreover, it was found that doctors chose the catheters and did not take nurses’ suggestions into consideration.In practical operations,nursing staff mostly relied on empirical selection rather than evidence-based decision-making. (3) Balloon Management:The compliance rate for Audit Indicators 7–9 ranged from 0%to 28.2%.Interviews with 10 nurses at the N2 level or above showed that 8 of them considered"empirical inflation"more efficient,with insufficient clear awareness of the clinical benefits of accurate balloon inflation.Additionally,the current nursing protocols in the department had not been updated in a timely manner based on the latest evidence,indicating that operational standards for balloon management had not been effectively implemented.In the future,the department could simplify operational procedures and reduce unnecessary documentation in line with evidence. Furthermore,case-based teaching and bedside demonstrations could be adopted to enhance nurses'recognition of and enthusiasm for evidence implementation [25–26].(4) Clogging Prevention:The compliance rate for Audit Indicators 14–15 was 0%,indicating that the department lacks scientifically and rationally developed bladder irrigation protocols or urinary catheter maintenance plans.Additionally,nurses were unfamiliar with the management procedures for patients with recurrent catheter clogging. Based on this, the next round of improvements could involve setting up standardized bladder irrigation procedures at a minimum, and also enhancing nurses’ training in skills related to dealing with patients who have recurrent clog issues so as to enable them to spot possible dangers such as bladder stones right away [27].(5) Staff training: The compliance rate for audit indicators 19–21 were between 0%−29.3%. Survey results showed that there was no sufficient departmental training about catheter management, a knowledge gap among nursing staff and also there is a need for improvement in terms of the format and content of the current training program. Current training mainly depends on lectures with few opportunities for high-fidelity simulation exercises which makes it hard for nurses to form a detailed picture of how urethra shapes differ from person to person. So to close those gaps we would recommend adding in high fidelity simulations as well as workshops [28] into the training framework to improve the transfer of operational skills. At the same time, it is necessary to establish a dynamic update mechanism for training content so that clinical practitioners can learn the latest knowledge and procedural standards. This will help them understand and use the best evidence for preventing and treating urinary leakage in ICU patients with catheters better. Currently, studies on how to prevent and deal with urinary leakage in ICU patients who have catheters mostly focus on finding out which things affect it and making plans to change those things. But when it comes to standardized management protocol studies, there aren’t as many. Clinical healthcare teams might do some surveys about how well they’re taking care of people with catheters who have urine leaking, to see what’s happening right now with stopping the leak and dealing with it. Based on these findings, they would then come up with a plan that involves different kinds of people working together to take care of the problem and put into action ways to make sure everything is done properly and all at once. This way can make the occurrence of urinary leakage in ICU patients with indwelling catheters less likely and lower the chance of getting an infection from using a catheter.
5. Conclusion
Urinary leakage management audits within our ICU show that clinical practices tend to be largely reactive and based on individual experience instead of standardized protocols. It’s due to two main reasons: one is that when applying international evidence directly, it doesn’t consider local staffing models and resources; another reason is that there aren’t any culturally appropriate patient assessment tools. In moving forward, we need to get past just bringing in guidelines and start co-designing practical interventions with the frontline teams. First thing first, we need to establish a single procedure framework–starting off with a validated risk-assessment scale and a clear decision-making algorithm for nurses. We expect such practice standardization can not only lower leakage occurrences but also lessen related problems, so as to set up a fresh criterion for evidence-based catheter care within our particular clinical setting.
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