Catheterisation in Adults - the Royal Cornwall Hospitals Trust ...

Patients will have their urinary catheter inserted/renewed using an agreed procedure and aplan of care developed to meet their individual needsReview and Amendment LogVersion No Type of Change Date Description of change3 of 16

saline is su itable. Observations should be recorded routinely 6indicated.monthly or as clinically4.11 Changing the CatheterThe principles of asepsis should apply to th e procedure of urinary catheterisation, bothurethral and suprapubic (Appendix 3).For recatheterisation procedures, the existing catheter should be re moved, examined forencrustations and disca rded at the start of the procedure. Extreme care should be takenwith supra-pubic cathe ters changes for those patients who are receiving anticoagulanttherapy or who have blood clotting disorders.The first ch ange for both routes of entry into the bladder can be don e in the co mmunity,either in the patient’s home, community clinic or hospital by a competent HCP. Unless thereis a need for recatheterisation in a controlled environment, there is no rationale fo r it to beonly done in a hospital setting. Urethral and supra-pubic lo ng-term catheters can be left inplace for up to 12 w eeks, but recatheterisations may need to be carried ou t soonerdepending on individual needs. Some patients and inf ormal carers can be taug ht how tochange their own urethral or supra-pubic catheter.Conversion to suprap ubic catheterisation from urethral catheterisation is no t alwayssuccessful for female patients, as there is a considerable risk of coincidental urethralleakage, and patients should be warned of this risk.4.12 Patient EducationPatients (and carers) need to be involved in their care, which includes b eing aware of thecomplications of cath eterisation and correct information on general catheter car e. It isimportant that patients (and carers) know how t o identify a potential problem (Appendix 4)and whom to contact f or help. A programme of learning should include appr opriateliterature, i.e. leaflets; Catheter Passport. It is r ecommended that HCPs document that thishas been done.Advice on c are options regarding sexual activity and cathe ters should be offered. Theseoptions may include teaching the patient how to remove and reinsert the catheter before andafter intercourse.4.13 Urine SamplingRoutine collection of urine specimens for cultur e is not useful and is unnecessary unless thepatient is symptomatic (Nicolle 200 1). When a specimen collection is justified, a clinicallyclean technique should be used, with disinfection of the needle-free sample port with alcohol70% and chlorhexidine 2% and allowed to dry t horoughly (Clinical Microbiology March 2012(BSOP 41)). It is important to include systemic symptoms on the clinical microbiology form.4.14 Care of the Suprapubic SiteIf dressings are clinically required, t hey must be sterile an d applied using an ase ptic nontouchtechnique. In most ca ses, a dressing will not be required and patients sh ould beencouraged to clean the site daily.4.15 TraumaCatheter tubing and the drainage bag should be secured to the leg so that it avoids kinks inthe tubing, t raction on t he bladder neck, trauma to the urethra, occlu sion of the catheter8 of 16

lumen, or causing excessive constriction to the limb. There are different choices of fixationmethod, such as strap s or sleeves, which needs to be based on individual need. It isimportant to allow enough slack to accommodate penile e rection, thus minimising risk ofurethral meatus injury. Tape should not be used as catheter material could be damaged dueto solvents.4.16 Bag positionDrainage bags need t o be positio ned below t he level of the bladder to avoid h ydrostaticsuction, which can cause damage to the bladd er mucosa. Higher rates of bacter iuria havebeen linked to in correct positioning. Drainage bags should be atta ched to a stand thatprevents contact with the floor. To avoid skin irritation and damage, alternating the leg onwhich the drainage bag is secured will minimise this risk.4.17 Bag emptyingWhenever possible, patients should be encouraged to empty their own drainage bag. If thisis not possible, the HCP or carer should wear non-sterile g loves, apron and goggles wherethe risk of splash injury is anticipated. Patients should have their own containers, w hich areeither disposable or heat-disinfected to prevent cross-infection.For patients in hospital, a single-use pulp product should be used to empty urine into andthen macerated. Where this is not available, a single-use sterile jug should be used for eachepisode of bag emptying or a sterile jug that can be retu rned to CSSD. Additionally, it isimportant to avoid conta mination of the tap or the environment by spillage. When dr ainagebags are three-quarters full, they should be emptied to avoid traction on the bladder.However, the closed system should not be broken more than is necessary. It is reportedthat decontamination of outlet spouts with an alcohol wipe is ineffective. Clean tissue shouldbe used to clean the outlet spouts.4.18 ValvesThese can be used as an alternative to a conventional drainage bag . As well as beingdiscreet, they allow the bladder to resume/continue its storage function. The use of a valveduring the day and continuous drain age at night has been found to be an ideal solution formany catheterised patients. There are man y different valves available and it is theresponsibility of the prescriber to be aware o f the strengths and limitations to enableappropriate product selection. The re is no evidence to su pport clamping of cathet er as away of assessing bladder tone prior to the removal of a catheter.4.19 BathingThe patient may take either a bath or shower. The build up of secretions at the urethralmeatus should be minimised by daily routine personal hygiene. Perineal care should also beincluded to facilitate reduction in extraluminal contamination.4.20 Drainage bag changeThe manufacturer’s recommendations should be followed for leg drainage bags; forexample, 5 – 7 da ys or earlier if the ba g is dama ged, which could then becomecontaminated with bacteria that ascend the system. For night time dra inage, a single useproduct should be used.9 of 16

4.21 FluidsUnless restricted for medical reasons, an adequate fluid intake should be encouraged per 24hours, as this maintains a flow of uri ne through the bladder and helps prevent constipation.There is no evidence of long-term benefit or ap propriate dosage of cranberry juice with useof catheters. Furthermore, caution should be exercised for those patients taking warfarin(Suvarna et al 2003). However, citrate-based d rinks are recommended as these have beenfound to positively affect the pH of the urine.4.22 Link drainage systemThe drainage bag sho uld not be disconnected from the catheter, b ut the night bag isconnected to the drainage tap. Patients in Care Homes (both residential and those thatprovide nursing) and in hospital must have a n ew single-use night drainage bag every nightwith disposal of the used bag. T here is minimal research regarding the issues on infectioncontrol for patients in their own homes who reuse their night bags for 5 – 7 nights (they areencouraged to rinse through with f reshly drawn tap water and left to drain). Se lf-caringpatients are more suite d to drainable bags than those who require carers to manage thecatheter system. However, should care needs change and the patient is no longer able toself-manage their catheter system, then switchi ng to single-use night drainage bags will benecessary.4.23 Storage of cathetersExcess quantities of stored catheters can in crease the risk of damage to the product orpassing the expiry date. For exa mple, latex catheters h arden when they are old and ifinserted after the expiry date, the risk of perforating the bladder is increased.It is important that equipment is available withi n the patient’s home, which will ensure thatthe correct catheter is used for individual needs. In the community, it is recommended thatpractitioners document that new stock has been ordered to replace what has been used. Inthe hospital environment, safe storage and stock rotation of the catheters is expected.4.24 Catheter-lifeThere are two distinct groups of patients to describe a catheter-life, that is, those who wear acatheter that blocks an d those tha t don’t (non -blocking). The main cause of a blockedcatheter is encrustation. Non-blocking catheters are those which maintain the patency of thecatheter for the duration of the catheter-life expectancy, such as 12 weeks for a long-termcatheter.Encrustations usually form on the tip of the catheter, the balloon area th at is bathed in urineand the lumen of the catheter. They are not usually found on the side of the balloon that isagainst the bladder mucosa or the surface that is in contact with the urethra.The duration of time that the catheter can be left in place before it becomes blocked, leaks oris pulled o ut by the patient is refe rred to as t he catheter-life. Monit oring this w ill helpeffective planning to reduce the risk of blockage as opposed to crisis intervention.Persistent blockage and other complications such as r ecurrent symptomatic CAUTI orhaematuria, may require investigation and refe rral for investigation. Cystoscopy should beconsidered to rule out t he presence of bladder stones. Th ere is no evidence that sendingcatheter tips to Clinical Microbiology is beneficial.10 of 16

4.25 Catheter Maintenance SolutionsThere is minimal evidence to identify if the use of solutions provides any benefit (Hagen et al2010). However, for catheters tha t block due to encrust ation resulting in a freq uency ofcatheter change that is unacceptab le to the pa tient, then a prescribed regime of an acidi ccatheter maintenance solution may be clinically justif ied for short-t erm use. It is notrecommended to use solutions for unblocking a catheter that is no longer draining.The principle aim of us ing a solution is to wa sh the catheter, not the bladder. The term‘bladder washout’ has been superseded by the more appropriate term of ‘cathetermaintenance solution’. The effectiveness o f acidic cat heter maintenance solutions indissolving encrustations has been demonstrated in laboratory-based studies. However, th einstillation of solutions for either encrustation or debris via an indwelling urinary catheter isnot recommended as a routine measure as th eir efficacy has not be en proven in larg eclinical trials. If prescribed howeve r, they shou ld only be u sed for a s hort period of time ,using the smallest volume (50mls or less) and discontinued if not effective. Frequency ofuse will need to be determined on an individual patient basis.The use of solutions can cause damage to the mucosa, causing irritation and spasm if the yenter the bladder. For further guidance, please see the ‘Treatment Al gorithm for Long-termCatheters’ in Appendix 5. Please consult the Bladder & Bowel Specialist Service (01726291042) or hospital specialist nurse if further advice is needed.4.26 Use of AntibioticsAntibiotic prophylaxis is not recommended for cardiac malfunction/stents/valves according toNICE Guidelines (NICE 2008). For any further information on when antibiotics may berequired, please consult with Clinical Microbiology.For those with sympto matic catheter associated urinary tract infection, t he catheter shouldbe changed at the start of antibiotic therapy.4.27 Decision to Remove CatheterIn secondary care and community hospital settings, daily review of cat heters is essential tominimise length of time in place with the aim to reduce healthcare acquired infections.For community hospitals, we encourage the use of the Stop-Order:On admission all patients with an indwelling urethral urinary catheter will haveremoved within 72 hours.catheterExceptions1. urinary obstruction leading to urinar y retention (where intermittent catheterisation is notviable)2. neurogenic bladder and urinary retention (where intermittent catheterisation is not viable)3. urological surgery4. open sacral wounds (stage 3 or 4) for incontinent patientsAll exceptions should be fully documented and reviewed every 7 daysIf any concerns, please contact the patient’s medical team or the Bladder & Bowel Serviceon 01726 29104211 of 16

Catheters should be re moved wherever clinically possible, following individual assessment,which takes into accou nt the patie nt’s condition and in co llaboration with the healthcareteam. Removal of the catheter sh ould be considered at each review, unless the patient'scondition requires continued catheterisation for clinical benefit and/or quality of life.Following removal, the patient’s condition should be monitored. A bladder scan ( portable)should be performed in the first few hours to measure for post-void residual urine, becauseurine retention is possible followin g removal of catheter and action should be t aken asnecessary (Appendix 6). Post-ope ratively, the catheter should be removed as soon asclinically possible. Attempts should be made to avoid removal of an in dwelling catheter onthe day of discharge or transfer from hospital.4.28 Adverse EventsConsideration should be given to user sensitisation to lat ex products, especially in thosepatients with spina bifida as they are a t high risk due to repeated exposurewww.asbah.org/libraryAutonomic dysreflexia is a serious life threatening condition that affects people with spinalcord injury at or above t he level of the 6th thoracic vertebrae. Bladder problems are one ofthe most common causes of this condition (Appendix 7).Lidocaine based lubricating gels should not be used during a catheterisation procedure inthe following circumstances:a) If the patient states they have an allergy/hypersensitivity to any of the activeingredients within the product.b) If the patient has noticeable abrasions and lesions on the penis or urethral orifice.Local anaesthetics should not be applied to a traumatised urethra as the drug maybe so rapidly absorbed that a systemic, rather than a local, reaction is produced(BNF 2012). These could include confusion, respiratory depression and convulsions;hypertension; and bradycardia (may lead to cardiac arrest).c) Nursing assessment prior to administration should include identification of patients atincreased risk of systemic effects and checking for possible drug interactions.d) All medical devices and medicinal products containing chlorhexidine have beenidentified as being a risk for anaphylactic reaction. HCP should ensure that anyknown allergies are recorded in the patient notes and report any adverse events tothe MHRA (MDA/2012/075)http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts4.29 Bladder & Bowel Specialist ServiceThis is a sp ecialist service, which of fers professional advice, guidance a nd information onthe promotion and management of continen ce; and fa cilitates best practice in continencecare for faecal and urinary incontinence, includ ing enuresis, and related bladder and bowelproblems for children and adults.For any further information or feedcontact via:back on the contents of this guideline, please makeBladder & Bowel Specialist ServiceSt Austell Community HospitalPorthpean RoadSt AustellPL26 6ADTel: 01726 29104212 of 16

Fax: 01726 2912495 Risk Management Strategy Implementation5.1 Implementation & DisseminationLocal organisations will take responsibility to ensure quality of service forindwelling urinary catheterisation.5.2 Training and SupportThrough self-regulation, the HCP who is learning this skill will remain accountablefor his or her competency in urin ary catheterisation, a s in the spir it of theirprofessional code. Informal learning pat hways, such as teaching from a teamcolleague who is co mpetent in the skill, should be documented to provideevidence of the learning experience. The ‘Developing Compet ence inCatheterisation’ study day, which is held at least twice yearly is available for staffto attend. Additionally, completion of ‘Urethra l Catheterisation Skills Training’pack is recommended, which is a vailable to download from the DocumentsLibrary. HCPs should inform their manager if they feel the y are not co mpetentand identify their training needs relating to this area of practice.Continence care will be supported by an educational framework that describesseveral levels of knowledge acquisition. Bef ore undertaking cathet erisation inpatients, all HCPs sho uld possess an understanding of the male an d femaleanatomy and physiology of micturition and reproduction (RCN 2012).All staff undertaking indwelling urinary catheterisation to attend the CPR andAnaphylaxis study days annually. All staff will carry an in date Anaphylaxis shockpack in case of allergic/ anaphylactic reactions. All staff will be trained on how toidentify signs of reactions and treat accordinglyWorkforce competences can be viewed at http://www.skillsforhealth.org.uk/‘Insert & secure urethral catheters’ (CC02)HWB7: Interventions and treatmentsLevel 4: Plan, deliver and evaluate interventions and/or treatments whenthere are complex issues and/or serious illness‘Care for individuals with urethral catheters’ (CC03)‘Manage supra-pubic catheters’ (CC04)HWB5: Provision of care to meet health and wellbeing needsLevel 2: Undertake care activities to meet health and wellbeing needs ofindividuals with a greater degree of dependency‘Review catheter care’ (CC07)HWB2: Assessment and care planning to meet people's health and wellbeingneedsLevel 3: Assess health and wellbeing needs and develop, monitor and reviewcare plans to meet specific needs13 of 16

5.3 DisseminationOnce ratified this policy will be loaded to the intranet (read only)Staff will be made aware of its existence through the appropriate communicationsmechanisms in local organisations.Confirmation of receipt is not required for this procedural document.5.4 Document Control & Archiving ArrangementsOnce ratified, this policy will be loaded to the documents library. Any previousversions will be electr onically archived by the Policy Administrator in theelectronic Policy Drive Archive Folder.A signed hard copy of the policy will be forwarded to the Policy Administrator andan electronic copy will be saved b y the Policy Administrat or in the electronicPolicy Drive. Further copies of cur rent and archived policies can be obtainedfrom the Policy Administrator includ ing versions in large pr int, Braille a nd otherlanguages.5.5 Equality Impact AssessmentPeninsula Community Health aims t o design an d implement services, policies andmeasures that meet the diverse needs of our service, po pulation and workforce,ensuring that none are placed at a disadvantage over others.As part of its development, this strategy and its impact on equalit y have beenassessed. The assessment is to minimise and if possible remove anydisproportionate impact on employees on the grounds of race sex, di sability, age,sexual orientation or religious belief. No detriment was identified.6 Process for Monitoring Effective ImplementationThe effective implementation of this policy will be monitored by the local organisati ons. Inaddition, monthly prevalence exercises on indwelling urinary catheterisation will beconducted by RCHT across all wards and departments. In the Peninsula Community Health(PCH), a weekly preva lence exercise is conducted and r eported contemporaneously tohospital matrons and community nurse team leaders.Key performance indicators: RCHT – Re duction of indwelling ur inary catheters over time (RCHT Quality Accounthttp://www.nhs.uk/Services/UserControls/UploadHandlers/MediaServerHandler.ashx?id=384&t=634199885116092346) PCH – Reduction of indwelling urinary catheters over time (supported by targ etedcommunity hospital/team visits to review individual cases).Educational take-up of indwelling urinary catheter learning events.Access to e-learning modules ‘Preventing Healthcare-Associated Infections Associatedwith Long-term Urinary Catheters’ & ‘Preventing Healthcare-Associated InfectionsAssociated with Short-term Urinary Cathetershttp://www.corelearningunit.nhs.uk/SignIn.aspx14 of 16

Catheter and catheter care policies will be updated every 2 years to reflect changingpractice.Nursing MetrixReduce number of MRSA Bacteraemias.7 Associated DocumentationThis document references the following supporting documents which should be referred to inconjunction with the document being developed.Infection, Protection and Control PoliciesStandard Operational ProceduresChaperoning GuidelinesGuideline for Urodynamic InvestigationsManagement of medical devices8 ReferencesBNF (2012) British National Formulary 63 MarchDepartment of Health (2006) Essential Steps to safe, clean care: urinary catheter careDepartment of Health, LondonHagen S, Sinclair L & Cross S (2010) Washout policies in long-term indwelling urinarycatheterisation in adults Cochrane Database of Systematic Reviews Issue 3, Art No:CD004012.DOI:10.1002/14651858.CD004012.pub4.NICE (2012) Infection Control: Prevention of healthcare-associated infection in primary andcommunity care; Clinical Guideline 139; National Institute for Clinical ExcellenceNICE (2008) Prophylaxis against infective endocarditis: Antimicrobial prophylaxis againstinfective endocarditis in adults and children undergoing interventional procedures; ClinicalGuideline 64; March; National Institute for Clinical ExcellenceNicolle L E (2001) The chronic indwelling catheter and urinary infection in long-term carefacility residents Infection Control and Hospital Epidemiology Vol 22 no5 316-321N & M C (2008) Code of Professional Conduct Nursing & Midwifery CouncilNPSA (2009) Female urinary catheters causing trauma to adult males Rapid ResponseReport (NPSA/2009/RRR02) National Patient Safety AgencyPratt R J, Pellowe C M, Wilson J A, Loveday H P, Harper P J, Jones S R L J, McDougallC & Wilcox M H (2007) epic2: National evidence-based guidelines for the preventinghealthcare-associated infections in NHS hospitals in England Journal of Hospital Infection655 (supplement) S1-S64RCN (2012) Catheter Care: RCN guidance for nurses Royal College of Nursing15 of 16

Tenke P et al (2012) Update on biofilm infections in the urinary tract World Journal ofUrology Volume 30, Number 1 (2012), 51-579 Further selected referencesEichhorst A M; Janken J K & Mullen T M (1997) The therapeutic value of cranberries intreating and preventing urinary tract infections The Online Journal of Knowledge Synthesisfor Nursing Vol 4; Document No 2Fader M; Pettersson L; Brooks R et al (1997) A multicentre comparative evaluation ofcatheter valves British Journal of Nursing Vol 6; No 7; 359-367German K; Rowley P; Stone D et al (1997) A randomized cross-over study comparing theuse of a catheter valve and a leg-bag in urethrally catheterized male patients British Journalof Urology 79 96-98Getliffe K (2002) Managing recurrent urinary catheter encrustation British Journal ofCommunity Nursing Vol 7; No 11; 574-580Khan A A , Mathur S, Feneley R & Timoney A G (2007) Developing a strategy to reducethe high morbidity of patients with long-term urinary catheters: the BioMed catheter researchclinic. British Journal of Urology International, 100: 1298-1301Maki D G & Tambyah P A (2001) Engineering out the risk of infection with urinary catheters.Emerging Infectious Diseases, 7: 1-6Nyman M H, Johansson J-E & Gustafsson M (2010) A randomised controlled trial on theeffect of clamping the indwelling urinary catheter in patients with hip fracture Journal ofClinical Nursing 19, 405-413Peate I (2001) Patient management following suprapubic catheterisation In: Management ofContinence and Urinary Catheter Care edited by Cruickshank J P & Woodward S; BJNMonograph; Mark Allen Publishing LtdRaz R, Schiller D & Nicolle L E (1998) Replacement of catheter improves the outcome ofpatients with permanent urinary catheter and symptomatic bacteriuria. Abstracts, 38th.Annual ICAAC, San Diego, California.Tambyah P A, Halvorson K T & Maki D G (1999) Prospective Study of Pathogenesis ofCatheter-Associated Urinary Tract Infections, Mayo Clinic Proceedings, 74:131-13616 of 16

Equality Impact Assessment ToolTo be completed and attached to any procedural document when submitted to theappropriate committee for consideration and approval.Yes √No XComments1. Does the document/guidance affect onegroup less or more favourably than anotheron the basis of: Race X Ethnic origins (including gypsies andtravellers)X Nationality X Gender X Culture X Religion or belief XSexual orientation including lesbian, gay,transgender and bisexual peopleX Age X Disability - learning disabilities, physicaldisability, sensory impairment and mentalhealth problems2. Is there any evidence that some groups areaffected differently?3. If you have identified potentialdiscrimination, are there any exceptionsvalid, legal and/or justifiable?4. Is the impact of the document/guidancelikely to be negative?XXN/AX5. If so, can the impact be avoided? N/A6. What alternative is there to achieving thedocument/guidance without the impact?7. Can we reduce the impact by takingdifferent action?N/AN/AIf you have identified a potential discriminatory impact of this procedural document, pleaserefer it to the Equality and Diversity lead, together with any suggestions as to the actionrequired to avoid/reduce this impact.For advice in respect of answering the above questions,please contact the Equality and Diversity lead.V1-0 Page 1 of 1 6-Mar-13