Author Sandra Foulkes, MSc, BSc, Dip Community Studies, CertEd, RN, is clinical nurse specialist, Pontypridd and Rhondda NHS Trust.
ABSTRACT Foulkes, S. (2008) Reducing admissions for urinary catheterisation. Nursing Times; 104: 5, 49–51.
Sandra Foulkes describes a service development that reduced emergency admissions for urinary catheter-related problems through collaborative working and community catheter clinics. This will be supported by the use of a case study.
The importance of interprofessional and collaborative working is evident in government policy documents that emphasise the need for more specialised care for people at home or in the community (Welsh Assembly Government, 2005; Wanless, 2004). Services should be accessible, fast, safe and effective, simple to understand, easy to use and responsive to changing needs.
Pontypridd and Rhondda NHS Trust has an established integrated continence service. As a clinical nurse specialist working in partnership with consultant urologists, my role involves caring for patients in primary and secondary care, thereby acting as a link between the two services.
An opportunity to further develop integrated continence services within the trust occurred through a joint project with the University of Glamorgan funded by the Clinical Effectiveness Support Unit Wales. It had been identified that large volumes of patients were admitted to acute services for catheter-related problems.
Other areas of concern were inappropriate selection of urinary catheters and poor arrangement for the supply of products in primary and secondary care. The poor arrangements made for patients discharged with an indwelling catheter from secondary care had a significant impact on the provision of care in the community. A project was initiated to address these areas of concern.
Formulating an effective strategy for developing and implementing evidence-based interventions intended to change the behaviour of individuals in complex organisations is a formidable challenge.
The project was supported by trust management and consultant urologists, and divided into three phases: secondary care; primary care; community catheter clinics and project evaluation.
Phase 1: secondary care
As project leader my initial challenge was to enlist the support of the chief pharmacist to develop and implement control procedures to restrict the catheter product range in secondary care. A formulary was developed as well as a database to facilitate evaluation of the project and ongoing outcome audit.
Local catheter guidelines including the choice of catheters to be used for routine catheterisation were developed following a review of available literature and national guidelines.
The consultant urologists played a central role in policy development and approval. The hospital pharmacy took the lead in introducing minimum and maximum stock levels on the wards. It was also responsible for issuing catheter packs for patients to take home, and all patients discharged home with a catheter were automatically captured on the pharmacy database. This allowed tracking and facilitated audit.
This phase produced both clinical and financial benefits in line with the trust’s clinical governance programme.
Phase 2: primary care
Communication between hospital and community was patchy. There was no communication between consultants and GPs about which catheter was required, why patients needed to be catheterised or how often they needed to be catheterised.
Training and support was inconsistent or absent and the only education was provided by commercial companies. This resulted in patients missing out on support and often resulted in unnecessary referrals to secondary care.
Given the issues raised above, and that a number of patients who use catheter products often fall into the category of vulnerable adult, there were clearly clinical governance issues.
These problems needed to be considered by all those involved in the prescribing loop, such as staff at the acute trust, primary care staff, nursing home staff and product suppliers. To address this, all catheter and associated products used within Rhondda Cynon Taff were audited in GP surgeries and issues around stock control were explored. Community catheter clinics were also established.
Phase 3: community catheter clinics and project evaluation
Discussions were held with the local health board prescribing group to raise awareness of the project. Funding was obtained from Innovations In Care (an organisation that aims to improve NHS care in Wales) for community catheter clinics and these were run by the continence nurse specialists.
The clinics were run parallel with the consultant- led urology clinic, allowing easy access to diagnostic and therapeutic services.
To inform staff, workshops were organised advising local GPs, nursing homes and hospital staff of the new service and referral pathways. The clinics were held within three areas of the trust, to allow easy access for patients. They also offered outreach services for those unable to get to the clinic.
Evaluation of the service
The service was evaluated by assessing improvement in quality-of-life issues using a validated tool and monitoring emergency admissions before, and six months after, implementation. This showed that over 200 patients were seen in the first six months who would otherwise have been admitted via A&E to the acute wards. Also, those patients referred to consultant urologist outpatient appointments for catheter-related problems were seen in the clinic, and this had an impact on waiting list times.
Community clinics offer accessible local services, are effective, flexible and value for money. They also provide a learning environment for staff in catheterisation and catheter-related problems.
Collaborative working to prevent emergency admission:
Mr Lund had a slowly progressive neuromuscular disorder and had a suprapubic catheter. Over one month he had been admitted six times as an emergency admission with a blocked catheter. Due to his complex condition he required a general anaesthetic with IV antibiotic cover for each catheter change.
My initial assessment identified that while the general management of his condition was good, little attention had been given to Mr Lund’s catheter care. He had little community and social support. He did not have help to change his catheter bag and as a result he restricted his fluid intake to keep his urine output to a minimum. As a consequence he was dehydrated and suffered from constipation. These factors resulted in the catheter becoming blocked and he had recurrent emergency admissions.
Due to unpredictable muscle spasms it was agreed that he should be managed at home rather than attend unfamiliar catheter clinics, which could trigger muscle spasms and result in hospital admission. However, two potential problems were identified with managing Mr Lund at home.
It was difficult to administer sedation for catheter changes due to the risk of respiratory depression and therefore a local anaesthetic gel was required.
Mr Lund was immunocompromised so prophylactic antibiotics were needed during the procedure. A choice between oral or IM antibiotics was available in his home. The microbiology and infectious disease consultant provided advice on an oral antibiotic regimen.
A case conference was arranged with Mr Lund’s general practitioner, district nurses and social services to agree a way of managing his care in the community.
A social services package was organised to help him with his activities of daily living. Prophylactic antibiotics and local anaesthesia were prescribed by the GP, and catheter changes were performed and overseen by the nurse specialist and then, following training, by district nursing staff.
This case study illustrates the close collaboration between all the specialties. A care pathway was put in place, giving direct access to the urology department, bypassing A&E
and offering support and advice from the consultant urologist and microbiologist. To date there have been no further emergency admissions for catheter-related problems.
'We need clarification about reusable drainage bags'
Jones et al use the terminology ‘reusable urine drainage bags’ in their article about the reuse of drainable urinary drainage bags (Continence Journal, 16 October 2007, p48–50).
These terms are not synonymous. A drainable urinary drainage bag is intended to be left connected to the catheter.
The authors say: ‘The ACA (2007) suggest that reusable drainage bags are changed every five to seven days in accordance with manufacturers’ recommendations and DH guidelines.’ However, the ACA’s Notes on Good Practice actually state: ‘Any bag (leg/night) bearing the single-use emblem must be discarded after each disconnection, whether it is drainable or not.’
Jones et al state that most of the articles reviewed recommended that reusable urine drainage bags are changed every five to seven days, referencing my article in Charter Continence Care but I did not use the term ‘reusable’.
They also state that cleaning of the bags is controversial, referencing Pomfret and Mackenzie (2005). But we questioned the length of time products are left in place.
Jones et al question whether it is safer to use clean, single-use, non-drainable night bags in all patient areas. With regard to night bags connected to leg bags, I would fully agree. Bags connected directly to catheters should be sterile.
Ian Pomfret, continence adviser, Central Lancashire PCT
One of our main concerns for performing the research was the reuse of drainable urinary catheter night drainage bags in patients’ homes.
It appears we may have confused the reader by referring to drainable night urinary drainage bags as reusable. Manufacturers do recommend that these drainable night urine drainage bags can be reused but only when used as part of the link system, and this is the aspect we were investigating.
I apologise if Mr Pomfret feels that we interpreted his articles incorrectly. His comments demonstrate the continuing confusion and lack of evidence to support clinical practice in this aspect of care.
Sarah Jones, continence adviser, Maidstone, West Kent PCT