Bedside Assessment

The DEFLATE Risk Assessment

A seven-factor bedside assessment for inflated-balloon Foley pullout risk.

The seven DEFLATE factors

  1. Delirium or dementia
  2. Extraction history
  3. Fidgeting or tugging
  4. Lightening of sedation
  5. Agitation or restraint
  6. Transport and transfers
  7. Emergence from anesthesia
Explore the factors Download the PDF

Traumatic catheter removal (TCR) is removal of an indwelling urinary catheter while the retention balloon remains inflated.

It is an underexamined yet common source of urethral injury. DEFLATE identifies circumstances associated with patient-initiated or unintended Foley removal while the retention balloon remains inflated, assembling seven factors drawn from the self-removal of medical devices (including Foley catheters), and unplanned extubation literature into a simple bedside assessment.

TCR typically occurs through two general mechanisms

  • Patient-initiated self-removal
  • Unintended removal when tubing is caught during movement or transport

About DEFLATE

DEFLATE is a bedside assessment designed to help healthcare professionals identify adult patients with indwelling Foley catheters who may be at risk for patient-initiated or unintended catheter removal with the retention balloon inflated. It is intended to support clinical judgment and does not direct diagnosis or treatment.

Explore the factors

Select a letter to read its bedside criteria, reported effect and sources.

D Delirium or dementia E Extraction history F Fidgeting or tugging at lines L Lightening or reduction of sedation A Agitation, restlessness or restraint T Transport and transfers E Emergence from anesthesia

Delirium or dementia

Bedside criteria

Active delirium or confusion, positive Confusion Assessment Method (CAM or CAM-ICU), sundowning, established cognitive impairment, or admission for altered mental status

Reported effect

Strongest independent predictor of device self-removal; OR 3.151 Late-day symptom exacerbation is well described in this population7

Sources: 1. Culhane et al., Cureus 2025; 7. Canevelli et al., Front Med 2016

Extraction history

Bedside criteria

Any prior/repeat accidental or unplanned self- or staff-removal with the balloon inflated, or documented self-extubation during the current admission

Reported effect

Standing criterion in unplanned-removal risk screening protocols4

Sources: 4. Crit Care Nurse 2026

Fidgeting or tugging at lines

Bedside criteria

Any observed line-directed behavior—picking at securement, tracing tubing, reaching for and/or pulling at any indwelling device

Reported effect

Nasogastric tubes, peripheral IVs and urinary catheters are the most frequently removed devices1,3

Sources: 1. Culhane et al., Cureus 2025; 3. StatPearls 2023

Lightening or reduction of sedation

Bedside criteria

The process of sedation reduction/weaning, such as during spontaneous awakening or breathing trial, the post-extubation interval, or evening wear-off. Target range RASS −1 to +2

Reported effect

Lower sedation level OR 2.0–5.4; higher consciousness level OR 1.4–2.02

Sources: 2. da Silva & Fonseca, Anesth Analg 2012

Agitation, restlessness or restraint

Bedside criteria

RASS ≥ +1, restlessness, undifferentiated agitation, aggression, or physical restraints already in place. Examples include traumatic brain injury, encephalopathy, alcohol, drug and nicotine withdrawal

Reported effect

Agitation OR 3.3–30.6; physical restraints OR 3.1; alcohol withdrawal OR 2.0; active smoking OR 3.13.1,2,5 Agitation documented within 2 h before 74% of patient-initiated removals (mixed ICU devices)6

Sources: 1. Culhane et al., Cureus 2025; 2. da Silva & Fonseca, Anesth Analg 2012; 5. Crit Care 2010; 6. Fraser et al. 2001

Transport and transfers

Bedside criteria

Bed-to-chair, stretcher transfers, or frequent inter-unit movement (such as for burn or soft-tissue infection patients). Mobility assistance: wheelchairs, walkers and commodes present risk

Reported effect

Distinct accidental mechanism; identified for heightened vigilance3

Sources: 3. StatPearls 2023

Emergence from anesthesia

Bedside criteria

Post-anesthesia or early post-operative patient with a catheter placed intra-operatively; tolerance not established while awake; heightened concern in patients after urologic surgery, in whom TCR can have severe consequences

Reported effect

Identified at-risk group in catheter self-extraction guidance3

Sources: 3. StatPearls 2023

DEFLATE has not been prospectively validated. It supports clinical judgment and does not produce a score, predict risk for an individual patient, or direct diagnosis or treatment. Read the limitations

Download the DEFLATE PDF

Limitations and device information

Important limitations

DEFLATE is a literature-based clinical assessment tool and has not yet been prospectively validated. Its accuracy and reliability have not been established, and most supporting evidence comes from adult ICU populations. Use in other care settings has not been evaluated.

Egress™ important device information

  • Indications for Use. The Egress Safety Catheter is intended for urethral catheterization for urological bladder drainage. The device is indicated for adult use only with a maximum indwell time of no more than 30 days.
  • Rx Only. Consult the Egress Instructions for Use for complete indications, contraindications, warnings, precautions and instructions. FDA 510(k) K241424.

References

  1. Culhane J, Okeke R, Bushe K, Freeman C. Self-removal of medical devices in the ICU: a retrospective study. Cureus. 2025;17(6):e86865.
  2. da Silva PSL, Fonseca MCM. Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations. Anesth Analg. 2012;114(5):1003–1014.
  3. Prevention of inappropriate self-extraction of Foley catheters. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2023.
  4. Decreasing unplanned extubation rates on an adult medical intensive care unit. Crit Care Nurse. 2026;46(4).
  5. Nicotine withdrawal and agitation in ventilated critically ill patients. Crit Care. 2010;14(2):R58.
  6. Fraser GL, Riker RR, Prato BS, Wilkins ML. The frequency and cost of patient-initiated device removal in the ICU. Pharmacotherapy. 2001;21(1):1–6.
  7. Canevelli M, Valletta M, Trebbastoni A, et al. Sundowning in dementia: clinical relevance, pathophysiological determinants, and therapeutic approaches. Front Med (Lausanne). 2016;3:73.

Source document: The DEFLATE Risk Assessment, MKT-0009 R02. Download the PDF

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