Although effective catheter reviews can facilitate timely removal of indwelling urinary catheters, there is no clear guidance on how to carry out this essential clinical skill
The presence of an indwelling urinary catheter is a patient safety issue, but timely removal and appropriate decision-making depend on a systematic approach to catheter reviews. This article discusses the factors influencing catheter reviews carried out by nurses within our local acute hospital and community organisation and their impact on the patient pathway. It describes a number of approaches to support best practice in catheter reviews and makes recommendations to help drive quality improvement.
Citation: Baines T et al (2017) Developing a guide for nurses to undertake regular catheter reviews. Nursing Times; 113: 1, 28-31.
Authors: Trixie Baines was formerly infection prevention and control nurse; Judy Cecil was formerly continence and urology lead nurse, both at Anglian Community Enterprise CIC; Heather Dakin is the senior infection prevention and control nurse at Colchester Hospital University Foundation Trust.
- This article has been double-blind peer reviewed
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Catheterisation is the leading risk factor for urinary tract infection (UTI), and costs the NHS an estimated £99m per year (Loveday et al, 2014). Best practice in catheterisation and catheter care is set out in clinical guidelines, and health professionals must be trained and competent to undertake these procedures (Loveday et al, 2014; National Institute for Health and Care Excellence, 2012).
NICE (2015) recommends catheters are reviewed regularly and removed as soon as possible, but nurses need the systems and skills in place to undertake this review process. Although the Royal College of Nursing (2012) provides guidance on what to consider during a catheter review, there is little information on catheter review decision-making and planning. Mavin and Mills (2015) suggest nurses need specialist continence support when considering alternative methods of management.
Catheter reviews require specific clinical skills, including assessing for continence aids and intermittent catheterisation (IC). High success rates have been achieved using IC in older patients who have urethral strictures, problems with bladder emptying and urinary retention (Parsons et al, 2012).
Catheter passports have been developed over recent years to improve management, support timely catheter removal and provide patients and health professionals with essential information on catheter care and history. In 2010, we created a local catheter passport, which we gradually rolled out from 2011 across North East Essex, in a partnership between our acute and community services.
Evaluation of the local catheter passport
From June 2012 to June 2013 we evaluated whether the passports, which contain details such as the date of insertion, reason for catheterisation and plan for removal, improved documentation, using data routinely collected from the catheter insertion page of the passport. When a catheter is first inserted, this page is routinely faxed by nurses to a central point and key information is entered onto an electronic catheter register.
We based our evaluation on 1,911 insertion page records. This did not represent the total number of patients catheterised, as staff used discretion in issuing a passport if the catheter was anticipated to be in place for less than 48 hours. We also assessed patient feedback from August 2012 to June 2013, using a random sample of 73 patients from the catheter register; 67 of them consented to participate in a telephone questionnaire.
Staff questionnaires were distributed to 25 acute ward areas and all the community nurse teams in June 2013. Nursing staff were invited to comment on key aspects of the passport and give specific examples and suggestions for practice improvement. A total of 76 questionnaires were received, of which four appeared to have been completed as team responses. The catheter register helped us to track patients and collect information about the factors influencing and delaying catheter review.
We found that 82% of indwelling catheters had been inserted in the acute setting; the rationale for insertion had been identified in 99% of cases; the majority of staff (83%, n=63) agreed that the passport had improved communication. We also received positive feedback from patients, with 90% rating the information they received as excellent or good.
Despite these findings, there was no significant reduction in catheter prevalence in the acute or community setting, and we identified key factors that influenced catheter reviews and removal. These were grouped into three common themes:
- Clinical knowledge deficits;
- Responsibilities and pathways;
- Managing patient expectation.
Clinical knowledge deficits
Best practice in catheter review and timely removal was recognised in both hospital and community settings. However, there appeared to be knowledge gaps among staff on how to approach catheter reviews, assess for alternative methods of management and determine follow-up plans, particularly in more complex cases. This was also reflected in patients’ experiences: 21% said they were unclear about the next step, while staff comments highlighted the need for more education and training in catheter reviews.
We also found that the terminology used to describe the reason for catheterisation could lead to delays in removal or assumptions being made about ongoing management. For example, retention of urine was used as a reason for catheterisation on 61% (1,166) of insertion pages. Urinary retention could be perceived as justifying ongoing catheterisation and a plan of routine changes be set up, particularly for patients transferring between wards and settings. This highlights the importance of staff establishing the underlying reason for retention, and ensuring alternative treatment options, investigations and specialist referrals have been considered and documented when patients are transferred. Similar problems were seen with catheters referred to as ‘long-term’, as it could be assumed that a decision had already been made for a permanent device.
Responsibilities and pathways
Catheter reviews are predominantly a nursing responsibility, and while nurses may be well placed and capable of undertaking reviews, they should be supported by clear guidance and processes detailing the wider clinical responsibilities across the entire patient pathway.
We found that catheter review decisions could ‘drift’ when staff were unfamiliar with catheter pathways, and plans were missing in 27% of insertion pages. Where nurses received patients without a plan they felt concerned about determining next steps.
The evaluation showed that reviewing a catheter was straightforward in many cases, but if patients had complex medical and nursing needs and/or social issues, catheter reviews were less likely to have been undertaken – possibly because, in such cases, significant skill and time are needed to establish information, balance risk and work through options. Where catheter removal is planned, it is important to anticipate continence and toileting needs, as well as the care package needed to avoid problems such as anxiety, falls and readmission. Planning help from other professionals, such as social workers, physiotherapists and occupational therapists, can also be important.
Managing patient expectation
Staff said some patients found discussing catheter removal upsetting, which may relate to the finding that 21% were unaware of catheter plans. Setting clear expectations with patients in the early stages regarding the temporary nature of the catheter (where possible), the plan for removal and alternatives is important to prepare patients and reduce anxiety. Including the increased risk of infection as part of patient education in catheter care supports patient understanding and informed decision-making (NICE, 2012).
NICE (2014) recommends that organisations have written protocols on the completion of procedures for the safe insertion, maintenance and timely removal of catheters, to minimise the risk of patients developing infections. Clear standards exist, against which the success of catheter insertion and care can be measured. These are set out in clinical guidelines, practice recommendations (Loveday et al, 2014; NICE, 2012) and care bundle approaches (Department of Health, 2007). However, there are no clear standards to support timely catheter removal.
Determining whether timely removal of catheters has taken place in different care settings presents a challenge because the point of removal is likely to be dictated by individual patient circumstances, and may depend on the assessor’s knowledge. However, as catheter reviews underpin and guide decision-making, it may be helpful to develop practice standards for this process. We have suggested such a standard (Box 1); it may help make a case for the investment needed to develop skills and pathways across care settings, providing a benchmark against which to measure best practice (NICE, 2014); the standard can be used in conjunction with existing guidance on management of indwelling catheters (Loveday, 2014; NICE, 2012).
Box 1. Proposed catheter review standard
- Urinary catheter review assessment and decision-making should be documented.
- Organisational guidance should be in place to support a systematic approach to urinary catheter review. It should identify clinical responsibilities, including those across the acute and community interface, to ensure urinary catheters are removed as soon as clinically appropriate.
- Those responsible for assessing the continuing clinical indication for a urinary catheter should be trained and competent in undertaking catheter review assessment and evaluation, use of alternative continence devices and intermittent catheterisation practice.
- The expectation that the urinary catheter is a temporary device (where possible) should be discussed with the patient/carers as soon as appropriate and reinforced at each catheter review.
Guidance and education
Following our evaluation we developed guidance to support community nurses undertaking catheter reviews in clinical practice. A follow-up of patients identified from the catheter register helped us to build a picture of common catheter review assessment factors (Fig 1, attached). This document acts as an aide-mémoire to help assessment and support informed decision-making; it is used in conjunction with a decision guidance flow chart (see below), which helps nurses to work through catheter reviews in a logical way. It also aims to define clinical ownership and maintain the momentum of the review by identifying the trigger points to ask for advice or to refer elsewhere. The decision guidance flow chart was added to organisational catheter procedures and accompanied by guidance for trial without catheter (TWOC) and acute retention of urine. The guidance was promoted in catheterisation clinical training and laminated mini sets were placed within diary covers for each community nurse with the slogan ‘Urinary catheters: Review not renew’.
Community nursing teams received education on how to carry out catheter reviews, including alternative methods of management and catheter terminology. Scenarios were used to support assessment and decision-making skills and this was also integrated into catheterisation skills training.
A community electronic patient record (SystmOne template) was developed to evidence catheter reviews and a key performance indicator for practice. The outcome of reviews for adult patients with newly inserted indwelling catheters is recorded by community nurses within 10 days following referral to the service.
Advice on managing patient expectation is included in the educational package and there are now specific prompts in the catheter passport, which are completed by staff. Patient information to support these discussions is included in the patient section of the passport.
Potential impact mapping
Potential impact mapping is an educational approach used to support learning and influence attitudes and behaviour. We used this approach with the aim of increasing staff’s understanding of the wider potential impact of catheters on patient safety and encourage a mindset of review. This activity is undertaken in workshops and involves asking participants to consider, discuss and map potential impacts of catheters, creating risk cycles. It is a simple interactive approach and there are no fixed rules for completion. The maps produced gradually build in complexity as thoughts extend beyond the device and most obvious risks. Fig 2 (attached) illustrates how this approach works.
We found that the process of mapping encouraged discussion and helped nurses to look at their own and others’ attitudes to catheters and to challenge practice routines. Participants appeared to find the activity motivating; it encouraged reflection on experiences and helped them to discuss their own ideas to develop practice. Creative and critical thinking are considered to complement each other, encouraging imagination and restructuring ways of working (Boore and Deeny, 2012). This supports the need for educational approaches to go beyond the procedural aspects of catheter insertion and care.
We have seen an improvement in catheter management since the introduction of the community electronic patient record; an average of 97.5% of adult patients referred to the community nurses with newly inserted indwelling catheters had a catheter review completed and the outcome recorded within 10 days of referral (April 2015 to January 2016 inclusive). Anecdotal evidence also suggests changes in practice behaviour, as there has been an increase in requests from community staff completing reviews for support from community continence and urology nurses. This includes advice regarding individual cases and support to review existing catheter caseloads. Monitoring community catheter prevalence and duration of insertion will support evaluating our progress.
We had found that 82% of indwelling catheters had been inserted in the acute setting; the decision guidance is being adapted for use in acute care. A survey undertaken in 425 care homes in the UK has shown that over half of care home residents with urinary catheters had them inserted while in hospital (McNulty et al, 2014). This highlights the need for hospitals and communities to work together to ensure continuity of care, patient safety and good patient experience. We suggest that optimal clinical outcomes can only be achieved in reducing catheter usage (and associated complications including readmissions) where common catheter review decision guidance and pathways are developed across the patient pathway.
The initiatives introduced were based on factors found to influence catheter reviews from a nursing perspective. Timely catheter removal relies on informed catheter review decision-making, and nurses in all settings require the skills and practice pathways to help them in this process.
Catheter review is a clinical skill and should be supported across acute and community settings by education, decision guidance and clear pathways that are complementary to each other and familiar to all those involved.
A key driver for change in guiding wider practice behaviour may be introducing catheter review standards within national clinical guidelines. These principles of best practice could help inform educational curricula and operational protocols, and encourage collaborative solutions to improve continuity of care and improvements across care settings. Working in partnership across organisations is fundamental in providing the coordinated care patients need, and is the principal vision for new models of care (NHS England, 2014). This may also help provide assurance to those commissioning services that processes are in place and followed consistently. All of this supports clinical ownership, ensuring a structured and considered approach to catheter review and sustainability in practice.
- Catheter review should be recognised as a clinical skill
- Staff must have education and training to carry out catheter reviews
- It is important to map pathways and clarify clinical responsibilities for catheter review across acute and community care
- Health professionals should explain to patients that, where possible, a catheter is a temporary device
- Potential impact mapping can be used to demonstrate to staff the effect of catheters on patient safety
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