VOL: 101, ISSUE: 08, PAGE NO: 54
Penny Bond, MSc, RN, is professional practice development officer, NHS Quality Improvement Scotland
Chris Harris, RN, is urology nurse specialist, Western General Hospital, Edinburgh
NHS Quality Improvement Scotland was established as a special health board in January 2003, bringing together Scotland’s five clinical effectiveness organisations, including the NMPDU. The aim of NHS Quality Improvement Scotland is to improve the quality of health care in Scotland by setting standards and monitoring performance, and by providing NHS Scotland with advice, guidance and support on effective clinical practice and service improvements.
Reasons for issuing a best practice statement on catheterisation and catheter care
Infection control issues - In response to the Health Department Letter Reducing the Risk of Healthcare Associated Infection: HDL (2002)82, the Scottish Executive Healthcare-Associated Infection (HAI) Task Force identified urinary catheterisation as a priority area for the development of a best practice statement, because of the risks of urinary tract infection (UTI) associated with catheterisation. The risk of UTI is affected by a number of factors, including the method and duration of catheterisation, the quality of catheter care and host susceptibility (Pratt et al, 2001).
UTI is the most common infection acquired in acute hospitals and in long-term care facilities. It accounts for about 30-40 per cent of all health care-associated infections and contributes to the extra mortality and cost associated with these (Emmerson et al, 1996). Studies have shown that up to 20 per cent of patients with an indwelling urethral catheter develop asymptomatic bacteriuria and 2-6 per cent symptomatic UTI (Garibaldi, 1993). Each hospital-acquired UTI results in an increased length of stay of 5-6 days in hospital and has additional cost implications for treatments (Plowman et al, 1999).
Catheter-associated infection is also a problem in long-term care such as care homes, where elderly residents may be catheterised for prolonged periods and are consequently at risk of recurrent UTI and complications associated with infection.
Patients in primary care settings who develop catheter-associated infections have been shown to have greater contact with their GP, receive more interventions from community nursing staff and visit hospital more frequently for outpatient appointments (Plowman et al, 1999). The aim of the best practice statement is to promote high quality care. In addition to the infection control issues, the statement addresses the day-to-day issues of living with a catheter, particularly for long-term catheter users. The statement has been developed to cover male and female catheterisation, including children in a variety of settings such as acute care, primary care and long-term care.
Who was involved in developing the statement?
A working group was formed to lead the development of the best practice statement, with a large wider reference group also being established in order to reflect the interdisciplinary approach that is essential in managing patients with a catheter. Working group membership included representatives from infection control and urology nursing from across Scotland, catheter users, continence nurse advisers and other nurse specialists. Advice was also sought from medical colleagues, community nurses, health care-acquired infection taskforce members and colleagues at the Scottish Centre for Infection Control and Environmental Health (SCIEH). The initial draft was commented on extensively by this group before a wider consultation exercise involving every NHS board and academic department of nursing and midwifery in Scotland. Collaboration with the HAI Task Force and SCIEH was an essential part of the consultation process.
An infection surveillance programme for catheter-associated UTI, developed by SCIEH, aims to evaluate any impact that the best practice statement has on the process of care in terms of catheter use and infection rates. Additionally, an audit tool developed by SCIEH allows staff to audit practice against the statement.
The format of the statement
The statement consists of 10 sections that cover key aspects of urinary catheterisation and catheter care:
- Decision to catheterise;
- Infection control;
- Intermittent catheterisation;
- Indwelling urethral catheterisation;
- Supra-pubic catheterisation;
- Urine sampling;
- Choice of catheter and drainage system;
- Catheter care;
- Catheter-maintenance solutions;
- Decision to remove the catheter.
These themes encompass the core elements of urinary catheterisation and catheter care and are applicable to all care settings. Each section consists of statements of best practice, reasons for the statement and methods of achieving them. Key points and the challenges presented by each statement are included. Children are recognised as having specific care needs that will alter as they grow and develop, making ongoing assessment a vital aspect of their future care. The considerable challenges in primary care are also highlighted. Appendices in the document cover specific aspects of catheter care and product selection and offer advice regarding issues for particular patient groups.
Main points of the statement
Decision to catheterise
A full assessment of the patient and his/her needs should be carried out before catheterisation. This assessment includes identifying the underlying cause(s) of the patient’s bladder-emptying problem. When considering catheterisation for intractable incontinence, this intervention should be considered only after all other non-invasive management options have been explored and found to be unsatisfactory.
The statement also advocates the use of intermittent catheterisation of the bladder in preference to indwelling catheterisation, provided this is a safe and acceptable alternative for the individual and his/her carers. Intermittent catheterisation is recognised as a safe and effective procedure (Bakke et al, 1997), carrying a reduced risk of infection compared with indwelling urinary catheterisation (Wyndaele and Maes, 1990; Bakke and Digranes, 1991).
Infection control - Links have been identified between poor environmental hygiene and the transmission of microorganisms that cause catheter-related UTIs (Garner and Favero, 1985; Dancer, 1999). Additionally, hand-mediated transmission is a major factor in increasing the risk of infection to patients (Gould, 1991; Bryan et al, 1995).
This section emphasises the vital importance of hand hygiene and appropriate use of personal protective equipment, such as aprons and gloves, in preventing the risk of UTI. Attention is also given to the environment in which catheter equipment is stored - storing equipment unopened in a dry, cool, dark place prevents damage and ensures the integrity of the products.
Intermittent catheterisation - Intermittent catheterisation is a technique that may be carried out by the patient, by his/her carer or by health care staff. Intermittent self-catheterisation allows individuals to have some control of their bladder and to be more independent (Addison, 2001). The importance of providing patients and carers with advice relating to frequency of catheterisation, the size of the catheter to be used and any documentation that should be kept is highlighted.
Indwelling urethral catheterisation - Where indwelling catheterisation is necessary, an aseptic technique should always be used to reduce the risk of infection. Following assessment of the reason for catheterisation, as small a catheter as possible should be used in order to minimise urethral trauma and enhance patient comfort. Larger diameter catheters are associated with increased irritation of the bladder that can predispose the patient to bladder spasm and bypassing of urine around the catheter. Catheters with 10ml balloons should be used wherever possible to maximise their drainage capacity.
Supra-pubic catheterisation - There are a number of indications for using the supra-pubic route of catheterisation, for example, urethral strictures. An aseptic technique during initial insertion is key to reducing the risk of infection. The size of catheter should be no smaller than 16Ch in adults with a 10ml balloon, as this allows the maintenance of a tract (opening), between the skin and bladder.
If the catheter becomes dislodged it should be replaced within 30-45 minutes or it may become difficult to re-catheterise. Patients in the community should have a contact number to call in the event of their catheter becoming blocked or dislodged.
Urine sampling - Breaking a closed drainage system to obtain a urine sample increases the risk of UTI (Wilson, 2001; Kunin, 1997). The use of drainage bags incorporating a sample port removes the need to break the closed system. Urine samples should be taken for a valid reason only, such as suspected infection.
Choice of catheter and drainage system - This section of the best practice statement emphasises patient choice and the need for systems to be adaptable to suit each patient’s lifestyle. Individuals (and carers where appropriate) should be involved in decisions regarding type of catheter and drainage system. Catheter valves are widely used as a means of draining the bladder intermittently and can provide patients with greater comfort and independence (Getliffe and Dolman, 2003). Catheters should be comfortable, easy to insert and remove and minimise secondary complications such as tissue inflammation, encrustation and colonisation (Table 1).
Catheter care - Clear guidelines are given in the best practice statement for ongoing catheter care and the maintenance of the closed drainage system, in order to help reduce the incidence of infection.
Catheter-maintenance solutions - While evidence for the use of catheter-maintenance solutions is limited, the working group recognised that these solutions are widely used and that, in some cases, their use can prolong the life of a catheter and therefore avoid the trauma of re-catheterisation. Their use is advised only following thorough assessment. The likely cause of the blockage should be identified and an appropriate solution identified to manage this.
Decision to remove the catheter - The timeframe for removal of urinary catheters depends on clinical judgement and findings of investigations. There may be clinical reasons why a catheter should remain in place; for example, to protect the patient’s upper renal tract. Catheters should be removed following assessment only, and after consultation with the individual and the health care staff responsible for the individual’s care.
The best practice statement aims to give clear, current advice and guidance and to ensure that patients benefit from a cohesive approach to their care regardless of the setting in which catheterisation may be performed and where ongoing catheter care is provided.
Following a national launch event in July 2004, 10,000 copies of the best practice statement were distributed via directors of nursing and practice development staff to clinical areas, including GP surgeries and care homes across Scotland. A number of local launch events have taken place since to raise awareness of the potential of the best practice statement. All such statements are reviewed every three years, and feedback is actively sought. A copy of the statement is available at: www.nhshealthquality.org