A review to evaluate evidence on supporting clinical practice and ensuring best practice in the management of urinary catheter drainage systems
Sarah Jones, MSc, FETC, RGN, is continence adviser, West Kent PCT, and members of the South East Thames continence advisory group; Anthony Brooks, BSc, CertEd, DEN,
RN, is highly specialist nurse continence adviser, East and Coastal Kent PCT, Sue Foxley, RGN, is consultant nurse, King’s College Hospital NHS Foundation Trust, Judith Dunkin, RGN, is continence adviser, Hastings and Rother PCT.
Jones, S. et al (2007) Care of urinary catheters and drainage systems. Nursing Times; 103: 42, 48–50.
A question about the reuse of drainable urinary catheter night drainage bags in a patient’s home promoted the South East Thames continence advisory group to examine the evidence for the management of urinary catheter drainage systems. The objective of this review was to establish if there is evidence available to support clinical practice and provide recommendations to staff and patients to ensure best practice.
Published and unpublished research, national and local guidelines, and information provided by professional organisations were reviewed. The review was divided into six questions.
Risks of catheterisation
Urinary catheterisation places a patient at significant risk of acquiring a urinary tract infection (UTI) (Tew et al, 2005). Catheter-associated UTIs have been shown to prolong the length of
hospital stay by 2.4 to 4.5 days (Joanna Briggs Institute, 2000). It is estimated that the cost of treating a UTI is £1,327 per patient (Roadhouse and Wellsted, 2004), and that the minimum cost to the NHS in England of catheters and catheter-related management products is approximately £40m a year, not taking into account the cost of associated drugs, bladder instillations or dispensing costs (Rawlinson and Clark, 2004).
Frequency of drainage bag emptying
It is widely accepted that the main benefit of sterile, continuously closed urinary drainage is to delay if not to prevent the onset of infection. Breaks in the system, such as unwarranted emptying or changing of the drainage bag, increase the risk of infection and should be avoided (Pellowe, 2004). However, there is little guidance about when a urine drainage bag should be emptied.
Stilwell (1992) advises that frequency of emptying will depend on the individual patient’s needs. Getliffe (1995) recommends frequent emptying in order to prevent the drainage bag becoming too heavy and to minimise problems of urethral tissue trauma and inflammation. Although this advice is more specific, it is still open to interpretation so it is therefore difficult to make clear recommendations based on
Bissett (2005) suggests emptying the bag when it is no more than half full to prevent backflow into the bladder. Penfold (1999) advises that the bag should be kept closed, except for emptying twice daily, or more often only if the bag is full. Others recommend every 4–6 hours (Toughill, 2005; Newman, 2002), or when it is three-quarters full (Coloplast, 2005).
The NICE (2003) guidelines advise that ‘the urine drainage bag should be emptied frequently enough to maintain urine flow and prevent reflux’, which is reiterated in the latest Epic guidelines (Pratt et al, 2007). This does not guide the caregiver to the optimum time for emptying the bag.
How should the drainage bag be emptied?
The majority of articles emphasise the need for handwashing before and after contact with catheters and drainage bags, and the use of
clean non-sterile gloves (Pratt et al, 2007; CPHVA, 2005; Pellowe and Pratt, 2004; Wilson, 1997).
Both Wilson (1997) and NICE (2003) specify the use of disposable plastic aprons to protect clothing from exposure to body fluids, secretions or excretions. There was a greater consensus over the type of receptacle used to empty the drainage bag. Wilson (1997) recommends emptying the bag into the toilet or into a clean receptacle, Stilwel (1992) suggests a container which is discarded or thoroughly washed (although does not specify how) and Penfold (1999) states that the receptacle used should be sterile, or have been washed in a bedpan washer and dried.
The Epic guidelines (Pratt et al, 2007) recommend a separate and clean container for each patient and that contact between the drainage tap and container should be avoided. Only one other article emphasised avoiding this type of contact as well as ensuring that the tap does not touch the floor (Stilwell, 1992).
There is conflicting advice regarding contact with the tap before and after emptying. Stilwell (1992) recommends that the tap should be cleaned before opening, and again afterwards,
but does not specify how this should be done. Sienty (1999) states that ‘caregivers must be taught to keep the drainage bag spout from becoming contaminated’ but does not say how this can
Wilson (1997), Penfold (1999) and Dougherty and Lister (2004) recommend that the outlet tap should be cleaned with a 70% isopropyl alcohol swab before opening and after closing. Epic2 (Pratt et al, 2007) does not mention handling of the tap.
Care of the reusable drainage bag when not in use
When a reusable night drainage bag is not in use within the patient’s own home, rinsing out the bag with a diluted bleach solution was frequently recommended (Madigan and Neff, 2003; Nash 2003; Newman, 2002).
There were also recommendations to clean and deodorise with distilled vinegar (Toughill, 2005; Washington, 2001), and to wash or rinse out with soap and/or water and allow it to dry thoroughly (Coloplast, 2005; Roe, 2001).
Coloplast (2005) reminds the user to replace the dust cap after rinsing. Tew et al (2005) make no recommendations but guide the caregiver to follow the manufacturers’ guidelines.
Interestingly, Toughill (2005) comments that cleaning of the bags remains controversial
and Pomfret and Mackenzie (2005) question the practice and highlight the need for further research.
How long can the drainage bag be used for?
Most of the articles reviewed recommend that reusable urine drainage bags are changed every five to seven days (Pomfret, 2006; Pellowe and Pratt, 2004). The Association for Continence Advice (2007) suggests that reusable drainage bags are changed every 5–7 days in accordance with manufacturers’ recommendations and Department of Health guidelines. However, Madigan and
Neff (2003) suggest that a bag can last up to four weeks if decontaminated daily with a 1:10 diluted bleach solution.
Tew et al (2005) is less helpful, suggesting that a drainage bag should be changed when clinically indicated, and Roe (2001) recommends reusing as per local policy or guidelines. The Epic2 guidelines (Pratt et al, 2007) advocate that ‘the connection between the catheter and the urinary drainage system is not broken except for good clinical reasons, for example changing the bag in line with the manufacturers’ recommendations’.
Meatal cleansing has always been considered an important area of catheter hygiene; however, there is little conclusive evidence as to best practice. Various techniques have been tried in the past including antibacterial creams, antiseptic solutions and four-hourly meatal care.
The latest Epic guidelines (Pratt et al, 2007) suggest that ‘vigorous meatal cleansing is not necessary and may increase the risk of infection, and that daily routine bathing or showering is all that is need to maintain meatal hygiene’.
Local primary care guidelines
The authors of this article also wanted to investigate if other continence caregivers were experiencing similar difficulties in establishing evidence-based catheter care. Guidelines from 20 randomly selected PCTs in England were compared using set criteria.
No consensus was evident about when a bag should be emptied. There was an even split between recommendation for two-thirds full, three-quarters full, enough to maintain flow and prevent reflux ‘when it felt it was straining’ and ‘when almost full’.
All 20 local primary care guidelines recommended washing and drying of hands before and after emptying the bags, and the use of gloves and plastic aprons if the task is performed by a health worker.
Again, all of the trusts’ guidelines recommended taking care not to contaminate the tap by avoiding contact with jugs or emptying receptacles. However, they differed in their advice on if or how to dry the tap mechanism afterwards. Three of the trusts recommended using an alcohol wipe, while four suggested wiping the tap, another four advised wiping the tap with tissue paper, and the remainder suggested ensuring that the tap was closed.
Most of the trusts advocated the use of reusable night bags for clients who cared for themselves in their own homes; however, care of the bags when not in use varied.
Some of the trusts suggested rinsing with water, and some with detergent and water. Some advocated draining and drying the bag with the lower tap open, while others merely mentioned that the upper connection should be capped. Interestingly, none of the reviewed guidelines suggested using bleach or other disinfectants to clean the bag.
The general consensus from all of the guidelines studied was that leg bags should be worn for up to seven days, unless the bag becomes disconnected, when it should be replaced with a new sterile one. Three of the trusts recommended disposable, single-use night bags, regardless of a client’s residential status.
All of the guidelines recommended maintenance of good personal hygiene – 80% suggested using soap and water to wash for meatal cleansing and most recommended daily washing. However, 50% of them recommended that talcum powder and creams or lotions should be avoided, while only one trust specified the use of a disposable washcloth for personal hygiene. One trust recommended meatal cleansing after every bowel action.
There is a lack of uniformity in the evidence guiding the care of urinary catheters and their drainage. There is also a considerable variation in the recommendations for how often the drainage bag should be emptied, allowing the caregiver freedom in their interpretation. The technique for emptying the drainage bag is described in most of the literature, allowing a more objective summary to be developed and translated into an evidence-based guideline.
There are conflicting opinions about the care of reusable drainage bags when they are not in use. Therefore translating this into care remains a challenge. The life of the reusable night drainage bag is unclear and the latest Epic guidelines (Pratt et al, 2007) have recommended that the bag is changed according to the patient’s need or the manufacturer’s recommendations. This advice is likely to continue to allow subjective interpretation, hindering the development of evidence-based guidelines. There does appear to be a degree of uniformity about meatal cleansing practice, although conclusive evidence supporting the approach was limited.
The small review of randomly chosen PCT guidelines would appear to demonstrate the need for further research in order to consolidate standards and information into a thorough and comprehensive evidence-based guideline.
The authors of this study had hoped to develop and/or update their guidelines for catheter care and drainage systems, ensuring that they were based on current evidence. Although the Epic2 guidelines (Pratt et al, 2007) are based on the ‘best currently available evidence’, the Epic notice board recognises that ‘this is not always the best possible evidence’ and has included suggestions for further research in each section.
It is essential that the use of indwelling urinary catheters is restricted unless absolutely necessary and that measures known to be effective in reducing the risk of infection be rigorously and consistently applied.
As a result of their findings, the authors question whether it is safer to use clean, single-use non-drainable night bags in all patient areas, despite the risk posed by the fact that these bags are not sterile and also have an environmental impact as seven bags are required per week instead of one. More research is needed to ensure that guidelines and resultant care are based on current evidence rather than custom and practice.
Box 1: Questions about managing urinary catheter drainage
How often and when should a catheter drainage bag be emptied?
How should the drainage bag be emptied, including handling of the tap?
How should a reusable bag be cared for when not in use?
How long can the drainage bag be used for?
How should meatal cleansing be performed?
What do local primary care guidelines on catheters and drainage bags advise?
Association for Continence Advice (2007) Notes on Good Practice. ACA. www.aca.uk.com
Bissett, L. (2005) Reducing the risk of catheter-related urinary tract infection. Nursing Times; 101: 12, 64–67.
Coloplast (2005) A Guide to the Care of Your Indwelling Catheter. Peterborough: Coloplast, Charter Healthcare.
CPHVA (2005) Urinary Catheter Insertion – Infection A2Z Web Series. www.healthcarea2z.org/n_infectiona2z.aspx
Dougherty, L., Lister, S. (2004) The Royal Marsden Manual of Clinical Nursing Procedures. Oxford: Blackwell Publishing.
Getliffe, K. (1995) Long-term catheter use in the community. Nursing Standard; 9: 31, 25–27.
Joanna Briggs Institute (2000) Management of Short-term Indwelling Urethral Catheters to Prevent Urinary Tract Infections. Best Practice Evidence-based Information Sheets for Health Professionals. www.joannabriggs.edu.au/best_practice/BPISIUC.php
Madigan, E., Neff, D. (2003) Care of Patients with Long-term Indwelling Urinary Catheters. 8: 3, 7. www.nursingworld.org
Nash, M.A. (2003) Best practice for patients self-cleaning urinary drainage bags. Urologic Nursing; 23: 5, 334–339.
Newman, D. (2002) Managing and Treating Urinary Incontinence. Annapolis, MD: Health Professions Press.
NICE (2003) Infection Control Prevention of Healthcare-associated Infections in Primary and Community Care. London: NICE.
Pellowe, C. (2004) Infection control during catheterisation. Urology News; 9:1, 13–14.
Pellowe, C., Pratt, R. (2004) Catheter-associated urinary tract infections: primary care guidelines. Nursing Times; 100: 2, 53–55.
Penfold, P. (1999) Urinary tract infection in patients with urethral catheters: an audit tool. British Journal of Nursing; 8: 6, 362–368.
Pomfret, I. (2006) Which Urinary System is for You? Charter Continence Care. Peterborough: Coloplast.
Pomfret, I., Mackenzie, R. (2005) Questioning practice – the need for research in continence care. Journal of Community Nursing; 19: 11, 32–36.
Pratt, R.J. et al (2007) Epic2: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection; 65S, S1–S64.
Rawlinson, M., Clark, J. (2004) Alternative approaches to managing a non-draining catheter. British Journal of Community Nursing; 9: 4, 141–147.
Roadhouse, A.J., Wellsted, A. (2004) The prevention of indwelling catheter-related urinary tract infections – the outcome of a performance improvement project. British Journal of Infection Control; 5: 5, 22–23.
Roe, B. (2001) Catheterisation. In: Norton, C. (ed). Nursing for Continence. Beaconfield: Beaconsfield Publishers.
Sienty, M. (1999) Preventing urosepsis from indwelling catheters. American Journal of Nursing; 99: 1, 24.
Stilwel, B. (1992) Catheter care: skills update. Community Outlook; 2, 26–27.
Tew, L. et al (2005) Infection risks associated with urinary catheters. Nursing Standard; 20: 7, 55–61.
Toughill, E. (2005) Indwelling urinary catheters; common mechanical and pathogenic problems. American Journal of Nursing; 105: 35–37.
Washington, E.A. (2001) Instillation of three per cent hydrogen peroxide or distilled vinegar in urethral catheter drainage bag to decrease catheter-associated bacteruria. Biological Research Nurse; 3: 2, 78–87.
Wilson, J. (1997) Control and prevention of infection in catheter care. Nurse Prescriber/Community Nurse; 3: 5, 39–40.