VOL: 103, ISSUE: 16, PAGE NO: 30-31

Jacqueline Rees, RGN, MSc, PGDip in adult education, ON Dip; Tracy Mawson, MA, BSc, ON Dip, RN

Jacqueline Rees is clinical nurse specialist; Tracy Mawson is trauma/acute orthopaedic nurse practitioner both at Newcastle General Hospital.

Rees, J. et al (2007) Guidelines on catheter use in hip fracture patients. www.nursingtimes.net

Rees, J. et al (2007) Guidelines on catheter use in hip fracture patients. www.nursingtimes.net

This article describes the development of catheter guidelines on an orthopaedic trauma unit. The guidelines were developed to promote best practice for patients admitted to hospital with a hip fracture, and to standardise their care.

Incontinence causes social isolation, psychological implications and has a huge impact on a person's quality of life. It affects six million people worldwide and in the UK the prevalence is about 40 per 1,000 adults. In an average community of 250,000 inhabitants it can be expected that 10,000 adults and 1,000 children will be incontinent at any one time (Getliffe and Dolman, 1997).

In busy acute wards, continence problems are often dealt with expediently at a late stage in the patient's stay, and sometimes the problem is managed by inserting a urethral catheter or using body-worn absorbent pads. These may not always be appropriate and the opportunity of assessment and correct treatment is lost.

Raising awareness of continence problems among health professionals is essential but the task of promoting continence care in an acute setting has been made more difficult by increasing levels of patient dependency, shorter hospital stays and staff shortages. Despite numerous Department of Health papers reporting that initial assessment and appropriate treatment is a requisite of all continence services there is still a gap with service provision (DH, 2003; 2002).

Assessment is a fundamental part of good continence care and should form part of any generic assessment. The focus should be on assessment and treatment, rather than containment, and a suitably trained health professional who asks the trigger question: 'Do you have problems with your bladder or bowels?' should be able to explore any problem or refer the patient for more specialist advice.

In conjunction with the assessment, a care-plan algorithm can help healthcare professionals to achieve optimal continence care. Algorithms can pull together all the elements of care and treatment for a particular condition, giving evidence-based directions of care, with the aim of achieving an agreed outcome. While the information may seem simplistic to the experienced clinician, the prescribed care can prevent inappropriate treatment.

Project development

The main aim of this project was to ensure that those patients admitted with a hip fracture had their continence needs assessed and received the most appropriate treatment.

Hip fracture in the aging population is a serious, costly, and increasing problem. It already affects more than 50,000 people per year in England and Wales, and nearly 6,000 in Scotland. Hip fracture accounts for about one-quarter of all orthopaedic bed use and costs in excess of £25 million per year, for hospital care alone (SIGN, 2002; DH, 1995). The incidence of fracture has increased, with the lifetime risk for women is approximately 18% and 6% in men (Gillespie, 2001).

Newcastle GeneralHospital provides a trauma service for a Newcastle upon Tyne resident population of 26,000. The orthopaedic unit comprises of two acute wards and a rehabilitation ward. The unit adopts a multidisciplinary approach to care delivery and care is based largely upon the recommendations specified in the SIGN guidelines (SIGN, 2002). These are considered to be the 'gold standard' of hip fracture management. The unit has also devised and implemented guidelines for proximal femoral fractures, which describe the best optimal patient care in order to achieve successful surgery, achieve early discharge and prevent complications.

Nurse practitioners have a specific remit to improve services for older patients admitted to the unit during the pre-operative phase, up to 48 hours postoperatively, and during their rehabilitation. They work closely with other nurse specialists to provide care based on best-practice guidelines and address the complex needs associated with this client group.

There was a concern that many urethral catheters remained in place for longer than was necessary following hip surgery, leading to the potential problem of urinary tract infection (UTI). After a catheter is removed patients may also experience associated problems with urinary frequency and urgency to micturate.

Local anecdotal evidence suggested that practice related to the use of urinary catheters could be improved. One particular problem was that patients were often catheterised before a bladder ultrasound was carried out to detect pre-existing urinary retention. Staff did not always consider intermittent catheterisation as a treatment option, and the indications for using a urethral catheter were not always clear. Anaesthetic consultants had also raised concerns that patients were incontinent perioperatively, which had implications for surgical intervention and wound management.

In general, catheterisation should be avoided except in the following circumstances: in the presence of urinary incontinence; where there is concern about urinary retention; and when monitoring renal/cardiac function (SIGN, 2002). When a urethral catheter is used, good urethral catheter care and management are essential to minimise the risk of complications.

In order to improve practice an audit was undertaken to obtain additional information regarding the general use of urethral catheters for patients admitted with a fracture neck of femur.

Audit of current practice

The project was aimed at all qualified nursing staff on the unit, who were invited to complete an anonymous questionnaire. The audit focused on the knowledge base of staff, more specifically relating to choice of catheter and indications for use, and assessing their level of knowledge and skills.

A literature search was also undertaken which highlighted the lack of specific evidence about urinary catheterisation in hip fracture patients (SIGN, 2002). There are no local or national guidelines advising when to catheterise or when to commence intermittent self-catheterisation if a residual urine volume is present in patients who have a fracture neck of femur. In general, catheterisation should always be avoided except in the following specific circumstances; in the presence of urinary incontinence and skin integrity becomes a risk, on a long journey for example, transporting patients, where there is concern about urinary retention and when monitoring renal/cardiac function (SIGN, 2002).

It is acknowledged that patients who have a urethral catheter, good urethral catheter care and management are a pre-requisite in preventing complications from occurring. The use of an indwelling urinary catheter increases the risk of infection and is the main factor that predisposes patients to UTIs (Godfrey and Evans, 2000).

Urinary tract infections are associated with pyrexia, bypassing of the catheter, foul offensive urine and can cause acutely confused states in older people. As well as the risk of UTIs, prolonged catheterisation increases the risk of urethral stricture formation, which may cause outflow obstruction and adversely affect continence when the catheter is removed.

Despite the disadvantages of urethral catheterisation, indwelling urinary catheters are frequently used in the initial acute period of care for patients admitted with a fractured neck of femur. It may be required to monitor urinary output, or to manage urinary incontinence when regular movement for hygiene purposes can exacerbate pain and discomfort.

Project outcome

It was acknowledged that there were limitations associated with the questionnaire in terms of the information staff would be willing to share. Additionally, the questions were very broad and not scientifically based, which may lead to some ambiguity.

The questionnaire asked if the participants felt competent in their ability to choose the correct type and size of catheter, and 90% of those who responded felt that they were competent. However, responses to questions about long-term and short-term use showed that fewer than 20% of staff could name the correct type of catheter for their patients' needs.

The questionnaire also asked in which circumstance nurses would consider catheterising a patient. The general responses were the three indications recommended by (SIGN, 2002): retention of urine; monitoring of urine; and in the presence of incontinence where tissue damage is a risk. However, the staff usually only gave one of those reasons, rather than all three.

The unit has its own bladder scanner and participants were asked if they felt competent in using it. Some 90% responded that they did, as well as responding that they would always use the scanner prior to catheterising a patient when retention is suspected. However, there was no guideline in place to recommend what to do in situations where patients were not managing to empty their bladder but had a low bladder volume. The questionnaire was successful in establishing current trends and practices among the trauma nurses and gave insight into potential training needs.

Recommendations generated after analysis of the completed questionnaires included providing further training about the indications for a catheter use, catheter selection and sizes, the reasons for this choice. It was also decided to develop local guidelines based on best practice in relation to hip fractures and continence care.

Guidelines for best practice

A multidisciplinary group of practitioners who had an interest in continence care developed two independent guidelines, one for the management of patients with urinary retention (Box 1) and the second related to the use of urethral catheters for patients undergoing orthopaedic surgery (Box 2). The guidelines have been formulated so that they can be used within other specialised areas or in clinical areas that have received patient outside their own specialty.

The guidelines are concerned with providing advice and guidance to all staff treating patients with a fractured neck of femur with urinary retention problems and general information relating to urethral catheterisation prior to hip surgery. The guidelines were launched with the overall objective of improving catheter care for this client group by standardising care across the trauma unit and incorporating the guidelines into the care pathway for hip fracture patients.

In the current economic climate healthcare professionals must achieve the best outcomes for every patient interaction. Adopting strategies such as pathways to aid the delivery of evidence-based practice is likely to enhance patient concordance with treatment and, most importantly, to enhance the outcomes achieved by that treatment.

References

Departmentof Health(2003). The Essence of Care: Patient-focused Benchmarking for Healthcare Professionals. London: DH.

Departmentof Health(2002). Good practice in Continence Services. London: DH.

Departmentof Health (1995) United They Stand: Co-Ordinating Care for Elderly Patients With Hip Fracture. London: DH.

Getliffe, K., Dolman, M.(1997) Promoting continence: A clinical and research resource. London: Bailliere Tindall.

Gillespie, W.(2001) Hip fracture, clinical evidence. British Medical Journal; 322: 968-975.

Godfrey, H., Evans, A.(2000) Management of long term urethral catheters: minimising complications. British Journal of Nursing; 9: 2, 74-81.

ScottishIntercollegiate Guideline Network(2002) Prevention and Management of Hip Fracture in Older People: A National clinical guideline. Edinburgh: SIGN.

Box 1. The pathway for the management of urine retention in patients admitted with fractured neck of femur

On admission to the ward, ascertain when the patient last passed urine, recording the time and volume. Ascertain fluid intake prior to admission. Record fluid intake and output. Ascertain whether the patient is constipated or symptomatic of a UTI, treat accordingly. Ascertain urinary history prior to admission. Offer the patient toilet facilities at 2-4-hourly intervals recording amount. If after six hours the patient has not passed urine, or is passing <200ml at intervals of less than two hours or is constantly leaking urine: Perform bladder scan Document and inform medical staff of urine residual Depending on the volume obtained from the scan, as well as considering the patients urinary symptoms and any discomfort, follow the appropriate pathways: Pathway A: volume>500ml Pathway B: volume <500ml 6. Insert urethral catheter 6a. Offer toilet facilities at 2-4 hourly intervals. Document and inform medical staff of urine residual and discuss starting intermittent catheterisation (IC) if urine volumes >200mls. 6b. Reassess every 3-4 hourly if no urine is passed scan bladder if urine volumes >200mls continue with (IC) offer toilet facilities every 3-4 hours, record fluid intake and output and residual for another 48 hours. Continually assess patients condition in relation to (IC) and assess skin integrity. Review requirement for urethral catheter daily and remove as soon as possible. N.B. Under no circumstances should the catheter be clamped. On removal of the catheter monitor urinary output and fluid intake. Rescan bladder if patient has not voided after six hours return to step 5 and discuss with medical staff further bladder management. If the patient is voiding good volumes, continue to record intake and output and perform post void bladder scan daily. Complete a continence assessment.

Box2.Pathway for the management of urethral catheterisation in orthopaedic patients prior to hip surgery

Clinical indications Insert urethral catheter perioperatively on induction: Pre-operatively for patients with incontinence and cognitive impairment If the patient has voiding difficulties If the patient deteriorating pressure areas due to incontinence If the patient medical problems, such as heart failure or renal failure, that require close monitoring of fluid balance Obtain informed consent Inform patient and if appropriate inform carers Inform medical staff Complete appropriate documentation General assessment Consider physical, psychological, social, environmental, cultural, and sexual issues Patients views, concerns and preferences Fluid intake/output Surgical history Previous difficulties with catheterisation Bowel pattern Urinalysis Medication Mobility/Dexterity Cognitive function Allergy (i.e. latex, soap, anaesthetic gel) Support carers Catheter selection Always follow manufacturer instructions. Follow trust catheter pathway and urethral catheter guidelines. Short-term use:Up to 28 days use PFT-coated latex catheter. Long-term use:Up to 12 weeks use all- silicone or hHydrogel-coated latex catheters Female 12/14ch There is rarely an indication for a catheter of greater than 16ch Female length of 23cm for ambulatory patients. If obese or immobile consider standard length Routine drainage, 10ml balloon. Male 12/14ch There is rarely an indication for a catheter of greater than 16ch Standard length of 41cm, for patients confined to bed Routine drainage, 10ml balloon. Catheter review Assess for removal of urethral catheter as soon as possible and daily thereafter Review clinical need for ongoing catheterisation Is the catheter still required? NOYES 1.Cease treatment 1.Continue with short term catheterisation Review daily. For further advice contact clinical nurse specialist or continence advisor